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{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3400
} | Medical Text: Admission Date: [**2108-8-22**] Discharge Date: [**2108-9-1**]
Date of Birth: [**2030-2-4**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Biaxin / Ibuprofen / Amoxicillin
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Asymptomatic right upper lobe and paraesophageal nodules.
Major Surgical or Invasive Procedure:
1. Flexible bronchoscopy.
2. Cervical mediastinoscopy.
3. Right upper lobe VATS wedge resection.
4. Right upper lobectomy.
5. Resection of paraesophageal mass.
6. Repair of tracheal laceration.
History of Present Illness:
78 year old woman who had undergone a resection of a left
frontal
atypical meningioma in [**2108-3-9**] and is also followed for CLL.
As part of her
preoperative work up in [**Month (only) 547**], she was found to have right upper
lobe
nodule on CT scan. This persisted over several months and is PET
positive. She presents for resection. In addition, the patient
is noted to have a 1.5 cm paraesophageal mass which was thought
to possibly be a lymph node. An esophageal
ultrasound did not clarify this further, so she presents for
resection of this simultaneously.
Past Medical History:
-- CLL diagnosed in [**2101**]
-- Left frontal meningioma s/p resection
-- peptic ulcer disease
-- colon adenoma
-- multinodular goiter with hypothyroidism
-- osteoporosis
-- osteoarthritis
-- hypercalcemia
-- emphysema based on CT, but not on inhalers
-- s/p cholecystectomy
Social History:
Retired lived with husband prior to surgery, has 3 daughters and
a son, all healthy. Resides half year in [**State 108**]. Smoked [**1-12**] PPD
for 27 years, quit [**2085**].
ETOH prior daily glass of wine. No recreational drug use.
Family History:
mother died from bile duct CA age 89.
sister [**Name (NI) **] died from gastric CA age'[**48**].
sister [**Name (NI) **] died from esophageal CA age 74.
sister [**Name (NI) 4489**] died from lower extr DVT age 82.
father died from ?MI age [**Age over 90 **].
Physical Exam:
General: pleasant female in NAD.
HEENT: PEERLA, EOMI, sclera non-icteric. Neck-supple, no LAD.
COR: RRR
Lungs: CTA bilat
ABD: soft, NT, ND, +BS, incision well healed.
Extrem: no C/C/E
Wound: dry, clean, no drainage
Brief Hospital Course:
Patient admitted on [**2108-8-22**] for correction of coumadin-induced
anticoagulation prior to surgery on [**2108-8-24**]. Please refer to
detailed operative report for additionnal information.
Post operative course without major complication. Patient spent
first 2 nights in ICU for cardio-respiratory monitoring and neo
weaning. The 2 chest tubes were initially on suction, then to
water seal, eventually removed on POD4 and POD6 respectively.
Serial CXR revealed no pneumothorax. Pain management achieved
with epidural catheter, maintained by pain service, until POD4
([**2107-8-29**]), then switched to PO meds. Patient's hematocrit
decerased slowly post operatively and was 25.5 on POD4 ([**8-28**]).
Patient was then transfused w/ 1 unit PRBC. Because of her hx of
DVT, IVC filter, patient is anticoagulated with IV Heparin,
starting on POD2; Coumadin is started on POD5. On POD6, patient
presents episode of atrial fibrillation, treated w/ IV
Metoprolol, followed by PO regimen, continued upon d/c.
On POD8, patient is d/c home, able to ambulate and in good
condition.
Coumadin dosing, INR level monitored by [**Hospital 18**] [**Hospital **] Clinic.
Medications on Admission:
Coumadin, Colace, Fosamax 70 qweek, Lasix 20', MVI, Paroxetine
10hs, Ranitidine 150",Synthroid 100', Tylenol ES
Discharge Medications:
1. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QTHUR (every
Thursday).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Zantac Maximum Strength 150 mg Tablet Sig: One (1) Tablet PO
twice a day.
5. Levothyroxine Sodium 100 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as
needed.
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) puff
Inhalation Q6H (every 6 hours).
9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*120 Tablet(s)* Refills:*0*
11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*75 Tablet(s)* Refills:*0*
12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
-- RUL nodule
-- Esophageal nodule
-- CLL (99)
-- left frontal meningioma s/p resection
-- peptic ulcer disease
-- multinodular goiter with hypothyroidism
-- osteoporosis
-- osteoarthritis
-- hypercalcemia
-- emphysema based on CT, but not on inhalers
Discharge Condition:
Good
Discharge Instructions:
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 170**] if you experience any
chest pain, shortness of breath, fever, chills, redness or
drainage from you incision site.
Do not drive while you are taking pain medication.
Take coumadin 5 mg evening [**9-1**], [**9-2**].
Have blood drawn for INR, coumadin level at [**Hospital3 **] [**Hospital1 **],
[**Hospital **] Clinic on Monday. Wait for results to know dosage for
Monday night and until next blood draw.
Resume all your pre-hospitalization medications. See specific
instructions for coumadin dosing.
Take all new medications as directed.
Followup Instructions:
Call Dr.[**Name (NI) 2347**] office for a follow up appointment in
[**9-21**] days.[**Telephone/Fax (1) 170**].
Please follow up INR (coumadin level) on MONDAY [**9-3**] and follow
up with primary care physician for level check
Completed by:[**2108-9-2**]
ICD9 Codes: 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3401
} | Medical Text: Admission Date: [**2135-7-11**] Discharge Date: [**2135-7-16**]
Date of Birth: [**2060-4-27**] Sex: M
Service: CCU
REASON FOR ADMISSION: Status post left carotid stent on
Neo-Synephrine.
HISTORY OF PRESENT ILLNESS: This is a 75-year-old gentleman
(with past medical history of coronary artery disease, CABG
(5 years ago), atrial fibrillation, ejection fraction of 30%,
peripheral vascular disease) status post left internal
carotid artery stent on Neo-Synephrine for systolic blood
pressure goal of 120-160 mm Hg. The patient has a history of
visual blurring with standing. No vertigo or dizziness.
Patient had 2-3 episodes of hemiparesis (face, arm, and leg),
and left sided numbness 2-3x. It was decided to place a
stent in the ICA because of a progressive left sided lesion
to 95% with symptoms.
In the Catheterization Laboratory on [**2135-7-11**], the patient
underwent left ICA stent. The findings intraoperatively were
a 95% [**Doctor First Name 3098**] lesion, 40% [**Country **] lesion. After the stent, there
was a 10% residual stenosis on the left with ipsilateral
filling of the [**Doctor First Name 3098**]. Secondary to intractable hypotension,
the patient was placed on a Neo-Synephrine drip with a goal
systolic blood pressure of 120-160.
REVIEW OF SYSTEMS: Negative for chest pressure, discomfort,
shortness of breath, or dizziness.
SOCIAL HISTORY: The patient is married, lives in [**Location **],
[**State 350**]. Is a machinist. Does not smoke. Has not had
a drink of alcohol since [**2116**].
FAMILY HISTORY: Father died in [**2131**] of a CCY complication.
Mother died at 62 years of age, cause unknown.
PAST MEDICAL HISTORY:
1. Coronary artery disease four vessel disease.
2. Chronic atrial fibrillation on Coumadin.
3. Diabetes mellitus x20 years (hemoglobin A1C 7.0).
4. Congestive heart failure with an ejection fraction of 30%.
5. Mitral regurgitation.
6. Hypertension.
7. Osteoarthritis.
8. Hyperlipidemia.
9. Peripheral vascular disease.
10. Bilateral carotid disease as described above.
11. Alcohol abuse.
12. Gastric ulcer.
13. Panic attacks.
14. Tonsillectomy.
15. Cataract surgery.
16. CABG with a LIMA to LAD graft and saphenous vein graft to
OM-1, D1, D2 graft.
ALLERGIES: No known drug allergies. Potential allergy to
dye.
MEDICATIONS ON ADMISSION:
1. Aspirin 81 mg po q day.
2. Metformin 850 tid.
3. Lisinopril 20 q day.
4. Isordil 20 [**Hospital1 **].
5. Lipitor 10 q day.
6. lanoxin 0.125 q day.
7. Toprol 50 [**Hospital1 **].
8. Persantine 75 tid.
9. Plavix 75 q day.
10. Norvasc 5 q day.
11. Coumadin 6/6/7.
12. Avandia 4 q day.
13. Amaryl 4 [**Hospital1 **].
14. Tranxene 7.5 tid.
PHYSICAL EXAM ON ADMISSION: Temperature 97.4. Blood
pressure on Neo-Synephrine 155/56. Heart rate 56.
Respiratory rate 20. Oxygenation 99% on 2 liters nasal
cannula. General: Patient appears younger than stated age
in no apparent distress, lying on back. Alert and oriented
times three with prompting. HEENT: Mucous membranes dry.
Pupils are equal, round, and reactive to light and
accommodation. Extraocular movements are intact. Neck is
supple. Neck veins are flat. Cardiovascular: Regular rate,
S1 greater than S2 at the apex, 2/6 systolic murmur at the
right base, 1+ carotid bruit on the right, nondisplaced point
of maximal impulse. Pulmonary: Clear to auscultation
bilaterally. Abdomen is nontender and nondistended,
normoactive bowel sounds, soft. Extremities: Right femoral
sheath clean, dry, and intact, 2+ dorsalis pedis, posterior
tibialis, and radial pulses bilaterally. No clubbing,
cyanosis, or edema. Neurologic: Cranial nerves II through
XII are grossly intact. Motor is [**5-9**] bilaterally. Sensation
is grossly intact.
LABORATORY STUDIES: Electrocardiogram showed normal sinus
rhythm at 75 beats per minute, left anterior fascicular
block, poor R-wave progression.
INR of 1.5. Sodium 140, potassium 4.7, chloride 106, bicarb
25, BUN 28, creatinine 1.4, glucose 84, hemoglobin A1C of
7.0.
Catheterization on [**2135-7-11**]: A stent was placed in the left
internal carotid artery, the dimensions of which were 8.0 x40
mm. The final residual is 10% with normal flow and no
dissections. Occlusion time seven minutes 0 seconds. The
patient remained neurologically intact throughout the
procedure.
BRIEF HOSPITAL COURSE: The patient was transferred to the
CCU from the Catheterization Laboratory, as he was on a
Neo-Synephrine drip.
ISSUES:
1. Intractable hypotension: The patient's Neo-Synephrine
drip was at 0.67 mcg/kg/minute on [**2135-7-12**]. Multiple
attempts at weaning with the systolic blood pressure goal of
120-160 were unsuccessful. The patient remained on
Neo-Synephrine until [**2135-7-16**], and maintained a systolic
blood pressure in the 120s-130s. Of note, all of his blood
pressure medications had been held.
2. Bradycardia: The patient's bradycardia was thought to be
secondary to heightened vagal tone. His heart rate remained
in the 40s throughout the majority of his inpatient stay. On
the day of discharge, his heart rate was normal sinus rhythm
in the 60s.
3. Anemia: The patient's nadir of his hematocrit was 27.6.
He was transfused 1 unit of packed red blood cells on
[**2135-7-12**]. It was presumed that the blood loss was secondary
to his catheterization. The patient received an additional
unit of packed red blood cells on [**2135-7-13**] to bring him to a
hematocrit of 33.3. The patient tolerated the transfusions
without difficulty.
4. Transient ischemic attack ?: The patient had an episode
of visual disturbance on [**2135-7-12**]. He described it as a
bilateral blurring/amaurosis fugax. The patient was also
transiently unresponsive. This episode lasted approximately
10-15 seconds. A neurological examination showed no motor or
sensory deficiency, no cranial nerve.
A STAT noncontrast head CT scan within one hour of symptom
onset demonstrated extensive evidence of chronic white
matter, small vessel ischemia with no other findings to
suggest acute or subacute infarction or hemorrhage.
The cause of the patient's transient vision changes and
unresponsiveness were not fully elucidated. A Neurological
consult was obtained with no additional recommendations.
5. Diabetes: The patient was placed on insulin-sliding scale
with qid fingersticks.
6. Agitation: The patient became increasingly agitated
throughout his hospital course. He was quite frustrated with
his clinical course. He was noted surreptitiously be taken
clorazepate from home and was continued on his clorazepate
7.5 tid po regimen with good effect. The patient was helped
markedly with frequent reorientation to person, place, and
time and reassurance and explanation regarding his clinical
course. It was recommended that BuSpar be tried as an
outpatient for the patient's anxiety disorder as Tranxene is
a long-acting benzodiazepine, which the patient was taking on
a prn basis.
7. Activity: The patient had a Physical Therapy evaluation
on [**2135-7-14**], which determined that he was stable to be
discharged home.
CONDITION ON DISCHARGE: On the date of discharge, the
patient's vital signs were as follows: Temperature 98.0,
blood pressure 156/60, respirations 14-19, heart rate in the
60s, and 98% on room air. Patient had been completely weaned
off Neo-Synephrine and was asymptomatic and hemodynamically
stable.
DISCHARGE STATUS: Good.
DISCHARGE MEDICATIONS:
1. Plavix 75 mg one po q day.
2. Coumadin 1 po q day, adjusted to INR.
3. Aspirin 81 mg tablet one po q day.
4. Atorvastatin 10 mg one po q day.
5. Clorazepate 3.75 tablets two tablets po tid.
6. Metformin 850 mg tablet one po tid.
7. Avandia 4 mg tablet one po q day.
8. Amaryl 4 mg tablet one po bid.
RECOMMENDED FOLLOWUP: The patient was to go to [**Hospital Ward Name **] Four on
Monday, [**7-18**] for blood pressure check at 10 am. The patient
was to followup for a vascular study on [**2135-9-13**] at 2:30 pm,
and follow up with Dr. [**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) **] on [**2135-9-13**] at 3 pm,
[**Telephone/Fax (1) 2207**]. The patient was advised to return to the
Emergency Room or call 911 with any new symptoms (eg,
lightheadedness, chest pressure, chest discomfort, shortness
of breath, dizziness, palpitations, vision or hearing
changes, weakness, or sensory loss).
PRIMARY DIAGNOSIS: Transient ischemic attack unspecified.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. [**MD Number(1) 5211**]
Dictated By:[**Last Name (NamePattern1) 1811**]
MEDQUIST36
D: [**2135-8-21**] 16:49
T: [**2135-8-23**] 10:26
JOB#: [**Job Number 42269**]
ICD9 Codes: 4280, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3402
} | Medical Text: Admission Date: [**2150-10-29**] Discharge Date: [**2150-11-8**]
Date of Birth: [**2068-1-11**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2518**]
Chief Complaint:
intracerebral hemorrhage
Major Surgical or Invasive Procedure:
endotracheal intubation
Radial arterial line
nasogastric tube placement
History of Present Illness:
Patient is an 82 yo woman with no significant PMH other than
osteoporosis who presents as transfer from [**Location (un) 14663**] intubated
with a left BG bleed. She has been in good health and takes no
medications. She lives with her son and today at around 4:30PM
she shreiked out three times, and then a loud thud was heard.
Her son found her on the floor, able to speak. Other details
about her state unavilable at this time.
EMS was called and noted that she was speaking to them. At the
OSH she was reported as having right facial droop and flacid
right hemiparesis and speaking. A CT scan showed ICH of the
left BG 18 x 21 mm with intraventricular spread into the left
lateral ventricle. She was intubated for transfer. It was
noted that with administration of propofol she became
hypotensive to 62/26,
but BP stabilized within 5 minutes and has been 110-160 since.
ROS: unable to offer.
Past Medical History:
Osteoporosis
No known history of hypertension or other cerebrovascular risk
factors.
Social History:
Lives with son, and daughter is very close by. No Tob/ETOh.
Very independent in her ADLs.
Family History:
Father died at 54 of bleeding ulcers. Mother had stomach CA.
Physical Exam:
T- 97 BP- 132/75 HR- 97 RR- 16 O2Sat 99%
Gen: Lying in bed, intubated, sedated with versed.
HEENT: NC/AT, intubated
Neck: supple, no carotid or vertebral bruit
Back:
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft.
ext: no edema
Neurologic examination:
Mental status: intubated and sedated. Intermittently writhing
and spontaneously moving LUE and LLE antigravity and RLE non
antigravity. No spont movement of RUE. Grimacing. Not
following commands midline or appendicular.
Cranial Nerves:
Pupils equally round and trace reactive to light, 2.5 to 2 mm
bilaterally. No blink to threat. No corneals. no Dolls.
Grimace
appears symetric but difficult with intubation.
Motor:
Flaccid RUE. Intermittently writhing and spontaneously moving
LUE and LLE antigravity and RLE non antigravity. No spont
movement of RUE. With noxious stim withdraws LUE and LLE
briskly. Withdraws RLE well but less strongly. Extensory
postures rigt UE.
Sensation: as above
Reflexes:
1+ in UE and symetric. Difficult to elicit in legs.
Toes up bilaterally
Pertinent Results:
[**2150-10-29**] 11:12PM TYPE-ART PO2-66* PCO2-36 PH-7.42 TOTAL CO2-24
BASE XS-0
[**2150-10-29**] 11:12PM K+-3.3*
[**2150-10-29**] 11:12PM freeCa-1.18
[**2150-10-29**] 02:55PM TYPE-ART PO2-119* PCO2-42 PH-7.42 TOTAL
CO2-28 BASE XS-3
[**2150-10-29**] 02:55PM GLUCOSE-158* LACTATE-0.9 NA+-131* K+-3.3*
CL--100
[**2150-10-29**] 02:55PM HGB-12.8 calcHCT-38
[**2150-10-29**] 02:55PM freeCa-1.11*
[**2150-10-29**] 04:31AM TYPE-ART PO2-96 PCO2-40 PH-7.35 TOTAL CO2-23
BASE XS--3 INTUBATED-INTUBATED
[**2150-10-29**] 04:31AM freeCa-1.13
[**2150-10-29**] 04:20AM GLUCOSE-182* UREA N-13 CREAT-0.6 SODIUM-133
POTASSIUM-3.3 CHLORIDE-102 TOTAL CO2-22 ANION GAP-12
[**2150-10-29**] 04:20AM CK(CPK)-108
[**2150-10-29**] 04:20AM CK-MB-8 cTropnT-0.06*
[**2150-10-29**] 04:20AM CALCIUM-8.0* PHOSPHATE-2.7 MAGNESIUM-1.6
[**2150-10-29**] 04:20AM PHENYTOIN-31.5*
[**2150-10-29**] 04:20AM WBC-10.7 RBC-4.01* HGB-12.7 HCT-38.3 MCV-95
MCH-31.5 MCHC-33.1 RDW-13.8
[**2150-10-29**] 04:20AM PLT COUNT-186
[**2150-10-29**] 04:20AM PT-12.4 PTT-28.7 INR(PT)-1.1
[**2150-10-28**] 09:39PM GLUCOSE-147* LACTATE-1.8
[**2150-10-28**] 09:39PM HGB-13.9 calcHCT-42
[**2150-10-28**] 09:20PM GLUCOSE-149* UREA N-20 CREAT-0.8 SODIUM-129*
POTASSIUM-3.9 CHLORIDE-92* TOTAL CO2-25 ANION GAP-16
[**2150-10-28**] 09:20PM CK(CPK)-102
[**2150-10-28**] 09:20PM cTropnT-0.12*
[**2150-10-28**] 09:20PM CK-MB-9
[**2150-10-28**] 09:20PM CALCIUM-9.0 PHOSPHATE-3.2 MAGNESIUM-2.0
[**2150-10-28**] 09:20PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2150-10-28**] 09:20PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2150-10-28**] 09:20PM WBC-9.2 RBC-4.42 HGB-14.5 HCT-41.6 MCV-94
MCH-32.8* MCHC-34.8 RDW-13.8
[**2150-10-28**] 09:20PM NEUTS-88.6* BANDS-0 LYMPHS-9.5* MONOS-1.6*
EOS-0.1 BASOS-0.1
[**2150-10-28**] 09:20PM PLT COUNT-175
[**2150-10-28**] 09:20PM PT-12.4 PTT-27.2 INR(PT)-1.1
[**2150-10-28**] 09:20PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
[**2150-10-28**] 09:20PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.006
[**2150-10-28**] 09:20PM URINE RBC-[**5-31**]* WBC-0-2 BACTERIA-OCC
YEAST-NONE EPI-<1
[**2150-11-3**] 12:02PM BLOOD %HbA1c-5.5
[**2150-11-3**] 06:38AM BLOOD Triglyc-64 HDL-48 CHOL/HD-2.5 LDLcalc-58
[**2150-11-2**] 1:11 pm ABSCESS Source: r arm abscess.
GRAM STAIN (Final [**2150-11-2**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
FLUID CULTURE (Final [**2150-11-5**]):
STAPH AUREUS COAG +. MODERATE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
PENICILLIN------------ =>0.5 R
TRIMETHOPRIM/SULFA---- <=0.5 S
ANAEROBIC CULTURE (Pending):
CT HEAD WITHOUT CONTRAST [**2150-10-28**]: An acute hemorrhage involving
the left basal
ganglion and thalamus measures approximately 18 x 21 mm with
surrounding
hypodense rim which likely represents edema. There is extensive
intraventricular blood within the ventricle as well as layering
blood within
the occipital horns of the lateral ventricles bilaterally.
There may be a
small amount of blood within the third ventricle. There is no
shift of
normally midline structures, or evidence of acute major vascular
territorial
infarct. Atherosclerotic calcification of the cavernous
carotids is observed
bilaterally. Mucosal thickening of the ethmoid air cells and
nasal mucosa is
noted bilaterally. The mastoid air cells are well aerated.
IMPRESSION: Left basal ganglion and thalamic intraparenchymal
hemorrhage with
ventricular extension as described.
CT HEAD WITHOUT CONTRAST [**2150-10-29**]: Unchanged appearance of the
previously seen left basal ganglia area
of high attenuation extending into the lateral ventricle and the
thalamus
suggestive of acute intraparenchymal hemorrhage. No masses,
mass effect,
midline shift or new parenchymal hemorrhagic areas are seen. No
areas of
acute infarction. The visualized osseous and soft tissue
structures are
within normal limits. Mild thickening of the mucosal lining of
the paranasal
sinuses is noted.
IMPRESSION: Unchanged appearance of the left basal ganglia and
thalamic
parenchymal hemorrhage extending into the ventricles. No
interval signs of
progression or new hemorrhagic areas. No midline shift.
Non Contrast Head CT [**2150-10-30**]: Significant image degradation due
to patient motion limits
evaluation, especially in the lower brain slices.
Unchanged appearance of the previously seen left thalamic
hemorrhage extending
into the ventricles. No evidence of ventricular dilation or
hydrocephalus.
Unchanged appearance of the hypoattenuating rim surrounding the
hemorrhage
consistent with vasogenic edema. No masses, mass effect or
midline shift is
noted. The osseous and soft tissue structures appear
unremarkable.
Mild mucosal thickening is noted in the bilateral sphenoid and
ethmoid
sinuses. Air-fluid level is noted in the left maxillary sinus,
indicating
sinusitis. Visualized portions of the orbits are unremarkable.
IMPRESSION: Unchanged appearance of the left thalamic
hemorrhage extending
into the ventricles. No evidence of ventricular dilation or
mass effect or
midline shift.
MRI/MRA head [**2150-10-31**]:
MRI head:
There is an acute left thalamic hemorrhage identified extending
to the left
corona radiata and also extending to the left lateral ventricle.
The hematoma
in the left lateral ventricle demonstrated increased T1 signal.
Following
gadolinium, no definite area of enhancement is identified within
the left
thalamic region or in the adjacent area. No abnormal flow voids
are seen in
this region. Mild periventricular changes of small vessel
disease are
identified. No evidence of slow diffusion seen in the left
thalamic region or
in other parts of the brain. There are soft tissue changes in
the visualized
paranasal sinuses and left mastoid air cells.
IMPRESSION: Left thalamic hemorrhage with intraventricular
extension of the
left lateral ventricle. No abnormal flow voids or enhancing
lesion identified
to indicate associated arteriovenous malformation or mass.
However, if there
is continued clinical suspicion for underlying lesion a followup
MRI can help.
MRA OF THE HEAD:
The head MRA demonstrates normal flow signal within the arteries
of anterior
and posterior circulation. Both posterior cerebral arteries are
fetal in
origin, a normal variation. There is no evidence of abnormal
vascular
structures in the region of left thalamic hemorrhage.
IMPRESSION: No significant abnormalities on MRA of the head.
CXR [**2150-10-29**]:
The ET tube tip is below the clavicular heads terminating about
1.8 cm above
the carina. The NG tube tip is in the stomach. The heart size
is enlarged to
a moderate degree. The lung volumes are low. Dextroscoliosis
is noted most
likely with element of kyphosis. A right chest deformity is
demonstrated
which may be related to old rib fractures with rounded opacity
projecting over
the mid right lung which may be related to pleural thickening or
represent
intraparenchymal lesion. In the absence of previous studies,
the precise
diagnosis is difficult. The left lung is grossly unremarkable.
There is no
evidence of congestive heart failure. Small left pleural
effusion cannot be
excluded.
CXR [**2150-11-3**]:
Distal end of the feeding tube overlies the region of the
duodenojejunal
junction. The opacity in the left paracardiac region likely
represents a
combination of elevated left hemidiaphragm andassociated
atelectasis, but it
is difficult to evaluate accurately in this single frontal view.
A small ill-
defined area of opacity at the right lung base is new since the
prior film of
[**2150-11-1**] and could be related to aspiration. No
pneumothorax.
IMPRESSION: Feeding tube tip remains in region of ligament of
Treitz. New
area of opacity right lung base could be secondary to
aspiration. Persistent
elevated left hemidiaphragm and associated left basilar opacity
possibly
related to atelectasis on this limited exam.
Rounded opacity projecting over the expected portion of the left
ventricle may
represent left ventricular enlargement. When the patient's
condition
improves, repeated PA and lateral radiographs are recommended
for precise
evaluation of cardiopulmonary findings.
Brief Hospital Course:
Ms. [**Known lastname **] is an 82 year old woman with no significant past
medical history other than osteoporosis who presented as a
transfer from [**Hospital 14663**] Hospital intubated with a left thalamic
hemorrhage with intraventricular spread. She was not on any
medications such as aspirin or coumadin. She did not have a
prior history of bleed.
1) Left thalamic hemorrhage-
After arriving intubated and sedated, her admission examination
was notable for a partial right hemiparesis, arm greater than
leg. Repeat CT on admission revealed stable size of thalamic
hemorrhage, but extension of blood from left lateral ventricle
into the right lateral ventricle and small ammount into 3rd
ventricle. Neurosurgery evaluated the patient on admission as
well as HD #2 and did not feel the pt would require an external
ventricular drain. The hemorrhage was in a typical location for
hypertensive bleed, but she had no clear history of this. She
may have had occult hypertension nocturnally as she did have
some episodes of hypertension while in hospital and MRI/MRA did
not reveal a underlying lesion.
She was admitted to the neurology ICU and monitored closely for
clinical change in her neurologic exam. Her blood pressure was
maintained for SBP 140-170 and MAP < 130. She was initially
loaded on dilantin, but this was discontinued given lack of any
cortical blood or other lesions. She was promptly extubated on
HD #1. MRI/MRA head was obtained to search for underlying mass
or vascular lesion to explain the patient's hemorrhage with
apparent lack of risk factors. MRI/MRA head did not reveal mass
or AVM. The patient was able to follow simple commands, and
remained with a dense R arm greater than leg hemiparesis. A
Dobhof tube was placed for NG feeds. She was stable for
transfer to the Neurology stepdown on [**2150-11-3**]. On her second
day on the stepdown ([**2150-11-4**]), she was able to speak in a
fluent, but dysarthric fashion.
With the patient more alert and her speech returning, her
swallowing was evaluated. However, the patient was aspirating
and it was determined that she would need a PEG tube to maintain
long-term nutrition. The feeding tube was placed by
interventional radiology on [**2150-11-6**].
2) Cardiac
The patient was noted to have an elevated troponin enzyme of
0.12 on admission, which trended down to 0.06 on repeat testing.
This was thought secondary to subendocardial demand related
ischemia during a period of hypotension following administration
of propofol at [**Hospital 14663**] Hospital prior to intubation. Repeat
EKG did not reveal ischemic changes. She was later rate
controlled with diltiazem and metoprolol PRN.
3) Infectious disease-
In the ICU, the patient was noted to have air fluid level in her
frontal sinuses by CT with clinical finding of erythema and ?
tenderness over her left frontal sinus. She was completed a
course of azithromycin for presumed sinusitis. Her right
antecubital fossa was noted to have marked warmth and erythema
and she was started on vancomycin for cellulitis. The site
underwent I and D. Levaquin was later started in the place of
vancomycin, then changed to clindamycin (to complete 5 day
course of clinda). A repeat CXR was done on the stepdown unit
after a coughing spell with concern for aspiration. Although
there was a question of a new opacity on the repeat CXR, no
antibiotics were started in response, as there was no fever,
WBC, or other indication of an aspiration pneumonia. It was
suspected that there might be aspiration pneumonitis.
On the day of discharge, the patient was in stable condition and
ready for departure.
Medications on Admission:
None
Discharge Medications:
1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
3. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
4. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for temperature > 100F or pain.
5. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
8. Clindamycin HCl 150 mg Capsule Sig: Two (2) Capsule PO Q6H
(every 6 hours) for 5 days: 5 more days of therapy after
discharge from hospital - for treatment of thrombophlebitis.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]
Discharge Diagnosis:
left thalamic intracerebral hemorrhage, likely hypertensive
superficial thrombophlebitis s/p I&D
sinusitis
Discharge Condition:
Improved - verbal output increasing, able to answer questions
and follow simple commands, fluent sentences and only minimally
dysarthric speech; unable to move right arm, trace tripleflexion
of right leg, right facial droop.
Discharge Instructions:
Please return to ER if you have new signs of cerebral hemorrhage
or stroke - including new weakness or numbness, new trouble
speaking or visual changes. Please take all medications and
keep all appointments.
Followup Instructions:
Follow up with your primary care physician after discharge from
rehab: [**Last Name (LF) **],[**First Name8 (NamePattern2) 674**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 75637**].
follow up with neurologist/Dr. [**First Name8 (NamePattern2) 2530**] [**Name (STitle) **] ([**Hospital3 **]
[**Hospital 75638**] Medical Center) after discharge from rehab - ([**Telephone/Fax (1) 19129**] - call for appointment
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2533**]
ICD9 Codes: 431, 2761, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3403
} | Medical Text: Admission Date: [**2130-1-31**] Discharge Date: [**2130-2-7**]
Date of Birth: [**2063-7-20**] Sex: M
Service:
CHIEF COMPLAINT: Gangrene and nonhealing ulceration of the
left fourth toe times three weeks.
HISTORY OF THE PRESENT ILLNESS: Mr. [**Known lastname 4281**] is a 66-year-old
male with a past medical history significant for noninsulin
dependent diabetes mellitus for the last twelve years along
with coronary artery disease, who presented with a nonhealing
ulceration and gangrene of his left fourth toe, which started
three weeks ago as a small pressure ulceration. The patient
deferred medical treatment until his wife took him to a
doctor one week prior to admission and he was directly
admitted for IV antibiotics. The patient also admitted to
rest pain of the foot, which was relieved with narcotics and
had been occurring in the same time frame. He denied any
previous history of claudications, fevers, chills, labile
blood sugars, nausea, vomiting, or shortness of breath. He
was admitted for angiogram and pre-anginal hydration with
renal protection as he had a mild chronic renal insufficiency
with the serum creatinine of 1.5. MRA done at an outside
hospital revealed a normal aortoiliac system, superficial
femoral artery, and popliteal artery with runoff. The
anterior tibial artery, which lead into a diseased dorsalis
pedis.
PAST MEDICAL HISTORY:
1. Positive for noninsulin dependent diabetes mellitus for
the last twelve years.
2. Hypertension.
3. Coronary artery disease with a myocardial infarction in
[**2126**] status post coronary artery bypass graft at that time.
4. Positive nicotine abuse of over 120 pack per year, but
stopped ten years ago.
5. The patient has a history of anemia of unknown origin,
most likely secondary to chronic renal insufficiency with
serum creatinine noted to be 1.5.
6. Benign prostatic hypertrophy.
7. Chronic obstructive pulmonary disease.
8. Neuropathy and arthritis of his left hand.
PAST SURGICAL HISTORY:
1. History is significant for Coronary artery bypass
grafting with the use of right greater saphenous vein in
[**2126**], as well as transurethral resection of the prostate.
2. Appendectomy.
3. Umbilical hernia repair.
MEDICATIONS ON ADMISSION:
1. Levaquin 500 mg PO q.d.
2. Colace 100 mg PO b.i.d.
3. Aspirin 325 mg PO q.d.
4. Digoxin 0.25 mg PO q.d.
5. Diltiazem 240 mg PO q.d.
6. Glipizide 10 mg PO b.i.d.
7. Trental 400 mg PO t.i.d.
8. Lasix 20 mg PO q.d.
9. Protonix 40 mg PO q.d.
10. Glucophage 750 mg PO q.a.m. and 500 mg q.p.m.
11. Tylenol #3.
12. Regular insulin sliding scale.
HOSPITAL COURSE: The patient was admitted to [**Hospital1 346**], where he was transferred from an
outside institution. He was initially started on oral
Levaquin and Flagyl for his toe ulceration. Angiogram was
scheduled for the day after admission and he was subsequently
hydrated gently overnight. He was given the Mucomyst
protocol. The Glucophage and Lasix were held prior to
angiogram. The creatinine was 1.6. The hematocrit at that
time was noted to be 25.
On hospital day #1, noninvasive studies were also obtained.
These revealed a limited study due to the examination being
technically difficult as the patient declined having the cups
placed for the volume recordings at any location other than
the ankles. EBIs were noted to be inaccurate due to
extensive vessel compressibility. The angiogram revealed no
significant proximal inflow disease from the level of the
renal arteries to the knee. The anterior tibial artery was
the only continuously patent leg vessel and it was severely
stenosed in its first and few centimeters. A patent dorsalis
pedis artery was noted. No plantar arteries were opacified.
Based on this information the patient was taken to the
operating room on [**2-2**], where a left superficial
femoral to dorsalis pedis artery bypass was performed with
the use of nonreverse saphenous vein graft. At that time a
left fourth toe open amputation was also performed. Details
of this procedure are dictated in a separate operative note.
The patient did fairly well hemodynamically, postoperatively
and was transferred up to the Vascular Intensive Care Unit.
PA catheter was placed, which revealed significant pulmonary
hypertension. This was noted on preoperative echocardiogram.
These were obtained from the [**Hospital **] [**Hospital **] Medical
records. A Cardiolite imaging study revealed a large fixed
hypoperfusion defect involving the inferior apical and
inferolateral regions. It was suggestive of an area of prior
myocardial infarction with no significant residual ischemia.
On gated images the left ventricle was moderately enlarged
with moderately reduced systolic function due to wall-motion
abnormalities. The right ventricle was also noted to be
enlarged. The pulmonary was noted to be approximately
56 mmHg and a left ventricular ejection fraction was noted
to be approximately 30%.
On postoperative day #2, the patient's pulmonary artery
catheter was pulled out to monitor CVP. He was able to get
out of bed to a chair and he was started on a regular diet.
He did have some nausea, which was relieved with Reglan and
Compazine.
Consultation was sought by his medical internist, Dr. [**Last Name (STitle) 3845**]
at that time.
On postoperative day #3, the CVP line was changed over to
central-venous catheter. He was transferred to the floor and
he started to ambulate with physical therapy. After that
time, he did extremely well and progressed very rapidly. His
wound was left open, however, it did continue to show
evidence of healing with pink granulation tissue. He had a
palpable dorsalis pedis graft pulse. He was seen by the
Department of Physical Therapy routinely throughout the
hospital stay and he was eventually cleared for discharge
home. He was sent home with a walker and he was only going
to need VNA care for his left fourth toe amputation site.
On postoperative day #4, he did have some nausea, while on
the floor. However, an EKG was obtained and revealed no
significant changes from previous EKGs. On postoperative day
#5, the patient was discharged to home on PO Keflex. It was
to be continued for approximately ten days. The patient was
instructed by Dr [**Last Name (STitle) 1391**] to followup in his office in ten
days to two weeks.
PHYSICAL EXAMINATION: Examination at the time of discharge
revealed a well-developed, well-nourished male appearing
slightly older than his stated age of 66. NECK: Neck was
supple without evidence of JVD or carotid bruits. HEART:
Regular rate and rhythm. LUNGS: Lungs were clear to
auscultation bilaterally. ABDOMEN: Soft, nontender,
nondistended without evidence of masses or bruits.
EXTREMITIES: Revealed 1+ edema on the left lower extremity.
He had a palpable dorsalis pedis graft pulse. The wound was
clean, dry, and intact and granulating well at that time.
Wet-to-dry dressings were initiated for the wound to be
changed twice daily. An ACE wrap was to be applied from the
toes to the knee while the patient was ambulatory. He was
able to full weightbearing with a healing sandle.
DISCHARGE MEDICATIONS:
1. Protonix 20 mg PO q.d.
2. Keflex 500 mg PO q.i.d. times ten days.
3. Albuterol metered dose inhaler two puffs q.i.d.
4. Reglan 10 mg PO q.i.d.
5. Lasix 20 mg PO q.d.
6. Trental 400 mg PO t.i.d. with food.
7. Lopressor 500 mg PO b.i.d.
8. Aspirin 325 mg PO q.d.
9. Digoxin 0.25 mg PO q.d.
10. Colace 100 mg PO b.i.d.
11. Diltiazem 240 mg PO q.d.
12. Glipizide 10 mg PO b.i.d.
13. Glucophage 750 mg PO q.a.m.; 500 mg PO q.p.m.
14. Tylenol 650 mg PO q.4h. and Percocet 1 to 2 mg q.4h.
DISCHARGE DIAGNOSIS:
1. Gangrene and nonhealing ulceration of the left fourth toe
secondary to tibial peroneal disease.
2. Noninsulin dependent diabetes mellitus.
3. Hypertension.
4. Coronary artery disease status post myocardial
infarction.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4417**]
Dictated By:[**Doctor First Name 22875**]
MEDQUIST36
D: [**2130-2-7**] 13:49
T: [**2130-2-7**] 14:43
JOB#: [**Job Number **]
ICD9 Codes: 496, 3572, 2859, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3404
} | Medical Text: Admission Date: [**2199-1-16**] Discharge Date: [**2199-1-24**]
Date of Birth: [**2140-2-1**] Sex: F
Service: MEDICINE
Allergies:
Tetracycline
Attending:[**First Name3 (LF) 5806**]
Chief Complaint:
Altered mental status, fever, abdominal pain
Major Surgical or Invasive Procedure:
Central line placement
Intubation
PICC line placement
History of Present Illness:
58yo female with hypertension, hyperlipidemia, OSA, who went to
church last evening and noted to be acting strange--poor eye
contact, yelling out, not answering questions so she was brought
to the ED by her church friends. According to her pastor she was
complaining of abdominal pain, having shaking chills, but alert
and oriented.
.
In the ED, initial vs were: 101.1 92 105/77 22 94 . The patient
was complaining of abdominal pain. Her mental status worsened
and she became somnolent, SBP 70s, tmax 101.7 and she was
intubated for airway protection, central venous line was placed,
and she was started on lephophed. Labs notable for WBC 10.9, no
bands. Creatinine 1.7. Lactate 3.3, normal LFTs. U/A negative.
An LP was attempted three times (including ED attending and was
unsuccessful) and so she was given Vanco, Zosyn, 2g IV
Ceftriaxone and tylenol x2. CT Torso showed no acute
intra-abdominal or pelvic process. Liver Ultrasound showed Nl
gallbladder. No intra- or extra-hepatic biliary dilatation. Did
not get urine or serum tox. Patient was noted to have a mild
cellulitis around her ankle which spread to the patient's knee
over the course of the evening. Surgery consulted who said did
not appear to be nec. fasc but she should have imaging of the
leg and consult vascular surgery. She was given IVF and her
blood pressure improved and she was weaned off pressors. Head CT
showed no acute intracranial process and tib/fib films showed no
air. On transfer, VS 116/56, HR 88, 100% on Fio2 50% and PEEP 5.
.
On the floor, the patient is normotensive and febrile to 101.9.
The patient says she is not in any pain except for her RLE which
is in quite a bit of burning pain. She states that she does not
think anything was happening in her RLE prior to her
presentation in the ED. She has had lower back pain for quite a
while that is worse when laying down.
.
ROS: Denies N/V/D, hematochezia, constipation, CP, SOB, cough,
sore throat, dysuria, hematuria, swollen lymph nodes, skin
puncture, trauma, sensory changes dizzy spells, headache,
syncope, rash.
Past Medical History:
Hyperlipidemia,
morbid obesity,
hypertension,
anal fistula,
sleep apnea,
GERD,
fatty liver disease,
osteoarthritis,
positive PPD
Social History:
Tobacco:Denies
ETOH: Denies
Ellicits: Denies
Family History:
Family History: Mother with leukemia. One sibling deceased of
CVA at the age of 52
Physical Exam:
Physical exam:
T 99.2 BP 143/52 HR 82 R 18 Sa02 100% RA
GEN: Sleepy obese women in bed NAD.
HEENT: Sclera anicteric, OP is clear, No LAD, No JVP distention
CV: RRR, S1 and S2 not appreciated secondary to large body
habitus.
Lungs: No adventitious sounds appreciated. Normal respiratory
effort.
Abdomen: Obese abdomen, soft, NT/ND.
Extremities: WWP, 2 + distal pulses. Darkening in lower
extremities consistent with venous insufficiency. Blanching
warm erythematous rash from right ankle to right knee. Has
receded from marker line. Nonpitting swelling in left upper
extremity.
Neurologic: Oriented times 3. Appropriate responses to
questioning. CNs II-XII intact to direct testing. Bulk and tone
are normal. Strength is full.
Skin: R. lower extremity rash noted above. No other rashes
noted.
.
Pertinent Results:
Admission labs [**2199-1-15**]:
WBC-10.9# RBC-4.40 Hgb-11.7* Hct-35.2* MCV-80* MCH-26.5*
MCHC-33.1 RDW-13.9 Plt Ct-150
Neuts-89.2* Lymphs-7.4* Monos-2.5 Eos-0.6 Baso-0.3
PT-13.8* PTT-26.3 INR(PT)-1.2*
Glucose-115* UreaN-22* Creat-1.6* Na-138 K-4.6 Cl-101 HCO3-25
AnGap-17
ALT-16 AST-37 CK(CPK)-151 AlkPhos-57 TotBili-0.6
Lipase-31
CK-MB-1 cTropnT-<0.01
Calcium-9.0 Phos-2.3* Mg-1.3*
AMS workup:
ASA-NEG Ethanol-NEG Acetmnp-9.6* Bnzodzp-NEG Barbitr-NEG
Tricycl-NEG
HERPES SIMPLEX (HSV) 1, IGG-Positive
HERPES SIMPLEX (HSV) 2, IGG-Positive
LEPTOSPIRA ANTIBODY-Negative
Most recent to discharge labs, [**2199-1-24**]:
WBC-6.1 RBC-3.78* Hgb-9.6* Hct-30.4* MVC-81* MCH-25.5* MHCH-31.7
RDW-14.9 Plt Ct-210
Glucose-99 UreaN-10 Creat-0.9 Na-140 K-3.9 Cl-103 HCO3-29
AnGap-12
Microbiology:
3/2 Blood cultures:
Blood Culture, Routine (Final [**2199-1-21**]):
BETA STREPTOCOCCUS GROUP B. FINAL SENSITIVITIES.
CLINDAMYCIN 0.12 MCG/ML.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
BETA STREPTOCOCCUS GROUP B
|
CLINDAMYCIN----------- S
ERYTHROMYCIN----------<=0.25 S
PENICILLIN G----------<=0.06 S
VANCOMYCIN------------ <=1 S
Anaerobic Bottle Gram Stain (Final [**2199-1-16**]):
GRAM POSITIVE COCCI IN CHAINS.
[**1-16**] Urine culture negative
[**1-16**] MRSA screen negative
[**Date range (1) 31835**] Blood culture pending (negative to date)
[**1-21**] Urine culture pending
Imaging:
CT Torso: No acute intra-abdominal or pelvic process. Dependent
atelectasis in the bilateral lungs, underlying infection not
excluded.
CT head: Eval for small focus of hemorrhage limited in setting
of prior contrast administration, but no e/o acute intracranial
hemorrhage or infarct. B/l ethmoid sinus disease.
MR [**Name13 (STitle) 430**]: No intracranial hemorrhage or mass. No evidence for
meningo-
encephalitis.
CXR: Nl gallbladder. No intra- or extra-hepatic biliary
dilatation.
Liver U/S: Nl gallbladder. No intra- or extra-hepatic biliary
dilatation.
TTE: The left atrium is mildly dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion. There is no valvular aortic stenosis. The
increased transaortic velocity is likely related to high cardiac
output. 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. No vegetation seen (cannot definitively
exclude).
Transvaginal ultrasound: Endometrial thickening measuring 1.8
cm, the differential diagnosis of which includes endometrial
carcinoma, hyperplasia or polyp. Tissue sampling is recommended
for further evaluation.
Tib/Fib x-ray: Muscular and subcutaneous appearances and fat
planes are probably normal with no soft tissue calcification.
Incidental note is made of posterior and plantar calcaneal
spurs. Tibia and fibula are normal without fracture or bone
destruction.
L shoulder x-ray: No evidence of acute fracture or dislocation.
Mild degenerative changes are seen involving the
acromioclavicular joint. No abnormal calcifications are seen.
R leg ultrasound: No evidence of collection in the right calf.
L arm ultrasound: No evidence of left upper extremity DVT.
CXR: Right PICC terminates in the superior vena cava. There is
mild congestive failure as demonstrated by prominence of central
pulmonary vasculature. Heart is top normal in size. Mediastinum
is within normal limits.
L shoulder MRI:
1. Tendinosis of the supra- and infrasinatus tendons. Possible
tiny
intrasubstance tendon tear, but no surfacing or full-thickness
tear.
2. Small amuont of edema within the teres minor muscle, of
uncertain etiology or significance.
3. Small amount of glenohumeral joint fluid, predominantly in
the
subscapularis recess, at the upper limits of normal in volume.
4. No suspicious marrow edema. No findings to suggest abcess or
osteomyelitis. Diffuse low T1 signl in them arrow could reflect
the presence of anemia.
Brief Hospital Course:
58 year old female who presented with altered mental status,
epigastric pain, found to be febrile and hypotensive in the ED,
intubated for airway protection and found to have lower
extremity cellulitis and GBS bacteremia. The cellulitis was
said to have first appear while the patient was in the ED,
however, another source for the bacteremia was not found on
extensive workup in the MICU and floor. This presentation may
have been a primary GBS bacteremia or may have been seeded
cellulitis.
# Altered Mental Status: She had delirium in the setting of GBS
bactermia, and her mental status greatly improved on
antibiotics. There was initially concern for
meningoencephalitis but her imaging was inconsistent. She does
have positive HSV antibodies but no signs of
meningoencephalopathy on exam.
# GBS Bacteremia: Blood cultures from admission grew 4/4 bottles
of group B strep. Her antibiotics were tapered to only
ceftriaxone, and her mental status cleared. After a thorough
workup, the suspected source is right leg cellulitis. No signs
of vegetations on TTE [**1-16**]. She was followed by infectiouse
disease who recommended a 14 day course of IV antibiotics given
the severity of her infection.
# Right lower extremity cellulitis: This was the suspected
source of her GBS bacteremia as her cellulitis was rapidly
worsening in the ED. There was concern for necrotizing fascitis
but no signs of gas formation on imaging. Her exam improved with
ceftriaxone, and there were no fluid collections on ultrasound.
#Acute Renal Failure: Most likely was pre-renal failure
secondary to sepsis. Creatinine 1.6 in ED but improved to near
baseline of 1.1 with IV fluids.
# Respiratory Status: Briefly intubated for airway protection on
admission. The vent was weaned on HD#1, and the patient was
extubated on [**2199-1-16**] without requiring further respiratory
support.
# Left shoulder pain: Patient developed left shoulder pain
overnight after coming to the floor. Given her GBS bacteremia,
there was concern for septic joint but her exam improved over
the day. Ultrasound was negative for DVT, x-ray ruled out
fracture and MRI showed possible small tear but no evidence of
abscess or osteomyelitis.
# Anemia: HCT lower than baseline 36 however levels have been
stable throughout hospital course, and anemia is normocytic.
Most likely due to inflammation and component of dilution from
fluids in MICU. However, may be Fe deficiency. Fe studies
should be done as an outpatient.
# Hypertension: HTN meds were initially held in the setting of
sepsis but blood pressures slowly rose at which time the
patients home doses of her antibiotics were restarted.
# Endometrial thickening: Seen on transvaginal ultrasound in
patient who has been menopausal since age 40. Recommend
outpatient endometrial biopsy.
# OSA: Will continue BiPAP at night.
# Hyperlipidemia: Continued simvastatin
Medications on Admission:
FLUTICASONE - 50 mcg Spray, Suspension - 2 (Two) sprays in each
nostril once a day
HYDROCHLOROTHIAZIDE - 12.5 mg Tablet - 1 Tablet(s) by mouth once
a day
IBUPROFEN - 800 mg Tablet - 1 Tablet(s) by mouth twice a day as
needed for pain
KETOTIFEN FUMARATE - 0.025 % Drops - 1 gtt in each eye twice a
day
LISINOPRIL - 5 mg Tablet - 1 Tablet(s) by mouth once a day
METOPROLOL SUCCINATE - 25 mg Tablet Sustained Release 24 hr - 1
Tablet(s) by mouth once a day
CPAP
RANITIDINE HCL - 150 mg Tablet - 1 (One) Tablet(s) by mouth
twice
a day
SIMVASTATIN - 40 mg Tablet - 1 Tablet(s) by mouth once a day
DOCUSATE SODIUM - 100 mg Capsule - 1 (One) Capsule(s) by mouth
twice a day
LORATADINE - 10 mg Tablet - 1 Tablet(s) by mouth once a day
Discharge Medications:
1. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
5. Ibuprofen 800 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for pain.
6. Ketotifen Fumarate 0.025 % Drops Sig: One (1) drop Ophthalmic
twice a day.
7. Calcium 500 + D 500 mg(1,250mg) -200 unit Tablet Sig: One (1)
Tablet PO once a day.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day.
10. BiPAP
Please continue your BiPAP at previous settings (22/16 cm).
11. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Ceftriaxone 2 gram Recon Soln Sig: Two (2) grams Intravenous
once a day for 5 days.
13. Hydrochlorothiazide 12.5 mg Tablet Sig: One (1) Tablet PO
once a day.
Discharge Disposition:
Extended Care
Facility:
Roscommon Extended Care
Discharge Diagnosis:
Primary:
Group B strep bacteremia
R lower leg cellulitis
Secondary:
Obstructive sleep apnea
Hypertension
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 for confusion and found to
have a blood stream infection and right leg skin infection.
Given your confusiona and low blood pressure, you were closely
monitored in the intensive care unit and briefly required a
breathing tube to protect your airway. You quickly improved on
antibiotics. The lining of your uterus is thicker than expected
for your age and you should see GYN for workup. Please
follow-up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] as below.
The following changes were made to your medications:
1. Started ceftriaxone, an antibiotic, to treat your blood
stream and skin infections.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] on [**2-1**] at 10 AM. Please call
[**Telephone/Fax (1) 5808**] if you need to reschedule.
You should see GYN regarding your increased endometrium. Dr.
[**Last Name (STitle) **] will discuss this with you and help set up an appointment.
Other scheduled appointments:
Provider: [**Name10 (NameIs) 900**] [**Name8 (MD) 901**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2199-3-12**] 9:20
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Name (STitle) **] Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2199-5-16**]
9:30
ICD9 Codes: 5849, 4019, 2724, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3405
} | Medical Text: Admission Date: [**2140-11-5**] Discharge Date: [**2140-11-18**]
Date of Birth: [**2101-3-21**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 39-year-old
female with end-stage renal disease secondary to diabetes.
She also has a history of hypertension, peripheral vascular
disease, and hypothyroidism who presented with chest pain.
The patient felt chest pressure while walking and had
associated shortness of breath and emesis. She did have
relief with rest. On admission, she did also note that her
blood sugars were running higher than normal. She did have a
stress test five years ago as a possibility for transplant
option which was normal.
In the Emergency Department, the patient was given aspirin,
ceftriaxone, Lopressor, and was chest pain free.
PAST MEDICAL HISTORY: (Her past medical history includes)
1. Type 1 diabetes with associated retinopathy and
neuropathy.
2. Hypertension.
3. Peripheral vascular disease.
4. End-stage renal disease (hemodialysis dependent). Her
hemodialysis schedule is on Monday, Wednesday, and Friday.
5. History of hypothyroidism.
6. Status post percutaneous transluminal coronary
angioplasty of the bilateral lower extremities.
7. Status post amputation of her right foot.
SOCIAL HISTORY: The patient moved here from [**State 108**] and
lives with her mother in [**Name (NI) 8**]. She does not smoke. She
does not drink alcohol. She does not use intravenous drugs.
She does ambulate with a cane.
ALLERGIES: The patient has allergies to CLINDAMYCIN (which
gives her diarrhea), LEVAQUIN (which gives her
gastrointestinal upset), and ZEMPLAR (which gives her a
rash).
MEDICATIONS ON ADMISSION: (Her medications on admission
included)
1. Plavix 75 mg by mouth once per day.
2. Atenolol 25 mg by mouth once per day.
3. NPH insulin 26 units subcutaneously in the morning with
16 units subcutaneously regular; in the evening 2 units
subcutaneously of regular and 4 units subcutaneously of NPH.
4. Tums by mouth three times per day.
5. Epogen 13,000 units with each dialysis.
6. Iron.
7. Vitamin D.
REVIEW OF SYSTEMS: The patient's review of systems was
positive for diarrhea for four days. No hematochezia. No
orthopnea. Positive for chest pain (as in History of Present
Illness). Positive for a dry cough.
PHYSICAL EXAMINATION ON PRESENTATION: The patient's physical
examination revealed she was a pleasant female in no apparent
distress; although she did look malnourished. The patient's
vital signs revealed her temperature was 98.5 degrees
Fahrenheit, her heart rate was 79, her blood pressure was
133/68, her respiratory rate was 16, and her oxygen
saturation was 94% on room air. Head, eyes, ears, nose, and
throat examination revealed multiple large cystic lesions on
her face and under her chin that were confluent. There was
no warmth, but there was positive pigmentation. The
patient's pupils were equal and reactive. The oropharynx was
clear. Her chest examination revealed the lungs were clear
to auscultation bilaterally. Cardiovascular examination
revealed a regular rate and rhythm. There was a 2/6 systolic
murmur at the right upper sternal border. The abdomen was
soft, nontender, and nondistended. There were positive bowel
sounds. Extremity examination revealed no edema. Her right
foot had a partial amputation. Her left foot had a dorsalis
pedis pulse of 1+. She had good capillary refill on the
right. Neurologic examination revealed her cranial nerves
were intact. Her strength was grossly intact and symmetric.
She did have decreased sensation in her lower extremities.
PERTINENT LABORATORY VALUES ON PRESENTATION: The patient's
laboratories on admission revealed her white blood cell count
was 17.5, her hematocrit was 38.9%, and her platelet count
was 344,000. The patient's sodium was 138, potassium was
3.8, chloride was 93, bicarbonate was 32, blood urea nitrogen
was 23, creatinine was 6.3, and her blood glucose was 46.
Her troponin was 0.3 and CK/MB was 2.
PERTINENT RADIOLOGY/IMAGING: The patient's chest x-ray
showed cardiomegaly with upper zone redistribution. No
effusions or consolidations.
The patient's electrocardiogram revealed 1-mm ST depressions
in V4 through V6 and there were T wave inversions in leads I,
V3, and V4 and minor changes.
CONCISE SUMMARY OF HOSPITAL COURSE: The patient was admitted
and eventually was sent for cardiac catheterization. The
cardiac catheterization revealed an ejection fraction of 35%
and 3-vessel disease (including 100% occlusion of the right,
80% left anterior descending artery, and 100% posterior
descending artery).
The patient was then referred to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for
coronary artery bypass grafting. While awaiting surgery, the
patient's Plavix was held and had no complications.
On [**2140-11-10**] the patient underwent coronary artery
bypass grafting times three with left internal mammary artery
to left anterior descending artery, saphenous vein graft to
the distal left anterior descending artery, and a saphenous
vein graft to the posterior descending artery.
The surgery was performed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] with Dr.
[**Last Name (STitle) 3111**] and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (PA-C) as assistants. The
surgery was performed under general endotracheal anesthesia
with a cardiopulmonary bypass time of 91 minutes and a
cross-clamp time of 64 minutes. The patient tolerated the
procedure well and was transferred to the Intensive Care Unit
with two atrial and two ventricular pacing wires with one
left pleural chest tube and dobutamine, Levophed, and
propofol drips. The patient was in a normal sinus rhythm.
Over the postoperative night, the patient was extubated
without complications. She remained on her dobutamine drip,
and the Levophed drip was weaned as tolerated.
By postoperative day one, the patient was to have
hemodialysis and her Plavix restarted. Following dialysis,
her chest tubes were discontinued without incident. The
patient's dobutamine was weaned off over this day. By
postoperative day two, the patient was started back on her
beta blocker.
Throughout the early postoperative period (over the first two
days postoperatively), the patient was on an insulin drip for
tighter control of her blood sugars. On postoperative day
five, the patient was finally off of her insulin drip and her
blood sugars were maintained with NPH and sliding-scale. The
patient continued during that time to receive regular
hemodialysis at the bedside.
On postoperative day six, the patient was transferred to the
regular floor and was continued on vancomycin and gentamicin;
especially for the lesions on her face.
By postoperative day seven, the patient was switched to by
mouth medications for the pustule lesions on her face; this
medication was Keflex. She had her pacing wires discontinued
without incident on this day, and the plan was for her to be
discharged to rehabilitation the following day.
On postoperative day eight, the patient was doing well. She
did receive an additional course of hemodialysis on this day.
It was felt that she was ready and stable to be discharged to
rehabilitation for further continuation and recovery from her
cardiac surgery.
PHYSICAL EXAMINATION ON DISCHARGE: The patient's discharge
examination revealed her vital signs to be stable with a
temperature of 97.8 degrees Fahrenheit, her heart rate was
96, her blood pressure was 140/67, her respiratory rate was
20, and her oxygen saturation was 100% on room air. In
general, the patient was alert and oriented times three. In
no apparent distress. Cardiovascular examination revealed a
regular rate and rhythm. Her wounds were clean, dry, and
intact. The lungs were clear to auscultation bilaterally.
Her abdomen was soft, nontender, and nondistended. The
patient's legs revealed no clubbing, cyanosis, or edema. Her
wounds were clean, dry, and intact.
PERTINENT LABORATORY VALUES ON DISCHARGE: The patient's
laboratories on discharge revealed her white blood cell count
was 15,000. Her hematocrit was 29.3%, and her platelet count
was 370,000. The patient's sodium was 132, potassium was
4.9, chloride was 94, bicarbonate was 28, blood urea nitrogen
was 40, creatinine was 7, and her blood glucose was 113.
PERTINENT RADIOLOGY/IMAGING ON DISCHARGE: A chest x-ray
showed very small bilateral pleural effusions, but no signs
of infiltrate.
DISCHARGE DISPOSITION: The patient was to be discharged to
rehabilitation today ([**11-18**]).
CONDITION AT DISCHARGE: The patient's condition on discharge
was good.
MEDICATIONS ON DISCHARGE: (Discharge medications included)
1. Colace 100 mg by mouth twice per day.
2. Aspirin 325 mg by mouth once per day.
3. Percocet one to two tablets by mouth q.4h. as needed
(for pain).
4. Atenolol 25 mg by mouth once per day.
5. Keflex 500 mg by mouth once per day (for 10 days).
6. Plavix 75 mg by mouth once per day.
7. Renagel 800 mg by mouth three times per day.
8. Protonix 40 mg by mouth once per day.
9. Multivitamin one tablet by mouth once per day.
10. Epogen 13,000 units subcutaneously with each
hemodialysis.
11. Calcium carbonate antacid 500-mg tablets one tablet by
mouth three times per day.
12. NPH insulin 26 units subcutaneously in the morning and
NPH 6 units subcutaneously in the evening.
13. Humalog insulin sliding-scale which varies depending
during the day.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was instructed to follow up with her primary
care physician (Dr. [**Last Name (STitle) 3112**] in one to two weeks.
2. The patient was instructed to follow up with her
cardiologist in two to three weeks.
3. The patient had several appointments; the first of which
was on [**2140-12-8**] with a physician at the [**Name9 (PRE) **] Clinic
at 4 p.m.
4. The patient was instructed to follow up with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] in four weeks.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Dictator Info 3114**]
MEDQUIST36
D: [**2140-11-18**] 11:03
T: [**2140-11-18**] 11:17
JOB#: [**Job Number 3115**]
ICD9 Codes: 4111, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3406
} | Medical Text: Admission Date: [**2114-5-25**] Discharge Date: [**2114-6-4**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
s/p mechanical fall at his birthday party with R frontal
intraparenchymal hemorrhage and small R SDH and Right
intertrochanteric femur fracture.
Major Surgical or Invasive Procedure:
Open reduction and internal fixation of right femur fracture
with percutaneous cephalomedullary nail, TFN, 11 x 130 x 170.
History of Present Illness:
Patient is a [**Age over 90 **]-year-old man transferred from OSH on [**5-25**] after
a mechanical fall in which he sustained a right
intertrochanteric hip fracture. Per previous notes, he was at
his 90th birthday party and "tripped and fell back" without any
symptoms of chest pain, dizziness, or weakness. There was no
LOC. Initially he was brought to an OSH where hip x-ray and head
CT showed a right intertrochanteric hip fracture, a frontal IPH
as well as a small SAH and SDH with no significant mass effect.
Patient was transferred to [**Hospital1 18**] for further management. Repeat
CT showed mildly R frontal intraparenchymal hemorrhage.
Patient was admitted to trauma service and evaluated by
neurosurgery, and per their most recent note he has a
"survivable, non-operative right frontal IPH." He was scheduled
for right hip.
Past Medical History:
- tonsillectomy
- cataract surgery bilaterally
- history of atrial fibrillation: diagnosed in [**2113-8-5**] -
seen by Dr. [**Last Name (STitle) 85632**] in [**2113**] (CHAD2 score of 2, did not start
coumadin) - never had an echocardiogram, never had holter
- no history of coronary artery disease
Physical Exam:
On discharge
98 97.8 105 134/100 20 96% RA
AOX2
card: afib HR in 100s
pulm: CTAB
GI: abd soft
ext: edema in LLE
neuro: PERRL EOMI CN grossly intact
trunkal, and extremity weakness bilaterally, d=minimal movement
or control
minimal verbalizaion, can not hold things. sensation intact
Pertinent Results:
CT head [**5-25**]
1. Size of acute large right superior frontal intraparenchymal
hemorrhage,
and small satellite along inferolateral aspect, are increased in
size since [**16**]
hours prior. Together with surrounding edema, this causes 6 mm
leftward
subfalcine herniation of the paramedian right frontal lobe.
2. Subarachnoid hemorrhage along the right sylvian fissure, not
appreciably
changed.
3. Acute subdural hematoma is more prominent in the right
frontal and the
right parieto-occipital regions, as described above.
[**2114-5-25**] 09:20PM UREA N-20 CREAT-0.9
[**2114-5-25**] 09:14PM GLUCOSE-96 LACTATE-2.2* NA+-141 K+-4.1
CL--100 TCO2-26
[**2114-5-25**] 09:20PM URINE RBC-[**11-24**]* WBC-0 BACTERIA-OCC YEAST-NONE
EPI-0
[**2114-5-25**] 09:20PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2114-5-25**] 09:20PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.009
[**2114-5-25**] 09:20PM PT-13.1 PTT-32.6 INR(PT)-1.1
[**2114-5-25**] 09:20PM WBC-17.0* RBC-3.98* HGB-12.3* HCT-37.4*
MCV-94 MCH-30.8 MCHC-32.7 RDW-14.2
[**2114-5-25**] 09:20PM URINE HOURS-RANDOM
[**2114-5-25**] 09:20PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2114-5-25**] 09:20PM cTropnT-<0.01
[**2114-5-25**] 09:20PM LIPASE-43
[**2114-5-25**] 09:20PM UREA N-20 CREAT-0.9
[**2114-6-2**] 07:10AM BLOOD WBC-13.1* RBC-3.33* Hgb-9.9* Hct-30.9*
MCV-93 MCH-29.9 MCHC-32.1 RDW-13.7 Plt Ct-366
[**2114-6-1**] 10:40AM BLOOD WBC-16.7* RBC-3.31* Hgb-10.0* Hct-30.7*
MCV-93 MCH-30.1 MCHC-32.4 RDW-13.7 Plt Ct-341
[**2114-6-1**] 04:14AM BLOOD WBC-17.3* RBC-3.23* Hgb-9.6* Hct-29.8*
MCV-92 MCH-29.7 MCHC-32.2 RDW-13.6 Plt Ct-316
[**2114-5-31**] 07:30AM BLOOD WBC-16.2* RBC-3.97* Hgb-11.8* Hct-37.0*
MCV-93 MCH-29.8 MCHC-31.9 RDW-13.8 Plt Ct-259
[**2114-5-27**] 02:32AM BLOOD WBC-14.4* RBC-4.27* Hgb-12.8* Hct-40.0
MCV-94 MCH-30.0 MCHC-32.1 RDW-13.8 Plt Ct-234
[**2114-5-27**] 02:16AM BLOOD WBC-13.3* RBC-3.86* Hgb-11.7* Hct-36.5*
MCV-95 MCH-30.3 MCHC-32.0 RDW-13.8 Plt Ct-241
[**2114-5-26**] 04:11AM BLOOD WBC-15.0* RBC-3.76* Hgb-11.6* Hct-34.9*
MCV-93 MCH-30.7 MCHC-33.1 RDW-13.7 Plt Ct-237
[**2114-5-25**] 09:20PM BLOOD WBC-17.0* RBC-3.98* Hgb-12.3* Hct-37.4*
MCV-94 MCH-30.8 MCHC-32.7 RDW-14.2 Plt Ct-247
[**2114-5-31**] 07:30AM BLOOD PT-14.3* PTT-36.6* INR(PT)-1.2*
[**2114-6-2**] 07:10AM BLOOD Glucose-105* UreaN-15 Creat-0.6 Na-137
K-4.3 Cl-106 HCO3-26 AnGap-9
[**2114-6-1**] 04:14AM BLOOD Glucose-131* UreaN-19 Creat-0.6 Na-135
K-4.3 Cl-103 HCO3-25 AnGap-11
[**2114-5-31**] 03:41PM BLOOD Glucose-106* UreaN-17 Creat-0.7 Na-138
K-4.2 Cl-103 HCO3-24 AnGap-15
[**2114-5-31**] 07:30AM BLOOD Glucose-98 UreaN-16 Creat-0.6 Na-136
K-4.0 Cl-102 HCO3-27 AnGap-11
[**2114-5-30**] 09:10AM BLOOD Glucose-107* UreaN-17 Creat-0.8 Na-136
K-4.5 Cl-101 HCO3-26 AnGap-14
[**2114-5-27**] 02:16AM BLOOD Glucose-103* UreaN-12 Creat-0.7 Na-138
K-4.2 Cl-102 HCO3-26 AnGap-14
[**2114-5-31**] 01:00AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2114-5-30**] 06:15PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2114-6-2**] 07:10AM BLOOD Calcium-7.8* Phos-1.8* Mg-2.1
[**2114-5-31**] 03:41PM BLOOD Calcium-8.5 Phos-2.6* Mg-1.9
[**2114-5-31**] 07:30AM BLOOD Calcium-8.6 Phos-2.1* Mg-1.9
[**2114-5-30**] 09:10AM BLOOD Calcium-8.7 Phos-2.8 Mg-1.9
[**2114-5-27**] 02:32AM BLOOD Calcium-9.1 Phos-2.1* Mg-2.0
[**2114-5-25**] 09:14PM BLOOD Glucose-96 Lactate-2.2* Na-141 K-4.1
Cl-100 calHCO3-26
Brief Hospital Course:
Pt was initially admitted to the ICU. CT was done which showed R
frontal intraparenchymal hemorrhage and small R SDH.
Neurosurgery was consulted, however family declined
neurosurgical treatment. In the ICU pt was hemodynamically
stable so on [**5-27**] he was transfered to the floor. Pt was
placed on perioperative ancef. On [**2114-5-31**], pt was cleared by
the medicine team for surgery, orthopedics brought pt back for
open reduction and internal fixation with percutaneous
cephalomedullary nail, TFN, 11 x 130 x 170. Pt was stable, never
required any blood transfusions, and recovered well from
surgery. Neurosurgery indicated that he had a survivable, non
operative right frontal IPH. They recommended Please continue
with Keppra as previously advised and have the patient follow up
with Dr. [**First Name (STitle) **] four weeks after discharge from the hospital. A
CT scan of the head after the OR demonstrated stable
intraparenchymal, subarachnoid, and subdural hemorrhage as
described above with approximately 1 cm of right to left midline
shift and subfalcine herniation, not significantly changed from
the prior study. No new hemorrhage or evidence of central
herniation. Stable mild prominence of the occipital and temporal
horns of the left lateral ventricle. Pt remained stable and
recovered well from surgery. Pt was cleared by speech and
swallow for nectar thickened but not thin liquids (was not
clearning this, concern for aspiration on thins). Pts HTC
dropped to 30s but then remained stable, did not require
transfusions. On discharge pt was stable, tolerating nectar
thickened foods without sign of aspiration, vital signs stable.
Labs are notable thus far for normal renal function.
During his stay pt did have atrial fibrillation (asymptomatic).
Cardiac biomarkers were negative. EKG showed atrial fibrillation
with ventricular rate of 90s to 120 and RBBB. Pt was placed on
metoprolol 12.5 TID for rate control per medicine
recommendations. During CXRs shows LLL atalectasis, otherwise
clear without evidence of cardiomegaly or CHF or PNA. Pt
remained afebile. WBC peaked at 24 s/p trauma but then trended
back down to 13 at discharge.
Pt was otherwise stable. Pt was hemodynamically stable
throughout most of his stay without any prolonged intubation or
need for pressors.
Medications on Admission:
aspirin 81
Discharge Medications:
1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezing.
2. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
4. Levetiracetam 500 mg/5 mL Solution Sig: One (1) Intravenous
[**Hospital1 **] (2 times a day).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
R frontal intraparenchymal hemorrhage and small R SDH and Right
intertrochanteric femur fracture.
Discharge Condition:
alert and oriented to self, calm but confused s/p head trama,
minimal verbal comunications. Pt not ambulating s/p surgery.
tolerating nectar thickened diet. Vital signs stable (in afib)
Discharge Instructions:
return to the hospital if you have:
fever, chills, weakness, SOB, chest pain, decline of mental
status.
Cardiac: may resume coumadin in 3 weeks. Follow up with your
primary care within 1-2 weeks with regards to managing atrial
fibirllation. Continue on metoprolol and lisinopril as long as
SBP > 100.
pul: use inceintive spirometer
diet: puree, nectar thickened solids crushed meds only
activity: ortho - WBAT RLE
Pt will need PT and OT.
Followup Instructions:
Follow up with neurosurgery surgery Dr. [**First Name (STitle) **] in [**3-8**] weeks with
a head CT w/o contrast. Please call Takeisha at [**Telephone/Fax (1) 4296**] to
make this appointment.
Follow up with orthopedic doctor Dr. [**Last Name (STitle) 1005**] [**Telephone/Fax (1) 1228**] in
[**1-6**] weeks.
Follow up with primary care physician regarding [**Name9 (PRE) 444**] of
atrial fibrillation within the next week or two.
ICD9 Codes: 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3407
} | Medical Text: Admission Date: [**2119-8-22**] Discharge Date: [**2119-8-29**]
Date of Birth: [**2063-10-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Glucotrol
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
exertional dyspnea/ abnormal exercise stress test
Major Surgical or Invasive Procedure:
cardiac catheterization
Coronary Artery Bypass Grafting x 3 (LIMA-LAD,SVG-OM, SVG-dRCA),
Resection of left atrial appendage, Partial Maze [**2119-8-25**]
Left heart catheterization and coronary angiography [**2119-8-23**]
History of Present Illness:
This is a 55 year old male who has a history of atrial
fibrillation, hypertension, hyperlipidemia and diabetes who was
cardioverted in the spring of [**2118**] He reverted to atrial
fibrillation in [**Month (only) 216**] and has developed shortness of breath on
exertion.
He underwent a nuclear stress test on [**2119-8-14**] where he was able
to exercise 4 minutes 15 seconds on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] protocol to a peak
heart rate of 96 and stopped due to chest pain and dyspnea. He
achieved 58% of maximum predicted heart rate, the EF was 64%.
Nuclear imaging demonstrated a reversible defect but the test
was thought to be suboptimal. He underwent an echo which showed
normal biventricular size and systolic function, no valve
abnormalities, but did have moderately severe left atrial
dilatation. He was told to take his last dose of coumadin on
[**2119-8-17**] and he was found to have a creatinine of 1.9 and is
being admitted for prehydration in preparation for cath
tomorrow.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope
or presyncope. Patient does report DOE and chest tighntess with
exertion.
Past Medical History:
Cardiac Risk Factors:
Diabetes Mellitus
Dyslipidemia
Hypertension
Obesity
Other Past History:
AFIB
s/p Rhinoplasty
osteoarthritis
Social History:
Social history is significant for the absence of current tobacco
use. There is social alcohol use.
retired US Army- 20 years
Family History:
There is no family history of premature coronary artery disease
or sudden death. Mother had DM and CAD, Father had rheumatic
fever.
Physical Exam:
Alert and oriented
HEENT- unremarkable
Lungs- sl. decreased breath sounds at bases.No rales or rhonchii
Cor- SR at 80. BP 110-120/60s
Exts- 1+ leg edema. Wounds clean and dry. Venous stasis changes
pretibially- bilaterally
Wounds- cleans and dry. Sternum stable.
Pertinent Results:
[**2119-8-22**] 06:49PM PT-13.3 PTT-24.8 INR(PT)-1.1
[**2119-8-22**] 06:49PM GLUCOSE-97 UREA N-14 CREAT-1.5* SODIUM-137
POTASSIUM-4.2 CHLORIDE-99 TOTAL CO2-29 ANION GAP-13
[**2119-8-22**] 06:49PM WBC-6.6 RBC-4.44* HGB-13.2* HCT-39.4* MCV-89
MCH-29.8 MCHC-33.6 RDW-13.5
[**2119-8-22**] 06:49PM PLT COUNT-224
Brief Hospital Course:
Mr. [**Known lastname 77427**] was admitted for hydration and cardiac
catheterization. catheterization on [**8-23**] demonstrated
triple vessel disease with preserved left ventricular function.
He had venous stasis changes with mild cellulitis of the lower
legs (pretibial) and was kept in house for antibiotics and vein
mapping. Unasyn was begun for the cellulitis, which improved
somewhat preoperatively.
On [**8-25**] he went to the operating room where coronary
revascularization, a partial Maze and left atrial ligation was
performed (se operative note for details).He weaned from
cardiopulmonary bypass on Neo-Synephrine and Propofol easily. He
remained stable on transfer to the ICU and was extubated easily
on the day of surgery and pressors were weaned to off.
He was transferred to the floor on POD 2. His CTs were removed
on POD 2 and pacing wires and right leg JP drain on POD3. He was
begun on diuretics, his Statin was resumed as was his Atenolol.
He reverted to AF at a controlled rate. Coumadin was resumed for
his rhythm.
At discharge wounds are healing well, the pretibial cellulitis
has resolved and his venous stasis changes are at baseline
according to the patient. He is ambulatory and is returning home
with VNA assistance.
Medications, instructions and follow up directions have been
discussed with him. His Coumadin will be controlled by Dr.
[**Last Name (STitle) 23956**] as before hospitalization.(stopped [**8-28**])
Medications on Admission:
Metformin 1000mg [**Hospital1 **], Atenolol 50mg QD, Lisinopril 40mgQD,
Sotalol 80mgQD,HCTZ 25mgQD, Actos 30mgQD, Glyburide 10mgQD,
Zocor 40mgQD, Disalcid 500mg prn, Androgel 5mgQD, ASA 325mgQD,
Lantus insulin 26-30 units QHS
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. Pioglitazone 15 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. Sotalol 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed.
Disp:*50 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. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours).
Disp:*30 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
9. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
10. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Metformin 500 mg Tablet Sig: Two (2) Tablet PO twice a day.
Disp:*120 Tablet(s)* Refills:*2*
12. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
13. Warfarin 2.5 mg Tablet Sig: as directed Tablet PO once a
day: daily dose as directed.
Disp:*100 Tablet(s)* Refills:*2*
14. Lantus 100 unit/mL Solution Sig: 26-30 units Subcutaneous
at bedtime.
Disp:*1 * Refills:*2*
15. androgel Sig: One (1) 5 mgm Topical once a day.
Disp:*1 * Refills:*2*
16. Hydroxyzine HCl 10 mg Tablet Sig: One (1) Tablet PO every
4-6 hours as needed for itching.
Disp:*50 Tablet(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
Diversified VNA [**Location (un) 1157**]
Discharge Diagnosis:
Coronary artery disease
diabetes mellitus
obesity
atrial fibrillation
hypertension
s/p coronary artey bypass grafting, resection Left atrial
appendage,partial MAZE
hyperlididemia
Discharge Condition:
good
Discharge Instructions:
No driving for 4 weeks and off all narcotics
No lifting more than 10 pounds for 10 weeks
Shower daily, no baths or swimming
no lotions, creams or powders to incisions
take all medications as prescribed
report any drainage from or redness of incisions
report any temperature greater than 101
Followup Instructions:
Dr. [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr.[**Last Name (STitle) 23956**] in [**1-8**] weeks
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 25270**] in [**1-8**] weeks
Completed by:[**2119-8-29**]
ICD9 Codes: 4019, 5859, 2724, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3408
} | Medical Text: Admission Date: [**2179-10-1**] Discharge Date: [**2179-10-12**]
Service: CSU
CHIEF COMPLAINT: Transfer from an outside hospital after
complaint of chest pain.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 57456**] is an 84-year-old
man with a history of PVD symptomatic by claudication
diagnosed 10 years ago and noticed over the past several days
to have a decreased walking ability. The patient is a former
smoker, quit 30 years ago. Last week the patient was golfing
and noticed substernal crushing chest pain radiating to his
arms and jaws. Also, 3-4 days prior to admission, the patient
noted dysuria and urinary frequency at night. The patient's
claudication is described as calf pain. He also has
dependent posturing pain. He was admitted to [**Hospital6 3426**] on the [**10-26**] and had an MRI with cardiac
catheterization done on the day of transfer that showed 50
percent left main and 80 percent LAD and 35 percent
circumflex with a 100 percent RCA lesion.
PAST MEDICAL HISTORY: Patient's past medical history is
significant for PVD, COPD and skin CA.
MEDICATIONS: Prior to admission include aspirin.
SOCIAL HISTORY: Former smoker. Occasional alcohol use.
FAMILY HISTORY: Father dies of a brain tumor. Mother died
of diabetes complications.
ALLERGIES: The patient states an allergy to penicillin.
PHYSICAL EXAM AT THE TIME OF ADMISSION: Vital signs:
Temperature 96.6, heart rate 102, blood pressure 138/70,
respiratory rate 30, O2 sat 93 percent on 4 liters. General:
The patient lying in bed in no acute distress. HEENT:
Pupils equally round and reactive to light. Extraocular
movements and clear OPs clear. Neck is supple with no
lymphadenopathy. Positive carotid bruits. Chest is clear to
auscultation bilaterally. Irregular rate and rhythm. Lungs
are clear. Abdomen is soft, nontender, nondistended.
Extremities with no clubbing, cyanosis or edema. Pulses:
Carotid two plus with a bruit bilaterally. Femoral two plus
with a bruit bilaterally. Dorsalis pedis dopplerable and
posterior tibial monomorphic.
LAB DATA: White count 12.3, hematocrit 38.9, platelets 528,
PT 14.4, PTT 41.3, INR 1.3, sodium 136, potassium 4.3,
chloride 97, CO2 of 28, BUN 33, creatinine 1.1, glucose 323.
Chest x-ray shows congestive heart failure. EKG shows A-fib
with frequent PVCs. nonspecific ST changes.
HOSPITAL COURSE: A Urology consult was obtained prior to
surgery as the patient reported prostatitis. The Urology
service dilated the meatus with up to 16 French and placed a
12 French Foley. On [**10-2**], the patient was brought to
the operating room for coronary artery bypass grafting.
Please see the OR report for full details. In summary, the
patient has CABG times three with the LIMA to the LAD,
saphenous vein graft to PDA and saphenous vein graft to OM.
His bypass time was 68 minutes with a cross-clamp time of 46
minutes. He tolerated the operation well, was transferred
from the operating room to the Cardiothoracic Intensive Care
Unit. At the time of transfer, the patient's rate was 89
beats per minute. He had a mean arterial pressure of 78 with
a CVP of 8.0. He had propofol at 20 mcg/kg/min, epinephrine
at 0.03 mcg/kg/min and lidocaine at 2 mg per minute.
In the immediate postoperative period, the patient had a low
cardiac index and was therefore begun on a milrinone infusion
following which the patient improved hemodynamically. He
remained intubated throughout the evening of his operative
day.
On postoperative day one, his sedation was weaned. He was
weaned from the ventilator and attempts at extubation caused
some hypoxia following which a pulmonary consult was
obtained. Pulmonary's recommendation was to begin on IV
steroids, to decrease his PEEP and FIO2 as tolerated.
Postoperative day two, the patient was hemodynamically
stable. His blood gases had improved dramatically. His PEEP
was weaned as was his of FIO2 and he was successfully
extubated. Following extubation, the patient was awake, alert
and oriented, following commands and moving all extremities.
His speech was clear.
While the patient was having a conversation with the
pulmonary service, he became unresponsive, not withdrawing to
painful stimuli. Also noted to be pursed-lip breathing.
Pupils were equal and reactive at that time. He was
immediately seen by the neurology service and was transported
to MRI for scanning. MRI revealed a small stroke. The
neurology service is aware and they are also questioning
whether the patient had seizure activity and was postictal,
this being the reason for his unresponsiveness. By the time
the patient returned from MRI, he was again alert, responsive
and moving all extremities. Additionally, the patient was
noted to have some periods of atrial fibrillation during
postoperative day two for which an amiodarone infusion was
begun. Following his neurological event, the patient was
begun on heparin and Coumadin as well and was discontinued.
For the next several days, the patient was monitored in the
Cardiothoracic Intensive Care Unit.
On postoperative day six, the patient was ultimately
transferred from the CSRU to 520 for continuing postoperative
care and cardiac rehabilitation. Once on the floor, the
patient had an uneventful hospitalization. His activity level
was advanced with the assistance of the nursing staff and
physical therapy. His medication regime was refined and on
postoperative day nine, it was decided that the patient was
stable and ready to be discharged to rehabilitation. At the
time of this dictation, the patient's physical exam is as
follows. Vital signs: Temperature 97.4, heart rate 84,
sinus rhythm, blood pressure 129/44, respiratory rate 20, O2
sat 93 percent on room air, weight preoperatively 97.7 kg, at
discharge 98.1 kg.
LABORATORY DATA: White count 16, hematocrit 32, platelets
360, PT 16.1, INR 1.6, sodium 141, potassium 4.3, chloride
103, CO2 of 22, BUN 44, creatinine 1.4.
PHYSICAL EXAM: Neuro: Alert and oriented times three, moves
all extremities, follows commands. Respiratory: Clear to
auscultation bilaterally. Cardiovascular: Regular rate and
rhythm, S1 and S2. Sternum is stable. Incision with Steri-
Strips open to air, clean and dry. Abdomen: Soft,
nontender, nondistended with positive bowel sounds.
Extremities are warm and well-perfused with one plus edema
bilaterally. Left leg saphenous vein graft harvest site with
Steri-Strips open to air, clean and dry.
CONDITION ON DISCHARGE: Good.
DISCHARGE DIAGNOSES: CAD status post coronary artery bypass
grafting times three with the LIMA to the LAD, saphenous vein
graft to the PDA and saphenous vein graft to the OM.
PVD.
Skin CA.
COPD.
DISPOSITION: The patient is to be discharged to rehab.
FOLLOW UP: He is to have follow-up with Dr. [**Last Name (STitle) 13175**] and 3-4
weeks, follow-up with Dr. [**Last Name (STitle) 36737**] in 4 weeks, follow-up with
Dr. [**Last Name (STitle) 32467**] in [**2-16**] weeks following his discharge from
rehabilitation and follow-up with Dr. [**Last Name (STitle) **] in [**4-20**] weeks.
DISCHARGE MEDICATIONS:
1. Colace 100 mg b.i.d.
2. Aspirin 81 mg once daily.
3. Coumadin, take as directed with a goal INR of [**2-16**].
Patient's last 4 days of Coumadin dosing have been 5, 5,
2, 5.
4. Additionally, the patient is to receive Percocet 5/325, 1-
2 tablets q. 4 hours p.r.n.
5. Albuterol MDI 2 puffs q 4 hours.
6. Keppra 1 gram b.i.d.
7. Pantoprazole 40 mg once daily.
8. Diltiazem extended release 240 mg once daily.
9. Lasix 20 mg once daily.
10. Potassium chloride 20 mEq once daily.
11.
Amiodarone 400 mg b.i.d. times one week, then 400 mg once
daily times one week, then 200 mg once daily.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**]
Dictated By:[**Last Name (NamePattern4) 1718**]
MEDQUIST36
D: [**2179-10-11**] 20:59:45
T: [**2179-10-12**] 14:15:31
Job#: [**Job Number 57457**]
ICD9 Codes: 4280, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3409
} | Medical Text: Admission Date: [**2136-2-8**] Discharge Date: [**2136-2-24**]
Date of Birth: [**2077-2-19**] Sex: F
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: This is a 59-year-old female
with a past medical history significant for type 2 diabetes
mellitus with diabetic neuropathy, hypertension,
hypercholesterolemia, low TSH, obesity, claudication, and a
bulging lumbar disk causing leg numbness.
PAST SURGICAL HISTORY:
1. Hysterectomy.
2. Tonsillectomy.
SOCIAL HISTORY: Patient is a smoker, smoking one pack per
week, drinking socially.
MEDICATIONS ON ADMISSION:
1. Aspirin 81 mg q day.
2. Toprol XL 100 mg [**Hospital1 **].
3. Imdur 60 mg q day.
4. Pletal 100 mg [**Hospital1 **].
5. Univasc 15 mg q day.
6. Prozac 40 mg q day.
7. Insulin NPH 40 [**Hospital1 **].
8. Insulin regular sliding scale.
9. Neurontin 600 mg q hs.
10. Zanaflex two [**Hospital1 **].
11. Lipitor 10 mg q day.
This is a 59-year-old female with known coronary artery
disease who is referred to [**Hospital1 188**] for an outpatient cardiac catheterization due to
increased exertional anginal symptoms. Over the past year,
the patient had been complaining of progressive angina
described as tightness of the left side of her chest with
left arm and shoulder discomfort, which was sometimes
accompanied by diaphoresis, nausea, and shortness of breath.
She also has a history of bilateral claudication of her legs
after walking about a half a block with her left greater than
right, being followed by Dr. [**Last Name (STitle) **].
Cardiac catheterization was performed which revealed left
main with 40% stenosis, right coronary artery with 80%
stenosis, posterior descending artery 80% stenosis, left
anterior descending artery 70% stenosis, circumflex with 80%
stenosis with an ejection fraction of 70% with no valvular
disease. The patient was subsequently referred for coronary
artery bypass grafting.
Patient underwent coronary artery bypass grafting x3 [**2136-2-20**] with a left internal mammary artery to the left
anterior descending artery, saphenous vein graft to the
posterior descending artery, and saphenous vein graft to the
obtuse marginal. Total cardiopulmonary bypass time was 123
minutes, total cross-clamp time was 49 minutes. The patient
was transferred in stable condition in normal sinus rhythm at
81 beats per minute on propofol at 10, insulin drip at 2, and
Neo-Synephrine at 0.7 mcg/kg/min.
Postoperative day one, 24 hour events included the patient
being extubated without event and a right chest tube being
placed at the bedside for a right pleural effusion. Patient
still on a Neo-Synephrine drip at 0.25, sinus tachycardic at
100 beats per minute, blood pressure stable, CVP 12. White
count of 16.3, hematocrit of 28.5, and a platelet count of
200. BUN of 15, creatinine of 0.5 and a glucose of 109.
Patient was transferred to the floor that same day
postoperative day one.
Postoperative day two, no significant events over the last 24
hours. The patient's right pleural chest tube was placed on
suction and then was later discontinued, with the mediastinal
chest tube still placed on suction, on physical examination,
the patient's lungs had coarse breath sounds bilaterally.
The patient was encouraged to use her incentive spirometer.
Her Foley was discontinued. Patient remained with a low
grade temperature of 99.8. Vital signs otherwise stable with
continued complaints of pain which was treated with Vicodin
and ibuprofen with good effect.
Postoperative day three, no 24 hour events of note with
patient's pain improving after administration of Neurontin.
Still had a low grade temperature at 99.7. Vital signs
stable otherwise, sating at 92% on room air. Physical
examination: Patient with 2+ edema of the lower extremities.
Plan for the patient is to possibly discontinue the patient's
chest tube, to get the patient out of bed with Physical
Therapy.
Postoperative day four, patient was discharged. Physical
examination was unremarkable, aside from the patient's 1+
pedal edema. Twenty-four hour events included transfusion of
1 unit of packed red blood cells for a hematocrit of 23
yesterday, [**2-23**]. The patient was discharged home in
good condition.
DISCHARGE MEDICATIONS:
1. Lopressor 25 mg [**Hospital1 **].
2. Lasix 20 mg [**Hospital1 **] for seven days.
3. Potassium chloride 20 mEq [**Hospital1 **] for seven days.
4. Colace 100 mg [**Hospital1 **].
5. Aspirin 325 mg q day.
6. Fluoxetine 40 mg po q day.
7. Lipitor 10 mg q day.
8. Vicodin 5/500 1-2 tablets po q4h prn pain.
9. Neurontin 600 mg [**Hospital1 **].
DISCHARGE INSTRUCTIONS: Followup with her cardiologist in
[**1-19**] weeks, and follow up with Dr. [**Last Name (STitle) 70**] in [**4-22**] weeks.
DISCHARGE DIAGNOSIS: Coronary artery disease status post
coronary artery bypass grafting x3.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Doctor Last Name 2011**]
MEDQUIST36
D: [**2136-4-3**] 14:39
T: [**2136-4-4**] 06:41
JOB#: [**Job Number 16250**]
ICD9 Codes: 5119, 3572 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3410
} | Medical Text: Admission Date: [**2136-9-6**] Discharge Date: [**2136-9-26**]
Date of Birth: [**2070-11-1**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 10293**]
Chief Complaint:
transfer for TIPS evaluation
Major Surgical or Invasive Procedure:
L thoracentesis
History of Present Illness:
The patient is a 65 yo male with ETOH cirrhosis, portal HTN, UGI
bleeding, CHF, COPD and hypertrophic cardiomyopathy, hepatic
hydrothorax s/p CT placement for [**Hospital 73974**] transfered from an OSH on
[**2136-9-6**] for TIPS. Patient was initially admitted [**8-18**] at an OSH
for hematemesis and found to have a bleeding ulcer that was
cauterized per Endoscopy. He subsequently developed SOB and
notable plueral effusions. He was treated with steroids,
prednisone 60mg daily with a taper, and a course of
levofloxacin. He underwent a thoracentesis c/b R sided PTX
requiring chest tube placement at OSH, which persistently
drained ~1L fluid/day. During that admission he did receive 4
units of PRBC. His BP notable for range 80s-90s with difficulty
continuing BB for hypertrophic cardiomyopathy due to
persistently low SBP. Cardiology followed pt and rec continuing
low dose nadolol and aldactone. He was transferred to [**Hospital1 18**] on
[**9-6**] for possible TIPS due to persistent Chest tube output
related to hepatic hydrothorax.
.
The patient was originally admitted to the medicine floor and
was evaluated by hepatology who decided he cannot undergo TIPS
due to mod pulmonary hypertension with PA pressure 47 mmHg, also
found mod to severe AS, mild AR and TR, mild to mod MR, and may
require pleuridesis. He triggerred 3 times on the floor for
persistent tachypnea, O2 Sats stable as well as for low BP in
the 80s, despite baseline SBP 80s-90s. He had low grade temps,
with plueral fluid growing GPC in pairs and clusters with Urine
growing coag neg staph. He did not receive any Abx on the floor.
Was transferred to MICU on [**2136-9-10**] for tachypnea and "nursing
concern".
.
While in the ICU, cultures from the OSH pleural fluid (right
side) grew MRSA and felt to be consistent with an empyema. He
was started on Vancomycin and Zosyn. He continued to spike
fevers. Blood and Urine also then grew out MRSA. The Zosyn was
d/c'd on [**9-11**]. He was continually note to have a large left
pleural effusion and there was concern that it was also
infected. On [**2136-9-11**] he had a left thoracentesis that drained
1400cc (non-purulent). He was transferred back to the floor
after respiratory status stabilized.
Past Medical History:
1. EtOH cirrhosis- c/b hepatic encephalopathy, esophageal
varices, new dx hepatic hydrothorax
2. Hypertrophic cardiomyopathy- EF >75% on [**9-7**] TTE
3. Aortic stenosis- AoVA 0.8cm2 on [**9-7**] TTE
4. Mitral regurgitation- 2+ on [**9-7**] TTE
5. COPD- denies tobacco hx but uses Combivent as outpt
6. ETOH Abuse- active
7. Psoriasis
Social History:
lives with girlfriend at home. non-smoker. no ETOH x 1 month
Family History:
non-contributory
Physical Exam:
PHYSICAL EXAM:
Vitals: T 100.6 BP 146/80 HR 96 RR 18 O2 95%RA
Gen: ill appearing obese male, laying in bed, NAD, comfortable
HEENT: MMM, JVD approx 6 cm. no LAD
Cardio: RRR, 3/6 systolic, holosystolic murmur. no thrills.
Resp: Decreased BS Bilateral bases, few scattered crackles. no
wheezes, no rhonci. Right sided chest tube in place, dressings
intact, no SOI
Abd: soft, obese, NT. dullness to percussion RLQ.
Ext: [**2-25**]+ BLE edema. + Asterixisis BUE
Neuro: AxO x 3
Pertinent Results:
LABORATORY RESULTS:
Micro:
[**2136-9-15**] Pleural Fluid (Right) - MRSA
[**2136-9-15**] Blood: negative
[**2136-9-13**] Pleural Fluid (right) - MRSA
[**2136-9-13**] blood - negative
[**2136-9-12**] Blood - negative
[**2136-9-11**] Pleural (Left) - no growth
[**2136-9-10**] Urine - no growth
[**2136-9-10**] Catether Tip - no significant growth
[**2136-9-9**] Urine - coag negative staph
[**2136-9-9**] Blood - [**2-28**] coag negative Staph
[**2136-9-9**] Pleural (Right) - coag + staph (MRSA)
[**2136-9-7**] Blood - negative
[**2136-9-7**] Urine - coag negative staph
[**2136-9-6**] Urine - coag negative staph
IMAGING:
[**9-7**] US of liver w/ doppler: The main portal vein is patent and
there is no evidence of cavernous transformation. The right
middle and left hepatic veins are also patent. There is no
perihepatic ascites. The pancreas and abdominal aorta are not
visualized. The spleen is borderline enlarged at 12.9 cm. The
gallbladder is not visualized.
The left kidney measures 12.7 cm in length and contains a 6.9 x
4.4 x 4.9 cm simple appearing exophytic cyst in the interpolar
region. The right kidney measures 12.4 cm in length. There is no
evidence of hydronephrosis in either kidney.
.
[**9-7**] ECHO: 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 left
ventricular outflow obstruction at rest or with Valsalva. There
is no ventricular septal defect. Right ventricular chamber size
and free wall motion are normal. The number of aortic valve
leaflets cannot be determined. The aortic valve leaflets are
mildly thickened. There is moderate to severe aortic valve
stenosis (area 0.8 cm2). Mild (1+) aortic regurgitation is seen.
[Due to acoustic shadowing, the severity of aortic regurgitation
may be significantly UNDERestimated.] The mitral valve leaflets
are mildly thickened. There is moderate thickening of the mitral
valve chordae. There is a minimally increased gradient
consistent with trivial mitral stenosis. Mild to moderate ([**1-24**]+)
mitral regurgitation is seen. [Due to acoustic shadowing, the
severity of mitral regurgitation may be significantly
UNDERestimated.] The tricuspid valve leaflets are mildly
thickened. There is moderate pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion. PASP 45mmHG.
.
[**9-9**] CXR: Similar to earlier CXR with Stable right pleural
effusion. Stable retrocardiac opacity likely reflects underlying
small- to moderate-sized pleural effusion with atelectasis,
difficult to exclude pneumonia.
.
[**2136-9-10**] LENI - No DVT identified in the left lower extremity.
.
[**2136-9-14**] Abd US: IMPRESSION:
1. Limited Doppler examination, but unobtainable flow in the
portal vein with hepatic arterialization suggests very low flow
within the portal system or possibly occlusion.
2. Bilateral pleural effusions.
3. Cirrhosis, trace fluid about the liver, and splenomegaly.
Brief Hospital Course:
A/P: 65 yo male with ETOH cirrhosis, dCHF, AS, initially
transferred from OSH with UGIB and hepatic hydrothorax s/p
thoracentesis c/b PTX with chest tube in place, for TIPS. Went
to MICU for respiratory distress and hypotension, found to have
a MRSA empyema and MRSE bacteremia.
.
.
# Cirrhosis: The patient has a history of EtOH cirrhosis c/b
hepatic encephalopathy in past presenting with hepatic
hydrothorax. He was initially transferred for TIPS procedure,
but he was not a suitable candidate due to comorbidities of
pulmonary HTN and severe AS. He was maintained on lactulose,
nadolol, diuretics, and MVIs for medical management of his liver
disease while in-house.
.
# Empyema: patient with empyema (growing MRSA) on right, with
chest tube in place to water seal. He was also treated with
thoracentesis x 2 on the left: both times large output (>1L),
transudative on labs, with gram stain showing no organisms. The
MRSA empyema was treated with vancomycin in house; however,
there was little clinical improvement on this medication.
Thoracic surgery consultatation recommended that no surgical
intervention (i.e. VATS) was possible. Interventional
pulmonology was able to place a Pleurex catheter to R sided
empyema with much output during hospital course. This was
ultimatey discontinued when the patient's clinical status failed
to improve and he was treated with comfort measures.
.
# Bacteremia/UTI: On admission blood and urine grew coag
negative staph. treated with vancomycin. Subsequent cultures
([**9-13**] onwards) yielded no growth.
.
# ARF: During hospital course the patient's renal function
continued to decline with increasing creatinine, oliguria, then
anuria. Decline in renal function appeared to be of prerenal
etiology based on clinical state and urine electrolytes, likely
HRS as the prerenal failure was not responsive to fluids or
albumin. Diuretics were held and midodrine/octreotide/albumin
triple therapy for empiric HRS treatment were started without
significant improvement in the patient's renal function. As per
the patient's wishes and the patient's poor prognosis since he
would not be a liver transplant candidate, the team and patient
opted against pursuing HD.
.
# CV: The patient had known hypertrophic cardiomyopathy and was
found to have severe AS (AoVA 0.8cm2) and moderate MR.
Clinically he appeared total body fluid overloaded secondary to
hypoalbuminemic state. He was continued on nadolol to increase
LV filling time for AS, with careful holding parameters.
Diuresis was avoided to prevent decreased forward flow.
.
# COPD: The patient was maintained on ipratropium nebs and
albuterol nebs for comfort.
.
During hospital course the patient's clinical status began to
deteriorate (declining renal function, persistent empyema,
increasing encephalopathy, and end-stage liver disease without
possible further surgical intervention; see below for further
discussion). The patient had expressed wishes to be DNR/DNI
during his hospital course. In collaboration with the patient's
family, it was decided not to pursue aggressive care, including
dialysis, as the patient had evidence of multi-system failure
and no option for transplant. The team and family chose to
pursue comfort measures with input from palliative care. On
[**2136-9-26**], the patient expired secondary to cardiopulmonary arrest.
The family was notified and chose not to pursue a postmortem
exam.
Medications on Admission:
Vitamin B1 (thiamine) 100 mg PO daily
Folic Acid 1 mg Po daily
MVI 1 tablet PO daily
Levaquin 500 mg PO daily
Combivent 2 puffs q4H
Zocor 40 mg PO daily
Protonox 40 mg PO daily
Lactulose 30 mL PO q6H
Nadolol 10 mg PO daily
Aldoactone 12.5 mg PO daily
Ativan 0.5 mg PO q6H PRN anxiety
Restoril 7.5 mg PO QHSPRN insomnia
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary Diagnosis: Alcoholic Liver Cirrhosis
Discharge Condition:
Expired.
Discharge Instructions:
none
Followup Instructions:
none
ICD9 Codes: 7907, 5990, 496, 5849, 2761, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3411
} | Medical Text: Admission Date: [**2177-9-27**] Discharge Date: [**2177-10-18**]
Date of Birth: [**2137-9-14**] Sex: F
Service: MICU
This is a 40-year-old woman with a history of HIV/AIDS, last
CD4 count of 460 in [**2177-7-3**], hypoparathyroidism,
hypopituitarism, prior CNS toxo with resulting seizure
disorder, who presents with chief complaint of diarrhea,
nausea, vomiting, dry cough, and progressive fatigue.
The patient first presented to her primary care physician two
days prior with chief complaint of headache, at which point
the patient refused to go to the Emergency Department. She
then presented to the Emergency Department on the day of
admission given progressive worsening of her symptoms over
the past two weeks. Decreased po intake x2 days. Positive
shortness of breath. No chest pain, no bloody stool, or
Recently discharged from [**Hospital1 **] [**9-9**] for admission with
nausea, vomiting, fever, chills, ulcerative skin lesions
which were positive for methicillin-resistant Staphylococcus
aureus and HSV. The patient had hypotension which was felt
to be secondary to her Addison's disease and was improved
with steroids. The patient was also treated with Augmentin,
Valtrex, Diflucan, and sent home on a prednisone taper.
In the Emergency Department, temperature 102.2, heart rate
110, blood pressure 100/50, respiratory rate 35, and O2 sat
of 66% on room air, which increased on 100% on face mask.
The patient was lethargic. Positive abdominal pain on
examination. CT scan was deferred secondary to patient's
inability to tolerate po contrast and nasogastric tube.
A chest x-ray showed diffuse alveolar infiltrates. ID was
consulted and the patient was given Bactrim 250 mg IV,
Levaquin 500 mg IV, Vancomycin 1 gram IV. The patient had
central line and Foley placed in the Emergency Department and
was transferred to the MICU.
Upon presentation to the floor, the patient continued to be
lethargic. Denies any pain.
PAST MEDICAL HISTORY:
1. Human immunodeficiency virus with CD4 count of 460 on
[**2177-7-3**], question of HIV or to HTLV variant with
opportunistic infections not relating to CD4 count.
2. Central nervous system toxoplasma unconfirmed on brain
biopsy in [**2170**], history of seizure disorder since [**2171**] with
last seizure greater than six months ago. Prior history of
tuberculosis, status post INH therapy.
3. ARDS secondary to Pneumonococcal sepsis.
4. History of methicillin-resistant Staphylococcus aureus
decubitus ulcers.
5. Chronic dermatitis and hyperpigmentation.
6. HPV and CIN-1 on endometrial curettage.
7. HSV-2 positive swab on [**9-3**], history of
disseminated HSV.
8. [**First Name5 (NamePattern1) 564**] [**Last Name (NamePattern1) 9293**] and esophageal ([**3-3**] by
esophagogastroduodenoscopy).
9. Recurrent otitis media.
10. Premature ovarian failure at the age of 38.
11. History of hypoparathyroidism with decreased calcium and
decreased PTH.
12. Questionable Addison's.
13. Questionable panhypopituitarism with empty sella turcica
on [**5-4**] on MRI and very small pituitaries seen.
14. Hypothyroidism.
15. History of L1 compression fracture.
16. Cesarean section 14 years ago.
ALLERGIES: The patient has an allergy to penicillin,
documented allergy of sulfa, although patient has been able
to tolerate Bactrim.
MEDICATIONS ON ADMISSION:
1. Zoloft 100 q day.
2. Clindamycin 300 tid.
3. [**Month (only) 9294**] 300 [**Hospital1 **].
4. Prilosec 20 mg q day.
5. Dilantin 400 qod.
6. Prednisone 5 q day.
7. Peramethamine 50 mg q day.
8. Leucovorin 10 mg q day.
9. .................... cream 2.4 grams topical [**Hospital1 **].
10. Cephalexin 250 mg qid.
11. Calcium carbonate 500 mg [**Hospital1 **].
12. Synthroid 25 mcg q day.
13. Stavudine 40 mg [**Hospital1 **].
14. Lamivudine 150 mg [**Hospital1 **].
15. Nelfinavir 1250 mg po bid.
16. Zinc sulfate 220 mg q day.
Noted, that there was a question of medical noncompliance
given that her Dilantin level was found to be subtherapeutic
on admission.
SOCIAL HISTORY: No tobacco, no alcohol, and no IV drug use,
lives with her husband and 14-year-old daughter. [**Name (NI) **] a
visiting nurse. Immigrated from [**Country 2045**] 15 years ago.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: Temperature 102.2, pulse 110,
respiratory rate 35, blood pressure 100/50. Sating at 100%
on face mask. In general, this is a lethargic woman, who
does not appear to be in acute distress. HEENT: Pupils are
equal and reactive. Extraocular muscles are intact. No
scleral icterus. Mucous membranes dry, no thrush or
oropharynx ulcers. Neck is supple with no lymphadenopathy.
No jugular venous distention. Chest: Bronchial breath
sounds, positive egophony at the right base, positive
bibasilar crackles. Cardiovascular: Tachycardic.
Gastrointestinal: Abdomen is soft and nontender, epigastric
left upper quadrant tenderness, positive bowel sounds, status
post C section with abdominal scar midline. Extremities: No
edema. Distal pulses 2+. Skin has sacral decubitus
ulceration in between the buttocks and hyperpigmented skin
changes. Neurologic grossly intact.
LABORATORIES UPON PRESENTATION: Her white blood cell count
is 9.9, hematocrit is 30.7, platelets 286. Differential: 38
neutrophils, 1 band, 49 lymphocytes. Sodium 129, potassium
2.9, chloride 97, bicarb 19, BUN 8, creatinine 0.8, glucose
105. ALT 79, AST 181, LDH 1233, amylase 46, total bilirubin
is 0.8, lipase 17, protein 8.1, CK of 103, albumin 3.5,
globulin 4.6.
Arterial blood gas: 7.36, 35, 64.
Electrocardiogram: Normal sinus, tachycardia at 107, normal
axis, and normal intervals, left atrial enlargement, T-wave
inversion in lead III.
Chest x-ray with diffuse infiltrates.
HOSPITAL COURSE BY ORGAN SYSTEM:
1. Pulmonary: The source of the patient's diffuse alveolar
infiltrates with resulting hypoxia was unclear. The patient
was started empirically on Levaquin for community acquired
pneumonia, Bactrim for possible PCP, [**Name10 (NameIs) **] for
disseminated HSV. The patient had [**Name10 (NameIs) **] evaluated for PCP,
[**Name10 (NameIs) 9277**] bacilli, fungal and bacterial cultures. She was
maintained on mask ventilation for one day, but then had
increasing hypoxia and at that point was intubated.
Bronchial lavage was done with sample sent for evaluation.
Patient's [**Name10 (NameIs) **] and BAL were negative for PCP. [**Name10 (NameIs) **] was
negative for tuberculosis. BAL was repeated with again a
negative PCP [**Name Initial (PRE) 9295**]. At that point, CT Surgery was
consulted for a VATS for tissue diagnosis. CT Surgery
evaluation recommended open lung biopsy.
The patient had a self extubation episode and Anesthesia was
called, and an ET tube was placed without difficulty.
Patient's lung biopsy was held secondary to acute
decompensation. The patient was resisting the vent with
increasing respiratory rate and breath stacking, and
development of worsened hypercarbic respiratory acidemia.
Patient was changed from her pressure support ventilation to
pressure controlled
ventilation and eventually assist controlled volume
ventilation. She had increasing sedation, was proned which
was unsuccessful, and eventually required paralytics in order
to obtain compliance with ventilation.
Given the patient's high peak inspiratory and plateau
pressures, the patient had esophageal balloon monitoring
which indicated the peak transpulmonary pressure was 35 and
the end expiratory transpulmonary pressure was 4. The
patient's paralytics were discontinued after a 24 hour period
secondary to concern of neuromyopathy with prolonged
paralytics given the patient on standing steroids.
The patient at that point had increasing dyssynchrony with
the vent with desaturation requiring increasing sedation.
The patient was maintained on a respiratory rate of 35, a
trial to decrease the respiratory rate was attempted, but
patient had worsened breath stacking.
A trial of changing of pressure control from volume control
ventilation to pressure control failed secondary to increasing
difficulty in ventilation. Redevelopment of increasing pCO2 with
acidemia. The patient
was at that point changed back to volume controlled
ventilation. Vecuronium was started to attempt better
oxygenation and ventilation.
Patient at that point was noted to have decreased breath
stacking, but increase in her peak inspiratory pressure and
plateau. Transesophageal balloon done at that time showed
that her transpulmonary pressures were between 28 and 30. At
that point it was felt that the paralytic drip did not offer
significant benefit, and the patient was not initiated on
paralytics. She was continued on heavy sedation.
Her sedation was then weaned in an effort to try to decrease
the amount of support provided by her ventilator setting. By
the time of this dictation, patient had been weaned to assist
controlled tidal volume of 400 with respiratory rate of 35, a
PEEP of 10 (maximum 20), FIO2 of 50%. Given that the patient
has been intubated for nearly three weeks, the issue of
trache was discussed with Interventional Pulmonary as well as
the patient's family. Patient has begun evaluation for
trache and if does not improve rapidly, will receive trache
in the following week.
2. Infectious Disease: Despite extensive workup for
infectious etiology of pulmonary infiltrate including
negative [**Name Initial (PRE) **] cultures for bacteria and fungal, negative
PCP, [**Name10 (NameIs) 5963**] AFB, negative cryptococcal antigen, negative
CMV antigenemia x2, negative Histoplasma, negative
Legionella, negative toxoplasma IgM, negative rapid viral
panel including influenza and parainfluenza.
The patient was on the following antibiotics: Levaquin for a
three week course, Bactrim for a three week course,
[**Name10 (NameIs) **], clindamycin, and Vancomycin for a two week course,
started on imipenem on the second hospital week. When the
patient had a temperature spike despite her broad antibiotic
coverage, at that point antifungal medication was empirically
started.
Patient was inappropriately given amphotericin rather than
Ambisome, which presumably contributed to subsequent acute renal
failure. The antifungal at that point was held, and patient was
later restarted on Ambisome. Patient developed positive
methicillin-resistant
Staphylococcus aureus in her [**Name10 (NameIs) **] nearly three weeks into
her hospital course. She was restarted on her Vancomycin.
Patient originally presented with complaints of headache and
abdominal pain. For this, Infectious Disease consult
recommended that the patient have a lumbar puncture and head
CT scan.
The head CT scan was was negative for any change.
The lumbar puncture was deferred secondary to patient's
tenuous clinical status, as well as resolution of headache
upon presentation to the floor. For patient's abdominal
symptoms, they also resolved immediately upon presentation to
the floor, with a negative abdominal examination.
The patient had stool cultures sent which were negative.
Strongyloides negative, celiac sprue laboratories with
antigliadin antibody was negative. The patient was scheduled
for an abdominal CT scan, but unable to tolerate contrast and
felt to be too unstable to go to the Radiology Suite.
She had a right upper quadrant ultrasound done at the bedside
when she spiked a temperature, which showed findings
consistent with a gangrenous gallbladder, no gallstones. At
this point, Surgery and IR were consulted for possible
cholecystectomy/percutaneous drainage. Patient was felt not
to be a surgical candidate.
IR felt that given the ultrasound without a CT scan to
evaluate for necrotic wall, the risks were very high for
percutaneous drainage at that time. Patient was just
continued on antibiotics with imipenem to cover for potential
organisms.
A repeat right upper quadrant ultrasound done several days
later showed interval improvement in her gallbladder.
Radiology was again consulted, and their interpretation at
this point was that the patient did not require drainage if
she continued to improve.
In summary, at the time of this dictation, had no positive
blood cultures, methicillin-resistant Staphylococcus aureus
in [**Name10 (NameIs) **], negative fungal culture, negative BAL cultures,
negative Mycoplasma IgG, negative wound cultures from the
right femoral central line, possible contamination with the
right IJ tip showing mixed bacterial types. Left A line was
no growth.
3. Cardiovascular: The patient had hypotension upon initial
presentation. She was given fluid boluses with minimal
improvement. The patient was started on Neo-Synephrine. The
patient has a history of chronic hypertension requiring
steroids. Stress dosed steroids at that point were started,
and the patient's pressors were weaned to off.
Again in her hospital course, the patient became hypotensive
requiring Levophed. This was also eventually weaned to off.
The patient then was again started on Levophed with the goal
of increasing her mean arterial pressures a little bit higher
in order to increase forward perfusion, and allow aggressive
diuresis, and increasing narcotic sedation.
Patient was started on vasopressin and Levophed was weaned to
off. The patient was then started on Dopamine and the
vasopressin was weaned off. At the time of this dictation,
her dopamine dose is at 2 mcg/hour and her mean arterial
pressure is ranging in the 80s.
4. Renal: Patient had acute renal failure developing likely
secondary to inappropriate dosaging of amphotericin as well
as hypotension. The patient maintained with good urine
output, however. Renal was consulted. The patient's
creatinine reached a high of 3.9. She had complicating
hyperkalemia for which she was aggressively treated with
development of hypokalemia.
Patient's creatinine appeared to improve, question of whether
it was assisted by the liposomal component of the Ambisome.
Patient had very large fluid overload secondary to obligate
intravenous fluids and drips. She was at that point
aggressively diuresed.
Her creatinine has been trending down with the last value at
2.9. Her BUN, however, continues to rise with her last value
at 148. Her phosphate is also elevated at 7.5. Renal has
been following closely in order to evaluate for any necessary
dialysis in order to remove volume. All of her medications
have been renally dosed.
The patient has hypernatremia with a sodium at 149 at the
time of this dictation for which she is being repleted with
1.5 liters of D5W.
5. GI: The patient had development of acalculous
cholecystitis as described above in ID. The patient also has
issues of ileus with no significant bowel movement at the
time of this dictation from admission. The ileus was felt to
be secondary to the large volume of narcotics required in
order to maintain compliance with ventilation.
In addition, to the acalculous cholecystitis, the patient has
her OG tube to intermittent low wall suction in order to
minimize abdominal distention. At the time of this
dictation, a KUB has been evaluated in order to evaluate for
obstruction. A TSH and free T4 are being checked in order to
rule out worsened hypothyroidism. Prior KUB at bedside was
unremarkable.
6. Neurologic: The patient has been maintained on high
sedation including Fentanyl increase to a maximum dose of
800, Versed at 30, propofol has been as high as 130. These
have been attempted to be decreased by 20% each day as
tolerated. The patient has been maintained on Haldol 10 mg
IV q6. Patient has a history of toxoplasma with result in
seizure disorder. Her Dilantin level was subtherapeutic upon
admission, and the patient was loaded on Dilantin and
restarted.
The patient later was found to have elevated Dilantin levels
and her anti-seizure medications at that point were
discontinued. At the time of this dictation, the patient
does not have any purposeful response to commands or
stimulus, however, her toes remain downgoing, there is no
posturing, pupils minimally reactive to light.
7. Heme: Patient had a low hematocrit for which she was
transfused. Her hematocrit remained low. There were no
signs of blood loss. A mixed venous saturation was checked
with her hematocrit at 20, which revealed that her mixed
venous saturation percentage of O2 was still 80%. At that
point, the patient was only transfused for a hematocrit less
than 20, which was one time.
Later in her hospital course, as per Renal recommendations,
the patient was transfused another unit when her hematocrit
was 25 in order to increase intravascular volume.
The patient's INR was elevated. She was given vitamin K and
her INR came to 1.6. With repeated vitamin K doses,
thereafter, her INR did not decrease any further. Her
platelets remained stable throughout her hospital course
until this time.
8. Endocrinology: The patient was given stress-dosed
steroids of Solu-Medrol at 80 mg IV tid. Endocrine was
consulted and did not find any evidence of mineral-corticoid
deficiency.
Patient was later transitioned to hydrocortisone given the
hyponatremia, hyperkalemia, and hypotension. This did not
change these parameters much. Patient was at that point
transitioned back to Solu-Medrol and placed on a taper given
her long course of steroids.
At the time of this dictation, her Solu-Medrol was at 30 mg
IV tid. Patient has a history of hypothyroidism for which
she is on Synthroid. As per Endocrinology, the patient was
found to be subtherapeutic on her current medication and was
changed to Synthroid of 50 IV. Her TSH and free T4 were
checked again secondary to episodes of hypothermia as well as
her persistent ileus.
The patient was placed on an insulin drip for a period of
time secondary to her hyperglycemia. Her blood sugars were
decreased, and patient was able to have this discontinued.
Her TPN was supplemented with insulin.
9. FEN: Patient was unable to continue tube feeds for
prolonged period of time secondary to her ileus. She was
started on TPN.
10. Prophylaxis: The patient is on Protonix, subQ Heparin,
and Heparin in her TPN.
11. Lines: The patient has a left IJ from the [**5-6**], a right A-line from the [**5-7**], Foley,
ETT, OG tube. She has also had prior central access via her
right groin, and right IJ which of both were discontinued.
She also had a former left A-line.
12. Communication: The [**Hospital 228**] healthcare proxy at this
time is her husband, [**Name (NI) 4597**] [**Name (NI) **].
13. Code: The patient is still full code.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 5587**]
Dictated By:[**Last Name (NamePattern1) 9296**]
MEDQUIST36
D: [**2177-10-18**] 19:11
T: [**2177-10-18**] 19:38
JOB#: [**Job Number 9297**]
ICD9 Codes: 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3412
} | Medical Text: Admission Date: [**2200-3-2**] Discharge Date: [**2200-3-8**]
Date of Birth: [**2121-2-8**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Dehydration
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 5395**] is a 79F with a PMH s/f DM and morbid obesity, who
was recently discharged from [**Hospital1 18**] [**2200-2-7**], after she underwent
an ORIF for a right femur fracture. At that time, she as also
treated for a lower extremity cellulitis with
unasyn-->augmentin, completed on [**2200-2-11**]. She has been at a
rehab center since then regaining function. Her son notes that
she has been largely bedbound at rehab, and had finally began to
ambulate this past friday. The patient was doing well, in her
usual state of health until yesterday, when her family noted her
to be more tired, less responsive, with a decreased appetite.
Of note, at baseline the patient has chronic diarrhea, stool has
been sent for O&P and culture, which have been negative. Per
nursing report from [**Hospital6 **], she has had poor PO
intake secondary to nausea, with three episodes of diarrhea.
They report that several patients on her floor have [**Location (un) **]
virus. Her vital signs became unstable today, where she had a
T=92, BP=104/51 (though the nurse reports it was as low as 80s
systolic), HR=66, RR=22, 94%2L. Fingersticks were in the 30s in
this setting. Labs showed a leukocytosis to 28.5, with ARF
(BUN/Cr= 27/2.6). Attempts to place an IV were unsuccessful,
and the patient's family requested transfer to [**Hospital1 18**].
.
ROS is notable for dizziness, decreased appetite, nausea,
diarrhea, new cough, and pain along her buttocks in the areas of
skin breakdown. She denies any headaches, pleuritic chest pain.
.
In the ED, her presenting vital signs were: T=96.0, BP=107/61,
HR=74, RR=18, O2sat 100%RA. Her abdomen was soft and nontender,
and was reported as benign. Labs were significant for a
leukocytosis to 28.9, a creatinine of 2.8 (baseline 1-1.2), and
a lactate of 3.5. She was given a dose of vancomycin, zosyn, and
flagyl for concern of an intra-abdominal infection. A left IJ
was placed for access. CXR shows a new right sided pleural
effusion.
Past Medical History:
1. Diabetes mellitus II
2. Hypertension
3. Chronic anemia
4. Chronic LE cellulitis/ulcerations
5. Right femur fracture s/p ORIF [**2-/2200**]
6. Hyperlipidemia
Social History:
Currently resides at [**Hospital6 28672**] after her recent femur fracture. Prior to that, lived
at home with her husband. Denies any current ETOH, smoking.
Family History:
Noncontributory
Physical Exam:
T=94.6 orally... BP=104/63... HR=69... RR=22... O2=100% 2L
.
.
PHYSICAL EXAM
GENERAL: Morbidly obese, lethargic, NAD. Responds appropriately
to questions with probing.
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. mucous membranes very dry
CARDIAC: Distant heart sounds, Regular rhythm, normal rate.
LUNGS: Distant, difficult to assess.
ABDOMEN: Obese, mild tenderness to deep palpation
EXTREMITIES: 4+ pitting edema bilaterally, bilateral heel
ulcers. Left ulcer is necrotic with edematous, erythematous
margins. No fluctuance. Multiple areas of skin breakdown
bilaterally on the lower extremities.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact.
Pertinent Results:
please see OMR
Brief Hospital Course:
Ms. [**Known lastname 5395**] is a 79F with a PMH s/f diabetes presenting with
decreased PO intake, diarrhea, and dehydration, also with
hypothermia and leukocytosis.
On presentation pt appeared to be septic with possible sources
including GI (Cdiff), skin ulcers, pneumonia (effusion may have
been parapneumonic). Pancultures were went and remained
negative. Due to persistent hypotension, hypoperfusion (altered
mental status, anuria and ATN, elevated lactate), pt required
fluid resuscitation and pressor support. Given her pulmonary
status, she was electively intubated to allow for aggressive
IVF. She was treated empirically with vancomycin, zosyn, and
flagyl to empirically cover for hospital acquired PNA and C.
diff.
Given difficulty finding infectious source, pt had CT scan -
which showed incidental finding consistent with endometrial
cancer, local metastases to bone and possible uterine infection.
She was evaluated by Oncology, Gyn-onc, and gynecology, but
given the entire presentation, the family decided to make pt [**Name (NI) 3225**]
and avoid furthur diagnostic procedures and treatements. Pt was
then extubated, started on Morphine drip and quickly passed
away.
Medications on Admission:
-Cholestyramine 1PKT daily
-Tramadol 75mg TID prn
-Metoprolol Succinate 100 mg daily
-Enoxaparin 40 mg [**Hospital1 **]
-Metformin 1,000 mg [**Hospital1 **]
-Pioglitazone 45 mg daily
-Glipizide 5 mg daily
-Lasix 40 mg daily
-Lispro sliding scale
-Lidocaine patch
-Ondansetron, oxycodone 5mg, bowel reg prn
.
Discharge Medications:
NOne
Discharge Disposition:
Expired
Discharge Diagnosis:
Cardiopulmonary Arrest, Sepsis
Discharge Condition:
Deceased
Discharge Instructions:
None
Followup Instructions:
None
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2200-3-8**]
ICD9 Codes: 0389, 5849, 4275, 2859, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3413
} | Medical Text: Admission Date: [**2101-5-22**] Discharge Date: [**2101-5-29**]
Date of Birth: [**2043-1-25**] Sex: F
Service: MEDICINE
Allergies:
Zestril / Bactrim Ds / Flagyl
Attending:[**First Name3 (LF) 1674**]
Chief Complaint:
LLQ Abdominal Pain
Major Surgical or Invasive Procedure:
Endotracheal Intubation
Central Venous Line Placement
History of Present Illness:
HPI: Ms. [**Known lastname **] [**Known lastname 13712**] is a 58 year old female with history of
hypertension, hypercholesterolemia, GERD, diabetes mellitus 2
who presents to the ED today with LLQ abdominal pain x 1 day.
On the evening prior to admission she developed nausea and
vomiting. According to ED notes, she denied fevers, chills,
chest pain, or shortness of breath. She presented to the [**Hospital1 18**]
ED for further evaluation.
.
On presentation to the ED, the patient's vital signs were T
98.6, BP 189/92, HR 109, RR 20, O2sat 97% on RA. She appeared
well initially however she developed rigors with temperature to
104.5, HR 156, BP 180/110. During the episode she became more
sedated but still responding to commands. She was given
tylenol, vancomycin 1g x1 and unasyn 3g IV x1. Hemodynamics
improved with these interventions however she had a second
episode shortly thereafter. Again she became tachycardic (HR
155), hypertensive (198/101) and T 105. She was intubated for
airway protection. Labs were notable for WBC count elevated to
17.2, 2% bands, then subsequently was low at 3.7 with 16% bands.
Lactate on admission was 6.1, improved to 3.3 after hydration.
UA was positive. LFTs within normal limits. CT abdomen showed
L>R perinephric fat stranding and wedge shaped density c/w
pyelo. She was given 6L IVF. CXR done post intubation showed
vascular engorgement and low lying endotracheal tube. Prior to
transfer to the [**Hospital Ward Name **] BPs noted to be systolic 80s, a
right subclavian was placed. She is being admitted to the [**Hospital Unit Name 153**]
for further monitoring and treatment of urosepsis.
.
On arrival to the [**Hospital Unit Name 153**] the patient is intubated and sedated.
Her BP was systolic 80s, HR 120s on arrival. Levophed was
started. She was changed from propofol to fentanyl/versed and
given 1L NS. Central line placement was confirmed. No further
history is able to be obtained.
Past Medical History:
Diabetes mellitus, type 2, last A1c 12.8% in [**Month (only) 547**].
Hypertension
Hypercholesterolemia
GERD
Social History:
The patient lives with her husband, no children. Her mother
died at age [**Age over 90 **] after a brief illness.
Family History:
non-contributory
Physical Exam:
GEN: Intubated, sedated.
HEENT: AT, NC, PERRLA, EOMI, no conjuctival injection,
anicteric, OP clear, MMM, Neck supple, no LAD, no carotid bruits
CV: RRR, nl s1, s2, no m/r/g
PULM: CTAB, no w/r/r with good air movement throughout
ABD: soft, NT, ND, + BS, no HSM
EXT: warm, dry, +2 distal pulses BL, no femoral bruits
NEURO: alert & oriented, CN II-XII grossly intact, 5/5 strength
throughout. No sensory deficits to light touch appreciated. No
asterixis
PSYCH: appropriate affect
Guaiac negative in ED
Pertinent Results:
[**2101-5-22**] 04:00AM WBC-17.2*# RBC-4.51 HGB-12.8 HCT-38.5 MCV-85
MCH-28.3 MCHC-33.2 RDW-13.3
[**2101-5-22**] 04:00AM NEUTS-80* BANDS-2 LYMPHS-12* MONOS-6 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2101-5-22**] 04:00AM PLT SMR-NORMAL PLT COUNT-378
[**2101-5-22**] 04:00AM URINE RBC-0 WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-0
[**2101-5-22**] 04:00AM URINE BLOOD-NEG NITRITE-POS PROTEIN-30
GLUCOSE-1000 KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2101-5-22**] 04:00AM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
[**2101-5-22**] 04:00AM TSH-1.7
[**2101-5-22**] 04:00AM T4-6.9 T3-90
[**2101-5-22**] 04:00AM ALBUMIN-4.5
[**2101-5-22**] 04:00AM ALT(SGPT)-17 AST(SGOT)-20 ALK PHOS-100 TOT
BILI-0.4
[**2101-5-22**] 04:00AM GLUCOSE-536* UREA N-24* CREAT-1.4* SODIUM-137
POTASSIUM-4.6 CHLORIDE-98 TOTAL CO2-24 ANION GAP-20
.
[**2101-5-22**] 10:10 am URINE Site: CATHETER
**FINAL REPORT [**2101-5-24**]**
URINE CULTURE (Final [**2101-5-24**]):
CITROBACTER FREUNDII COMPLEX. >100,000 ORGANISMS/ML..
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
CITROBACTER FREUNDII COMPLEX
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
[**2101-5-22**] 7:23 pm BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Preliminary):
CITROBACTER FREUNDII COMPLEX. FINAL SENSITIVITIES.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
CITROBACTER FREUNDII COMPLEX
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Anaerobic Bottle Gram Stain (Final [**2101-5-23**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**2101-5-23**] AT 08:25AM.
GRAM NEGATIVE ROD(S).
Aerobic Bottle Gram Stain (Final [**2101-5-26**]): GRAM NEGATIVE
ROD(S).
.
[**5-22**] CT ABD/Pelvis
CT ABDOMEN: The lung bases are clear. Bibasilar atelectasis is
noted. The
liver, pancreas and gallbladder are unremarkable. The spleen is
small.
Bilateral adrenal glands are unremarkable. Within both kidneys,
there are
areas of wedge-shaped hypoattenuation which may represent
scarring or old
infarcts. The left kidney demonstrates marked perinephric fat
stranding and
asymmetrical enlargement. A small amount of fluid in the left
paracolic
gutter is also identified. Given these findings, there may be an
acute-on-
chronic presentation of pyelonephritis on the left. Contrast is
seen
throughout the course of the ureters with bilateral ureteral
jets. No evidence
of ureteral calculi. The presence of renal calculi is
indeterminate given the
IV contrast on board. There is no evidence of hydronephrosis or
hydroureter.
Small bowel loops are normal in caliber and without focal wall
thickening.
There is no mesenteric or retroperitoneal lymphadenopathy.
CT OF THE PELVIS: The sigmoid, rectum, bladder and uterus are
unremarkable.
There is no evidence of diverticulosis or diverticulitis. There
is no pelvic
or inguinal lymphadenopathy. There is no free air.
BONE WINDOWS: There are no suspicious lytic or sclerotic lesions
identified.
A tiny sclerotic focus in the left iliac [**Doctor First Name 362**] likely represents
a bone island.
IMPRESSION:
1. Left perinephric fat stranding and asymmetrical enlargement
with a small
amount of free fluid is seen in the left paracolic gutter. These
findings are
concerning for acute pyelonephritis. No definite renal calculi
identified,
however the presence of IV contrast limits this evaluation.
2. Bilateral wedge-shaped hypoattenuating areas likely suggest
old scarring
or possibly chronic pyelonephritis. Clinical correlation is
recommended
.
[**5-22**] CT HEAD
FINDINGS: There is no shift of normally midline structures. The
ventricles
and sulci are unremarkable. There is normal [**Doctor Last Name 352**]-white matter
differentiation. There is no evidence of acute hemorrhage or
fracture. The
visualized paranasal sinuses are clear.
IMPRESSION: No evidence of acute hemorrhage.
.
[**5-24**] CT CHEST
FINDINGS: Subtle analysis of the lung parenchyma is compromised
by severe
motion artifacts related to ventilation. At both lung apices,
there is
minimal subpleural scarring. Bilaterally, small pleural
effusions and
subsequent atelectasis in the dependent parts of the lungs are
seen. Minimal
fluid marking of the interstitium at the bases of the lungs
indicates mild
interstitial fluid overload. There are no focal parenchymal
opacities
suggestive of pneumonia, and no lung masses. In the mediastinum,
notably in
the para-aortic and retrocaval region, numerically increased but
normal to
borderline-sized lymph nodes are seen. The size of the heart is
slightly
increased, there is no pericardial effusion, however, coronary
calcifications
are seen. Endotracheal tube and nasogastric tube are in situ.
IMPRESSION: Extensive motion artifacts caused by ventilation.
Subtle fluid
overload, subtle bilateral pleural effusions with bilateral
atelectasis. No
evidence of inflammatory or neoplastic lung disease.
Endotracheal and
nasogastric tube in situ.
Brief Hospital Course:
.
#. Urosepsis: The pt presented with complaints of LLQ abdominal
pain x 1 day prior to presentation. She was intially
hypertensive but developed an altered mental status and BP
dropped to 80s systolic. The pt was intubated for airway
protection and had a central line placed for IVF resuscitation.
Vancomycin and Unasyn were started. UA demonstrated evidence of
UTI. Clinical presentation was consistent with pyelonephritis
with bandemia, fevers, and hypotension. CT scan with left
perinephric fat stranding and asymmetrical enlargement with a
small amount of free fluid is seen in the left paracolic gutter
c/w acute pyelonephritis. On transfer to the [**Hospital Unit Name 153**] the pt
remained hypotensive requiring levophed overnight. She received
6L NS. Her antibiotics were transitioned to cefepime and cipro.
Vanco and unasyn were discontinued. Her blood cultures and urine
cultures grew Citrobacter freundii - pansensitive and her
antibiotics were tapered to cipro to complete a 14 day course
for bacteremia and pyelonephritis. Surveillance cultures
negative.
.
#. Altered mental status: In the ED the pt had an acute MS
change and required intubation for airway protection. This
change was felt most likely related to severe sepsis. Initial CT
Head was WNL. The patient had a persistently altered mental
status, was minimally responsive to verbal stimuli despite
weaning off sedation. Her fentanyl and versed were transitioned
to dexmedetomidine as it was felt that her MS may be due to
sensitivity to benzodiazepines. The pt briefly developed
profound hypotension with the use of Dexmedetomidine requiring
the initiation of levophed and neosynephrine. The
Dexmedetomidine was discontinued abruptly and her hypotension
resolved. Her sedation was changed to propofol and on her fifth
hospital day the patient's altered mental status resolved and
she was successfully extubated. AMS likely due to sepsis and
benzodiazepine effect. Now with normal mental status.
.
# Respiratory distress: Occurred in the ED in the setting of
fever, rigors. The patient has no underlying lung pathology. The
patient was extubated although now CXR is fluid overloaded.
Intubated in the ED. The pt was extubated on [**5-24**] however
required reintubation due to poor mental status and pulmonary
edema in the setting of hypertension. CT scan demonstrated
evidence of volume overload. She was diuresed approx 3L prior to
her successful extubation of [**5-27**].
.
# Elevated CK: The pt had a CK elevation to 3000 on admission
felt related to rigoring during sepsis vs a component of rhabdo
secondary to either sepsis or electrolyte abnormalities ( ie
hypokalemia, hypophosphatemia on admission). Also possible
component of demand ischemia given elevated troponin but minimal
MB fraction. She was treated with IVF and electrolyte repletion.
CK trended down appropriately.
.
# Diabetes mellitus: Last A1c 12.9 in [**2101-4-4**]. The pt was
started on an insulin gtt on admission to [**Hospital Unit Name 153**] for tight glucose
control. There was no evidence that she was in DKA. She was
transitioned back to RISS and lantus 20 U in ICU. As her fsbg
remained elevated, she was given 10 units lantus the following
morning and told to take lantus 60 that night then her prior
regimen of lantus 70 the following night.
.
# Hypercholesterolemia: Statin initially discontinued as pt
presented with marked CK elevation. CKs trended down and other
LFTs were within normal. Felt that this was no likely to be
related to statin use. Therefore statin was restarted.
.
# GERD:
- Continued PPI.
.
#CODE: FULL
.
#COMMUNICATION: [**Name (NI) **] (husband) [**Telephone/Fax (1) 101417**], [**Name (NI) **] [**Name (NI) 6330**]
(sister) [**Telephone/Fax (1) 101418**]
Medications on Admission:
Aspirin 81mg daily
Lipitor 80mg daily
Albuterol 90mcg QID PRN
Advair 250/50 1 puff [**Hospital1 **]
Flovent 110mcg 2 puffs [**Hospital1 **]
Flonase 50mcg [**12-8**] sprays daily
Hydrochlorothiazide 12.5mg daily
Diovan 320mg daily
Metformin 1000mg [**Hospital1 **]
Insulin Glargine 70U
Byetta 10mcg/0.04mL [**Hospital1 **]
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Diovan 320 mg Tablet Sig: One (1) Tablet PO once a day.
3. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
4. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
5. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
7. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) puff
Inhalation four times a day.
8. Flovent HFA 110 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation twice a day.
9. Lantus 100 unit/mL Solution Sig: Seventy (70) u Subcutaneous
at bedtime.
10. Byetta 10 mcg/0.04 mL Pen Injector Sig: as per prior dosing
Subcutaneous twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Urosepsis
diabetes mellitus
Discharge Condition:
stable
Discharge Instructions:
Please follow up in Dr.[**Month (only) 28614**] clinic within the next 2 weeks.
If he is unavailable to see you, ask to make an appointment
with one of his nurses or residents. Return to the ER with any
confusion, fever over 101.4, abdominal pain, or other concerning
symptoms. Please restart your dose of Lantus tonight, but only
give yourself 60 units, then tomorrow night return to lantus 70
units per night.
Followup Instructions:
Please follow up in Dr.[**Name (NI) 28614**] clinic within the next 2 weeks.
If he is unavailable to see you, ask to make an appointment
with one of his nurses or residents.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1677**]
Completed by:[**2101-5-29**]
ICD9 Codes: 5849, 2762, 2768, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3414
} | Medical Text: Admission Date: [**2118-10-26**] Discharge Date: [**2118-11-21**]
Date of Birth: [**2118-10-26**] Sex: F
Service: NB
REASON FOR ADMISSION:
1. Prematurity (32-6/7 weeks gestation).
2. Respiratory distress syndrome.
MATERNAL HISTORY: [**Known firstname 402**] [**Known lastname **] is a 33-year-old G1, P0-2
woman with past medical history notable for unexplained
infertility. Prenatal screens were as follows: O- (status
post RhoGAM), DAT negative, HBS antigen negative, RPR
nonreactive, rubella immune, GBS unknown.
FAMILY HISTORY: Noncontributory.
Her [**Last Name (un) **] was [**2118-12-15**]. Her current pregnancy was
complicated by increasing transaminases and pruritus
consistent with cholelithiasis of pregnancy. She received
Actigall. Betamethasone was administered on [**2118-10-24**],
and [**2118-10-25**]. She progressed to a cesarean section for
maternal indication. Rupture of membranes occurred actively
and yielded clear amniotic fluid. There was no intrapartum
fever or other clinical evidence of infection.
DELIVERY: Baby was [**Name2 (NI) **] by elective C-section. She was noted
to be rigorous at delivery. Apgars were 8 and 9 at one and
five minutes, respectively. She was admitted to NICU in lieu
of prematurity.
PHYSICAL EXAMINATION ON ADMISSION: Preterm infant with
examination consistent with 33 weeks gestation. Birth weight
2085 grams, head circumference 30.5 cm, length 43 cm.
Temperature 98.1, heart rate 168, respiratory rate 50-60,
blood pressure 74/33 (48), saturation is 87% in 35% FiO2.
HEENT: Anterior fontanel at level, nondysmorphic. Palate
intact. Neck, mouth: Normal. Normocephalic. Mild nasal
flaring. Red reflex present. Chest: Mild intracostal
retractions, grunting respirations, fair breath sounds
bilaterally, few scattered crackles. CVS: Well perfused.
Regular rate, rhythm. Femoral pulses normal. S1, S2 normal.
No murmur. Abdomen: Soft, nondistended. No organomegaly. No
masses. Bowel sounds active. Anus patent. Three-vessel
umbilical cord. GU: Normal female genitalia. CNS: Active.
Responds to stimulation. Tone is slightly decreased but
symmetrical in distribution. Suck/gag intact. Facies
symmetrical. Spine, extremities and hips: Normal.
HOSPITAL COURSE BY SYSTEMS:
RESPIRATORY: The initial respiratory coursewas consistent with
mild respiratory distress syndrome postop. She was put on CPAP
therapy soon after birth. On day of life #3 she successfully
transitioned to room air with no CPAP. She has stayed in room air
throughout her hospital stay. She was commenced on caffeine
on day of life #4 for apnea of prematurity which was
discontinued by day of life #8, after which she had
insignificant apneas and desaturations. At the time of
discharge she is comfortably breathing in room air and has
been free of apneas and bradyarrhythmias for approximately 5
days.
Cardiovascular: She was noted to have a moderate size PDA on
[**2118-10-27**], which responded to a course of Indomethacin.
Fluids, electrolytes, nutrition: She was initially NPO and
received parenteral nutrition for the 1st few days of life.
Feeds were gradually introduced on day of life #4 and
advanced to a maximum of 150 ml/kg per day of breast milk 24
calories/ounce by day of life #10. She has shown good weight
gain. At the time of discharge she is on ad lib. p.o. feeds
of breast milk 24 made with Similac powder. If taking
approximately 110 to 145 ml/kg per day in addition to breast
feeds. Weight at discharge 2545 grams, head circumference 32
cm, length 49 cm.
GI: No complications. She received phototherapy for
physiological jaundice exaggerated by prematurity with a
maximum bilirubin of 8.3/0.3 on day of life #3.
Infectious disease: She received IV antibiotics for the 1st
48 hours of life for sepsis rule-out. She had no episodes of
suspected or proven sepsis.
Neurology: No clinical concerns. She does not fulfill
criteria for routine head ultrasound/scan screening.
Sensory: She passed her newborn hearing screen.
Ophthalmology: She does not fulfill criteria for routine ROP
screen.
Psychosocial: No concerns.
CONDITION ON DISCHARGE: Well.
DISCHARGE DISPOSITION: Home.
NAME OF PRIMARY CARE PEDIATRICIAN: Dr. [**Last Name (STitle) **]; telephone [**Telephone/Fax (1) 58389**].
CARE RECOMMENDATIONS: Ad lib. p.o. feeds of breast milk 24
with Similac powder along with breast feeding.
MEDICATIONS: Ferrous sulfate
CARSEAT SCREENING: Passed.
NEWBORN SCREENING STATUS: Initial report normal. Full report
awaited.
IMMUNIZATIONS RECEIVED: Hepatitis B vaccine on [**2118-11-8**].
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) [**Month (only) **] at less than 32
weeks, 2) [**Month (only) **] 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 1st 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out-of-home caregivers.
FOLLOW-UP APPOINTMENTS SCHEDULED/RECOMMENDED:
1. With pediatrician 2-3 days following discharge.
2. VNA visit 1-2 days following discharge.
DISCHARGE DIAGNOSES:
1. Prematurity (32-6/7 weeks gestation).
2. Mild respiratory distress syndrome.
3. Mild apnea of prematurity.
4. PDA (treated with indomethacin).
Reviewed By: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 53043**], [**MD Number(1) 53044**]
Dictated By:[**Name (STitle) 66431**]
MEDQUIST36
D: [**2118-11-22**] 12:58:51
T: [**2118-11-22**] 14:58:42
Job#: [**Job Number 69006**]
ICD9 Codes: 769, 7742, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3415
} | Medical Text: Admission Date: [**2180-6-11**] Discharge Date: [**2180-6-20**]
Service: SURGERY
Allergies:
Vicodin
Attending:[**First Name3 (LF) 1390**]
Chief Complaint:
left sided abdominal pain
Major Surgical or Invasive Procedure:
PROCEDURES:
1. Exploratory laparotomy.
2. Small-bowel resection x1 with anastomosis.
3. Repair of left femoral hernia.
History of Present Illness:
Ms. [**Known lastname 14799**] is an 89 year old female who was transferred from
[**Hospital3 **] for incarcerated left femoral hernia. History
was obtained from patient and her daughter. [**Name (NI) **] report, patient
has been having L side abdominal pain for the past few days with
poor PO intake. She has been worked up for UTI which was
negative
for infection. She presented to ED at [**Location (un) 620**] today and was
diagnosed with L femoral hernia and hyponatremia. She was then
transferred to [**Hospital1 18**] for further management. She denied any
fever, chills, emesis. However, she endorsed abd distention and
some pain over the L groin. She reported to continue passing
flatus with regular BMs.
Past Medical History:
- DM type 2
- Pneumonia with pleural effusion treated about 4 weeks ago
- HTN
- HLD
- UTI
- Deaf
- Afib on Coumadin, last INR 2.1
- Hypothyroidism
- Constipation
Past Surgical History:
- Cervical LN bx
- Lap ccy [**2169**]
- Bilateral groin hernia repair
Medications:
- Diovan 80mg qd, aspirin 81mg he, prilosec 20mg levothyroxine
125mg qd, metformin 500mg [**Hospital1 **], colace 100mg [**Hospital1 **], metoprolol 50mg
tid, simvastatin 10mg qd, Coumadin 4mg qd, cipro 250mg [**Hospital1 **]
Social History:
Social History:
- Lives with her daughter, rather independent at baseline
- Never smoking/drinker
Family History:
Family History:
- Father with CAD
- Mother with DM
Physical Exam:
Physical Exam:
Vitals: 96.9 72 160/76 16 99%
GEN: A&Ox2, NAD
HEENT: No scleral icterus, dry mucus membrane
CV: irreg irreg, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, distended with tympany, tender at L groin with a
palpable bulge below the inguinal ligament with slight erythema
over the overlying skin
Ext: trace LE edema, LE warm and well perfused
Pertinent Results:
[**2180-6-19**] 05:28AM BLOOD WBC-4.8 RBC-3.07* Hgb-9.4* Hct-27.7*
MCV-90 MCH-30.6 MCHC-33.9 RDW-15.3 Plt Ct-286
[**2180-6-18**] 05:35AM BLOOD WBC-7.1 RBC-3.40* Hgb-10.1* Hct-30.7*
MCV-90 MCH-29.7 MCHC-32.9 RDW-14.9 Plt Ct-313
[**2180-6-17**] 06:20AM BLOOD WBC-6.5 RBC-3.39* Hgb-10.3* Hct-30.5*
MCV-90 MCH-30.2 MCHC-33.6 RDW-15.0 Plt Ct-305
[**2180-6-19**] 05:28AM BLOOD Plt Ct-286
[**2180-6-19**] 05:28AM BLOOD PT-11.7 INR(PT)-1.1
[**2180-6-19**] 05:28AM BLOOD Glucose-129* UreaN-12 Creat-0.6 Na-133
K-3.9 Cl-99 HCO3-22 AnGap-16
[**2180-6-18**] 05:35AM BLOOD Glucose-125* UreaN-11 Creat-0.6 Na-132*
K-4.0 Cl-98 HCO3-22 AnGap-16
[**2180-6-17**] 04:45PM BLOOD Glucose-128* UreaN-10 Creat-0.6 Na-130*
K-3.5 Cl-96 HCO3-22 AnGap-16
[**2180-6-11**] 11:43AM BLOOD Glucose-161* UreaN-16 Creat-0.8 Na-120*
K-3.7 Cl-88* HCO3-22 AnGap-14
[**2180-6-14**] 05:30AM BLOOD CK(CPK)-32
[**2180-6-13**] 10:00PM BLOOD CK(CPK)-43
[**2180-6-14**] 05:30AM BLOOD CK-MB-3 cTropnT-0.02*
[**2180-6-19**] 05:28AM BLOOD Calcium-8.2* Phos-2.6* Mg-1.8
[**2180-6-18**] 05:35AM BLOOD Calcium-8.0* Phos-2.4* Mg-1.8
[**2180-6-12**] 02:25AM BLOOD Triglyc-46 HDL-50 CHOL/HD-1.5 LDLcalc-15
[**2180-6-11**] 10:07AM BLOOD Hgb-10.4* calcHCT-31
[**2180-6-11**] 08:38PM BLOOD freeCa-1.00*
[**2180-6-11**]: EKG:
Sinus rhythm. Delayed R wave progression is likely a normal
variant. Compared to the previous tracing of [**2171-8-29**] no
significant difference.
[**2180-6-11**]: portable abdomen:
FINDINGS: Since the previous study, the nasogastric tube has
been readjusted.
The tip and side port are now within the fundus of the stomach.
There is a portion of a left IJ central venous line with the
distal lead tip in proximal superior vena cava. The lower lung
fields are grossly clear. The cardiac silhouette and
mediastinum are within normal limits. There are some
calcifications of the thoracic aorta. The visualized portion of
the bowel gas pattern is unremarkable. There is air and stool
seen throughout non-dilated loops of colon. Surgical clips are
seen in the right upper abdomen.
[**2180-6-13**]: EKG:
Atrial fibrillation with rapid ventricular response. Low limb
lead voltage.
ST segment depression in leads I, aVL and V2-V6 which may
represent
concomitant anterolateral ischemia. Compared to the previous
tracing
of [**6-11**]-1-2 atrial fibrillation with rapid ventricular response
and ischemic appearing ST-T wave changes have appeared. Followup
and clinical correlation are suggested
[**2180-6-13**]: Chest x-ray:
Heterogeneous opacification in the right lung at the apex, and
increasing at the right base could be due to pneumonia. There
is a new triangular opacity filling the left lateral pleural
sulcus, with a shape suggesting pulmonary infarction. Dr.
[**Last Name (STitle) 14800**] was paged at 9:35, one minute after recognition, to
discuss this new finding, and he directed me to page the Acute
Care Service who did not respond to the initial page at 9:40. I
discussed the findings by telephone with Dr [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] at 12:20pm.
Heart size is normal. Left internal jugular line ends at the
junction of
brachiocephalic veins. Nasogastric tube loops in the stomach
and passes out of view. Normal cardiomediastinal and hilar
silhouettes. No pneumothorax.
[**2180-6-13**]: knee x-ray:
IMPRESSION:
1. No obvious fracture.
2. Mild degenerative changes, progressed compared with 4/[**2169**].
3. Chondrocalcinosis, new compared with 4/[**2169**].
4. Trace joint fluid.
[**2180-6-13**]: CTA chest:
IMPRESSION:
1. Bronchopneumonia right upper lobe. Follow-up chest
radiograph after
treatment is recommended to document resolution. Bilateral
moderate,
nonhemorrhagic, pleural effusions.
2. No pulmonary embolism. Possible pulmonary arterial
hypertension.
3. Extensive coronary and aortice atherosclerotic
calcification. Mitral
annulus heavily calcified.
[**2180-6-15**]: EKG:
Atrial fibrillation with a rapid ventricular response, new
compared to the previous tracing of [**2180-6-13**]. There is variation
in precordial lead placement while the diffuse ST segment
changes persist without diagnostic interim change.
TRACING #1
[**2180-6-16**]: EKG:
Atrial fibrillation with a rapid ventricular response. Low limb
lead voltage.
Compared to the previous tracing of [**2180-6-15**] the ventricular
response has
increased. Followup and clinical correlation are suggested.
Brief Hospital Course:
The patient was admitted to the acute care service with left
sided abdominal pain. Upon admission, she was made NPO, given
intravenous fluids, and underwent a cat scan. The patient was
found to have an incarcerated left femoral hernia. She was taken
to the operating room on [**2180-6-11**] for repair. She was given FFP
prior to the procedure to help bring down her INR. She had an
exploratory laparotomy due to the concern fo ischemic/necrotic
bowel and due to the unhealthy appearance of the bowel involved
with the hernia, there was need for small bowel resection. Her
operative course was stable with a minimal blood loss. She was
extubated after the procedure and transferred to the intensive
care unit for monitoring. Please refer to Dr.[**Name (NI) 12389**]
operative note for additional details.
Post-operatively, she was admitted to the Trauma intensive care
unit, primarily due to her mental status which was believed to
be related to her hyponatremia. Her sodium upon admission was
112. She received additional intravenous fluids and her
electrolytes were closely monitored.
REVIEW OF SYSTEMS:
Neuro: She had altered mental status on admission, thought to
be due to her hyponatremia. She received normal saline
resuscitation (she received 2 NS boluses of 250 cc and NS @
100cc/hr. Her sodium slowly improved and was 126 prior to
transfer to the floor on POD 3. Her mental status improved with
her improving hyponatremia. Her current sodiuim is 133 and she
is conversant and oriented.
CV: She has a known history of afib, anticoagulated on coumadin.
She was rate controlled with metoprolol 5 mg q6' decreased to
2.5IVQ6 due to perioperative blood pressure issues. She
remained rate controlled and in normal sinus rhythym while
leaving the intensive care unit. Since her transfer to the
surgical floor, she required additional metoprolol for episodes
of atrial fibrillation with a rapid ventricular rate. She was
evaluated by the Cardiology service who made recommendations for
beta-blockade to control her heart rate. Recommendations made
for metoprolol 75 mg TID. With this regimen, she has had less
episodes of rapid rate and has required less interval dosing.
To rule out a pulmonary embolism, she underwent CTA of her
chest. No pulmonary embolism was seen but a right
brocho-pneumonia was identified. She did not exhibit signs of
pneumonia or fever and was maintaining adequate oxygenation and
no intervention was indicated.
Resp: She has been maintained on room air with an oxygen
saturation of 97%.
GI: Prior to her surgery, she had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-gastric placed for
bowel decompression. The patient removed the tube on HD #4.
After she passed flatus, she was started on a regular diet.
GU: See Neuro re: details regarding hyponatremia. She had a
foley catheter and produced adequate urine. Her foley catheter
was removed and she has been voiding without difficulty.
ID: She was treated for a UTI (positive UA/UCx at the OSH prior
to transfer - 50-100,000 citrobacter) with a one week course of
ciprofloxacin. She completed her week course of ciprofloxacin.
MUSCULOSKELETAL: Prior to her admission, she reported right knee
pain without evidence of trauma. An x-ray of the knee did not
reveal a fracture. A knee immobilizer was applied for
additional support. Because of her prolonged hospitalization,
she evaluated by physical therapy and recommendations were made
for discharge to an extended care facility where she can further
regain her strength and mobility.
She is preparing for discharge with instrucitons to follow-up
with the acute care service, cardiology, and her primary care
provider.
Of note: She did receive 1 dose of lovenox as a bridge on [**6-19**].
It was d/c as per Dr. [**Last Name (STitle) **] because of concern for
retroperitoneal bleed. She currently is on coumadin and
aspirin.
Medications on Admission:
[**Last Name (un) 1724**]: Diovan 80mg qd, aspirin 81mg he, prilosec 20mg
levothyroxine 125mg qd, metformin 500mg [**Hospital1 **], colace 100mg [**Hospital1 **],
metoprolol 50mg tid, simvastatin 10mg qd, Coumadin 4mg qd, cipro
250mg [**Hospital1 **]
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
4. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM.
6. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day): hold for sys. bp <100, hr <60.
9. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO three
times a day: hold for sys bp <100, hr <60.
10. simvastatin 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
11. Diovan 80 mg Tablet Sig: One (1) Tablet PO once a day: ON
HOLD, TO FOLLOW UP WITH CARDIOLOGY BEFORE RESUMING.
12. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day: ON
HOLD, TO FOLLOW UP WITH CARDIOLOGY BEFORE RESUMING.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Incarcerated left femoral hernia
hyponatremia
atrial fibrillation
urinary tract infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital with left sided abdominal
pain. You were found to have an incarcerated left femoral
hernia. You were taken to the operating room where you underwent
repair of the hernia. You were monitored in the intensive care
unit after the surgery because of a low sodium associated with
mental status changes. You were transferred to the surgical
floor where you have had problems with rapid heart rate. The
cardiology service was consulted and made recommendations for
medical management of the heart rate. Your vital signs are
slowly improving and you are now preparing for discharge to a
rehabilitation facility where you can further regain your
strength and mobility.
Followup Instructions:
Name: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
When: Thursday [**6-29**] at 11am
Location: [**Hospital1 **] [**Location (un) **] CARDIOLOGY
Address: [**Street Address(2) **], [**Location (un) **],[**Numeric Identifier 14801**]
Phone: [**Telephone/Fax (1) 4105**]
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: TUESDAY [**2180-7-4**] at 4:15 PM
With: Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 853**]
With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2180-6-27**]
ICD9 Codes: 2761, 5990, 4019, 2724, 2449, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3416
} | Medical Text: Admission Date: [**2175-12-31**] Discharge Date: [**2176-2-24**]
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Increased SOB
Major Surgical or Invasive Procedure:
Tracheal intubation
Mechanical ventilation
Chest tube placement x 2
Arterial cannulation
Central venous cannulation
Bronchoscopy
Tracheostomy
PEG tube placement
Pleurodesis
History of Present Illness:
85 year old woman admitted with a chief complaint of hypoxia.
She was admitted to [**Hospital1 **] [**2175-12-27**] after 10 day
hospitalization at [**Hospital1 18**] for left below the knee amputation. She
has a history of steroid use for oxygen dependent COPD. On
arrival at [**Hospital1 **], her O2 sat was 97% on 2L. She has had a
steadily increasing oxygen requirement since, progressing to the
point on the day of admission of being on BiPap 14/8 15L. When
her mask is removed for even a few seconds, she desaturates to
the low 70s. She has been evaluated for her hypoxia by various
coverage physicians over the weekend and was treated with
nebulizer treatments and lasix with little improvement. She also
had a CXR on [**12-28**] which showed a left lower lobe pneumonia for
which she is on ceftriaxone, flagyl, and vancomycin. On the day
of admission, she was tachypneic, more hypoxic, with decreased
responsiveness, and was sent in for evaluation. On exam in the
ED, she was noted to have decreased air movement with rhonchi
and faint wheezes which improved with nebulizer treatments. Her
CXR was not impressive. An EKG showed multifocal atrial
tachycardia and mild lateral ST depressions. She was initially
placed on Bipap in the ED; after nebulizer treatments, she
improved and was put back on nasal cannula. She then again got
worse in the ED, and an ABG was 7.25/94/66. The patient was thus
intubated in the ED for worsening respiratory failure and sent
to the [**Hospital Unit Name 153**].
Past Medical History:
type 2 diabetes
hypertension
gout
osteoporosis
chronic obstructive pulmonary disease, steroid dependent,
oxygen-dependent, (FVC 1.89,FEV1 0.83, FEV1/FVC 44, DLCO:
Severely reduced)
paroxysmal atrial fibrillation
anemia
peripheral neuropathy secondary to diabetes
gastroesophageal reflux disease
history of MRSA
hyperthyroidism
PAST SURGICAL HISTORY:
right below knee popliteal bypass graft with nonreversed
saphenous vein and a left popliteal bypass graft with saphenous
vein angiogram on [**2175-9-30**].
mastectomy in [**2150**].
PICC line placement [**2175-9-30**].
left BKA
Social History:
The patient is a resident at [**Hospital **] rehabilitation. There is
no smoking or alcohol history.
Family History:
Noncontributory
Physical Exam:
T 100.8 HR 106 BP 163/69 O2Sat 90% AC Tv 400 x 20 PEEP 5 FiO2
0.5
Gen: Patient intubated, responsive and sedated
Heent: PERRL, sclera anicteric, OP with ulcers, MMM
Lungs: Diffuse tubular sounds ant/lat
Cardiac: Irregularly Irregular no murmurs
Abdomen: soft NT NABS
Ext: Left BKA, surgical wound intact, staples in place; Right LE
no edema, black necrotic right big toe. Right DP +2 at ankle
Neuro: sedated
Pertinent Results:
Admission labs:
CBC: WBC-21.1*# RBC-3.64* Hgb-10.2* Hct-33.3* MCV-91 MCH-27.9
MCHC-30.6* RDW-17.9* Plt Ct-646*
Diff: BLOOD Neuts-81.8* Lymphs-13.3* Monos-3.5 Eos-0.8 Baso-0.6
Coags: PT-13.3 PTT-37.1* INR(PT)-1.2
Chem 10: Glucose-86 UreaN-28* Creat-1.0 Na-147* K-4.2 Cl-103
HCO3-38* Calcium-7.9* Phos-2.6* Mg-2.0
ABG: Type-ART Temp-37.0 Rates-40/ FiO2-50 pO2-66* pCO2-94*
pH-7.25* calHCO3-43* Base XS-9 Intubat-NOT INTUBA
Comment-VENTIMASK
Other: Lactate-1.1
Cardiac enzymes: CK(CPK)-14* CK-MB-NotDone cTropnT-0.06* ->
CK(CPK)-14* CK-MB-1 cTropnT-0.04*
Thyroid tests: TSH-0.10* Free T4-0.7* T4-3.3*
Discharge labs:
Imaging:
Admission CXR:
1. Worsening of right upper lobe opacity near the future, which
are somewhat linear. Although it could represent subsegmental
atelectasis, cannot rule out the presence of pneumonia.
2. Background emphysema and pulmonary fibrosis as well as
pulmonary artery hypertension.
3. Bilateral small pleural effusions are stable.
Admission CTA Chest:
1. No evidence of central pulmonary embolism.
2. Right lower lobe consolidation/atelectasis; this likely
represents
pneumonia in the correct clinical setting.
3. Stable mediastinal lymphadenopathy, most prominent in the AP
window and precarinal distribution.
4. Severe fibrotic, bronchiectatic, and cystic changes
consistent with the known history of COPD. No pneumothorax as
was demonstrated on the prior CT.
5. Several smaller focal areas of consolidation bilaterally, the
most prominent of which in the left lower lobe, just superior
and anterior to the dominant area of consolidation. While these
may represent multifocal areas of infection or fibrotic change,
followup should be obtained to exclude malignancy.
6. Small left-sided pleural effusion.
7. Mild prominence of the central main pulmonary artery, likely
consistent with the given history of pulmonary arterial
hypertension.
Head CT [**2176-1-5**]: There is no evidence for hemorrhage. The
ventricles, sulci, and cisterns demonstrate no effacement. The
[**Doctor Last Name 352**] white matter junction is preserved. There are multiple
hypodensities seen in the subcortical and deep white matter as
well as both thalami that are the sequelae of chronic small
arterial ischemia. There is a frothy fluid within both maxillary
sinuses, sphenoid sinuses, and right mastoid air cells that may
indicate sinusitis. The osseous structures are unremarkable.
CXR [**2176-1-5**]: Very large left-sided pneumothorax with signs of
tension.
Chest CT [**2176-1-5**]:
FINDINGS: The large left hydropneumothorax, mostly air filled
was also shown on plain chest radiographs earlier today. Since
it shifts the mediastinum rightward and everts the left
hemidiaphragm, it may be causing hemodynamic tension as well.
The left lung is tethered to the chest cage by many pleural
adhesions.
Right lower lobe consolidation is improving and edema has
resolved. Emphysema is severe. A 6- cm bulla marginates the left
major fissure and smaller bullae are seen elsewhere . The
airways are patent up to the segmental bronchi. There is no
right pleural or any pericardial effusion.
Subcentimeter mediastinal nodes not meet CT size criteria for
lymphadenopathy. Extensive atherosclerotic coronary artery
calcifications are noted, along with substantial aortic valvular
calcification. There is no pericardial effusion.
In the upper abdomen, the imaged liver, spleen, adrenals, and
kidneys are unremarkable. A 24-mm gallstone is noted without
evidence of cholecystitis.
There are no suspicious bone findings.
ET tube and NG tube are in good position with the NG tube
terminating in the body of the stomach and the ET tube well
above the carina.
IMPRESSION:
1. Large left hydropneumothorax could be under tension and
hemodynamically significant.
2. Severe emphysema including a 6 cm bulla along the left major
fissure.
3. Improving right lower lobe consolidation.
4. Decreasing pulmonary edema.
CXR [**2176-1-5**] pm: Compared with the examination obtained
approximately 6 1/2 hours earlier, a left chest tube has been
inserted, with its tip ending in the apex. The left pneumothorax
has markedly diminished and is now small, best seen at the left
lateral costophrenic angle. The mediastinum is now midline. The
endotracheal tube is in satisfactory position. A nasogastric
tube descends into the abdomen. There is a background of chronic
lung disease and emphysema. Scattered nonspecific opacities are
present bilaterally.
CXR [**2176-1-8**]: Left lung appears to be completely re-expanded. The
left apical pleural tube is relatively short intrathoracic and
the tip of the basal tube is not its entire course is
extrathoracic. Little if any left pleural effusion or pleural
air. Mild pulmonary edema is unchanged. Heart size is normal,
although larger than it was prior to chest tube insertion. Tip
of the ET tube is in standard placement and a nasogastric tube
passes into the stomach and out of view. Dr. [**First Name (STitle) **] was paged to
discuss these findings at the time of dictation.
CXR [**2176-2-5**]: One of the two left basal pleural tubes have been
withdrawn approximately 6 cm now projecting over the cardiac
apex and left hemidiaphragm. The other tube is unchanged in
position, tip just to the left of the midline at the level of
the left hemidiaphragm. No appreciable left pneumothorax. Small
left pleural effusion may have increased. Small right pleural
effusion unchanged. Subcutaneous emphysema in the chest wall and
neck is still severe but improving. Heart size remains top
normal. Heterogeneous opacification in the lungs is probably a
combination of pulmonary edema, multifocal pneumonia and
emphysema. Tracheostomy tube in standard placement.
GRAM STAIN (Final [**2176-2-18**]):
[**10-23**] PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final [**2176-2-20**]):
OROPHARYNGEAL FLORA ABSENT.
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup will be performed appropriate to the isolates
recovered from
this site.
YEAST. SPARSE GROWTH.
ENTEROBACTER CLOACAE. RARE GROWTH.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
203-0763R
[**2176-2-11**].
STAPH AUREUS COAG +. RARE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # 203-1121R
[**2176-2-12**].
Brief Hospital Course:
Assessment: 85yo woman with chronic obstructive pulmonary
disease, admitted with respiratory failure, intubated in the ED,
likely secondary to multilobar pneumonia, chronic obstructive
pulmonary disease, and congestive heart failure, complicated by
a pneumothorax.
Hospital course is discussed below by problem:
1. Respiratory failure - Her initial respiratory failure was
thought to be multifactorial, secondary to multilobar pneumonia,
chronic obstructive pulmonary disease with very poor baseline
function, and congestive heart failure. She was treated with
vancomycin, zosyn, and azithromycin for 14 days for broad
coverage given that she had recently been living in health care
facilities. DFA for influenza and urinary legionella antigen
were both negative. Sputum cultures only grew yeast, which was
thought to be contamination. Most recent sputum cultures grew E
coli, thought to be a contaminant as well, as the patient has
been afebrile, with resolving leukocytosis, unremarkable chest
x-ray, and no other symptoms of a pneumonia. She then developed
a low grade temperature and with 2/16 sputum culutres with 2+
GNR and with a history of enterobacter, she was restarted on a
10 day course of meropenem to be finished at rehabilitation. Her
sputum culture grew gram positive cocci and she was started on a
course vancomycin, to complete a 10 day course of vancomycin and
10 day course of meropenem. Her vancomycin had been
supratherapeutic and was being monitored daily for dosing
purposes. She was day [**7-8**] fo vancomycin on [**2176-2-23**], she still
remained supratherapeutic on day of discharge at 31 (on day
[**8-8**]). Her chronic obstructive pulmonary disease was treated
with albuterol and atrovent, though she was not very responsive
to these medications. She was also given a dose of solumedrol
125mg IV, with a subsequent prednisone taper that was ongoing at
the time of discharge. She was diuresed intermittently
throughout the hospitalization (see below) She was intubated in
the emergency room and had a tracheostomy on [**1-18**]. Her
ventilator weaning was complicated by a cuff leak, requiring
30mmHg pressure to seal. This improved, and she has done well on
pressure control. She has also had several trach collar trials,
during which she tires within 10-15 minutes.
2. Pneumothorax - On the morning of [**2176-1-5**], the patient's chest
x-ray showed a vertical linear opacity consistent with
pneumothorax. A chest CT at the time confirmed a large
pneumothorax involving most of her left lung. This was thought
to occur secondary to positive pressure with preexisting severe
bullous disease, and likely occurred the night prior to the
chest x-ray, as she began to have low blood pressure responding
to IV fluids that night. Thoracic surgery was called, and in
concert with interventional pulmonology, they placed a chest
tube in the apex of the left lung. She was determined to still
have an element of pneumothorax at her left lung base, so a
second chest tube was placed. The apical chest tube was
displaced slightly and caused subcutaneous emphysema, but it was
effective and was able to be clamped and removed on [**1-10**] without
complications. The basilar chest tube manifested an inspiratory
leak which resolved until the patient's tracheostomy, at which
time the leak recurred. As such, the thoracic team performed
pleurodesis x 3 ([**Date range (1) 40042**]) with doxycycline. The chest tube was
set to suction and the inspiratory leak resolved. The chest tube
was clamped and removed [**1-24**] without complications. A chest
x-ray after chest tube removal showed no pneumothorax. However,
that night she became increasingly tachypneic, and a CXR in the
morning showed recurrence of the pneumothorax. Another chest
tube was placed, with a significant amount of resulting
subcutaneous emphysema (head to toe) and no significant change
in the pneumothorax. A second chest tube was thus placed, which
resulted in some improvement in the pneumothorax. Her course was
also complicated by a bronchopleural fistula, requiring pressure
control ventilation. Her fistula gradually resolved, and she has
been able to be adequately supported on pressure control
ventilation. Since that time, her subcutaneous emphysema has
gradually improved. Her chest tubes were put to water-seal on
[**2176-1-31**], then were clamped on [**2-9**], and daily CXRs have
revealed no evidence of recurrent PTX. The chest tubes were
sequentially clamped and then removed with serial chest xrays
revealing no pneumothorax. The pt is to follow up with
thoracics surgeon Dr. [**Last Name (STitle) **] after discharge.
3. Hypotension - She had an episode of hypotension in the
setting of her pneumothorax. Initially, it responded to fluid
boluses and, given that the patient had been aggressively
diuresed previously, was thought to be secondary to hypovolemia.
This was likely just a contributing factor to hypotension caused
by pneumothorax. It resolved after chest tube placement. Once
she was normotensive, her metoprolol was restarted.
4. Fluid status - On admission, the patient was volume
overloaded. She responded well to lasix 40mg IV. This was held
in the setting of hypotension (with her pneumothorax), and was
thought to be hypovolemic at that time. She has been
intermittently volume overloaded, with good response to lasix.
Over the past 4 days prior to discharge the pt was euvolemic,
not requiring any lasix.
5. Mental status - Early in the hospitalization, the patient was
noted to have decreasing responsiveness. This was likely related
to her sedation, as once the sedation was lessened, she became
very appropriate and responsive. She also has had difficulty in
regulating sleep/wake cycles. Primary team has been moderately
succesful in improving this with pm ambien, gabapentin,
nortriptyline, and haldol.
6. Yeast infection - She had urine cultures sent that showed
only yeast, and vaginal discharge consistent with yeast. She was
treated with one dose of fluconazole with resolution of her
symptoms.
7. Atrial tachycardia - She had a rhythm consistent with
multifocal atrial tachycardia, most likely secondary to her
underlying pulmonary issues. Her metoprolol was restarted and
the tachycardia resolved.
8. Atrial fibrillation with rapid ventricular response - Ms.
[**Known lastname 7474**] has known PAF, but she had increasingly frequent episodes
of RVR to the 150s, with stable blood pressures. Her metoprolol
and diltiazem dosages were increased, with some effect, but she
continued to have these episodes with maximal doses. She was
placed on an esmolol drip, which helped Ms. [**Known lastname 7474**] to revert to
NSR at a dose of 100mcg/min, but experienced recurrent episodes
on the drip. The electrophysiology service was consulted, who
recommended started amiodarone. She was PO loaded, and placed on
200mg PO bid, in addition to her previous dose of diltiazem. Her
comorbid lung and thyroid conditions were noted in terms of
managing with amiodarone, but this was thought to be the most
appropriate treatment option. Daily EKGs were obtained to assess
for prolonged QT. The pt was switched from diltiazem to
metoprolol as the pt has been noted to have better rate control
with BB than CCB. The pts amiodarone was weaned down to 200 mg
po qd prior to discharge. She developed episodes of atrial
fibrillation while on amiodarone and cardiology was consulted
and she was started on a low dose heparin drip for possible DCCV
if she became hypotensive. Long term anticoagulation is to be
determined as an outpatient The pt will need EKG's to assess for
QT prolongation. Her outpt PCP will also need to assess
reinitiation of coumadin; pt seems to be a likely fall risk per
nursing. Her heparin gtt was discontinued on day of discharge.
9. Diabetes - She was monitored with fingersticks. Initially,
she was treated with an insulin drip, but she was later switched
to a sliding scale. Her BS were generally well controlled.
10. Urinary tract infection - Urine culture grew E. coli and
Enterobacter clocae on [**1-24**]. She was treated with a 7 day
course of meropenem.
9. Hypertension - Other than during her brief episode of
hypotension, she was treated with her outpatient metoprolol and
diltiazem. The pts medications wer changed to metoprolol and
amiodarone.
10. Peripheral vascular disease - Plavix and aspirin was
continued. Vascular surgery was consulted to assess her
gangrenous toe, but the decision was made to defer any
interventions until such time as her respiratory status had
significantly improved. The pt is to follow up with vascular
surgery 1 month after discharge to f/u her dry gangrene. She had
no post-operative complications stemming from her recent left
BKA.
11. Hyperthyroidism - She was continued on methimazole. Her TSH
was high and free T4 low. This needs to be readdressed as an
outpatient, as her current status was likely complicated by her
stay in the ICU, and should be assessed once in an outpatient
setting.
Nutrition - She was treated with tube feeds, initially by
orogastric tube, then by PEG once she had the tracheostomy.
Communication - her son, [**Name (NI) **] [**Name (NI) 7474**], lives in [**State **], and can usually be reached at [**Telephone/Fax (1) 56720**].
Code status - full
Medications on Admission:
Atrovent neb
Flagyl 500mg IV q8
Ceftriaxone 1gm IV daily
Monistat derm [**Hospital1 **]
Lasix 40mg po q8
Vancomycin 1gm IV daily
Fosomax 70mg q Sat
ASA 325mg daily
Tapazole 5mg po daily
Lopressor 75mg q8
Plavix 75mg daily
Cardizem 30mg po q8
Colase 100mg [**Hospital1 **]
[**Doctor First Name **] 60mg daily
Nuerontin 100mg [**Hospital1 **]
Robitussin 200mg [**Hospital1 **]
Heparin SC
RISS
MVI
Prednisone 2.5mg daily
Nortrptyline 25mg qhs
Zantac 150mg
Serevent 50 [**Hospital1 **]
Probenecid 500mg [**Hospital1 **]
Accolate 10mg daily
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Methimazole 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Six (6)
Puff Inhalation Q4H (every 4 hours).
5. Zafirlukast 20 mg Tablet Sig: 0.5 Tablet PO daily ().
6. Docusate Sodium 150 mg/15 mL Liquid Sig: Thirty (30) ml PO
BID (2 times a day) as needed.
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
8. Zantac 150 mg Capsule Sig: One (1) Capsule PO once a day.
9. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
11. Insulin Glargine 100 unit/mL Solution Sig: Fifteen (15)
units Subcutaneous at bedtime.
12. Insulin Regular Human 100 unit/mL Solution Sig: sliding
scale units based on FS see attached sheet for details.
Injection four times a day.
13. Multi-Vitamin Tablet Sig: One (1) Tablet PO once a day.
14. FOSAMAX 70 mg Tablet Sig: One (1) Tablet PO once a week:
once weekly on Sat.
15. [**Doctor First Name **] 60 mg Tablet Sig: One (1) Tablet PO once a day.
16. Nortriptyline 25 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
17. Lorazepam 0.5-1 mg IV Q6H:PRN
Use before haldol for agitation
18. Fluticasone 110 mcg/Actuation Aerosol Sig: Four (4) Puff
Inhalation [**Hospital1 **] (2 times a day).
19. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day.
20. Morphine Sulfate 1-4 mg IV Q2H:PRN
21. Ferrous Sulfate 300 mg/5 mL Liquid Sig: Five (5) cc PO DAILY
(Daily).
22. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
23. Gabapentin 250 mg/5 mL Solution Sig: One Hundred (100) mg PO
BID (2 times a day).
24. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
25. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed.
26. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q1HR () as needed.
27. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed.
28. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q4H (every 4 hours).
29. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for toe pain.
30. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig:
Thirty (30) mg PO once a day.
31. Meropenem 1 g Recon Soln Sig: One (1) Intravenous twice a
day for 2 days.
Disp:*4 grams* Refills:*0*
32. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO three
times a day.
Disp:*135 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary:
1. Pneumonia
2. COPD with bullous disease on home oxygen
3. Pneumothorax
4. Atrial tachycardia
5. Atrial fibrillation
Secondary:
1. DM II
2. Peripheral vascular disease with necrotic toes
3. Hyperthyroidism
4. Anemia
5. Hypertension
Discharge Condition:
Stable.
Discharge Instructions:
Please follow up with all of your doctors, including your PCP as
well as your vascular surgeon regarding your necrotic toes.
Please weight yourself daily, if you notice a significant
increase in your weight more than 3lb daily, please call your
PCP for possible change in medications.
Please note several changes have been made in your medication
regimen. For details, see the following changes:
1. You should continue your antibiotics for the prescribed
length of time.
2. Please continue to take your aspirin, plavix, and lopressor
as you have been doing. You are on a new medication called
amiodarone.
3. Your serevent has been discontinued as it would be difficult
to take with the tracheostomy tube. Instead place take
albuterol IH 6 puffs Q4 hours in addition to the atrovent IH 6
puffs Q4 hours.
4. Please continue your other medications as you have been
doing as well.
If you develop any chest pain, palpitations. shortness of
breath, fevers, chills, nauseas, vomiting, diarrhea or other
concerning health problems, please call your PCP or come
directly to the ED.
Followup Instructions:
1). Please follow up with your PCP within two weeks of
discharge.
2). Please follow up with thoracics Dr. [**Telephone/Fax (1) 56721**]
3). Please follow up with Dr. [**Last Name (STitle) 1391**] (vascular surgeon) on
[**3-27**] at 9:45 AM, [**Last Name (NamePattern1) **] Suite 5c, [**Telephone/Fax (1) 1393**]
ICD9 Codes: 5070, 4280, 5990, 486, 3572 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3417
} | Medical Text: Admission Date: [**2157-6-2**] Discharge Date: [**2157-6-7**]
Date of Birth: [**2120-8-28**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5868**]
Chief Complaint:
Headache, ?seizure.
Major Surgical or Invasive Procedure:
Factor VIII infusions
History of Present Illness:
The pt is a 36 year old male with a history of hemophilia A, HIV
(CD4 count 500 per pt) who presented from OSH on [**2102-6-2**] with a
subdural hemorrhage. The pt. stated that he began to develop a
diffuse, "throbbing" headache on the morning of admission. He
is an attorney and was giving a deposition in a courtroom on the
day of when he suddenly fell to the ground, had what was
described as a generalized seizure lasting several minutes, and
was barely responsive afterwards. The first thing that the pt
recalled after giving the fall and possible seizure is awaking
in the hospital with a "terrible" headache. He was taken to an
OSH where workup included a head CT which showed a subdural
hematoma over the left frontal lobe, interhemispheric fissure,
and around the midbrain. The patient was then transferred to the
[**Hospital1 18**] for further care.
On transfer to [**Hospital1 18**], the pt complained of fatigue and a
headache. The was described as "throbbing" and diffusely
located. He also admitted to photophobia. No neck stiffness,
recent n/v/fevers/recent travel. He is compliant with his
medications. The pt. denied recent neck/back manipulations. He
stated that this sort of episode has never happened before.
There has been no remote head trauma.
The pt. was admitted to the neurologic ICU where he remained for
one day. During this time, he underwent two serial head CTs
which showed stable size of the left frontoparietal subdural
hematoma. He was also loaded with dilantin for seizure
prophylaxis. A hematology/oncology consult was obtained in
light of the pt's diagnosis of hemophilia A. They recommended
q8h factor VIII infusions, which the pt. has received. As the
pt. remained hemodynamically stable, experienced no further
seizures and had a stable size SDH, he was transferred to the
floor on hospital day 2.
At the time of my encounter, the pt. again complained of fatigue
and headache. He stated that there has been no change in the
quality of the headache since onset as described above. He
rated the intensity [**8-13**] despite morphine and demerol. He
otherwise offered no complaints.
Discussion with the pt's parents and brother later on the day of
transfer revealed that the pt. had been complaining of headache
for about 4 days prior to the aforementioned incident on the day
of admission. In addition, the pt's brother stated that he had
spoken to a workmate who was in court with the pt. at the time
of the incident who did not recall any seizure-like activity.
Per this witness, the pt slumped over on a table in a sitting
position and became less responsive during the deposition but
did not have any abnormal movements. Obviously this could not be
confirmed with the pt.
Past Medical History:
1. Hemophilia A/factor VII dependent
2. HIV, cd4 count 500 per pt.
3. Hepatitis C.
Social History:
He does not drink alcohol, smoke tobacco, or use illicit drugs.
He is an attorney and works as an assistant attorney general. He
is single.
Family History:
No family members with hemophilia, seizures.
Physical Exam:
PE: T-98.6F BP-134/60 HR-88 RR-18
Gen: lying in bed, asleep in no apparent distress
Heent: NCAT, oropharynx clear
Neck: supple, no carotid bruits
Chest: clear to auscultation b/l
CV:regular rate, normal s1s2, no m/r/g
Ext: no c/c/e, 2+ dorsalis pedis pulses b/l
Neurologic Exam:
MS: Asleep but easily arousable.
Oriented to person, place and time.
The patient is unable to say moyb. He can do dowb.
Fluent speech, repetition, naming intact. Able to read and
write.
Memory [**2-3**] registration, encodes [**12-7**] with interference. Recall
[**12-7**] at 5 minutes.
No apraxia, neglect, frontal signs. Calculation intact.
CN:
Visual fields intact to confrontation
Pupils normal round 4mm->2mm with light.
EOMI without nystagmus.
Normal facial sensation and musculature.
Hearing intact to finger rub.
Palate rises symmetrically. Tongue midline.
Motor:
Normal tone and bulk. No tremors or fasciculations.
Pronator drift absent.
Strength: 4-/[**3-7**]+ = mild/moderate/great resistance
[**Doctor First Name **] Tri [**Hospital1 **] WrF WrE FiF [**Last Name (un) **] Ilio Quad Ham FoF FoE [**Last Name (un) 938**]
L 5 5 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5 5
Reflexes:
There are [**1-7**] reflexes throughout/
Plantar reflexes flexor bilaterally.
Sensory:
Intact to pinprick, vibration, proprioception and temperature
throughout.
Coordination:
Intact FTN b/l.
Intact [**Doctor First Name **].
Gait:
Romberg sign absent
narrow based, stable, good arm swing. Tandem intact.
Pertinent Results:
Labs on admission:
[**2157-6-2**] 08:35PM BLOOD WBC-14.2*# RBC-4.77 Hgb-13.8* Hct-41.2
MCV-86# MCH-28.8 MCHC-33.4 RDW-14.8 Plt Ct-135*
[**2157-6-2**] 08:35PM BLOOD Neuts-80.2* Lymphs-15.2* Monos-4.4
Eos-0.2 Baso-0.1
[**2157-6-2**] 08:35PM BLOOD PT-12.7 PTT-33.8 INR(PT)-1.1
[**2157-6-3**] 05:36AM BLOOD WBC-11.3* Lymph-18 Abs [**Last Name (un) **]-2034 CD3%-66
Abs CD3-1346 CD4%-21 Abs CD4-428 CD8%-44 Abs CD8-886*
CD4/CD8-0.5*
[**2157-6-2**] 08:35PM BLOOD FacVIII-27*
[**2157-6-2**] 08:35PM BLOOD Glucose-106* UreaN-23* Creat-0.9 Na-140
K-3.2* Cl-104 HCO3-26 AnGap-13
[**2157-6-3**] 05:36AM BLOOD ALT-24 AST-19 LD(LDH)-176 CK(CPK)-131
AlkPhos-96 Amylase-140* TotBili-1.3
[**2157-6-2**] 08:35PM BLOOD Calcium-8.9 Phos-3.0 Mg-2.2
Imaging:
Head CT ([**2157-6-2**]):
FINDINGS: There is a left frontal and parietal acute subdural
hemorrhage measuring 9 mm adjacent to the left frontal lobe,
where it appears widest on axial images. There is mass effect on
the left cerebral hemisphere and narrowing the left lateral
ventricle, with minimal shift of the normally midline structures
to the right. Subdural blood continues across the left tentorium
and is be present in the left middle cranial fossa, under and
around the temporal lobe. No parenchymal hemorrhage is
identified. The density values of the brain parenchyma are
within normal limits and the [**Doctor Last Name 352**]- white matter differentiation
is preserved.
The surrounding osseous and soft tissue structures are
unremarkable. The visualized paranasal sinuses are normally
aerated.
IMPRESSION: Acute left subdural hemorrhage causing mass effect
on the left cerebral hemisphere with slight shift of the midline
Head CT ([**2157-6-3**]):
CT HEAD FINDINGS: The small left frontal convexity subdural seen
on the prior day's scan is unchanged in size, again exerting
mass effect on the adjacent brain parenchyma. Once again,
subdural blood traverses over the left tentorium, but is again
unchanged compared to the prior study. No new foci of
intracranial hemorrhage are identified. The left ventricle is
mildly effaced, the ventricles are otherwise unremarkable. There
is no obvious blurring of the [**Doctor Last Name 352**]-white interface or focal
effacement to suggest infarction. Bone windows demonstrate no
evidence of fracture. The orbits are unremarkable, and the
sinuses are clear.
IMPRESSION: No significant change in the size or associated mass
effect of the left subdural hematoma compared to the prior day's
study. No new foci of hemorrhage are identified.
Head MRI ([**2157-6-4**]):
FINDINGS: A thin rim of subdural hematoma is identified
extending from the left frontal to the occipital region without
significant mass effect on the adjacent brain. The maximum width
of the subdural is approximately 3 mm. A thin rim of subdural is
also seen along the tentorium on the left side. There is no
midline shift or mass effect. There is no evidence of slow
diffusion to indicate acute infarct. There is no evidence of
focal signal abnormalities within the brain. On susceptibility
weighted images, there is no evidence of acute or chronic blood
products in the brain parenchyma. Following gadolinium, no
evidence of abnormal parenchymal or vascular enhancement seen.
IMPRESSION: Small left-sided subdural from frontal to occipital
region with extension along the tentorium, unchanged from the
previous CT of [**2157-6-3**]. No mass effect or midline shift seen. No
evidence of slow diffusion or intraparenchymal abnormalities. No
evidence of abnormal enhancement.
Brief Hospital Course:
1. Left frontal subdural hematoma: It was felt that the most
likely scenario was that the pt. had low factor VIII levels
secondary to underlying hemophilia A and sustained a spontaneous
SDH. The hematology/oncology service consulted on the pt. and
recommended q8h factor VIII infusions and p.o. steroids (both
were scheduled as tapered doses on discharge as below). The pt
had serial head CTs which demonstrated stable size of the
hematoma. He is to follow-up with a repeat head CT with the
neurosurgical service in 8 weeks to document size. There was
question of whether the pt actually had seizure. Since it was
felt that if the pt were to seize off anti-seizure medication,
in the context of hemophilia, he would be at risk to develop
another intracranial bleed. Therefore, the decision was made to
discharge the pt. on an anti-convulsant. The pt. was originally
loaded with and maintained on phenytoin. He developed a diffuse
papular rash on this medication, however, and the regimen was
changed to keppra prior to discharge. The pt. also had a
signficant headache and blurred vision with a mild degree of
photophobia during the hospital stay. He was initially placed
on intravenous morphine and demerol prn with little effect. He
was therefore placed on a dilaudid PCA. When his requirements
were determined, he was transitioned to p.o. dilaudid prior to
discharge. He was also started on verapamil for headache in the
context of hypertension when this was unsuccesful, Neurontin was
also added. His headache control was tolerable on this regimen,
by time of discharge.
2. Hypertension: The pt. developed difficult-to-control
hypertension during the course of the hospital stay after he was
taken off of labetalol drip. He was placed on captopril with
increasing doses, eventually reaching 50mg tid. Beta-blockers
were held since he was significantly bradycardic on telemetry
(HR in 40s). He was also placed on verapamil as above.
3. HIV: The pt. was maintained on his usual HAART regimen.
The infectious disease service consulted on the pt and felt that
an infectious workup was not warranted given the pts
constellation of symptoms.
Medications on Admission:
1. Factor VIII replacement.
2. Ambien.
3. Zoloft.
4. Prilosec.
5. NSAIDs for arthritis.
Discharge Medications:
1. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Abacavir 300 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane
QID (4 times a day).
4. Fosamprenavir Calcium 700 mg Tablet Sig: Two (2) Tablet PO
Q12H (every 12 hours).
5. Lopinavir-Ritonavir 133.3-33.3 mg Capsule Sig: Three (3) Cap
PO BID (2 times a day).
6. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
7. Lamivudine 150 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Verapamil 120 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q24H (every 24 hours).
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
9. Prednisone 10 mg Tablet Sig: six Tablet PO once a day for 1
days: Take 60mg daily on [**6-8**], take 40mg daily on [**6-9**], take 20mg
daily on [**6-10**], take 10mg on [**6-11**], take 5mg on [**6-12**]. .
Disp:*14 Tablet(s)* Refills:*0*
10. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain/headache.
Disp:*50 Tablet(s)* Refills:*0*
11. Captopril 25 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*180 Tablet(s)* Refills:*2*
12. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
Disp:*180 Capsule(s)* Refills:*2*
13. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day): Take 1 tab po bid for one week, then take 2 tabs
po bid thereafter until instructed otherwise.
Disp:*100 Tablet(s)* Refills:*2*
14. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
15. Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
Discharge Disposition:
Home
Discharge Diagnosis:
1. Left Frontal Subdural Hemorrhage
2. Hemophilia A/factor VIII dependent
3. HIV
4. Hepatitis C
5. Hypertension
Discharge Condition:
Pt. was still complaining of headache (although overall improved
since admission) and some residual photophobia and blurred
vision.
Discharge Instructions:
Continue with medications listed below. Please attend all
follow-up appointments.
Call your doctor or go to the Emergency Room if you have
worsening headache, blurred vision, seizures, dizziness,
worsening nausea/vomiting or any concerning symptoms.
Continue factor VIII replacement as follows:
-one infusion every 8 hours for 3 more days
-then one infusion every 12 hours for 3 days
-than one infusion daily thereafter or until instructed
otherwise by Dr. [**Last Name (STitle) 9625**].
Followup Instructions:
Please call Dr. [**Last Name (STitle) 9625**] ([**Telephone/Fax (1) 9701**]) for follow-up appointment
within the next week.
Provider: [**Name Initial (NameIs) 703**] (H3) GENERAL 2 RADIOLOGY Where: [**Hospital6 29**]
RADIOLOGY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2157-6-10**] 3:00
Please follow-up with neurosurgery in 8 weeks. Please call Dr. [**Name (NI) 14075**] office at [**Telephone/Fax (1) 1669**] to schedule an
appointment. You will need to have a CT of the head performed
prior to this appointment. Please call radiology [**Telephone/Fax (1) 327**]
to schedule an appointment in 8 weeks.
Please call the [**Hospital 878**] Clinic at [**Telephone/Fax (1) 541**] to schedule an
a follow-up appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 575**] and Dr. [**First Name8 (NamePattern2) 9485**]
[**Last Name (NamePattern1) **] in [**3-9**] weeks.
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3418
} | Medical Text: Admission Date: [**2180-10-22**] Discharge Date: [**2181-1-18**]
Date of Birth: [**2132-6-30**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 10435**]
Chief Complaint:
adbominal pain, bloody diarrhea
Major Surgical or Invasive Procedure:
sigmoidoscopy with rectal biopsies
paracentesis
Total abdominal colectomy with end ileostomy on [**2180-11-16**]
History of Present Illness:
48F with cirrhosis on transplant list, Hx ulcerative colitis,
transferred from OSH where she was being treated for suspected
flare of ulcerative colitis with c difficile positive stool.
She has had nonbloody diarrhea since [**Month (only) 205**] when she received an
NJ tube to improve her nutritional status related to
decompensated cirrhosis. The NJ tube was removed in [**Month (only) 216**]
because she tolerated it poorly and was not gaining weight as
intended. She presented to her PCP in early [**Name9 (PRE) **], again
for diarrhea and weight loss, and due to a high WBC count noted
on labs was referred to OSH ER and subsequently hospitalized for
acute cholangitis and an ulcerative colitis flare, and treated
with zosyn and ertapenem and steroid enemas. She was discharged
on [**10-2**], but re-presented to the OSH on [**10-18**] with abdominal
pain, nausea, vomiting, and six bowel movements per day. She
was unable to hold steroid enemas and stopped using them three
days prior to admission. In the ED at OSH, CT scan showed
diffuse colitis with ileal involvement. She was admitted and
treated with IV fluids, flagyl 500 TID, mesalamine [**2169**] mg [**Hospital1 **],
rectal mesalamine, pantoprazole, oral vancomycin 500 mg Q6h,
rectal vancomycin 500 Q6h. Her WBC count initially responded,
decreasing from 20.3 on admission to 10.2, but on the morning of
transfer it was again elevated to 18.6. Her stools became
bloody on [**10-21**]. She was hypotensive with concern for low urine
output (both of unspecified degree), and according to records
received 4L of NS without improvement in BP but with abdominal
distension. A CVL was placed and she was transferred to the OSH
MICU and a central venous catheter was inserted. She was given
750 mg albumin, and 15 mg vitamin K for coagulopathy.
Labs on the morning of discharge from OSH include: WBC 18.6, HCT
38.2, platelets 352, BUN 3, Cr 0.56, AST 31, ALT 17, Alk phos
392, Albumin 1.5, and Tbili 1.1.
On admission, the patient felt cold and complained of diffuse
abdominal pain greater on the right of her belly. Her nausea
and vomiting had improved, although she had been given zofran at
OSH. She denies sick contacts. Feels that her legs are swollen
above. Denies cough, SOB, CP.
Past Medical History:
ESLD due to primary sclerosing cholangitis diagnosed in [**2179**]
according to daughter, with recent decompensation in the past 12
months, including portal hypertension, hyperbilirubinemia,
hypoalbuminemia, coagulopathy, and hepatic encephalopathy;
required NJ feeding tube for malnutrition with subsequent
improvement. Per [**Hospital1 18**] and OSH records, she has had recurrent
ulcerative colitis episodes since [**2178**], and recurrent C
difficile infections since [**2178**], although her daughter claims
that the first C difficile infection was in [**2180-3-21**] at which
time she says ulcerative colitis was first diagnosed on
colonoscopy.
Past Surgical History:
Denies.
Social History:
Lives with sister and sister's family in [**Doctor Last Name **]. Denies
tobacco, alcohol, or drugs.
Family History:
(from OMR and patient) Mrs. [**Known lastname 88568**] is one of 7 siblings. She was
born in [**Country **], and her family fled to [**Country 3396**] in [**2148**]. They
lived in a refugee
camp until [**2151**] when they left for the [**Country 31115**] for 3 months,
then eventually coming to the US directly to RI to live with her
sister. Since leaving [**Country 31115**], she's travelled to [**Country **]
once, [**Country 6607**], and [**Location (un) 3844**], [**State 1727**], [**State 2748**], and [**State 108**]
in the US. She's also been through the Caribbean, but on a
cruise ship with minimal on-shore time.
Physical Exam:
VS: 97.7F, 102, 101/73, 99% on 2L
- general: tired appearing but in no acute distress, alert,
oriented x3
- HEENT: normocephalic, atraumatic; PERRL, EOMI, sclera hazy but
not icteric; oral mucosa moist; neck midline and supple without
masses; no cervical, supraclavicular, or axillary
lymphadenopathy
- CV: tachycardic, no M/R/G
- Resp: CTAB anteriorly, no respiratory distress
- Abd: rare BS, diffuse tenderness greater on the right UQ and
LQ, minimal guarding, no masses, minimal distension
- Rectal: rectal tube in place draining slightly blood-tinged
watery stool
- Ext: swelling with trace edema of the bilateral thighs,
pressures stockings in place on bilateral lower extremities
without edema, 2+ DP pulses bilaterally, all extremities WWP
Discharge: Expired
Pertinent Results:
[**2180-10-22**] 06:23PM WBC-10.3 RBC-2.99* HGB-8.3* HCT-26.9* MCV-90
MCH-27.7 MCHC-30.8* RDW-17.8*
[**2180-10-22**] 06:23PM NEUTS-82.1* LYMPHS-11.8* MONOS-1.8* EOS-4.1*
BASOS-0.2
[**2180-10-22**] 06:23PM PLT COUNT-191#
[**2180-10-22**] 06:23PM PT-17.6* PTT-39.5* INR(PT)-1.6*
[**2180-10-22**] 06:23PM GLUCOSE-128* UREA N-3* CREAT-0.5 SODIUM-142
POTASSIUM-3.3 CHLORIDE-116* TOTAL CO2-16* ANION GAP-13
[**2180-10-22**] 06:23PM ALT(SGPT)-13 AST(SGOT)-22 LD(LDH)-97 ALK
PHOS-272* AMYLASE-19 TOT BILI-3.1*
[**2180-10-22**] 06:23PM LIPASE-14
Pertinent Results
Imaging:
RUQ U/S [**2180-10-26**]: 1. Coarsened liver echotexture with ascites and
splenomegaly, consistent with sequelae of portal hypertension.
Normal Doppler study. 2. Segmental intrahepatic biliary
dilatation in the right and left hepatic lobes, consistent with
diagnosis of primary sclerosing cholangitis. The degree of
intrahepatic ductal dilatation on the left is mildly improved
when compared to [**2179-3-22**]. 3. Bilateral pleural effusions.
CT abdomen [**2180-10-26**]: IMPRESSION: 1. Bilateral pleural effusions
with adjacent compressive atelectasis. 2. Hepatic cirrhosis with
evidence of portal hypertension. 3. Dilated intrahepatic biliary
system with evidence of stricturing, consistent with provided
history of primary sclerosing cholangitis. 4. Worsening ascites
and anasarca. 5. A haustral and featureless appearing colon
consistent with provided history of ulcerative colitis. 6. Bowel
wall edema involving the colon, which can be either due to
portal hypertension, colitis from either ulcerative colitis, or
C. diff colitis.
KUB [**2180-10-31**]: IMPRESSION: No evidence of megacolon.
CT abdomen [**2180-11-10**]: IMPRESSION: 1. Interval decrease in
bilateral pleural effusions with adjacent compressive
atelectasis. 2. Liver cirrhosis with evidence of portal
hypertension as seen on prior. 3. Mild interval worsening of the
intrahepatic biliary dilation; correlate with LFTs. Evidence of
stricturing and beading consistent with history of primary
sclerosing cholangitis. 4. Persistent anasarca. Moderate
ascites, with interval increase in size compared to prior. 5.
Ahaustral featureless colon in keeping with history of
ulcerative colitis. Diffuse colonic wall edema, appears more
than typically seen in third spacing, may be related to history
of ulcerative colitis or colitis of other etiology. 6.
Geographic regions of hyperemia in the liver may be perfusional
in nature
or might be related to cholangitis. 7. Calcified focus,
presumably gallstone, remains lodged without change in the
cystic duct as on the prior CT examinations.
Rectal biopsy [**2180-10-23**]:
Rectum: Chronic active colitis with ulceration (see note).
Note: No granulomas or dysplasia identified. The findings are
not characteristic of ischemic colitis. No definitive CMV
staining is seen. Controls satisfactory.
Biopsy [**2180-11-1**]: 1. Colon biopsies: A. Descending colon: Chronic
mildly active colitis. B. Sigmoid colon: Chronic inactive
colitis. C. Rectum: Chronic severely active colitis with
ulceration.
Note: No granulomata or dysplasia identified.
Immunohistochemical stains are negative for cytomegalovirus on
all biopsies; controls are adequate.
Sigmoidoscopies
[**2180-10-23**] Impression:Loss of vascularity, erythema, congestion,
ulceration and exudates in the rectum and distal sigmoid colon
compatible with colitis (biopsy) Otherwise normal sigmoidoscopy
to distal sigmoid colon.
[**2180-11-1**]: Ulceration, granularity, friability, erythema,
congestion and loss of the normal vascular pattern in the entire
visualized segments of the colon. (biopsy) Otherwise normal
sigmoidoscopy to splenic flexure
[**2180-11-7**]: Improvement in colitis as compared to previous flex
sig.
[**2181-1-13**] 03:53AM BLOOD WBC-35.7*# RBC-3.01* Hgb-10.2* Hct-30.5*
MCV-101* MCH-33.8* MCHC-33.4 RDW-24.7* Plt Ct-431
[**2181-1-12**] 05:52PM BLOOD Neuts-96* Bands-0 Lymphs-3* Monos-1*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2181-1-12**] 05:52PM BLOOD Hypochr-NORMAL Anisocy-3+ Poiklo-1+
Macrocy-3+ Microcy-1+ Polychr-NORMAL Target-1+ Burr-OCCASIONAL
Tear Dr[**Last Name (STitle) 833**] [**Name (STitle) 24904**]
[**2181-1-12**] 05:52PM BLOOD PT-15.4* PTT-43.9* INR(PT)-1.4*
[**2181-1-13**] 04:00PM BLOOD Glucose-86 UreaN-38* Creat-0.9 Na-139
K-3.4 Cl-98 HCO3-28 AnGap-16
[**2181-1-13**] 03:53AM BLOOD cTropnT-0.01
[**2181-1-12**] 05:52PM BLOOD CK-MB-2 cTropnT-0.02*
[**2181-1-13**] 04:00PM BLOOD Calcium-9.2 Phos-2.5* Mg-2.2
Brief Hospital Course:
Ms [**Known lastname 88568**] is a 48 yo Cambodian woman with a PMH of ulcerative
colitis and primary sclerosing colangitis with cirrhosis
currently on the liver transplant list who was transferred from
an outside hospital with Cdiff pancolitis as well as ulcerative
colitis flare.
Leukocytosis/Fevers: Throughout Ms. [**Known lastname 88569**] admission, her WBC
were waxing and [**Doctor Last Name 688**] ranging from 10k-28k. Unclear etiology.
Pt has remained afebrile and infectious workup (BCx, UCx, C.
diff, CXR, Biliary cultures, peritoneal fluid cultures) have
been repeatedly negative. Paracentesis was consistent with SBP
on [**2180-12-31**], but all prior paracenteses were inconsistent. She
was given 3 doses of Cefazolin and Flagyl immediately post op
from her TAC. Ms. [**Known lastname 88568**] became febrile on POD 7, and was started
on Vanc/Zosyn and was transferred tto the unit for
encephalopathy and tachycardia attributed to an infection.
Eventually after 7 days of antibiotics and a lack of change in
her clinical status, antibiotics were discontinued and she was
called out to the floor. She immediately became febrile,
tachcardic with low SBPs 80's-90's, and returned to the SICU.
She was restarted on Vanc/Zosyn and stabilized. She was
transferred to the floor the next day where antibiotics were
continued, but continued to have low grade (99-100.5F) daily.
Repeat urine cultures demonstrated yeast, and in light of
recalcitrant fevers micafungin was continued. During her second
week on the floor a trial off antibiotics was attempted, and Ms.
[**Known lastname 88568**] developed higher grade (101-102F) fevers and vanc/zosyn
were restarted on [**2180-12-30**]. Upon transfer to [**Doctor Last Name **] [**Doctor Last Name **], all
cultures remained negative. Per ID recs Vanc/Zosyn were
discontinued due to prolonged exposure Meropenem was started.
Also a trial of Methylprednisone was instituted with the
suspicion of a possible crohns fare causing her abdominal pain
and prior noted intestinal ulcers. Ileoscopy was performed on
[**12-27**] and [**1-10**]. Biopsy of ulceration from [**12-27**] was negative
for CMV and AFB smears. [**1-10**] ileoscopy showed what looked like
bowel ischemia, but MRA abdomen was negative. The patient
continued to spike temperatures, with unclear etiology.
.
After a goals of care discussion with the patient's daughter and
sister, it was decided to make her DNR. She was ultimately made
DNR and CMO, and all antibiotic therapy was stopped.
.
C.Diff Pancolitis- patient had evidence of positive C diff toxin
at the OSH, but all were negative here at [**Hospital1 18**]. Given this
history she was treated with a 14 day course of po and rectal
vancomycin and IV metronidazole. She was also covered
empirically for SBP with cefepmine on arrival. Although Pt
continued to have loose stool and high ileostomy output, her
multiple C diff stool toxin tests have remained negative during
this admission including those sent after the total abdominal
colectomy. The patient continued to have high ostomy stool
output and was continued on octreotide to help with her
diarrhea. Ultimately, the patient was made DNR and CMO and the
goal was to treat her abdominal pain.
.
Inflammatory Bowel [**Name (NI) **] Given Pt's continued diarrhea and
history of UC flares, Pt had a sigmoidoscopy on [**10-23**] showing
friability and ulceration consistent w/ UC flare. Rectal
biopsies were also consistent w/ colitis. She was made NPO and
was started on IV solumedrol, with some response in her CRP.
After about a week of treatment she underwent a repeat
sigmoidoscopy, which showed some improvement. Pt was continued
on IV solumedrol and started on cyclosporine to increase
immunosuppression. Her third flex sig showed some improvememnt
in the colitis and she was transitioned to po prednisone and po
cyclosporine. She originally was having >1L of diarrhea per day
which reduced down to ~600mL daily. However, Pt continued to
have significant abdominal pain [**6-30**] in intensity. Given her
lack of significant clinical improvement, very high inflammatory
markers ([**11-14**] CRP 107 and ESR 90), GI recommended consulting
colorectal surgery for possible colectomy. Pt was discussed at
length with multiple teams, and Pt understand high operative
risk but wants to proceed. Pt had her TAC with end ileostomy on
[**2180-11-16**]. Intra-op she had 3l of ascitic fluid taken off. She
was then transferred to the colorectal service for postoperative
care at this point. She was brought to the ICU intubated
post-operatively and was extubated on POD 0 without issue. She
was continued on hydrocortisone 100mg Q8 and cyclosporine. On
POD1 she was noted to have a Hct drop to 21.3 and was
transfused 2URBC with a Hct bump to 29 and was otherwise doing
well. Ostomy consult was initiated. She was noted to have
continued tenderness to palpation. On POD 2 her T bili was up to
12 with a MELD score of 17. She was doing well respiratory wise
and was continued on a 3 day steroid taper. Patient was given
TPN for nutrition. On POD 3 TPN was continued, her abdominal
pain persisted, her JP drain continued to have high output, and
her ostomy only had sweat. Her bilirubin began trending down at
this point. Her JP output was repleted with a combination of
albumin and normal saline. Ostomy site looked pink but without
output at this point and she was tolerating small sips. She was
noted to have bilateral pedal edema. On POD4 she continued to
have JP output and was repleted for this. Her ostomy continued
to look good but only scant output. She was transitioned to a
prednisone taper. By PDO 6 her JP continued to have high output
as did her ostomy. She was actively repleted at this point. The
patient's fluid balance proved difficult to manage as she had
very high ileostomy output as well as high output of acities
from the JP drain site. This was managed as needed with boluses
of IV albumin, 1/2NS or NS, and TPN. The JP drain was removed
from the abdomen after two weeks and the midline surgical
incision as well as ileostomy site showed no sign of drainage of
aicties. The patient was seen by the gastroenterology service
after having almost 4 liters of ileostomy output and a CT scan
which showed thickening in the small bowel without showing signs
of improvment with metamucil wafers, she remained NPO, high dose
imodium, and tincture of opium. The patient was started on
subcutaneous octreotide which had some affect on the output. On
[**2180-12-4**] the dose of imodium was titrated up and she continued
to show improvement. Her elctrolytes were monitored closely
throughout this time and she was repleated as necissary. At the
time of transfer from the colorectal surgery service to
hepatology, the patient's midline incision was closed and intact
with staples and ileostomy was pink and draining liquid green
stool. Given consistently high ostomy output, Crohn's disease
was entertained as an etiology. Post-operatively, Ms. [**Known lastname 88568**] [**Last Name (Titles) 4579**]d significant output from her jejunostomy 2-3L daily
which persisted despite tincture of opium and octreotide. Fluids
were repleted with 5% albumin. Jejunal biopsy from [**12-27**]
demonstrated an ulceration which was negative for bacteria, CMV,
and AFB upon smear. Ileoscopy from [**1-10**] demonstrated ischemia,
but MRA abdomen was normal.
.
# PSC/Cirrhosis- patient has history of PSC and has cirrhosis
and is on the liver transplant list. She is Childs Class B and
felt to have a poor outcome prognostically for having a
colectomy, but after extensive discussions with GI, Liver,
Transplant and Colorectal surgery teams as well as with the
patient, Pt was taken for colectomy on [**2180-11-16**] (see above). Her
LFTs slowly worsened during her admission with AST 20s and ALT
10s, AP 200-300s, total bili [**3-25**] worsening to AST 40s-80s, ALT
30s-50s, AP 400-800, total bili 7-9s. MELD score ~13-15. Pt
continued to have significant lower extremity edema and ascites,
requiring multiple therapeutic taps, and [**Hospital1 **] albumin.
.
Bilirubinemia: Ms. [**Known lastname 88569**] total bilirubin (direct predominant)
remained elevated at 6-10 through her stay, elevated from 3 on
admission. The differential include progression of PSC or
cholangitis. The bilirubinemia did not improve significantly
with antibiotic therapy or with PTC which was performed by IR on
[**2180-12-26**]. The patient continued to spike fevers, and towards the
end of [**Month (only) 1096**] started having increasing bilis, and it was
thought that the biliary drain was obstructed; however, an IR
study showed that it was patent. The patient's drain was
ultimately pulled when she was made CMO.
.
Pain Management: Ms. [**Known lastname 88568**] complained of diffuse pain worse in
abdomen and proximal LLE secondary to cutaneous zoster vs. IBD.
Pain management was consulted, and this pain improved but was
not completely eliminated by TID gabapentin, QHS nortryptiline,
fentanyl 75mcg/hr, and PRN IV dilaudid (approximately 30mg
daily). After goals of care discussion with family, the patient
was made CMO and pall care and pain management were both
following the patient.
.
Derm: On [**11-17**] the patient developed a vesicular rash over
her right groin and thigh. This closely resembled Herpes Zoster.
Dermatology was consulted for recommendatons in this very
complicated patient. The patient applied cool compresses to the
rash for comfort. Ms. [**Known lastname 88568**] was treated with a 10 day course of
acyclovir. These zoster lesions crusted over by late [**Month (only) **].
.
CMV viremia: Initially elevated on [**12-3**] to 2040 and Ms. [**Known lastname 88568**]
was started on twice daily ganciclovir. Subsequent CMV titres
were negative, and Ms. [**Known lastname 88568**] was decreased to daily dosing of
gancyclovir on [**2180-12-29**]. She was then maintained on maintenance
gancyclovir.
.
Nutrition: The patient's nutrition labs were monitored closely
during her inpatient stay. Her nutrition status was maintained
initially on TPN, but given concern for sepsis, TPN was
discontinued. A Dobhoff was placed while she was in the SICU and
tube feeds were given at 70 cc/hr.
.
GI Bleeding: transferred to MICU on [**2181-1-12**] for hemodynamic
monitoring from bloody ostomy output. Concerned for ischemia so
went to IR for contrast injection but everything patent. Got
5mg Vitamin K for INR of 1.9 and 2 units PRBCs. Developed chest
pain; CXR showed pulmonary edema, patient given 40mg IV Lasix.
Cardiac enzymes negative. Responded well to diuresis. Ostomy
put out brown stool with no evidence of frank blood overnight.
Hct did not change much to transfusion. Pt was stable so
transferred to [**Doctor Last Name **] [**Doctor Last Name **] service.
.
The patient was ultimately made DNR and eventually CMO after
ongoing discussions with her family. She expired overnight
[**2100-1-18**]. Post mortem examination was requested.
Medications on Admission:
MetRONIDAZOLE (FLagyl) 500 mg IV Q8H
Ondansetron 4 mg IV Q8H:PRN nausea
FoLIC Acid 1 mg PO/NG DAILY
Pantoprazole 40 mg IV Q24H
Heparin 5000 UNIT SC TID
Lactinex *NF* (lactobacillus acidoph & bulgar) 1 million cell
Oral
Mesalamine DR 1200 mg PO TID
Vancomycin Oral Liquid 500 mg PO/NG Q6H
Vancomycin Enema 500 mg PR
Mesalamine (Rectal) 4000 mg PR HS
Morphine Sulfate 1 mg IV Q4H:PRN pain
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary:
Ulcerative colitis flare
Secondary:
Cirrhosis
Primary sclerosing cholangitis
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 10438**]
ICD9 Codes: 2761, 5990, 5715 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3419
} | Medical Text: Admission Date: [**2128-8-21**] Discharge Date: [**2128-8-23**]
Date of Birth: [**2064-12-29**] Sex: M
Service: MEDICINE
Allergies:
Lisinopril / Shellfish Derived
Attending:[**Doctor First Name 2080**]
Chief Complaint:
tongue swelling
Major Surgical or Invasive Procedure:
Laryngoscopy
History of Present Illness:
This is a 63 year old male with a PMH significant for
hypertension recently started on lisinopril who presents with
one day of facial and tongue edema. He states that [**8-22**] after
eating some shrimp he woke up around 3 am and noticed that his
face and tongue felt swollen; he tried to go back to sleep but
was unable to sleep. When he finally got up in the morning he
drank a cup of coffee and showered, but when his face was not
improving he called his daughter to come get him and take him to
the hospital. He said that he was having some trouble
swallowing but denied having any shortness of breath. He says
he had a similar episode about two months ago that was not as
severe and resolved without intervention. Also, he recently
started lisinopril in [**Month (only) **], no other new medications. He says
that he has had shrimp multiple times in the past, and that
eating shrimp was not associated with his prior episode.
In the ER, his initial vitals were: 96.6 65 135/82 18 100. He
was given SQ epinephrine, 125mg solumedrol, benadryl and pepcid.
He was evaluated by ENT in the ER, who felt that he had a more
impressive exam internally by DL than expected based on his
presentation. As a result he was admitted to the [**Hospital Unit Name 153**] for
closer monitoring.
At the time of transfer his vitals were: 71, 117/79, 16, 96% on
RA. Upon arrival to the ICU, patient had no complaints, denied
any shortness of breath, difficulty swallowing, trouble
controlling his own secretions or difficulty speaking in
complete sentences; he also denied any rash or pruritus. On
review of systems he did note increased frequency of urination
in last three days, particularly after lying down.
Denies fever, chills. Denies headache, visual changes, sinus
pain, rhinorrhea. Denied cough, shortness of breath. Denied
chest pain or tightness, palpitations. Denied nausea, vomiting,
diarrhea, constipation or abdominal pain. No recent change in
bowel or bladder habits.
In the ICU he was treated with dexamthasone, benadryl, and
famotidine. He was followed by ENT who felt he was stable to
transfer to floor. Currently he feels totally back to normal and
wants to go home.
Past Medical History:
-Hypertension
-Latent TB Infection, s/p 9 months isoniazid
-H/O Prostatitis
-H/O Bladder Stones
Social History:
The patient is currently living with his wife and two children
at home. He is a retired assembly line worker. He walks
approximately 30-45 minutes every day in the morning. He is a
lifelong nonsmoker. Drinking approximately zero to one
drinks per day of either beer or whisky, generally less than
seven in a given week. Denies any illicit drug use.
Family History:
The patient denies any knowledge of any family history any
illness.
Physical Exam:
VS: T 98.3 HR 85 BP 137/70 RR 20 Sat 97% RA
Gen: Well appearing man in NAD
Eye: extra-occular movements intact, pupils equal round,
reactive to light, sclera anicteric, not injected, no exudates
ENT: mucus membranes moist, no ulcerations or exudates, tongue
appears mildly enlarged but per pt is normal
Neck: no thyromegally, JVD: flat
Cardiovascular: regular rate and rhythm, normal s1, s2, no
murmurs, rubs or gallops
Respiratory: Clear to auscultation bilaterally, no wheezes,
rales or rhonchi
Abd: Soft, non tender, non distended, no heptosplenomegally,
bowel sounds present
Extremities: No cyanosis, clubbing, edema, joint swelling
Neurological: Alert and oriented x3, CN II-XII intact, normal
attention, sensation normal, asterixis absent, speech fluent,
motor [**3-23**] UE/LE
Integument: Warm, moist, no rash or ulceration
Psychiatric: appropriate, pleasant, not anxious
Hematologic: no cervical or supraclavicular LAD
Pertinent Results:
Admission labs:
WBC-7.3# RBC-4.69 Hgb-13.0* Hct-38.1* MCV-81* MCH-27.6 MCHC-34.0
RDW-15.1 Plt Ct-296
Neuts-68.0 Lymphs-27.6 Monos-2.7 Eos-1.5 Baso-0.2
Glucose-116* UreaN-19 Creat-1.1 Na-138 K-3.7 Cl-99 HCO3-30
AnGap-13
.
MRSA screen pending.
.
Ua negative
Brief Hospital Course:
63 yo man hypertension admitted with angioedema.
1. Angioedema: Likely related to either shellfish/lisinopril
exposure. Was admitted to the MICU for respiratory observation.
Patient was evaluated by ENT who saw glottis and soft tissue
swelling. He was started on decadron, famotidine, and
diphenhydramine with significant improvement in his symptoms.
He was transferred to the floor. Over the course of 48hrs his
symptoms resolved, confirmed on repeat laryngoscopy. He
tolerated POs well. He was discharged with specific
instructions to avoid shellfish/seafood as well as lisinopril.
He was discharged with a rapid prednisone taper over 5 days, as
well as famotidine and diphenhydramine. JHe has ENT and PCP
follow up, and would benefit from allergy follow up to further
establish a cause.
.
2. Hypertension, benign: Maintained on HCTZ with good effect.
Lisinopril was stopped.
.
3. Latent TB: Continued pyridoxine
.
4. Abnormal CT scan finding: It was noticed that he had a
finding on CT Chest which will require 3 month follow up (in
[**Month (only) 321**]). It was discussed with the patient whp understands.
Medications on Admission:
Medications at home:
-Lisinopril-HCTZ
-Sildenafil prn
-Pyridoxine originally supposed to be with isoniazid; he has now
completed his course of isoniazid but has continued to be with
pyridoxine
Medications on transfer:
Heparin 5000 UNIT SC TID
Acetaminophen [**Telephone/Fax (1) 1999**] mg PO Q6H:PRN pain
Hydrochlorothiazide 12.5 mg PO DAILY
Dexamethasone 4 mg IV Q6H Duration: 6 Doses (to complete 48
hours)
DiphenhydrAMINE 25 mg PO Q6H Duration: 4 Days Order date: [**8-22**]
@ 1112
Famotidine 20 mg PO DAILY Duration: 4 Doses 10/04 @ 1112
Discharge Medications:
1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
2. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) for 5 days: may cause drowsiness.
Disp:*20 Capsule(s)* Refills:*0*
3. Prednisone 10 mg Tablet Sig: 1-4 Tablets PO once a day for 4
days: [**8-24**]: 4 pills (40mg)
[**8-25**]: 3 pills (30mg)
[**8-26**]: 2 pills (20mg)
[**8-27**]: 1 pill (10mg)
then STOP.
Disp:*10 Tablet(s)* Refills:*0*
4. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
Disp:*30 Tablet(s)* Refills:*0*
5. Pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Angioedema/Allergic Reaction
Hypertension, benign
Discharge Condition:
Good, stable respiratory system
Discharge Instructions:
You were admitted with throat and tongue swelling called
"angioedema." This was caused by either shellfish/seafood, or
your lisinopril. You improved with steroids. Please DO NOT eat
any seafood/shellfish or take your lisinopril for now.
.
Appointments have been made to follow up with your PCP, [**Name10 (NameIs) **] the
ENT doctors. You should also see an allergist to be arranged by
your PCP.
.
You will be given prescriptions for prednisone to taper each day
over 5 days. You will also be given prescriptions for
famotidine and benadryl, as well as part of your blood pressure
pill, hydrochlorothiazide.
.
Return to the hospital if you have recurrence of throat/tongue
swelling, fevers/chills, or any other concerning symptoms.
.
Additionally, as we discussed, a chest CT scan performed in
[**Month (only) 216**] showed non specific findings. A 3 month follow up CT was
recommended to make sure this finding resolved, and was not part
of a concerning process.
Followup Instructions:
Appointment #1
MD: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1887**]
Specialty: Primary Care
Date and time: Friday, [**8-27**] at 1:45pm
Location: [**Hospital Ward Name 516**], [**Company 191**] [**Hospital Ward Name 23**] Bldg, [**Location (un) **] Central Suite
Phone number: [**Telephone/Fax (1) 250**]
Special instructions if applicable:
.
Appointment #2
MD: Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Specialty: Otolaryngology (ENT)
Date and time: Wednesday, [**9-22**] at 10am
Location: [**Hospital Ward Name 517**], [**Location (un) 61116**]
Phone number: [**Telephone/Fax (1) 41**]
.
Follow up CT scan of the chest in [**Month (only) **]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3420
} | Medical Text: Admission Date: [**2118-3-18**] Discharge Date: [**2118-3-24**]
Date of Birth: [**2046-7-22**] Sex: M
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: The patient is a 71-year-old
male who has been experiencing left arm pain that radiates
from his shoulder to his wrist since early [**Month (only) 956**]. This
pain was associated with exertion and resolves with rest. He
denied shortness of breath or diaphoresis. He had a positive
ECG on [**2118-3-1**] and underwent cardiac catheterization on
[**2118-3-7**] at [**Hospital1 69**] which
revealed LMCX nonobstruction, LAD severely diffusely diseased
with multiple lesions in the mid LAD up to 95% in the mid
vessel, D1 80%, mid 50%, left circumflex OM moderate diffuse
disease, PDA proximal 80%, RCA proximal 80%, thin vessel 50%,
RPDP mid 50%, acute marginal 50%, LVEF preserved. He was
admitted at this time for an elective coronary artery bypass
grafting.
PAST MEDICAL HISTORY: 1. Hypertension. 2. Diet-controlled
diabetes mellitus. 3. Pelvic and left arm fracture. 4.
Right knee surgery. 5. Bilateral ear surgery. 6. PE when he
had pelvic fracture in [**2101**]. 7. Vertigo. 8.
Gastroesophageal reflux disease.
HOME MEDICATIONS: 1. Atenolol 25 mg p.o. q.d. 2.
Hydrochlorothiazide 25 mg p.o. q.d. 3. Zantac 150 mg p.o.
q.d. 4. Aspirin 325 mg q.d.
SOCIAL HISTORY: The patient has a 20-pack-year history, he
quit in [**2082**].
PHYSICAL EXAMINATION: In general the patient was in no acute
distress, afebrile, vital signs stable. HEENT:
Normocephalic, atraumatic. Pupils equal, round and reactive
to light, extraocular movements intact. Nasopharynx benign.
Neck: Supple with full range of motion, no lymphadenopathy,
no thyromegaly. Carotids 2+ bilaterally without bruits.
Lungs: Clear to auscultation bilaterally. Cardiac: Regular
rate and rhythm, no murmurs. Abdomen: Obese, nontender, no
masses, no hepatosplenomegaly. Extremities: No cyanosis,
clubbing or edema. Pulses 2+ bilaterally throughout.
Bilateral lower extremity varicosities. Neurologic:
Nonfocal.
HOSPITAL COURSE: The patient was admitted on [**2118-3-18**] and
taken directly to the operating room where coronary artery
bypass grafting was performed. The patient tolerated the
procedure well initially only requiring a propofol drip. The
patient left the operating room to the cardiothoracic surgery
intensive care unit with chest tubes in place and pacing
wires in place. He received four perioperative doses of
Kefzol. Postoperatively the patient was treated with beta
blockers and started on Lasix. He was quickly advanced on a
regular diet. His chest tubes and pacing wires were removed
at the appropriate times. After only a couple of days in the
intensive care unit the patient was transferred to the
regular cardiothoracic surgery floor where he continued to do
well. He received physical therapy who ultimately cleared
him to go home. While on the floor the patient was noted to
be anemic for which he received iron supplements.
It[**Last Name (STitle) 49642**]w [**2118-3-24**] and the patient is being discharged in
good condition. He is to follow up with Dr. [**Last Name (Prefixes) **] in
four weeks. He is also to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5730**] in
one to two weeks and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7047**] in two to three weeks.
The patient should observe a heart-healthy diabetic diet and
may shower but should not take baths. He should avoid
strenuous activity and he should not drive while on pain
medications.
DISCHARGE MEDICATIONS:
1. Lopressor 25 mg p.o. b.i.d.
2. Lasix 20 mg p.o. q. 12 x seven days.
3. Potassium 20 mEq q. 12 x seven days.
4. Colace 100 mg p.o. b.i.d.
5. Ranitidine 150 mg p.o. b.i.d.
6. Enteric-coated aspirin 325 mg p.o. q.d.
7. Percocet 1-2 tablets p.o. q. 4 p.r.n. pain.
8. Iron sulfate 325 mg p.o. t.i.d.
9. Vitamin C 500 mg p.o. b.i.d.
10. Multivitamins one capsule p.o. q.d.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern4) 49643**]
MEDQUIST36
D: [**2118-3-24**] 09:57
T: [**2118-3-24**] 10:10
JOB#: [**Job Number 24462**]
ICD9 Codes: 2859, 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3421
} | Medical Text: Admission Date: [**2136-7-31**] Discharge Date: [**2136-8-4**]
Service: NEUROLOGY
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Found unresponsive
Major Surgical or Invasive Procedure:
None
History of Present Illness:
88 year-old Cantonese-speaking woman who presented with
unresponsiveness. The pt does not remember the events of
yesterday, does not know why she is here. The following history
is per EMS, the ED team, and her PCP.
The pt was found next to her bed yesterday morning by a
family friend. EMS was called shortly thereafter and she was
brought to the [**Hospital1 18**] ED for further evaluation. Per the EMS
note, v/s were 88 208/91 20 87%ra. She was given narcan with no
response. She was moving her L arm/leg less than the R.
On presentation to the ER, Code Stroke was called (at 12:23),
but
no time of onset was known. Therefore protocol was aborted.
The
pt was intubated shortly after directed neurologic examination
over concern for airway protection.
The pt was unable to offer a review of systems.
She was admitted to the ICU. Her course in the ICU has been
unremarkable. She was extubated without difficulty last evening
[**7-31**] at 6pm. She has a UTI and was started on antibiotics (no
cultures). She had one episode of nausea/vomiting today after
she
received cipro on an empty stomach. A central line was placed
but
the patient did not require a drip to sustain her blood
pressure.
Past Medical History:
As [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 429**] [**Last Name (NamePattern1) **], PCP [**Telephone/Fax (1) 16171**]:
Hx prior PNA
DM2
LE edema (EF 50%, sestimibi stress [**5-11**] neg)
HTN
GERD
Asthma
Anxiety
Dx of PD [**7-11**] (not on meds, gait difficulty)
Stroke [**6-11**]
Lung cancer [**2131**]
Social History:
Widowed, lives with son. Two other children. Walks with walker.
Family History:
Unable to obtain
Physical Exam:
Vitals: 100.1 Tm 135/62 83 18 100% on 2L
General: sitting in chair, using the telephone
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: supple
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, +murmur
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-mental status: awake and alert, language fluent without errors.
Speaks at length on telephone to Cantonese translator. Follows
simple commands. Oriented. No memory for yesterday.
-cranial nerves: PERRL 2.5 to 2mm. Funduscopic exam revealed no
papilledema, exudates, or hemorrhages. EOM full. Gag reflex
intact. Slight L NLF flattening.
-motor: Normal bulk throughout. No pronator drift. b/l asterixis
present. Strength 5/5 throughout upper and lower extremities. No
adventitious movements noted. Normal tone throughout.
-sensory: withdraws legs and arms to noxious stimuli in all four
extremities.
Gait: stands, then retropulses and sits back down
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 2
R 1 1 1 3 2
Plantar response was extensor on both sides.
Pertinent Results:
[**2136-8-2**] 06:40AM BLOOD WBC-6.2 RBC-4.33 Hgb-9.6* Hct-30.7*
MCV-71* MCH-22.1* MCHC-31.3 RDW-17.5* Plt Ct-168
[**2136-7-31**] 11:55AM BLOOD Neuts-67.6 Lymphs-26.8 Monos-3.0 Eos-1.7
Baso-0.9
[**2136-7-31**] 11:55AM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-1+
Microcy-3+
[**2136-7-31**] 11:55AM BLOOD PT-11.8 PTT-23.2 INR(PT)-1.0
[**2136-8-2**] 06:40AM BLOOD Glucose-90 UreaN-14 Creat-0.8 Na-141
K-3.4 Cl-108 HCO3-24 AnGap-12
[**2136-8-2**] 06:40AM BLOOD ALT-13 AST-17 AlkPhos-42 Amylase-89
TotBili-0.5
[**2136-8-2**] 06:40AM BLOOD Lipase-23
[**2136-8-1**] 03:58AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2136-8-2**] 06:40AM BLOOD Albumin-3.6 Calcium-8.6 Phos-2.8 Mg-2.2
Iron-116 Cholest-152
[**2136-8-2**] 06:40AM BLOOD calTIBC-200* VitB12-337 Folate-10.3
Ferritn-212* TRF-154*
[**2136-8-1**] 03:58AM BLOOD %HbA1c-6.0* [Hgb]-DONE [A1c]-DONE
[**2136-8-2**] 06:40AM BLOOD Triglyc-51 HDL-86 CHOL/HD-1.8 LDLcalc-56
[**2136-7-31**] 11:55AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2136-7-31**] 05:36PM BLOOD Type-ART pO2-292* pCO2-34* pH-7.45
calTCO2-24 Base XS-0
Study Findings:
CT C-SPINE W/O CONTRAST:
No fractures or dislocations. Normal alignment. Enlarged
osteophytes with impingement upon the foramen transversarium at
the C4 and C5 vertebral bodies in levels.
CTA HEAD & NECK W&W/O CONTRAST & RECON:
No evidence of an intracranial hemorrhage or mass effect.
Chronic microvascular infarcts. The CTA does not demonstrate any
vessel cut off/filling defect or aneurysm. There is diffuse
dolichoectasia likely due to long standing hypertension.
CHEST (PORTABLE AP):
Satisfactory positioning of lines and tubes. No acute
cardiopulmonary abnormality.
CHEST PORT. LINE PLACEM:
Right subclavian central venous catheter tip in the lower SVC.
No pneumothorax.
ECG:
Sinus rhythm
Atrial premature complex
Possible left atrial abnormality
Left ventricular hypertrophy
Modest nonspecific lateral ST-T wave changes
No previous tracing available for comparison
EEG:
Results pending
CHEST (PA & LAT):
Pulmonary nodule in the left upper lobe. CT is recommended for
further characterization.
Brief Hospital Course:
Patient is a 88 year-old with multiple medical problems admitted
to ICU on [**2136-6-29**] after being found unresponsive at bedside in
her home. She was admitted to ICU and intubated for desats down
to 87%. She was hypertensive with systolics in 220s and placed
on labetelol drip. Head CT revealed chronic microvascular
infarcts but was negative for an acute intracranial hemorrhage
or mass effect. CTA was negative for vessel cut off/filling
defect or aneurysm. These findings suggested toxic-metabolic or
seizure etiology for unresponsiveness. She was started on
dilantin for seizure prophylaxis. She was extubated the evening
after admission and had stable sats on 2L oxygen. On admission
to ICU, patient was arousable only to noxious stimuli by opening
eyes but did not follow commands and unable to move left arm.
Urinalysis was postive for UTI and ciprofloxacin was started.
Patient became hemodynamically stable and remained afebrile with
WBC count within normal limits.
She was transferred to the Stroke service and her neurological
exam had improved. Patient was awake and following commands. She
had decreased strength 4/5 in upper and lower extremities with
[**1-9**] reflexes. EEG showed generalized slowing without focal sharp
waves/spikes consistent with encephalopathy. Dilantin was
discontinued given low likelihood for seizure and her outpatient
medications for hypertension and anxiety were re-started.
Patient had lower extremity edema on exam and echocardiogram was
done to evaluate for congestive heart failure. Echo was negative
for ASD or thrombi, mild LVH, EF 70%, no valvular prolapse.
Patient was started on B12 therapy for low levels.
CXR revealed 7mm lung nodule in left upper lobe concerning for
lung cancer given her history of cancer in [**2131**]. There was also
faint opacity in the right lower lobe consistent with a
developing pneumonia. She was started on broad antibiotic
coverage with flagyl and ciprofloxacin. Brain MRI was done due
to lack of concrete etiology for patient's unresponsiveness for
this admission and past history of stroke. Patient's language
barrier also made it difficult to collect more information. MRI
showed: Chronic right basal ganglia subcortical infarct.
Moderate-to- severe changes of small vessel disease. No definite
evidence of acute infarct. No mass effect. It should be noted
that the examination was performed without gadolinium which
limits evaluation for metastasis or other enhancing mass
lesions. If there is continued suspicion for metastasis,
consider gadolinium-enhanced images.
PT/OT evaluated the patient and was cleared to go home without
rehab services. She was given a choice to receive PT services at
home if she can get health insurance. Patient will followup with
PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 429**] [**Last Name (NamePattern1) **] for medical management. She will continue on
outpatient medications, in addition to B12. She will need a
chest CT outpatient to evaluate lung nodule and PCP was notified
about the finding.
Medications on Admission:
Protonix 40
Toprol xl 200
Lasix 20mg po daily (via VNA)
KCl 8meq daily
NTG PRN
ASA 81
Colace [**Hospital1 **]
Nortryptiline 25mg po qhs
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
5. Nortriptyline 25 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
Disp:*30 Capsule(s)* Refills:*2*
6. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Metabolic encephalopathy [**2-9**] UTI, hypoxia
Hx prior PNA
Diabetes mellitus II
LE edema (EF 50%, sestimibi stress [**5-11**] neg)
HTN
GERD
Asthma
Anxiety
? Dx of PD [**7-11**] (not on meds, gait difficulty)
Stroke [**6-11**]
Lung Cancer [**2131**]
Discharge Condition:
Stable
Discharge Instructions:
Please take all medications.
Followup Instructions:
PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 429**] [**Last Name (NamePattern1) **] for medical management ([**Telephone/Fax (1) 16171**]).
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
Completed by:[**2136-8-7**]
ICD9 Codes: 5990, 486, 4019, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3422
} | Medical Text: Admission Date: [**2142-8-27**] Discharge Date: [**2142-9-4**]
Date of Birth: [**2082-10-28**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Sulfa (Sulfonamides) / Erythromycin Base
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
Anterior/Posterior thoracolumbar fusion with vertebrectomy of
T12.
History of Present Illness:
59 yo female s/p MVC with + seatbelts, - airbags with prolonged
extrication brought to [**Hospital6 19155**] on [**8-24**] with
c/o neck pain. CT and MRI at MVH showed T11-12 compression
fracture, L1-3 tranverse process fracture. Patient transferred
to ICU at MVH with subsequent transfer to ICU at [**Hospital1 18**].
Past Medical History:
Diverticulosis
HTN
Hypothyroid
Lap chole
Tubal ligation
Social History:
Denies tobacco, +EtOH socially
Family History:
N/C
Physical Exam:
AVSS
Vomiting, uncomfortable
CTA B
S1S2, RRR
Abd soft, NT/ND
Ext- [**6-1**] bilateral upper and lower extremties; sensation and
pulses intact distally
Pertinent Results:
[**2142-9-1**] 04:03AM BLOOD WBC-9.6 RBC-3.40* Hgb-10.1* Hct-28.7*
MCV-84 MCH-29.7 MCHC-35.2* RDW-14.2 Plt Ct-181
[**2142-8-31**] 01:53AM BLOOD WBC-9.7 RBC-3.28* Hgb-9.8* Hct-27.2*
MCV-83 MCH-30.0 MCHC-36.1* RDW-14.3 Plt Ct-136*
[**2142-8-30**] 01:09AM BLOOD WBC-6.6 RBC-3.60* Hgb-10.7* Hct-29.5*
MCV-82 MCH-29.6 MCHC-36.1* RDW-14.5 Plt Ct-133*
[**2142-8-29**] 05:23PM BLOOD WBC-6.3 RBC-3.81* Hgb-11.4* Hct-30.6*
MCV-80* MCH-30.0 MCHC-37.4* RDW-14.0 Plt Ct-132*
[**2142-8-29**] 03:33PM BLOOD WBC-5.0 RBC-3.37* Hgb-10.2* Hct-27.3*
MCV-81* MCH-30.4 MCHC-37.5* RDW-14.1 Plt Ct-119*
[**2142-8-29**] 02:26PM BLOOD WBC-7.4 RBC-3.96* Hgb-11.6* Hct-31.9*
MCV-81* MCH-29.2 MCHC-36.3* RDW-14.1 Plt Ct-172
[**2142-8-29**] 05:14AM BLOOD WBC-7.4 RBC-3.40* Hgb-10.0* Hct-27.4*
MCV-81* MCH-29.4 MCHC-36.5* RDW-13.9 Plt Ct-196
[**2142-8-28**] 03:24PM BLOOD WBC-7.1 RBC-3.77* Hgb-11.1* Hct-30.1*
MCV-80* MCH-29.4 MCHC-36.9* RDW-13.7 Plt Ct-190
[**2142-8-27**] 06:07AM BLOOD WBC-8.6 RBC-3.77* Hgb-10.7* Hct-30.3*
MCV-80* MCH-28.5 MCHC-35.4* RDW-13.6 Plt Ct-170
[**2142-9-2**] 07:45AM BLOOD Glucose-120* UreaN-5* Creat-0.4 Na-135
K-3.1* Cl-95* HCO3-33* AnGap-10
[**2142-8-31**] 01:53AM BLOOD Glucose-115* UreaN-8 Creat-0.5 Na-137
K-3.8 Cl-103 HCO3-30 AnGap-8
[**2142-8-30**] 01:09AM BLOOD Glucose-108* UreaN-11 Creat-0.6 Na-140
K-4.2 Cl-107 HCO3-28 AnGap-9
[**2142-8-29**] 05:23PM BLOOD Glucose-149* UreaN-14 Creat-0.6 Na-140
K-3.8 Cl-106 HCO3-29 AnGap-9
[**2142-8-28**] 03:24PM BLOOD Glucose-174* UreaN-10 Creat-0.7 Na-137
K-4.2 Cl-103 HCO3-25 AnGap-13
Brief Hospital Course:
Ms. [**Known lastname 42086**] was admitted to the [**Hospital1 18**] for evaluation of her T12
bust fracture. In addition she had a left avulsion fracture off
of her distal fibula. The burst fracture was her lone operative
injury and she was admitted to the Trauma service for 24 hours.
She was informed and consented for an anterior/posterior
thoacolumbar fusion with T12 vertebrectomy. Please see
Operative Notes for procedures in detail.
Post-operativley she was admitted to the T/SICU for observation
of her fluid status. She was extubated POD1 and had no
difficulty breathing off the ventilator. She was transfered to
the floor and began working with PT. She was fitted for a TLSO
brace and was encouraged to wear it when she was out of bed.
She made improvements in strength and balance and was able to
ambulate with a walker. Her diet was slowly advanced and she
was able to move her bowels.
She was discharged to rehab and will follow up in the
Orthopaedic Spine clinic and the Orthopaedic Trauma clinic for
her ankle. She was given a walking boot for her ankle.
Medications on Admission:
Atenolol
HCTZ
Prozac
Levothyroxine
Discharge Medications:
1. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed.
2. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4-6H (every 4 to 6 hours) as needed for
wheezing.
3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed for wheezing.
4. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. Hydrochlorothiazide 25 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
6. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
8. Oxycodone 10 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO Q12H (every 12 hours).
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for breakthrough.
10. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Levothyroxine 200 mcg Tablet Sig: One (1) Tablet PO once a
day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) **]
Discharge Diagnosis:
T12 compression fracture with canal narrowing
Left distal fibula avulsion fracture
Discharge Condition:
Good
Discharge Instructions:
Please continue to take your pain medication with an over the
counter laxative. Call the clinic if you notice any redness or
diacharge from the incision site. Call the clinic for any
additonal concerns.
Physical Therapy:
Activity: Activity as tolerated
Thoracic lumbar spine orthotic: when OOB
Treatments Frequency:
Please continue to change the dressings daily with dry, sterile
gauze.
Followup Instructions:
Please follow up in the Orthopaedic Spine Clinic in 2 weeks.
Call [**Telephone/Fax (1) 11061**] for an appointment.
Orthopaedic Trauma clinic in 2 weeks. Call [**Telephone/Fax (1) 2007**] for an
appointment.
Completed by:[**2142-9-4**]
ICD9 Codes: 4019, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3423
} | Medical Text: Admission Date: [**2152-3-30**] Discharge Date: [**2152-4-2**]
Date of Birth: [**2072-1-21**] Sex: M
Service: MEDICINE
Allergies:
Levaquin / Ethambutol
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Transferred from BIDN ED with SOB.
Major Surgical or Invasive Procedure:
none
History of Present Illness:
80 year old male with met lung CA to brain/ bone, COPD presented
to [**Hospital1 **] [**Location (un) 620**] for increased dyspnea/ fever for 2-3 days. There
the patient was in moderate respiratory distress with initial O2
Sat at 87 improving to 87-90 on 3l of oxygen. His CXR showed
progression of his disease and probable new infiltrate. The pt
was unable to tolerate BIPAP 2/2 good mental status. He was
treated with CTX/azithro, nebs with some improvement. Extensive
d/w family (son and daughter) and patient and pt confirmed to be
DNR/DNI.
.
He was transferred to our ED for further care and admission to
the oncology service. VS on arrival to the ED POX93% RR 3l HR 97
BP 98/61. Patient received nebs and ativan for anxiety and was
admitted to OMED.
.
On arrival to the oncology floor, T 98.3 111/74 98 28 90% on 5L
NC
ABG 7.21/77/76 with lactate 0.7. Goals of care readdressed with
family and wishes were for reattempt at non-invasive
ventilation. Patient was transferred to the [**Hospital Unit Name 153**].
.
On arrival to the [**Hospital Unit Name 153**], patient was deep suctioned with good
effect and placed on non-invasive ventilation. Further details
of presentation where unable to be confirmed with patient.
.
Review of sytems: unable to obtain [**2-29**] mental
status/non-invasive ventilation
Past Medical History:
Abdominal Aortic Anerysm
-PVD s/p L fem [**Doctor Last Name **] '[**16**]
-COPD on 2L home O2
-Hyperlipidemia
-s/p Zenker's diverticulum repair x2
- bilateral DVT's
- BPH
- B12 deficiency and anemia
Right hip fracture.
ONCOLOGIC HISTORY:
-NSCLC: thoracoscopic left upper lobectomy for a pathologic
stage T2, N0 adenocarcinoma of the lung in [**2147**] s/p [**Doctor Last Name **] and
Taxol. He was also treated for TB at that time.
In [**2148**], he had recurrence in his lung and new disease in his
sacrum, for which he received radiation. He has received Alimta.
On [**2151-9-12**], he fell and had a right proximal femur fracture
which required fixation and was also noted to be metastatic
disease. Brain mets were found [**7-5**] s/p cyberknife XRT.
Social History:
Married, lives w/ wife. 3 children, 3 grandchildren, smoker 1ppd
for 45 years, quit [**2117**].
Family History:
Father died age 64- ?MI
Mother healthy until 84-died stroke
Sister- DM
3 children, 3 grandchildren healthy
Physical Exam:
General: Drowsy, in respiratory distress
HEENT: Sclera anicteric, MMD, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: coarse expiratory wheezing throughout on non-invasive
mask ventilation
CV: Regular rate and rhythm, HS distant
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, multiple ecchymoses
Pertinent Results:
Labs: OSH
WBC RBC HGB HCT MCV MCH MCHC PLT [**First Name9 (NamePattern2) **] [**Last Name (un) **] MON EO BAS
11.8 4.28 13.4 41.7 97.3 31.4 32.3 175 79.7 6.8 7.4 5.9
0.2
ABG7.30/60.0/ 82.0
lactate 1.4
CHEM7
NA 139 K5.4 CL98 HCO3 33.8 GLu 93 BUN 22 CRT 0.9 CA 7.2 ALb 3.3
TP 6.7 Bili 0.25 AP 267 ALT 27 AST 21
.
Micro:
OSH blood Cx - pending
CXR - IMPRESSION:
DEVELOPMENT OF PATCHY BILATERAL DENSITIES MOST SUSPICIOUS FOR
PNEUMONIA. SUBSEGMENTAL ATELECTASIS. BILATERAL PULMONARY NODULES
CONSISTENT WITH METASTATIC DISEASE. REDEMONSTRATION OF AN
OSTEOBLASTIC LESION IN THE LEFT 7TH RIB.
Brief Hospital Course:
Mr. [**Known lastname **] is an 80 yo M with metastatic small cell lung Ca to
brain and bone who presented from home with increased dyspnea
and fever x2-3 days with imaging concerning for infiltrate and
hypercarbic/hypoxic respiratory failure.
The patient was initially admitted to the Oncology Service for
treatment of pneumonia and hypoxia. Earlier in the day, the
patient had been seen at an OSH for fever and respiratory
distress and was found to have a leukocytosis and new pulmonary
infiltrate. There, he failed a trial of BiPAP before being
transferred to the [**Hospital1 18**]. On admission, the patient was placed
on broad spectrum antibiotics, stress dose steroids, nebulizer
treatments, and supplemental oxygen, but he remained
persistently hypoxic and hypercarbic on 100% facemask. After
discussion with his family, he was transferred to the MICU to
attempt a second trial of BiPAP. In the MICU, the patient was
again, unable to tolerate BiPAP despite numerous attempts. After
discussion with his family, who reiterated the patient's wish
not to be intubated, they requested that he be placed on a
Morphine gtt for comfort while his antibiotic and supportive
therapy continued. This treatment approach was employed, but he
did not improve clinically and passed away on HD4. The family
consented to an autopsy.
Code: DNR/DNI
Communication: Son [**Name (NI) **] H:[**Telephone/Fax (1) 51005**], C: [**Telephone/Fax (1) 51006**]
Daughter [**Name (NI) 17**] [**Telephone/Fax (1) 51007**]
Medications on Admission:
Symbicort (budesonide, formoterol) 160/4.5 2 puffs [**Hospital1 **]
Combivent 2 puffs [**Hospital1 **]
Albuterol PRN
Restoril 15mg [**Hospital1 **]
Senna
Dilantin 300mg [**Hospital1 **]
Prilosec 20mg daily
Neurontin 300mg daily
Hytrin 5mg [**Name (NI) **]
MOM
Tylenol
[**Name2 (NI) **] 81mg daily
Decadron 2mg daily
Artifical eye gtt
Discharge Disposition:
Expired
Discharge Diagnosis:
Pneumonia
Metastatic Lung cancer
COPD
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expire
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
ICD9 Codes: 486, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3424
} | Medical Text: Admission Date: [**2192-10-31**] Discharge Date: [**2192-11-9**]
Date of Birth: [**2138-8-4**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
s/p Coronary Artery Bypass Graft x 2
History of Present Illness:
54 y/o male who presented to OSH c/o intermittent episodes of
chest pain for 2 weeks. Pt had +ST elevation on EKG and was
subsequently brought for a Cardiac Cath which revealed a 95%
stenosed left main. An IABP was placed and pt was transferred to
[**Hospital1 18**] for CABG.
Past Medical History:
Hypertension
Hypercholesterolemia
Social History:
Tobacco: 2ppd
Alcohol: 7 beers qd
Denies recreational drug use
Family History:
Non-contributory
Physical Exam:
Note: PE done after emergent CABG
VS: 99.9 80 A-paced 91/56
Skin: Sternal incision CDI, sternum stable
HEENT: PERRLA, trachea midline, NC/AT
Neck: -JVD, -Carotid bruits
Heart: RRR +S1S2, -c/r/m/g
Lungs: CTAB -w/r/r
Abd: Soft, NT/ND NABS
Ext: W/D +2 DP/PT bilat, -c/c/e, -varicosities
Neuro: A&O x 3, follows commands, MAE, non-focal
Pertinent Results:
Echo [**11-2**]: The left atrium is mildly dilated. Left ventricular
wall thicknesses and cavity size are normal. There is moderate
regional left ventricular systolic dysfunction with focal
akinesis of the midportion of the anterior septum and anterior
walls. The basal anterior septum, distal anterior wall, and apex
are also hypokinetic. The remaining segments contract well. No
masses or thrombi are seen in the left ventricle. Right
ventricular chamber size is normal. There is mild global right
ventricular free wall hypokinesis. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. The
pulmonary artery systolic pressure could not be determined.
There is a trivial/physiologic pericardial effusion.
CXR [**11-7**]: Interval improvement of bilateral patchy opacities
and bilateral pleural effusions. There remains a tiny left
pleural effusion.
[**2192-10-31**] 06:20PM BLOOD WBC-8.6 RBC-3.52* Hgb-12.1* Hct-33.6*
MCV-96 MCH-34.5* MCHC-36.0* RDW-12.0 Plt Ct-209
[**2192-11-2**] 02:26AM BLOOD WBC-9.3 RBC-3.29* Hgb-10.6* Hct-31.1*
MCV-95 MCH-32.2* MCHC-34.0 RDW-13.8 Plt Ct-149*
[**2192-11-8**] 06:25AM BLOOD WBC-8.9 RBC-3.19* Hgb-10.5* Hct-29.7*
MCV-93 MCH-33.0* MCHC-35.4* RDW-12.7 Plt Ct-431
[**2192-10-31**] 06:20PM BLOOD PT-13.2 PTT-74.2* INR(PT)-1.2
[**2192-11-7**] 06:20AM BLOOD PT-13.5* PTT-36.1* INR(PT)-1.2
[**2192-10-31**] 10:40PM BLOOD Glucose-136* UreaN-10 Creat-0.9 Na-139
K-3.3 Cl-100 HCO3-29 AnGap-13
[**2192-11-8**] 06:25AM BLOOD Glucose-103 UreaN-24* Creat-1.0 Na-134
K-3.6 Cl-94* HCO3-28 AnGap-16
[**2192-11-7**] 06:20AM BLOOD Calcium-9.1 Phos-4.5 Mg-2.3
Brief Hospital Course:
As mentioned in the HPI, pt was transferred from [**Hospital1 **] and
brought emergently to the operating room where he underwent
Coronary Artery Bypass surgery. Pt. tolerated the procedure well
and there were no complications. Please see op note for surgical
details. Total bypass time was 85 minutes and cross-clamp time
was 51 minutes. He was transferred to the CSRU in stable
condition, intubated and on Amiodarone, Epinephrine, Lidocaine
and Neo. Pt. remained intubated until post-op day #2. Sedation
and vent was weaned and pt. was extubated. He was alert, awake,
and moving all extremities. He remained on Neo and Epi for BP
support until POD #2 when both were weaned off. IABP was removed
on POD #2. Diuretics and b-blockers were initiated per protocol
POD #2,3. Chest tubes were removed on POD #3. Pt. was confused
apparently from Delirium Tremons. Proper control was given. He
was transferred to telemetry unit on POD #4. Pt. continued to
have DT's, meds were given and a patient observer was placed in
room. Pt. became quite confused and agitated and was transferred
back to the CSRU on POD #5. He was then again transferred back
to the telemetry floor with a sitter on POD #6. Epicardial
pacing wires and Foley were d/c'd on POD #7. DT's were slowly
resolving and Haldol was d/c'd but remained on Ativan prn.
Consult for addiction services was done. Pt's mental status
slowly improved, he began to get OOB and ambulate more. On POD
#9 pt appeared to be doing well and was discharged home with VNA
services and the appropriate follow-up appointments.
Medications on Admission:
Atenolol
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:*0*
3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
4. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO BID (2 times a day) for 10
days.
Disp:*40 Capsule, Sustained Release(s)* Refills:*0*
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*1*
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
Disp:*30 Patch 24HR(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
AllCare VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Coronary Artery Disease s/p Acute Myocardial Infarction, s/p
Coronary Artery Bypass Graft x 2
Hypertension
Hypercholesterolemia
Discharge Condition:
Good
Discharge Instructions:
Can take shower. Wash incisions with warm water and gentle soap.
Gently pat dry. Do not bath or swim.
Do not apply any lotions, creams, ointments, or powder to
incisions.
Do not lift more than 10 pounds for 2 months.
Do not drive for 1 month.
Take all prescribed meds and make appropriate follow-up
appointments.
If you notice drainage, redness from incisions or have fever
>101, call office immediately.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] in 4 weeks.
Follow-up with Dr. [**Last Name (STitle) 1295**] in 2 weeks.
Follow-up with Dr. [**Last Name (STitle) 25356**] in [**1-29**] weeks.
Completed by:[**2192-11-9**]
ICD9 Codes: 9971, 4019, 2720, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3425
} | Medical Text: Admission Date: [**2198-8-22**] Discharge Date: [**2198-8-28**]
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: This is a 79-year-old male
patient with severe 3-vessel coronary artery disease with
recent increase in symptoms of angina.
PAST MEDICAL HISTORY: The patient has a history of back
problems with multiple back surgical procedures performed in
the past. He has gastroesophageal reflux disease, history of
upper gastrointestinal bleed, hypertension, peripheral
vascular disease with claudication, and non-insulin-dependent
diabetes mellitus.
MEDICATIONS ON ADMISSION: Preoperative medications include
Mevacor 40 mg p.o. q.d., Micronase (unclear doses), [**Name (NI) 35856**]
(unclear doses), captopril 50 mg p.o. t.i.d., Prilosec 20 mg
p.o. q.d.
PHYSICAL EXAMINATION ON ADMISSION: The patient was alert and
oriented. He had no jugular venous distention. No carotid
bruits noted. His neurologic examination was intact. His
blood pressure was 170/78, his heart rate was 70 in normal
sinus rhythm. The patient complained of back pain. Lungs
were clear with mild rhonchi bilaterally. His abdomen was
obese, nondistended, and nontender. Legs with no
varicosities bilaterally, and weak peripheral pulses were
palpated.
RADIOLOGY/IMAGING: The patient's cardiac catheterization
film revealed severe 3-vessel coronary artery disease with an
left ventricular ejection fraction of 35%. The patient was
admitted to the hospital on the day of surgery, [**2198-8-22**].
LABORATORY DATA ON ADMISSION: Preoperative laboratory values
were unremarkable with the exception of a creatinine of 1.9.
HOSPITAL COURSE: The patient was taken to the operating
room on [**2198-8-22**], where he underwent coronary
artery bypass graft times three by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] with left
internal mammary artery to the obtuse marginal, a saphenous
vein graft to the left anterior descending artery, and a
saphenous vein graft to the posterior descending artery.
Postoperatively, the patient was atrially paced via his
temporary pacing wires. He was transported from the
operating room to the Cardiac Surgery Recovery Unit where he
was hemodynamically over the course of the first night. The
patient remained intubated overnight due to hypoxia which
resolved by the following morning. The patient had required
nitroprusside and nitroglycerin for hypertension but was
converted over to oral antihypertensive medications and
weaned off those drips.
On postoperative day one, the patient was stable. His
oxygenation had significantly improved, and he was extubated.
This was delayed a little bit because he was a very difficult
intubation initially requiring a fiberoptic scope, and we had
to await the anesthesiologist to stand by in the Intensive
Care Unit during the extubation. This was uneventful. He
was extubated without problem.
On postoperative day two, the patient remained
hemodynamically stable. He was still hypertensive but was
being managed well with oral agents. He remained in normal
sinus rhythm, and he was transferred from the Intensive Care
Unit to the telemetry floor. Later in the day on
postoperative day two, the patient was noted to have some
atrial fibrillation with a ventricular rate in the 90s to
110s and was started on oral amiodarone and increased dose of
beta blocker.
On the morning of [**2198-8-26**], postoperative day
three, it was noted that the patient had some ventricular
bigeminy. His blood pressure remained stable. He was alert
and oriented at the time, and he was atrially paced for a
short while to override the ectopic beats. Later in the day,
on postoperative day three, the pacemaker was discontinued.
The patient remained in normal sinus rhythm to sinus
bradycardia in the middle 50s with a stable blood pressure.
His electrolytes were checked and replaced as indicated.
On [**2198-8-27**], on postoperative day five, the patient
remained hemodynamically stable. However, on the night prior
to this he had been somewhat disoriented and agitated and
required a sitter for safety. This resolved by morning and
remained stable throughout the day. The patient still had a
fairly high oxygen requirement and was on 5 liters of oxygen
via his nasal cannula and became very dyspneic with any
physical exertion. A chest x-ray was obtained which revealed
what appeared to be a significant left-sided pleural
effusion. A thoracentesis was performed at the bedside for
approximately 450 cc of serosanguineous fluid. The patient
tolerated the procedure well. His post procedure chest x-ray
was unremarkable and showed decreased effusion on the left
side. He still remained with some left lower lobe
atelectasis. It was also noted on [**8-27**] that the
patient's creatinine which had been in the 1.7 to 1.9 range
had bumped to 2; although, his baseline is 1.9.
The patient's oxygenation had improved and today, on
postoperative day six, [**2198-8-28**], the patient remained
hemodynamically stable and ready to be transferred to a
rehabilitation facility to progress with cardiac
rehabilitation and physical therapy.
On today, [**2198-8-28**], the patient's physical examination
was as follows. Temperature 96.8, pulse 67 in normal sinus
rhythm, respiratory rate 20, blood pressure 137/77, oxygen
saturation was 94% on 3 liters per minute by nasal cannula.
His weight today was 116 kg, which is just 3 kg above his
preoperative weight of 113. Neurologically, the patient was
alert and oriented with no apparent deficits. His pulmonary
examination revealed his lungs were clear to auscultation
bilaterally, slightly diminished bilateral bases, left
greater than right. His coronary examination was a regular
rate and rhythm with S1/S2. No rubs, and no murmurs noted.
Abdomen was obese, nontender, and nondistended. His
extremities were warm and well perfused. His sternum was
stable. His incision was clean, dry, and intact. His leg
incision was also unremarkable with no drainage or erythema.
MEDICATIONS ON DISCHARGE:
1. Norvasc 5 mg p.o. q.d.
2. Amiodarone 400 mg p.o. t.i.d. times two more days;
then 400 mg p.o. b.i.d. times one week; then 400 mg p.o. q.d.
3. Lopressor 12.5 mg p.o. b.i.d.
4. [**Year (4 digits) 35856**] 15 mg p.o. q.d.
5. Percocet 5/325 one p.o. q.4h. p.r.n.
6. Mevacor 40 mg p.o. q.h.s.
7. Glyburide 2.5 mg p.o. b.i.d.
8. Lasix 20 mg p.o. q.d. times one week.
9. Potassium chloride 20 mEq p.o. q.d. times one week.
10. Colace 100 mg p.o. b.i.d.
11. Zantac 150 mg p.o. b.i.d.
12. Aspirin 81 mg p.o. q.d.
13. Ibuprofen 400 mg p.o. b.i.d. p.r.n.
14. Sliding-scale regular insulin before meals and at
bedtime as follows: Blood sugar of 150 to 200 use 3 units
subcutaneous, 201 to 250 use 6 units subcutaneous, 251 to 300
use 9 units subcutaneous.
DISCHARGE STATUS: The patient was to be discharged to a
rehabilitation facility.
CONDITION AT DISCHARGE: In stable condition.
DISCHARGE FOLLOWUP: He was to follow up with Dr. [**Last Name (STitle) **] in
one month for postoperative check. The patient was also to
follow up with his primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 18654**] [**Last Name (NamePattern1) 30168**],
upon discharge from rehabilitation facility as well as his
primary cardiologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], at the recommendation
of Dr. [**Last Name (STitle) 30168**] upon discharge from rehabilitation facility.
DISCHARGE DIAGNOSES:
1. Coronary artery disease.
2. Status post coronary artery bypass graft.
3. Postoperative atrial fibrillation.
4. Non-insulin-dependent diabetes mellitus.
5. Hypertension.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Name8 (MD) 964**]
MEDQUIST36
D: [**2198-8-28**] 08:10
T: [**2198-8-28**] 07:21
JOB#: [**Job Number 35857**]
ICD9 Codes: 4111, 9971, 4019, 5119 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3426
} | Medical Text: Admission Date: [**2175-8-1**] Discharge Date: [**2175-8-9**]
Service: MEDICINE
Allergies:
Iodine; Iodine Containing
Attending:[**First Name3 (LF) 1674**]
Chief Complaint:
sob and confusion s/p chlorine inhalation
Major Surgical or Invasive Procedure:
intubation with mechanical ventillation for 5 days
History of Present Illness:
88 yo M h/o CAD s/p CABG, HTN, brought in by EMS for
unresponsiveness and difficulty breathing. Pt was in USOH until
evening of presentation. After dinner he went to help his son
work on a leak in their pool's pump room. Per pt's wife, water
was spraying the room and its contents including containers of
granulated chlorine. The pt went inside the room and was there
for approximately three minutes. He walked from the room and was
stumbling/confused. He collapsed several minutes later and was
unresponsive, breathing shallowly. EMS was called. Pt
transported to [**Hospital1 18**].
.
In the ED vitals initially: t 99.9, hr 59, bp 154/71, rr 30, sat
98% on ? 02. Pt was intubated on presentation for airway
protection. In the ED CT head negative and CXR showed low lung
volumes. Pt transferred to MICU.
.
In the MICU pt was intubated for 5 days. Toxicology consult was
obtained and it was determined that pt's presentation was
chloride toxicity complicated by chemical pneumonitis.
Past Medical History:
nephrolithiasis, colon angioectasis, coronary artery disease,
hypertension, kidney stones, hyperlipemia, stable pulmonary
nodule, asthma (recently diagnosed)
Social History:
Pt is a lawyer. [**Name (NI) **] lives with his wife, with family members
nearby. [**Name2 (NI) **] drinks socially, no tobacco or drug use.
Family History:
non contributory
Physical Exam:
ON ADMISSION:
Temp 96.2
BP 146/56
Pulse 61
Resp 20
O2 sat 98% on vent AC 450X20 peep 10, fiO2 40%
Gen - Alert, no acute distress
HEENT - pupils pinpoint, anicteric, mucous membranes slightly
dry
Neck - no JVD, no cervical lymphadenopathy
Chest - diffusely wheezing
CV - Normal S1/S2, RRR, no murmurs appreciated
Abd - Soft, nontender, nondistended, with normoactive bowel
sounds
Extr - 1+ pitting edema to ankles b/l. 2+ DP pulses bilaterally
Neuro - intubated, sedated
Skin - No rash
Pertinent Results:
Chest X ray prior to discharge: The sternotomy wires and
mediastinal clips are unchanged from prior exam. The heart size
is normal. The aorta is heavily calcified. There is no
consolidation or vascular congestion in the lungs. There is
persistent blunting of the left costophrenic angle. Osseous
structures are unchanged.
IMPRESSION: No evidence of volume overload.
Brief Hospital Course:
1)Chemical pneumonitis due to chlorine. Pt presented to ED with
unresponsiveness and was intubated for airway protection and
difficulty breathing. A toxicology consult was obtained and pt
was treated with a course of steroids as per their
recommendations. After 5 days of mechanical ventillation pt was
extubated without difficulty. There was a minor component of
reactive airway disease and so pt was given tiotropium and
Advair. Because he has no history of COPD and was previously
without respiratory compromise, tiotropium was discontinued. As
he continued to have mild wheeze, Advair was continued with
instrution to discontinue after one more week.
2)Possible aspiration pneumonia in addition to pneumonitis: On
arrival to the MICU, there was concern that the pt may have
developed an aspiration pneumonia in the setting of decreased
consciousness. He was treated with 7 day course of antibiotics.
3)Renal failure: Pt had acute renal failure which resolved with
administration of IV fluids.
4)CAD s/p CABG: Continues on home asa/statin/bb. Confirmed with
pt and PCP that pt is no longer on plavix.
comm: wife/hcp [**Name (NI) **] [**Telephone/Fax (1) 104898**]
code: full (confirmed with wife)
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Atorvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
5. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) puff Inhalation [**Hospital1 **] (2 times a day) for 1 weeks.
7. Timoptic
continue home regimen
Discharge Disposition:
Home
Discharge Diagnosis:
chemical pneumonitis
Discharge Condition:
ambulating well, O2 sat 96% on room air, breathing without
difficulty, eating without difficulty
Discharge Instructions:
Please call your doctor or return to the emergency room with any
difficulty breathing or other concerning symptoms. Take advair
for one week and then finish.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) 1313**] within the next few weeks.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1677**]
Completed by:[**2175-8-18**]
ICD9 Codes: 5849, 2760, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3427
} | Medical Text: Admission Date: [**2156-3-29**] Discharge Date: [**2156-4-1**]
Date of Birth: [**2122-4-22**] Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: This is a 33 year old male
transferred to [**Hospital1 69**] from
[**Hospital3 3834**] with the diagnosis of acute myocardial
infarction. The patient had been experiencing one month's
worth of dyspnea on exertion accompanied by occasional
nausea, vomiting whenever he would walk greater than 100
feet. In the past week the patient had gone to the [**Hospital3 28116**] Emergency Room twice with worsening dyspnea on
exertion and burning chest discomfort. At this time he was
diagnosed with asthma and prescribed bronchodilators. The
day prior to admission starting at 3:00 p.m. he developed
[**6-29**] substernal chest pain with shortness of breath,
diaphoresis and nausea. This eased somewhat by itself over
the night and he went to work on the day of admission. At
7:00 a.m. on the day of admission he developed chest
discomfort and was taken to [**Hospital4 3834**] [**Hospital5 **] [**Hospital6 **].
In the emergency department he was noted to have ST
elevations consistent with an anterior MI. He was started on
Lopressor, heparin drip, aspirin, Aggrastat drip and
transferred to [**Hospital1 18**] for primary angioplasty.
PAST MEDICAL HISTORY: No past medical problems.
ALLERGIES: No known drug allergies.
MEDICATIONS: The patient took two aspirin on the day of
admission.
SOCIAL HISTORY: The patient is single, works as a forklift
driver at [**Company 22916**]. Has smoked about two marijuana joints a
day for the past 15 years. One to two drinks of alcohol.
Denies use of cigarettes or chewing tobacco.
FAMILY HISTORY: Father has hypertension. There is a history
of noninsulin dependent diabetes mellitus on the mother's
side. No family history of coronary artery disease,
cerebrovascular disease, hypercholesterolemia, sudden death
or cancer.
PHYSICAL EXAMINATION: On physical exam the patient was
afebrile 98.6, pulse 64, blood pressure 118/108, respiratory
rate 20, sating 99% in room air. HEENT exam normocephalic,
atraumatic. Pupils were equal, round and reactive to light
and accommodation. Extraocular movements were intact.
Anicteric sclerae with moist mucous membranes. Neck was
supple without lymphadenopathy. Lungs were clear to
auscultation bilaterally. Cardiovascular exam regular rate
and rhythm, normal S1, normal S2, no S3, no murmurs. On
precordial exam there was a nondisplaced dime-sized PMI
approximately 10 cm from the midsternum. JVP 5 cm, carotids
normal volume, brisk upstroke, no bruits. Abdominal exam was
soft, nontender, nondistended with normoactive bowel sounds.
Extremities had no clubbing, cyanosis or edema, no femoral
bruits on either side.
LABORATORY DATA: EKG performed on [**2156-3-29**], showed
normal sinus rhythm at 91 beats per minute with an axis of
approximately negative 30 degrees, intervals of 173, 89 and
459 corrected with inverted T waves in leads 1, 2, L, V3, V4,
V5, V6. Prominent ST elevations of 1 mm in V1, 3 mm in V2,
5 mm in V3, 3 mm in V4, 1 mm in V5. EKG performed on [**2155-10-2**] showed normal sinus rhythm at 72 beats per minute,
intervals of 166, 98, 427 corrected, axis 17 degrees, T wave
inversions in 1, L, 2, 3, 4, 5, 6. Persistent ST elevations
of 1 mm in V2, 3 mm in V3 and 3 mm in V4. Late R wave
progression. Chem-7 was within normal limits. CK peak of
891. Total cholesterol 171, LDL 118, HDL 37, triglycerides
80. Alpha lipoprotein A pending at the time of discharge.
Homocystine 6.6 with normal range 0 to 8.9.
The patient underwent cardiac catheterization on [**2156-3-31**].
This showed diffuse right coronary 30% mid-RCA stenosis,
right posterior lateral branch 30% stenosis. Left main was
normal. LAD had diffuse disease with 99% to 80% discrete
stenosis of the distal LAD. Diffusely diseased intermedius
with 90% stenosis. Proximal circ with 46% discrete stenosis.
OM with 80% stenosis. OM1 was treated with stenting with 0%
residual stenosis and normal flow. The ramus was treated
with stenting with 0% residual stenosis and normal flow. The
patient underwent cardiac catheterization [**2156-3-29**] and was
found to have an EF of 36% with hypokinesis of the anterior
lateral wall, dyskinesis of the apical wall. He underwent
successful stenting of the distal LAD and successful stenting
of the right posterior lateral ventricular branch.
HOSPITAL COURSE: The patient was admitted to the CCU service
transferred from the [**Hospital3 3834**] service for
intervention in the setting of an acute MI. The patient
underwent cardiac catheterization with stenting of the distal
LAD and the right posterior lateral ventricular branch. The
patient tolerated the procedure well and was pain free
following the procedure. The following day the patient
underwent cardiac catheterization with stenting of the large
ramus branch and the OM1. The patient tolerated the
procedure well. The following day the patient was stable,
had tolerated the addition of both an ACE inhibitor and a
beta blocker. Had also been ambulating without difficulty.
He was seen by the nutrition staff, physical therapy staff
and was deemed to be stable. The patient was discharged
home.
DISCHARGE MEDICATIONS:
1. Atenolol 50 mg q.day.
2. Aspirin 325 mg q.day.
3. Plavix 75 mg q.day to be continued for 30 days.
4. Univasc 15 mg q.day.
5. Lipitor 10 mg q.day.
6. Coumadin 5 mg q.day.
7. Subcu enoxaparin b.i.d. until Coumadin is therapeutic.
The patient has scheduled followup with cardiologist and
primary care physician near his home.
[**Name6 (MD) 9272**] [**Name8 (MD) 9273**], M.D. [**MD Number(1) 9274**]
Dictated By:[**Last Name (NamePattern1) 21698**]
MEDQUIST36
D: [**2156-4-1**] 13:27
T: [**2156-4-2**] 07:22
JOB#: [**Job Number 33143**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3428
} | Medical Text: Admission Date: [**2187-8-26**] Discharge Date: [**2187-8-28**]
Date of Birth: [**2139-8-22**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
None
History of Present Illness:
40 y/o male found underneath a bicycle with positive ETOH of
219. The patient states that he recalls drinking 6-7 beers at
the bar starting at 7pm. He does not recall the events before or
after fall. There were no witnesses to the event. Patient c/o
headache, neck pain, nausea, emesis, L shoulder pain, and R arm
pain.
Past Medical History:
HIV, HTN, DM
Social History:
Lives alone. Works as a cleaning supervisor. Tob DC'ed
1 mon ago, prior to that he smoked 6 cig per day for 15 years.
Family History:
NC
Physical Exam:
Physical Exam at Admission:
T 97.6 BP: 107/83 HR: 103 R 21 99%NCO2Sats
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 4-3.5 B reactive EOMs intact
Neck: C-spine collar. No palpable tenderness.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, hospital, and date.
Language: Speech fluent with good comprehension. Speaks Spanish
but had no difficulty with interrogation.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally.
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: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-24**] throughout with the exception
of
Left deltoid-not tested due to pain and restricted ROM. No
pronator drift
Sensation: Intact to light touch.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger.
Pertinent Results:
CT head w/o contrast [**2187-8-26**]:
L parietal soft tissue edema, coup-countercoup injury involving
subarachnoid blood in the middle cranial fossa, R ambient
cistern, and inferior bifrontal subarachnoid blood with poss
intraparaenchymal extension.
CT HEAD W/O CONTRAST [**2187-8-26**] 1:31 PM
1. Interval progression of hemorrhagic contusions in the left
inferior
frontal lobe and the right inferior temporal lobe, with
new/emergent focus of hemorrhagic contusion in the right
cerebellar hemisphere
2. Stable subarachnoid hemorrhage. No new mass effect or
herniation
CT HEAD W/O CONTRAST [**2187-8-27**]
1. Stable appearance of hemorrhagic contusions
2. Subarachnoid blood unchanged.
3. No new mass effect or herniation.
Brief Hospital Course:
Patient is a 48 y/o male s/p bicycle accident, details of
accident unclear, no witness. He was positive for ETOH
consumption and came to the ED complaining of headache, n/v, L
shoulder pain, and R arm pain. Patient recieved a CT scan which
showed a countercoup injury with a R EDH and SAH. He was
admitted to trauma ICU for further observation. CT scan showed
no mass effect or midline shift. Repeat head CT in afternoon
showed no change from previous scan. Cervical spine was cleared
by trauma for injury. On physical exam, patient's left shoulder
had limited ROM secondary to pain. He was also reported to be
vomitingx2. Patient is alert and oriented x3, with good strength
overall. He also presents with dysmetria on the R when asked to
perform finger to nose. EOMs intact, but some end gaze nystagmus
noted. Head CT in AM of [**8-27**] stable from previous scans and
patient was transferred to floor. Physical therapy worked with
the patient. It was felt that he could be discharged to home. He
was sent home in a chair car on [**2187-8-28**].
Medications on Admission:
Lisinopril, Lantus, Metformin,
HIV med-no name given.
Discharge Medications:
1. Outpatient Lab Work
Please have a dilantin level drawn in 1 week.
Please have results faxed to [**Telephone/Fax (1) 87**].
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Emtricitabine-Tenofovir 200-300 mg Tablet Sig: One (1) Tablet
PO DAILY (Daily).
4. Efavirenz 600 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Metformin 500 mg Tablet Sustained Release 24 hr Sig: Two (2)
Tablet Sustained Release 24 hr PO DAILY (Daily).
7. Phenytoin Sodium Extended 200 mg Capsule Sig: One (1) Capsule
PO BID (2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
8. Fioricet 50-325-40 mg Tablet Sig: One (1) Tablet PO four
times a day: This medication contains Tylenol. Do not take
additional Tylenol with it.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Closed head injury
R EDH
SAH
Discharge Condition:
Neurologically Stable
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, and
Ibuprofen etc.
?????? You have been prescribed dilantin, an anti-seizure medicine,
take it as prescribed and follow up with laboratory blood
drawing in one week. Please have results faxed to [**Telephone/Fax (1) 87**].
??????
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.
Followup Instructions:
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast.
Follow-up with your primary care physician for your shoulder
pain in 2 weeks.
Completed by:[**2187-8-28**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3429
} | Medical Text: Admission Date: [**2176-7-31**] Discharge Date: [**2176-8-6**]
Date of Birth: [**2119-5-12**] Sex: M
Service: MEDICINE
Allergies:
Naprosyn / Aspirin / Nylon 12 / Spironolactone
Attending:[**First Name3 (LF) 1515**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Attempted biventricular upgrade of ICD
History of Present Illness:
57 year old male with CAD s/p MIx4, CABG, DM2, HLD, HTN, CHF,
CVA p/w with chief complaint of substernal chest & back pain
with diaphoresis which occurred around 10am in [**Hospital Ward Name 23**] lobby.
Pt. took 2 sl NTG AT 10:15AM & again 10:30 AM (O.6MG). Came up
to [**Hospital Ward Name **] 7 for cardiology appt with more substernal/back pain
withdiaphoresis. Given 2 more sl NTG at 11am with relief. Dr.
[**First Name (STitle) 437**] evaluated pt. EKG LBBB morphology which is wider, SR.
BP122/80 [**Last Name (un) **]/STANDING, AFTER NTG 114/80, HR 86-90. No N/V/SOB.
Feels some indigestion. Dr. [**First Name4 (NamePattern1) 437**] [**Last Name (NamePattern1) 95937**] requested CTA to
rule out aortic dissection & PE, ? cath.
.
In the ED, he had no further chest pain (initially). A CXR with
No ACP and no mediastinal widening. Per ED, it was discussed
with Dr. [**First Name (STitle) 437**] and he was put into Obs for two sets and a
stress. He ruled in on the second set with a trop of 0.13. He
received ? 1-2L of NS for unclear reasons and an amiodarone
bolus for 5 beat run of NSVT. The ED then found him c/o chespt
pain with radiation to back and tachycardic and believed that he
was in Afib with RVR. He developed a new O2 requirement with 91%
on 5L and a CXR was apparently c/w pulmonary edema. He received
0.125 mg Digoxin, zofranm large doses of morphine,was placed on
bipap, ntg drip, heparin drip with resolution of his chest pain.
His EKG was c/w SR with apcs and vpcs. After CCU admission was
requested, he then received 5 mg of IV metoprolol and 50 mg of
Lopressor for HR 130. His rate fell to 80's. He also received 60
mg of IV lasix.
.
On review of systems, he denies any prior history of deep venous
thrombosis, pulmonary embolism, bleeding at the time of surgery,
myalgias, joint pains, cough, hemoptysis, black stools or red
stools. He denies recent fevers, chills or rigors. He denies
exertional buttock or calf pain. All of the other review of
systems were negative.
.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-CHF (last echo [**12-19**], EF 20-25%)
-Coronary artery disease, status post myocardial infarction
times four; last one in [**2166-7-11**]. Status post 3x coronary
artery bypass grafting in [**2155**]. Stented in '[**60**], but had
re-stenosis within 6 months. Had 3-vessel disease on cath in
[**2-20**].
3. OTHER PAST MEDICAL HISTORY:
-History of left middle cerebral artery stroke in [**2166-7-11**]
with residual Broca aphasia.
-History of seizure disorder with last seizure in [**Month (only) 404**] of
[**2167**].
-Type 2 diabetes mellitus; most recent hemoglobin A1c of 7.3.
-Gastroesophageal reflux disease.
-Peptic ulcer disease.
-History of upper gastrointestinal bleeds.
-Bilateral CEA
Social History:
Canadian. The patient is married. His wife was recently
discharged from the hospital with a new diagnosis of Alzheimer's
disease. He is responsible for most of the chores at home. He
has a 70 pack-year tobacco history. He quit two years ago.
Sometimes he would smoke up to four packs per day. He denies
alcohol or drug abuse. He was previously an ombudsman in [**Country 6607**]
and was a handyman in the United States. He notes financial
struggles.
Family History:
The patient's father died of a myocardial infarction at age 50.
His mother has a history of CAD, DM2, and bladder cancer. The
patient has multiple siblings who have had heart attacks in
their 40s.
Physical Exam:
On admission:
BP: 119/73 Pulse: 85 RR: 21 O2: 99%
General Appearance: Well nourished, No acute distress,
Overweight / Obese
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (S1: Normal), (S2: Normal), S3
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Not assessed),
(Left DP pulse: Not assessed)
Respiratory / Chest: (Expansion: Symmetric), (Percussion: No(t)
Dullness : ), (Breath Sounds: Crackles : bibasilar)
Extremities: Right lower extremity edema: Trace, Left lower
extremity edema: Trace, No(t) Cyanosis, No(t) Clubbing
Skin: Not assessed, No(t) Rash:
Neurologic: Attentive, Responds to: Not assessed, Oriented (to):
x3, Movement: Not assessed, Tone: Not assessed
On discharge:
T: 98.2 HR: 62 BP 125/60 RR 18 O2: 95% RA
Gen: NAD
CV: irregularly irregular, normal S1/s2
Resp: CTAB
Abd: soft, NT/ND
Ext: no lower ext edema
Skin: warm, dry
Pertinent Results:
CBC:
[**2176-7-31**] WBC-8.6 Hgb-13.1* Hct-39.8* MCV-92 Plt Ct-275
[**2176-8-6**] WBC-8.7 Hgb-10.6* Hct-31.3* MCV-92 Plt Ct-234
BMP:
[**2176-7-31**] BG-214* UreaN-17 Creat-1.4* Na-138 K-4.3 Cl-98 HCO3-33*
AnGap-11
Calcium-10.0 Phos-3.6 Mg-1.7
[**2176-8-6**] BG-107* UreaN-27* Creat-1.3* Na-136 K-4.1 Cl-94* HCO3-32
AnGap-14
Calcium-8.7 Phos-3.6 Mg-1.8
Coags:
[**2176-7-31**] PT-14.2* PTT-25.2 INR(PT)-1.2*
[**2176-8-2**] PT-15.8* PTT-60.5* INR(PT)-1.4*
Cardiac Enzymes:
[**2176-7-31**] 12:00PM BLOOD cTropnT-0.03*
[**2176-7-31**] 06:40PM BLOOD cTropnT-0.13*
[**2176-8-1**] CK-MB-107* MB Indx-10.4* cTropnT-1.40*
[**2176-8-1**] CK-MB-51* MB Indx-6.8* cTropnT-2.39*
[**2176-8-2**] CK-MB-20* cTropnT-2.46*
[**2176-8-1**] 03:22AM BLOOD ALT-30 AST-133*
[**2176-8-1**] BLOOD CK(CPK)-1024*, CK(CPK)-755*,
Lipid Pannel
[**2176-8-1**] Triglyc-101 HDL-42 CHOL/HD-3.8 LDLcalc-99
Blood Digoxin Level
[**2176-8-2**] Digoxin-1.3
Other Studies
- ECG: SR at 120 with APC and VPC, LBBB
.
- ECHO [**2176-7-31**]:
The left atrium is elongated. Left ventricular wall thicknesses
are normal. The left ventricular cavity is severely dilated.
There is severe global left ventricular hypokinesis (LVEF <20
%). The estimated cardiac index is borderline low
(2.0-2.5L/min/m2). The right ventricular cavity is mildly
dilated with moderate global free wall hypokinesis. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Mild to moderate ([**2-11**]+) mitral regurgitation is seen.
The estimated pulmonary artery systolic pressure is normal.
There is no pericardial effusion.
IMPRESSION: Severe left ventricular dilation with severe global
left ventricular hypokinesis. Mildly dilated right ventricle
with moderate global hypokinesis. Mild to moderate mitral
regurgitation.
.
CXR [**2176-7-31**]
Stable chest x-ray examination with no acute pulmonary process
identified. The tracheal deviation in the course of the
contiguous [**Month/Day/Year 26418**] lead is in keeping with a large left thyroid
lobe which grossly is stable.
CXR [**2176-7-31**]
1. New mild pulmonary edema.
2. Intact [**Month/Day/Year 26418**]/pacemaker lead in standard position.
3. Stable rightward tracheal deviation due to known thyroid
mass.
Brief Hospital Course:
57 year old male with CAD s/p MIx4, CHF, CVA p/w with chief
complaint of substernal chest & back pain found to have NSTEMI
who was not a candidate for interventional therapy so received
medical management.
.
ACTIVE ISSUES:
# NSTEMI: Pt presented with CP and found to have NSTEMI by
enzymes. Previous cath suggested pt would benefit best from
medical management. Started on nitroglycerin drip, heparin gtt x
48 hrs, [**Month/Day/Year **] (allergy was previous GI bleed) and [**Month/Day/Year 4532**]. Nitro
drip d/c'ed on [**8-1**] and pt re-started on home imdur. Pt
experienced another episode of CP while undergoing PT, though no
EKG changes were noted. Amlodipine 10mg was added to help
improve pt's CP. Max dose of Crestor was added in place of
atorvastatin for suboptimal lipid control. Also started on [**Month/Year (2) **].
Pt was not started on an ACEI during this admission as it had
been noted in the chart that he had developed hyperkalemia when
on ACEIs in the past.
.
# RHYTHM: Pt's rhythm is underlying sinus though marked by
considerable ectopy. Pt is s/p ICD from a previous admission. To
improve functional status, pt was upgraded to BiV pacing on [**8-5**]
though the ventricular lead could not be positioned, so an
epicardial lead may have to be placed at a later date. During
the procedure, the patient had an episode of Afib/flutter which
converted back to sinus with APC and VPC. Pt's home metoprolol
and amiodarone were continued.
.
CHRONIC ISSUES:
# Chronic Systolic CHF: Per prior Echo, pt's EF is 20% and had
evidence of dyskinesis for reason why CRT was pursued and should
continue to be followed as an outpatient. Pt's BPs were in the
low 100s throughout most of the hospitalization so his home
torsemide was introduced as pt's BP could tolerate. Pt's home
digoxin was continued.
.
# HLD Pt's LDL (99) is above his goal given his recent cardiac
event. Pt was switched from atorva 80 to Crestor 40 to better
optimize his lipid levels.
.
# DIABETES TYPE 2: Pt's blood sugars were in the 300s while on
sliding scale insulin but improved upon resumption of pt's home
regimen of 40u lantus [**Hospital1 **].
.
# CKD: Pt's Cr was at his new baseline of 1.6. Meds were renally
dosed and nephrotoxins avoided.
.
# GOITER/HYPERTHYROIDISM: Continued pt's home methimazole
.
# s/p LMCA CVA: Stable. He has chronic Broca's aphasia at
baseline. In addition to his home [**Last Name (LF) 4532**], [**First Name3 (LF) **] was started this
admission as pt's allergy was a hx of GI bleed.
.
# SEIZURE DISORDER: Stable. Continued pt's home keppra.
.
# GASTROESOPHAGEAL REFULX DISEASE/PEPTIC ULCER DISEASE: Stable.
Continued pt's home ranitidine.
.
# ASTHMA: Stable. Continued home advair and albuterol prn
.
TRANSITIONAL ISSUES:
1. BiV placement was unsuccessful. Will need follow up with CT
surgery for evalution for placement of epicardial lead.
2. Blood pressure: Consider adding [**First Name8 (NamePattern2) **] [**Last Name (un) **] as an outpatient. It
was deferred in the hospital because pressures were tenuous in
the setting of uptitrating of other medications.
3. diuretics: Patient was also very sensitive to his home dose
of torsemide while in the hospital perhaps because of effective
salt restriction. Please reevaluation kidney function and weight
in next clinic visits.
4. Aflutter: Patient was found to have Aflutter during his EP
procedure, otherwise in sinus. Deferred the question of
anticoagulation to his outpatient physicians.
Medications on Admission:
ALBUTEROL SULFATE - prn
AMIODARONE - 200 mg Tablet daily
ATORVASTATIN - 80 mg Tablet daily
AZELASTINE [ASTELIN] - 137 mcg qd
CLOPIDOGREL - 75 mg Tablet - qd
DIGOXIN - 125 mcg Tablet - qd
FLUOCINOLONE - 0.025 % Ointment - [**Hospital1 **] for Eczema
FLUTICASONE [FLONASE] - 50 mcg Spray - 2 sprays qd
FLUTICASONE-SALMETEROL 500 mcg-50 mcg/Dose [**Hospital1 **]
GLUCAGON EMERGENCY KIT - 1MG Kit
INSULIN GLARGINE [LANTUS] - 40 twice a day
INSULIN LISPRO [HUMALOG] - QID SS
ISOSORBIDE MONONITRATE - 60 mg qd
LEVETIRACETAM [KEPPRA] - 500 mg Tablet - 3 in AM and 2 in PM
METHIMAZOLE - 20 mg daily
METOPROLOL SUCCINATE - 50mg [**Hospital1 **]
NITROGLYCERIN - 0.6 mg prn
OXYCODONE-ACETAMINOPHEN - 5 mg-325 mg Tablet q4-6 prn
POTASSIUM CHLORIDE 20meq qd
RANITIDINE HCL - 150 mg Tablet [**Hospital1 **]
TORSEMIDE - 20 mg Tablet - 4 Tablet(s) by mouth in the morning
once goes up to 258 lbs or higher
Discharge Medications:
1. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*2*
2. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. methimazole 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
10. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
Disp:*1 bottle* Refills:*0*
11. levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO QAM
(once a day (in the morning)).
12. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO QPM (once
a day (in the evening)).
13. torsemide 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
14. amlodipine 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
15. insulin glargine 100 unit/mL Solution Sig: Forty (40) units
Subcutaneous twice a day.
16. insulin lispro 100 unit/mL Solution Sig: 1-12 units
Subcutaneous as per home sliding scale.
17. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 7 days.
Disp:*28 Capsule(s)* Refills:*0*
18. rosuvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
19. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
20. Astelin 137 mcg Aerosol, Spray Sig: One (1) spray Nasal once
a day.
21. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Discharge Disposition:
Home
Discharge Diagnosis:
Non ST Elevation Myocardial infarction
Acute on Chronic Systolic congestive heart failure: no ACE/[**Last Name (un) **]
because of low blood pressures.
Secondary diagnosis:
Diabetes Mellitus Type 2
Gastro esophageal reflux disease
Discharge Condition:
Mental Status: Clear and coherent with baseline expressive
aphasia s/p CVA.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory with cane
Discharge Instructions:
It was a pleasure taking care of you here at [**Hospital1 771**]. You were admitted because you had
chest pain and were found to have a mild heart attack. We
treated your heart attack medically and did not perform a
cardiac catheterization. We attempted to upgrade your ICD to a
type that paces both ventricles to help with your heart failure.
We were not able to do this and you may need to return to have
this done surgically. You have an appt with Dr. [**Last Name (STitle) **] to
discuss this. In the meantime, please take all of your medicines
and weigh yourself daily in the morning. Call [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] if
weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days.
Take all your home medications as directed EXCEPT for the
following medication changes or additions that were made during
your hospital stay:
1. We want you to start taking Aspirin 325mg by mouth daily to
help prevent another heart attack. Your allergy is listed as a
prior GI bleed which is not considered a true allergy.
2. We want you to stop taking atorvastatin 80mg by mouth daily
and instead start taking Rosuvastatin Calcium 40mg PO to control
your high cholesterol.
3. We want you to start taking Nitroglycerin 0.3mg under the
tongue as needed for chest pain instead of Nitroglycerin 0.6mg.
You can also try taking an antacid such as mylanta to see if
this helps with the pain.
4. We want you to start taking Amlodipine 10 mg by mouth daily
to help relieve your chest pain.
5. Start taking Cephalexin for one week to prevent an infection
at the ICD site
6. Change the Metoprolol tartrate to metoprolol succinate to
treat your heart disease. This once a day formulation is better
for your heart failure
7. Continue to hold your valsartan because of your low blood
pressure. Dr. [**Last Name (STitle) 7790**] can consider adding this medicine back
on if your blood pressure is a little higher.
Followup Instructions:
Department: CARDIAC SERVICES
When: WEDNESDAY [**2176-8-14**] at 11:00 AM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: RADIOLOGY
When: THURSDAY [**2176-8-15**] at 9:00 AM
With: CAT SCAN [**Telephone/Fax (1) 327**]
Building: Gz [**Hospital Ward Name 2104**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3202**]
Campus: EAST Best Parking: Main Garage
Department: CARDIAC SERVICES
When: MONDAY [**2176-8-19**] at 9:15 AM
With: ICD CALL TRANSMISSIONS [**Telephone/Fax (1) 59**]
Building: None None
Campus: AT HOME SERVICE Best Parking: None
Department: [**Hospital1 18**] [**Location (un) 2352**]
When: TUESDAY [**2176-8-13**] at 11:10 AM
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
We are working on a follow up appointment in Cardiology with Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] within 2 weeks. The office will contact you at
home with an appointment. If you have not heard within 2
business days or have any questions please call [**Telephone/Fax (1) 62**].
Completed by:[**2176-8-6**]
ICD9 Codes: 4254, 4271, 4280, 2724, 412, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3430
} | Medical Text: Admission Date: [**2117-5-24**] Discharge Date: [**2117-6-2**]
Date of Birth: [**2046-6-16**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Heparin Agents
Attending:[**First Name3 (LF) 1055**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
70M sent from [**Hospital1 1501**] w/ h/o recent PNA, as well as CHF, COPD
presents after noted to be dyspneic and hypoxic at [**Hospital1 1501**]. Room air
sat on arrival was low 80s, was given O2, Steroids, Bipap, and
rose to 90s-100s. HR initially 130s-> improved to 110s.
Transiently dropped pressure to 80s, but came up spontaneously.
Gas 7.31/67/85 on Bipap. Pt adamantly refused intubation in ED,
initially agreed to short term BIPAP, refusing after short trial
in MICU. He states his breathing currently feels well. Pt states
he has 4 sons, but he wants to make his own medical decisions,
and is very clear that he does not want intubation. He denies
any recent fever, chills, chest pain, abdominal pain. He has
lower back pain where is he noted to have diffusely macerated
skin. Initial trial at foley insertion with pus returned. Pt
states he has chronic indwelling foley after past surgery.
.
In ED labs significant for BNP 3800, elevated troponin with Cr
1.0, although prior hx of renal failure. Also noted to have RBBB
on EKG, but no STT changes per ED. CXR limited by motion. Given
Vanco/levo in ED in addition to 20mg lasix IV.
.
Pt refused intubation in ED, prior documentation at rehab with
full code.
Note he was admitted to OSH mid [**Month (only) 116**] to [**2117-5-17**] after being found
on floor in feces. Treated that admit for ARF, hepatitis,
pneumonia.
Past Medical History:
most per phone conversation with rehab nurse:
DM II
HTN
COPD (on 3-4L NC O2 per pt)
CHF
CAD
ARF
Hemorrhagic cystitis
Skin ulcers
Social History:
has 4 sons, closest in [**Name (NI) **], states it is not a closely
knit family, does not want any of them to be primary decision
makers. 60 pack year smoking hx, previous heavy etoh hx, not
recently.
Family History:
NC
Physical Exam:
Temp 98.4, BP 150/54, HR 112, RR 26, O2 sat 95% on 4L NC
GENERAL: elderly, obese male, mild respiratory distress, awaker,
fully oriented, coherent
HEENT: OP clear, anicteric, L nares with some fresh bleeding
NECK: full neck, unable to examine for JVD
CARDIOVASCULAR: regular tachycardic, no murmurs
LUNGS: diffuse wheezes, no crackles
ABDOMEN: obese, non-distended, non-tender
BACK: large area of erythema, macerated skin, and ulceration
starting at coccyx
EXTREMITIES:
NEURO: AAOx3, moves all extremities
Pertinent Results:
EKG: irregular, tachycardic, RBBB, no ST changes or T wave
changes (same as previous read at prior hospitalization)
.
Admission CXR: very poor quality, lung volumes are low. There is
likely a left pleural effusion with associated atelectasis. No
large pneumothorax is identified.
.
Admission Labs:
[**2117-5-24**] 05:00AM PT-12.9 PTT-24.0 INR(PT)-1.1
[**2117-5-24**] 05:00AM HYPOCHROM-3+ ANISOCYT-2+ MICROCYT-2+
[**2117-5-24**] 05:00AM NEUTS-76.4* LYMPHS-17.4* MONOS-4.3 EOS-1.0
BASOS-0.9
[**2117-5-24**] 05:00AM WBC-17.0* RBC-4.07* HGB-10.6* HCT-35.3*
MCV-87 MCH-26.0* MCHC-30.0* RDW-19.7* PLT COUNT-531*
[**2117-5-24**] 05:00AM CALCIUM-8.4 PHOSPHATE-4.2 MAGNESIUM-2.1
[**2117-5-24**] 05:00AM CK-MB-7
[**2117-5-24**] 05:00AM cTropnT-0.21* proBNP-3799* CK(CPK)-118
[**2117-5-24**] 05:08AM LACTATE-2.5*
[**2117-5-24**] 05:00AM GLUCOSE-159* UREA N-12 CREAT-1.0 SODIUM-138
POTASSIUM-6.3* CHLORIDE-100 TOTAL CO2-29 ANION GAP-15
[**2117-5-24**] 05:30AM URINE RBC-0-2 WBC->50 BACTERIA-MANY YEAST-NONE
EPI-0
[**2117-5-24**] 05:30AM URINE BLOOD-MOD NITRITE-POS PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-MOD
[**2117-5-24**] 05:30AM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.016
[**2117-5-24**] 05:31AM K+-4.4
[**2117-5-24**] 05:31AM TYPE-ART RATES-/40 PEEP-8 O2-80 PO2-84*
PCO2-67* PH-7.31* TOTAL CO2-35* BASE XS-4 AADO2-417 REQ O2-73
INTUBATED-NOT INTUBA VENT-SPONTANEOU
[**2117-5-24**] 10:12AM LACTATE-1.4
[**2117-5-24**] 10:12AM TYPE-ART O2-40 PO2-66* PCO2-64* PH-7.33*
TOTAL CO2-35* BASE XS-4 INTUBATED-NOT INTUBA
[**2117-5-24**] 12:03PM ALBUMIN-3.2* MAGNESIUM-2.0
[**2117-5-24**] 12:03PM ALT(SGPT)-15 AST(SGOT)-17 CK(CPK)-39 ALK
PHOS-139* TOT BILI-0.3
[**2117-5-24**] 12:03PM CK-MB-NotDone cTropnT-0.19*
.
CXR [**6-1**]: AP semiupright view. Evaluation is limited by patient
positioning and body habitus. Cardiac and mediastinal contours
are unchanged. There are moderate bilateral pleural effusions,
left greater than right, and basilar atelectasis, unchanged
compared to the previous study.
IMPRESSION: Limited study. No interval change
.
R LENI [**5-28**]: IMPRESSION: Limited study secondary to patient
body habitus. No evidence of DVT seen within the right common
femoral, proximal superficial femoral, and popliteal veins.
.
Head CT [**5-24**]:
FINDINGS: Patient motion and positioning within the scanner
somewhat limits assessment. No intra- or extra-axial hemorrhage
is clearly identified. There is no mass effect or shift of
normally midline structures. The ventricles do not demonstrate
any hydrocephalus. The basal cisterns are visualized. Paranasal
sinuses appear clear. The patient is edentulous. Soft tissue
structures appear unremarkable.
.
IMPRESSION: Limited study. No obvious intracranial hemorrhage
or mass
effect.
.
Note added at attending review: There is an incompletely
visualized expansile mass in the left maxillary alveolar ridge
and there is a partially calcified mass in the left frontal
sinus. Ct scan of the facial bones suggested.
.
CT Sinus, prelim read: 2.4 x 1.4 cm expansile mass in the left
maxillary alveolar ridge. There is thinning of the cortical
margins and areas of focal dehiscense. The findings may be
consistent with an ameloblastoma. Partially calcified mass in
the left frontal sinus. Right maxillary and ethmoid sinus
mucosal thickening.
.
TTE:
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. There is moderate symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Overall left
ventricular systolic function is normal (LVEF>55%). The right
ventricular cavity is mildly dilated. Right ventricular
systolic function is normal. The aortic root is moderately
dilated. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
There is no aortic valve stenosis. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen. The
estimated pulmonary artery systolic pressure is normal. There
is no pericardial effusion.
.
Urine Culture:
URINE CULTURE (Final [**2117-5-27**]):
PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML..
PROTEUS MIRABILIS. 10,000-100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
| PROTEUS MIRABILIS
| |
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- 16 I
CEFEPIME-------------- 2 S <=1 S
CEFTAZIDIME----------- 4 S <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN--------- =>4 R =>4 R
GENTAMICIN------------ <=1 S =>16 R
IMIPENEM-------------- <=1 S
LEVOFLOXACIN---------- =>8 R
MEROPENEM-------------<=0.25 S <=0.25 S
PIPERACILLIN---------- 8 S 32 I
PIPERACILLIN/TAZO----- 8 S <=4 S
TOBRAMYCIN------------ <=1 S 8 I
TRIMETHOPRIM/SULFA---- =>16 R
Brief Hospital Course:
COPD exacerbation - Initially admitted to the MICU. No previous
available ABG values, however initial ABG with partly
compensated respiratory acidosis and component of newly worsened
hypercarbia c/w COPD exacerbation. Pt became progressively
sedated over the course of HOD #1 -> continued on BIPAP, pCO2
trended up to 76 (ABG 7.31/76/154). Pt became more arousable
overnight with continued BIPAP, repeat ABG 7.38/65/188. He was
started on high dose steroids with solumedrol 125 mg q6hrs and
Q4H scheduled atrovent/albuterol nebs, q2hrs prn. Placed on
ceftriaxone, azithromycin for cough, productive of yellow
sputum, recent pneumonia, finished a course of this in-house.
On HOD #2 pt. refused further positive pressure ventilation,
BiPAP, or intubation. Repeat ABGs with pCO2 as high as 80,
pH>7.30. Prednisone was tapered to 40 mg PO, and pt. was
transferred to the floor as he was refusing any invasive
ventilation.
.
On the floor pt. continued to have elevated PCO2 levels, which
peaked at 95 and then trended down to 70s. Pt. had no further
sedation or AMS. He maintained O2 sats 88-92% on 4 L
throughout. Prednisone was weaned to 30 mg QD after 5 days at
40 mg, and a slow wean should be continued in rehab.
.
CHF exacerbation - EF 55-60% on TTE, evidence of diastolic
dysfunction (see results above). Difficult to evaluate fluid
status on CXR although he did have marked LE edema on exam, and
elevated BNP suggested CHF exacerbation. Diuresed with lasix
40mg IV bid, Bun/Cr stable in MICU, with ~ 1L negative QD in the
MICU. This was initially continued on the floor, and then
decreased to 40 mg daily as he was 2-3 L negative daily -> 1-1.5
negative with 40 IV QD. On discharge lasix was d/ced and Bumex
reinitiated at 1 mg QD, along with aldactone, which was started
for K+ sparing and to avoid contraction alkalosis.
.
# CAD - elevated troponin on presentation suggestive of previous
ischemic event, trended down. Continued ASA, metoprolol,
losartan. No need for statin based on lipids, LDL<70. Noted to
have allergic reaction to heparin in past, appears most likely
had thrombocytopenia?, but HIT negative. Covered with
Fondaparinux for DVT prophylaxis in house as it is safe if he
really did have HIT in past.
.
# HTN - continued losartan, metoprolol. Started on Aldactone on
discharge for K+ sparing and to avoid contraction alkalosis (pt.
was beginning to develop a contraction alkalosis from lasix).
.
# A Fib: continued beta-blocker. Elected not to anti-coagulate
given acute illness, bleeding risk, though this should be
considered in the future. He had converted back to NSR at 65 BPM
by discharge.
.
# Mass L maxillary ridge- this was noted incidentally on Head CT
performed in MICU. It was followed up with a CT sinus, the
prelim read of which showed a mass concerning for ameloblastoma.
ENT was consulted and recommended outpatient work-up by OMFS
and ENT (Dr. [**First Name (STitle) **] from ENT reviewed imaging and felt that it
was c/w frontal sinus osteoma). Final read of sinus CT was
pending at time of discharge and should be follow up by Dr.
[**First Name (STitle) **]. He will see Dr. [**First Name (STitle) **] in about 2 weeks.
# UTI - treated with ceftriaxone and then cefepime in-house and
discharged on the rest of a 12 day course (see urine culture
above)
.
# Decubitus ulcer - no clear cellulitis, but given past
colonization with MRSA, elevated WBC, initially covered with
vancomycin, stopped after cx's negative x48 hrs, afebrile.
- frequent turns
- continued skin care as recommended by wound care consult (see
page 2 attached)
.
# FEN: cardiac diet
.
* Prophylaxis: no heparin products given previous allergy.
Pneumoboots/Fondaparinux, PPI.
.
* Code status: DNR/DNI, no non-invasive ventilation per several
discussions with pt.
By discharge the patient was much improved but still
significantly SOB with any exertion in bed. He needs more
diuresis. At rest his Sa02 was 92-96% on [**2-13**] L o2.
Medications on Admission:
ASA 81mg daily
Cyclopentolate drops L eye [**Hospital1 **]
Dexamethasone maxidex 5mL [**Hospital1 **] L eye
brinzolamide 5 mL L eye [**Hospital1 **]
Albuterol
Advair
Atrovent
FeSo4 300mg TID
Panptoprazole 40 mg [**Hospital1 **]
Losartan 50md daily
Toprol XL 75mg daily
Tramadol 50mg TID
Theophylline 300mg PO BID
Bumex 2mg PO QOD
Discharge Medications:
1. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
2. Regular Insulin Sliding Scale
please check FS before meals and at bedtime and administer
insulin per sliding scale attached
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Cyclopentolate 1 % Drops Sig: Two (2) Drop Ophthalmic [**Hospital1 **] (2
times a day).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Dexamethasone 0.1 % Drops, Suspension Sig: Two (2) Drop
Ophthalmic Q12H (every 12 hours).
8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
9. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
10. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
11. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
12. Prednisone 20 mg Tablet Sig: One (1) Tablet PO once a day
for 5 days: [**Date range (1) 110167**]/26.
13. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO
twice a day.
14. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q4-6H (every 4 to 6 hours) as needed.
15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
16. Cefepime 1 g Recon Soln Sig: One (1) Recon Soln Intravenous
Q12H (every 12 hours) for 2 days.
17. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-14**] Sprays Nasal
QID (4 times a day) as needed.
18. Fondaparinux 2.5 mg/0.5 mL Syringe Sig: One (1)
Subcutaneous once a day.
19. Bumex 1 mg Tablet Sig: One (1) Tablet PO once a day.
20. Aldactone 25 mg Tablet Sig: One (1) Tablet PO once a day.
21. Brinzolamide 1 % Drops, Suspension Sig: Five (5) mL
Ophthalmic twice a day: 5 mL L eye [**Hospital1 **].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary: COPD Exacerbation, Diastolic CHF, Frontal Sinus Osteoma
.
Secondary:
Type II DM, well-controlled
HTN
CAD
Morbid obesity
Decubitus Ulcer
Hemorrhagic cystitis
Discharge Condition:
Stable, O2 sats 88-92% on 4L (on home O2)
Discharge Instructions:
Please call your doctor or go to the ER if you have any
shortness of breath, chest pain, fevers, chills, cough, or any
other symptoms that concern you.
.
Please take all medications as prescribed
Followup Instructions:
Oral Surgery: You have an appointment scheduled with Dr. [**Last Name (STitle) **]
on Tuesday, [**7-13**] at 2:00. His office is located at [**Street Address(2) 110168**], [**Apartment Address(1) 110169**], [**Location (un) **], phone # [**Telephone/Fax (1) 110170**]. You had
a mass in one of the bones in your face that he will follow up
further.
.
ENT: You have an appointment scheduled with Dr. [**First Name (STitle) **] on Friday,
[**6-18**] at 8:30AM. His office is located at [**Location (un) **].,
[**Apartment Address(1) **]. Please call his office at [**Telephone/Fax (1) 2349**] with any
questions.
.
Primary Care: Please call your primary care doctor to set up a
follow up appointment in the next 1-2 weeks.
Completed by:[**2117-6-2**]
ICD9 Codes: 4280, 2762, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3431
} | Medical Text: Admission Date: [**2116-4-11**] Discharge Date: [**2116-4-13**]
Date of Birth: [**2082-3-28**] Sex: F
Service: MICU
HISTORY OF PRESENT ILLNESS: The patient is a 34 year old
morbidly obese female with a history of sleep apnea requiring
assist control ventilation and now presenting with fevers,
chills and headache since [**2116-4-10**]. She complains of nausea,
low back pain likely chronic and mild photophobia.
PAST MEDICAL HISTORY:
1. Obstructive sleep apnea.
2. Asthma for which she was intubated and tracheostomy.
ALLERGIES: The patient is allergic to Percocet and Vicodin
for which she gets a rash.
MEDICATIONS: She is on Fluticasone inhaler, Fioricet,
Heparin subcutaneous, Salmeterol, Venlafaxine and Albuterol.
HOSPITAL COURSE:
1. Headache - The patient had symptoms consistent with
meningitis versus subarachnoid versus sinusitis. In terms of
meningitis, she is being treated empirically with Ceftriaxone
and Vancomycin due to inability to do a lumbar puncture given
her size. She has a low grade temperature but no elevated
white blood cell count throughout her hospital stay.
2. In terms of subarachnoid, it is unlikely. Neurologic
checks q4hours did not show any focal deficit.
3. In terms of sinusitis, she has symptoms of maxillary
tenderness, though x-ray did not show any fluid levels in her
sinuses. However, she was given Pseudoephedrine throughout
the course to alleviate it. Her headache did go down from
ten out of ten to five out of ten and continues to get
better.
4. In terms of her fever, she has an unclear etiology,
likely infectious, but urinalysis was clear. Chest x-ray was
clear. Blood cultures are pending. Given that temperature
is coming down, it is reassuring.
5. Depression - She continued her Effexor.
6. Pulmonary - She continued on her ventilation at home for
obstructive sleep apnea.
In terms of her discharge, she received a PICC line in her
arm to receive her antibiotics for meningitis and she will
continue a ten day course.
DISCHARGE DIAGNOSES:
1. Question rule out meningitis.
2. Obstructive sleep apnea.
3. Depression.
MEDICATIONS ON DISCHARGE:
1. Pseudoephedrine.
2. Ceftriaxone two grams intravenously q12hours.
3. Vancomycin one gram q12hours.
4. Salmeterol one puff twice a day.
5. Fluticasone 110 mcg two puffs twice a day.
[**Name6 (MD) 34651**] [**Name8 (MD) 34652**], M.D. [**MD Number(1) 34653**]
Dictated By:[**Last Name (NamePattern1) 19796**]
MEDQUIST36
D: [**2116-4-13**] 17:17
T: [**2116-4-13**] 17:55
JOB#: [**Job Number 34654**] and [**Numeric Identifier 34655**]
ICD9 Codes: 2761 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3432
} | Medical Text: Admission Date: [**2149-2-28**] Discharge Date: [**2149-3-3**]
Service:
CHIEF COMPLAINT: Bright red blood per rectum.
HISTORY OF PRESENT ILLNESS: This is a 79-year-old male with
a history of diverticulosis, hypertension, thalassemia and
prostate cancer who presents with bright red blood per rectum
starting at approximately 4:30 AM on the day of admission.
He was up at 4 AM, had some [**Last Name (un) **] water, then had a loose
yellow bowel movement with no blood. About one-half hour
later he had bright red blood per rectum then came
immediately to the emergency room where he reports three more
episodes of bright red blood per rectum. Usually the patient
has one brown bowel movement per day, no melena or bright red
blood per rectum usually. He ate four handfuls of popcorn
last night and watermelon with seeds. He denies chest pain,
shortness of breath, abdominal pain, nausea, vomiting, or
diarrhea. He was dizzy only when an nasogastric tube was
attempted to be placed. In the emergency room the patient
received fluids and Protonix and had a stable blood pressure.
Gastrointestinal saw the patient and recommended a
colonoscopy but not urgently. No nasogastric lavage was done
as the tube could not be passed.
PAST MEDICAL HISTORY: Hypertension, thalassemia, prostate
cancer not being treated, history of a diverticular bleed ten
years ago. He reports having a normal colonoscopy here at
that time though it is not in our computer system. The
patient states he has a history of a heart murmur, history of
gout.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS: Atenolol 50 mg p.o. q.d.; Accupril dose
uncertain q.d.; allopurinol q.d.
SOCIAL HISTORY: He lives with his wife. [**Name (NI) **] worked in the
heating business. He has two sons, one is deceased. No
tobacco. He drinks a quart of wine per day. He has never
withdrawn. He has no primary care physician at present, as
his primary care physician [**Name Initial (PRE) **].
FAMILY HISTORY: Diabetes and coronary artery disease in his
mother.
PHYSICAL EXAMINATION: On admission his vital signs were
temperature 98.8, pulse 62, respiratory rate 18, blood
pressure 144/54 and 100% on room air. Generally, he was
alert and oriented x 3 in no apparent distress. HEENT showed
pupils were equal, round, and reactive to light, extraocular
movements intact, no lymphadenopathy. Cardiac examination
was regular rate and rhythm, a [**3-6**] murmur at the left lower
sternal border that radiated to the axilla not to the neck.
Lungs were clear to auscultation bilaterally; no wheezes, no
rales. Abdomen was soft, nontender, and nondistended,
positive bowel sounds. Genitourinary examination showed
bright red blood per rectum per the emergency room.
Extremities had no edema. Neurological examination showed
cranial nerves two through 12 were intact. Strength was [**6-2**]
throughout.
He had an EKG that was normal sinus rhythm at 67, left axis
deviation with normal intervals, no ST elevation or T wave
inversion. He did have mild upsloping of the T wave in V2
through V4 which could be called J point elevation. There is
no old film to compare.
LABORATORY STUDIES: His admission hematocrit was 36.7.
Discharge hematocrit was 30.4. White count 10.7, MCV 67,
58.2 neutrophils, 35.8 lymphocytes, 3.0 monocytes, 2.3
eosinophils, 0.6 basophils. Platelet count was 133. PT
12.8, PTT 28.3, INR 1.1. Glucose 131, BUN 9, creatinine 0.8,
sodium 138, K 5.1, hemolyzed, chloride 105, bicarbonate 22,
ALT 16, AST 41, amylase 45. CKs x 3 were 59, 30 and 36.
Lipase was 34, troponin less than 0.3 x 3. Calcium 8.9,
phosphorous 4.4, magnesium 1.9, iron 84, TIBC 324, ferritin
364, TRF 249, hemoglobin A1c 6.1.
HOSPITAL COURSE: This was a very pleasant 79-year-old man
with a lower gastrointestinal bleed.
1. Gastrointestinal: The patient received a total of four
units of packed red blood cells with only one more episode of
bright red blood when he reached the intensive care unit.
The patient had a colonoscopy which showed multiple
diverticula and internal hemorrhoids. The patient did
receive p.o. Protonix during his course here, though he was
not discharged on that. The patient was discharged and
advised to avoid seeds, nuts and popcorn.
2. Hypertension: The patient had a history of hypertension.
His medications were held here and he was advised to restart
them as an outpatient on the day after discharge.
3. Thalassemia: Stable with his low MCV.
4. Endocrine: The patient had an elevated blood glucose when
he arrived. We did q.i.d. fingersticks x 1 day and
hemoglobin A1c was sent. On further information the patient
said he has had some glucose intolerance in the past and
actually sees a doctor [**First Name8 (NamePattern2) **] [**Last Name (Titles) **].
5. Cardiovascular: The patient had a murmur that he states
was worked up in the past with echocardiogram. He stated he
has not had a recent stress test. Due to the J point
elevation and repeat EKG showing some T wave flattening,
would recommend and outpatient stress and an outpatient
echocardiogram to work-up the patient's murmur.
DISPOSITION: The patient was discharged to home in stable
condition. He was given the phone number for Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 1058**] and [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Associates to follow up for his
primary care physician.
DISCHARGE MEDICATIONS: He was to return to his regular
outpatient regimen of atenolol, Accupril and allopurinol.
The patient was to follow up with his new primary care
physician in two weeks.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 5587**]
Dictated By:[**Last Name (NamePattern1) 22309**]
MEDQUIST36
D: [**2149-3-4**] 01:12
T: [**2149-3-5**] 08:07
JOB#: [**Job Number 99469**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3433
} | Medical Text: Admission Date: [**2137-1-31**] Discharge Date: [**2137-2-4**]
Date of Birth: [**2091-1-5**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Percocet / Demerol / Ceftin / Toradol / Naprosyn
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Abdominal/back pain s/p nephrostomy tube replacement [**1-31**], also
fever/chills.
Major Surgical or Invasive Procedure:
none
History of Present Illness:
45 yo woman with recurrent Stage III papillary serous
Ovarian CA s/p TAH/BSO, two subsequent tumor debulkings,
chemotherapy, RT, now receiving home hospice, who is referred
s/p
nephrostogram/tube replacement with RLQ pain, R flank pain,
fever/chills since day prior to yesterday. She also reports
diarrhea that has since resolved. She denies nausea/vomiting.
The remainder of her ROS is negative.
Past Medical History:
PAST MEDICAL HISTORY:
- Stage III papillary serous ovarian cancer s/p chemotherapy
currently receiving RT
- recurrent UTI with e. coli and enterococcus
- Recent hospitalization for pyelonephritis
- migraine headaches
- atrophic left kidney
- congenitally atrophic right arm below the elbow
- seasonal asthma
- HTN
PAST SURGICAL HISTORY
1. Cholecystectomy
2. Ovarian cancer cytoreduction s/p TAH-BSO & omentectomy in
'[**25**], then 2 debulking surgeries in '[**31**] and '[**35**];
3. R ureteral stent [**2136-5-18**] for right-sided hydronephrosis
secondary to extrinsic ureteric compression from advanced
ovarian cancer, R percutaneous nephrostomy on [**2136-6-8**], with
replacement by IR [**2137-1-31**] (pyelogram revealed distal
obstruction)
Social History:
Lives with: 27 year old daughter ([**Name (NI) **]) in [**Location (un) 2251**]
Occupation: previously worked in medical billing at [**Hospital1 2025**]
Tobacco: Smoked 1 pack per month x15 years; quit several yeas
ago
EtOH: Denies
Drugs: Denies
Mood: Depressed
Support system: Feels support from daughter/friends "sometimes"
Family History:
Mother: Recurrent lung CA; DM
Father: HTN, CVA at age 48
Sister: Cervical CA
Physical Exam:
T 98.9 84 92/44 15 98
NAD
RRR CTAB
Abd soft +TTP RLQ no g/r
+R CVAT
Nephrostomy tube in place, site intact with no erythema/exudate
Pelvic deferred
Pertinent Results:
Labs: WBC 6.3 (68% PMNs, 0 bands), HCT 26.3 (baseline 27-31),
PLT 492 (baseline 200)
PT 12.9 INR 1.1 PTT 31.0
Creatinine 1.1 (baseline 1.3)
Na 142, K 4.1, Cl 107, HCO3 27, BUN11, Gluc 92
Brief Hospital Course:
45 yo woman with recurrent Stage III papillary serous Ovarian CA
s/p TAH/BSO, two subsequent tumor debulkings, chemotherapy, RT,
now receiving home hospice, who is referred s/p
nephrostogram/tube replacement with RLQ pain, R flank pain,
fever/chills since [**1-29**]. At presentation on [**1-31**], there was no
clear evidence of infection given that her WBC was normal and
she was afebrile. Her nephrostomy pigtail was replaced and
antegrade pyelogram indicated functional nephrostomy tube and
persistent distal ureteral obstruction. On CXR, the lungs were
clear. She was admitted for pain control. However, her UA
revealed >100K WBCs and, on [**2-1**], she mounted a fever to 100.7F.
She was placed on zosyn and vancomycin was added when she was
persistently febrile. Despite urine WBC count as above, urine
cultures revealed only yeast 10-100K.
A pain consult was requested and they recommended dilaudid PCA.
She was started on the dilaudid PCA, but had several episodes of
hypotension while on increased narcotics for her pain requiring
transfer to the ICU for monitoring. Her PCA was discontinued
and her fentanyl patch was restarted.
Psychiatry was consulted for management of depression and
affective instability and recommendations regarding her multiple
medications including clonazepam, lorazepam, mirtazapine and
narcotics. During her stay, she was showing signs of mild
delirium with decreased attention and concentration. Thus
psychiatry recommended continuing her mirtazapine and
clonazepam, but suggested limiting prn ativan and narcotics as
possible, recognizing the difficulty in this given her chronic
pain. They also suggested using seroquel for anxiety and
insomnia.
In the setting of increased pain medication, specifically
narcotics, she became hypotensive to 70s systolic. She was
mildly lightheaded at this time. She was transferred to the ICU
where she received IV fluids to which her BP responded with
systolics returning to the low 100s mmHg. Her hypotension was
thought more likely [**2-8**] to her pain medication regimen and poor
PO rather than hypotension [**2-8**] to sepsis.
During her stay, multiple family meetings including her pastor
were had to evaluate code status. She had previously been in
the care of hospice prior to this admission. During her stay in
the setting of hypotension, code status was readdressed and she
decided that she no longer wished DNR/DNI, but wanted full code.
While in the ICU, this was again readdressed with her family,
pastor, and patient, and code status was changed to CMO. She
requested transfer back to her home hospice care.
Medications on Admission:
Fentanyl 150 mcg/hr Patch
Lorazepam 1mg prn
Clonazepam 0.5 mg HS
Hydromorphone 10 mg PRN
Docusate Sodium 100 mg Capsule po bid
Senna QD
Reglan PRN
Mirtazapine 30 mg HS
Omeprazole 20 mg QD
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).
3. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
4. Mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)) as needed.
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
6. Metoclopramide 10 mg IV Q6H:PRN
7. Zyprexa Zydis 5 mg Tablet, Rapid Dissolve Sig: One (1)
Tablet, Rapid Dissolve PO at bedtime: Please give at 10pm.
8. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO every six (6)
hours.
9. Ativan 1 mg Tablet Sig: 0.5-1 Tablet PO every 4-6 hours as
needed for agitation.
10. Ativan 2 mg/mL Syringe Sig: 0.5-1 mg Injection every [**6-14**]
hours as needed for agitation: [**Month (only) 116**] give IV or SC.
11. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO Q4H PRN AND HS
PRN as needed for insomnia.
12. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO twice a day.
13. Fentanyl 100 mcg/hr Patch 72HR Sig: Two (2) patches
Transdermal every seventy-two (72) hours.
14. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours).
15. Morphine 10 mg/5 mL Solution Sig: Five (5) ml PO q4hrs: prn
as needed for pain.
16. Haloperidol 5 mg Tablet Sig: One (1) Tablet PO BID: prn as
needed for agitation.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
ovarian cancer
abdominal pain
depression
anxiety
renal insufficiency
urinary tract infection
hypertension
Discharge Condition:
Good
Discharge Instructions:
Call if fever, worsening pain, other concerns/questions
Followup Instructions:
Home Hospice
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
ICD9 Codes: 5990, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3434
} | Medical Text: Admission Date: [**2117-5-2**] Discharge Date: [**2117-5-13**]
Date of Birth: [**2056-4-16**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
SOB and Fever
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
61yo M with COPD on home O2, Type II DM, and obesity who
presents with acute onset of SOB. The pt reports he was in his
USOH until this AM when he awoke with a [**First Name3 (LF) **]. The [**First Name3 (LF) **] is
non-productive but pt believes there is sputum "deep down".
Since this AM, the pt has not been able to "catch his breath".
He has not appreciated on any wheezing himself but tried his PRN
medications without success. In addition, the pt also reports
subjective fevers with chills as well. The pt denies any cp,
palpitations, LE edema, PND, orthopnea (one pillow), he also
denies any abd pain, n/v/d. He reports he has received his flu
vaccine this year.
In the ED, the pt was found to be febrile to 101, tachycardic
and hypertensive. His physical exam was significant for diffuse
wheezing throughout the lung fields. He was given Ceftriaxone
and Azithromycin as well as Solumedrol and combivent nebulizers
with some improvement in his SOB.
Past Medical History:
1. COPD- on home O2 (3L), FEV 590, FEV1 20% predicted, FEV1/FVC
ratio 38% predicted, multiple previous intubations. followed by
Pulm
2. Tobacco Abuse
3. DM II
4. Diverticulosis
5. h/o SBO
6. C6-C7 HERNITATION
7. B12 Deficiency- on monthly injections
8. Obesity
Social History:
Pt is married and lives with wife and 3 children. He is
currently umemployed- former restaurant manager
Tob: smokes 6 cig 2-3x/week. He used to smoke [**4-17**] ppd for 40+
years but has been cutting back recently.
EtOH: last drink was last X-mas.
Family History:
Father, mother died of lung cancer in their 60's.
Physical Exam:
PHYSICAL EXAMINATION:
VS: T: 101, HR: 80, BP: 139/56, RR: 23, SaO2: 95% 3L
GEN: obese caucasian male in NAD, conversing fluently in full
sentences.
HEENT: EOMI, anicteric, mmm
CV: distant heart sounds, RRR, S1, S2, no m/r/g
Chest: diffuse wheezing throughout, poor air movement
ABD: obese, soft, NT, ND, BS+
Ext: wwp, no c/c/e
Pertinent Results:
LLE US: IMPRESSION: No evidence of left lower extremity deep
venous thrombus.
Spirometry [**4-22**]:
Actual Pred %Pred
FVC 1.77 4.11 43
FEV1 0.52 2.92 18
MMF 0.20 2.90 7
FEV1/FVC 29 71 41
[**2117-5-13**] 07:10AM BLOOD WBC-11.1* RBC-4.34* Hgb-12.5* Hct-38.7*
MCV-89 MCH-28.9 MCHC-32.4 RDW-14.0 Plt Ct-222
[**2117-5-2**] 05:45PM BLOOD WBC-9.4 RBC-4.41* Hgb-13.2* Hct-39.6*
MCV-90 MCH-29.9 MCHC-33.3 RDW-13.9 Plt Ct-166
[**2117-5-6**] 08:14PM BLOOD Neuts-85.5* Lymphs-7.2* Monos-6.3 Eos-0.9
Baso-0.2
[**2117-5-13**] 07:10AM BLOOD Plt Ct-222
[**2117-5-11**] 03:00AM BLOOD PT-12.5 PTT-28.3 INR(PT)-1.1
[**2117-5-13**] 07:10AM BLOOD Glucose-147* UreaN-23* Creat-0.7 Na-139
K-4.4 Cl-98 HCO3-35* AnGap-10
[**2117-5-2**] 05:45PM BLOOD Glucose-147* UreaN-19 Creat-0.8 Na-146*
K-4.1 Cl-103 HCO3-34* AnGap-13
[**2117-5-7**] 04:50AM BLOOD CK(CPK)-108
[**2117-5-6**] 08:14PM BLOOD CK(CPK)-101
[**2117-5-7**] 04:50AM BLOOD CK-MB-3 cTropnT-<0.01
[**2117-5-6**] 08:14PM BLOOD CK-MB-4 cTropnT-<0.01
[**2117-5-13**] 07:10AM BLOOD Calcium-9.3 Phos-2.3* Mg-1.8
[**2117-5-10**] 06:17AM BLOOD Type-ART Temp-36.2 pO2-96 pCO2-75*
pH-7.36 calHCO3-44* Base XS-13
[**2117-5-6**] 12:02PM BLOOD Type-ART FiO2-91 pO2-82* pCO2-94*
pH-7.22* calHCO3-41* Base XS-6 AADO2-487 REQ O2-81
Brief Hospital Course:
61yo M with COPD on home oxygen (3L) and DM p/w progressive SOB
and fevers. Pt had episode of desat to 60's 2 days ago, treated
with nebs, solumedrol, and 100% NRB. O2 sat then recovered to
>90% on 3L. Pt now with increasing oxygen requirement, although
he "feels about the same." Very poor air movement and wheezy on
exam.
.
#) COPD exacerbation: In the ED, the pt was found to be febrile
to 101, tachycardic and hypertensive. His physical exam was
significant for diffuse wheezing throughout the lung fields. He
was given Ceftriaxone and Azithromycin as well as Solumedrol and
combivent nebulizers with some improvement in his SOB. Admitted
to the floor until [**5-6**], when he desaturated and had ABG of
7.22/94/82. Pt was mentating and plyaing solitaire. Given two
nebs with some improvement in exam. Over the next 15 mins, he
became more somnolent, refused noninvasive ventialtion. A code
blue was called for intubation.
.
Admitted to the ICU for hypercarbic resp failure. His influenza
A DFA returned positive and was started on tamiflu. His IUC
course was signficant for IV solumedrol, antibiotics (7 days
azithromycin) and positive pressure ventilation. He was
extubated [**5-10**] without complication, when his azithro stopped
also. Finished day #[**6-18**] of tamiflu. Was on 6 days of IV
solumedrol, now on oral prednisone. In ICU, he did not require
his baseline ACE while on the vent, now needs BP meds.
Will send patient to rehab on the following oral prednisone
taper: 60mg X 7 days, 40 mg X 7 days, 30mg X 7 days, 20mg X 7
days, 10mg X 7 days, then 10mg every other day thereafter. Will
continue nebs. Smoking cessation. Low carbohydrate diet, if
possible. Pt will follow up with Dr.[**Last Name (STitle) **] as an outpt.
.
#) DM: cont. outpt regimen of Metformin 1000mg [**Hospital1 **]. Pt says he
does not take glyburide [**3-18**] hypoglycemia. Pt has had elevated
FS, likely secondary to steroids. He never had any episodes of
hypoglycemia, DKA or NK hyperglycemia. Will send to rehab with
metformin 1000mg [**Hospital1 **] and ISS.
.
#) CV:
A. CAD: The pt has multiple risk factors for CAD including age,
sex, tob, HTN and DM. However, his mortality is limited by
critical COPD, not coronary disease. Will continue ASA. ACE
inhibition will protect his kidneys from diabetic nephropathy.
No beta-blocker.
.
#) Anemia: Hct stable. the pt is on Ferrous Sulfate 325mg once
daily and IV Vit B 12 injections. Continue outpt ferrous
sulfate.
Medications on Admission:
1. Prednisone 10mg QOD
2. Combivent 2 puffs [**Hospital1 **]
3. Advair [**Hospital1 **]
4. Albuterol PRN
5. Metformin 1000mg [**Hospital1 **]
6. Glyburide 5mg QOD
7. Aspirin 325mg once daily
8. Lisinopril 20mg once daily
9. Furosemide 20mg once daily
10. Ferrous Sulfate 325mg once daily
11. Docusate TID and Senna
12. Protonix 40mg [**Hospital1 **]
13. Mag Oxide 400mg once daily
14. Ranitidine 300mg once daily
15. Ibuprofen 600mg TID
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Upper respiratory infections
COPD
Secondary:
Type II diabetes mellitus
obesity
viamin B12 deficiency
Discharge Condition:
Patient had a [**Location (un) **], but O2 sat was >93% on baseline 3LNC and
felt better.
Discharge Instructions:
You may return home. Please continue your previous medications,
and take prednisone in a tapering fashion as outlined below.
If you have recurrent problems breathing, [**Name2 (NI) **], shortness of
breath, or other concerns, please call your PCP or return to the
ED.
Followup Instructions:
Dr[**Doctor Last Name **] office will call you with an appointment. If they
do not call your house by [**2117-5-20**], call them at ([**Telephone/Fax (1) 513**].
Please follow up with:
Provider: [**First Name8 (NamePattern2) 1409**] [**Last Name (NamePattern1) **], NP Date/Time:[**2117-5-17**] 2:20 as
scheduled.
You also have these follow up appointments previously scheduled:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2117-6-10**] 11:20
Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2117-8-16**] 11:40
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2117-5-13**]
ICD9 Codes: 4280, 2762, 2859, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3435
} | Medical Text: Admission Date: [**2105-1-7**] Discharge Date: [**2105-1-8**]
Date of Birth: [**2036-12-15**] Sex: M
Service: [**Company 191**] MED
IDENTIFYING INFORMATION: This is a 68 year old male status
post drug overdose and aspiration.
HISTORY OF PRESENT ILLNESS: The patient is a 68 year old
male with a past medical history significant for obstructive
sleep apnea on C-PAP, chronic obstructive pulmonary disease,
DDD pacemaker, right lower lobectomy, orthostatic hypotension
and depression, who initially presented to [**Hospital3 **]
status post overdose with Klonopin and Amitriptyline in an
attempted suicide after argument with wife on [**12-31**]. [**Name2 (NI) **] had
been emergently intubated and placed in the Intensive Care
Unit there. The patient was found to have pulmonary
infiltrates suspicious for aspiration pneumonia and was
febrile and then started on Clindamycin and Ciprofloxacin.
While there in the Intensive Care Unit, the patient
self-extubated himself and was later re-intubated emergently.
On [**1-5**], the patient was then transferred here at [**Hospital1 1444**] due to difficulty weaning and
possible tracheostomy placement. Here in the [**Hospital Unit Name 153**], he again
self-extubated himself. He was placed on C-PAP and now
weaned down to two liters nasal cannula O2 which is his home
O2 requirement.
He was transferred out of the [**Hospital Unit Name 153**] to the [**Company 191**] Medicine
Service to be evaluated by Psychiatry and likely to be
transferred to inpatient psychiatry service after medically
stable condition.
Here in the [**Hospital Unit Name 153**], the patient is currently stable without
complaints. He does not wish to go back to home with wife.
PAST MEDICAL HISTORY:
1. Obstructive sleep apnea on C-PAP, 12 mm HG.
2. Chronic obstructive pulmonary disease with [**Month (only) 1096**] PFTs
with an FVC of 1.93, FEV1 of 1.07 and a ratio of 52%.
3. Depression.
4. DDD pacemaker placement in [**2104-9-18**].
5. Right lower lobectomy for bronchiectasis.
6. Orthostatic hypotension.
ALLERGIES: Penicillin, Naproxen.
MEDICATIONS (on Transfer):
1. Levofloxacin times seven days, course completed.
2. Clindamycin 10 day course total, for three more days.
3. Albuterol and Atrovent nebulizers.
4. Combivent MDI.
5. Flovent MDI.
SOCIAL HISTORY: The patient lives with wife; no alcohol use
since [**2104-2-17**]. Quit smoking. He is a retired
carpenter.
PHYSICAL EXAMINATION: (on admission) Vital signs:
Temperature is 97.8 F.; heart rate equals 80; blood pressure
equals 100 to 133 over 60 to 70; O2 saturation is 100% on two
liters nasal cannula. General appearance, in no acute
distress, comfortable. HEENT: Normocephalic, atraumatic
head. Pupils equally round and reactive to light.
Extraocular muscles are intact. Oropharynx clear. Moist
mucous membranes. No jugular venous distention.
Cardiovascular: Regular rate and rhythm with normal S1 and
S2 with no murmurs, rubs or gallops. Lungs with bilateral
wheezing end-expiratory throughout with upper airway sounds.
No rhonchi or rales. Abdomen: Soft, nontender,
nondistended, normoactive bowel sounds. Extremities with no
edema bilaterally in the lower extremities. Neurologic:
Alert and oriented times two; thinks he is at [**Location (un) **].
Cranial nerves II through XII grossly intact and nonfocal.
LABORATORY DATA: White blood cell count equals 7.4;
hematocrit 33.6, platelets equals 302. Chem 7 is normal.
Calcium, phosphorus and magnesium is normal. Last arterial
blood gas was normal.
SUMMARY OF HOSPITAL COURSE: The patient is a 68 year old
male status post drug overdose and aspiration, now stable for
transfer from the [**Hospital Unit Name 153**] to the Medical Floor status post
extubation. The patient is being treated for his aspiration
pneumonia with Levofloxacin for a seven day total, of which
his course is already finished and Clindamycin for a ten day
course total. The patient also has a history of chronic
obstructive pulmonary disease and obstructive sleep apnea on
C-PAP at 12 mm HG at night which was continued while in
hospital. The patient was transitioned from nebulizer to
Combivent and Flovent MDI. While on the medical floor, the
patient was afebrile with normal blood count, in stable
respiratory condition status post extubation in the Intensive
Care Unit. The patient was maintained at his home O2
requirement of two liters by nasal cannula.
The patient was evaluated by Psychiatry while in hospital.
The patient was continued on one-to-one sitter observation
due to having limited insight into his actions and remaining
at risk for self-harm. His delirium was resolved while in
hospital. Psychiatry recommended acute level of psychiatric
care and facilitated transfer to Psychiatric inpatient
setting. Psychiatric medications for now were held off.
The patient is medically stable for transfer to inpatient
Psychiatric facility as evidenced by resolved delirium,
stable laboratory data and resolving pneumonia being treated
with antibiotics.
CONDITION AT DISCHARGE: Stable.
DISCHARGE STATUS: To Psychiatric facility.
DISCHARGE DIAGNOSES:
1. Aspiration pneumonia.
2. Status post drug overdose, now resolved.
3. Chronic obstructive pulmonary disease.
4. Obstructive sleep apnea on C-PAP 12 mm HG q. h.s.
5. Depression.
6. Orthostatic hypotension.
7. DDD pacemaker.
DISCHARGE MEDICATIONS:
1. Clindamycin 450 mg p.o. four times a day (until
[**2105-1-10**]).
2. Combivent, four puffs MDI four times a day.
3. Flovent, 110 mg strength MDI, two puffs twice a day.
4. Baseline O2 requirement by nasal cannula of two liters.
5. C-PAP at 12 mm HG q. h.s. for obstructive sleep apnea.
[**Doctor Last Name **] [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5712**]
Dictated By:[**Last Name (NamePattern1) 1183**]
MEDQUIST36
D: [**2105-1-8**] 11:52
T: [**2105-1-8**] 12:36
JOB#: [**Job Number 38004**]
ICD9 Codes: 5070, 496, 311, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3436
} | Medical Text: Admission Date: [**2201-5-31**] Discharge Date: [**2201-6-1**]
Date of Birth: [**2158-11-18**] Sex: F
Service: MICU Green
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 19730**] is a 43-year-old
female with a longstanding history of type 1 diabetes
mellitus, end-stage renal disease on peritoneal dialysis and
hemodialysis, and atrial fibrillation. The patient was in
her usual state of health until the morning of admission when
she awoke and felt lightheaded. She took her blood pressure
and it was roughly 76/40. At that time, she had her mother
check her fingerstick which was critically high on her home
glucose monitor. At that point, the patient came in to be
evaluated at the [**Hospital1 69**].
She denied any fever or chills, nausea, vomiting, diarrhea,
sore throat, cough, rhinorrhea, abdominal pain, back pain.
No changes in her skin. Of note, the last hemodialysis one
week prior to admission, and the patient had normal po intake
on the days prior to admission. She denied missing any
insulin or eating any concentrated sweets. She denied
missing any of her midodrine.
PAST MEDICAL HISTORY:
1. Type 1 diabetes mellitus complicated by triopathy.
2. End-stage renal disease on peritoneal dialysis and
hemodialysis.
3. Atrial fibrillation.
4. History of an atrial thrombus.
5. Barrett's esophagus.
6. Labile blood pressure.
7. Hypothyroidism.
ALLERGIES:
1. Tetracycline.
2. Erythromycin.
3. Morphine.
4. Dilaudid.
5. ACE inhibitors.
MEDICATIONS AT HOME:
1. Midodrine 10 mg po tid.
2. Reglan 10 mg po qid.
3. Levoxyl 75 mcg po q day.
4. Nephrocaps one cap q day.
5. Renagel 800 mg one tablet tid.
6. PhosLo 667 mg one tablet [**Hospital1 **] with lunch and dinner.
7. Amiodarone 200 mg po q day.
8. Neurontin 100 mg po tid.
9. Protonix 40 mg po q day.
10. Coumadin varying dose currently on 2.5 mg po q day.
11. Epogen 1200 units subQ [**Hospital1 **]-weekly.
12. Humalog insulin-sliding scale.
13. Lantus insulin 20 units every evening.
14. Compazine 10 mg prn.
15. Senokot two tablets at bedtime prn.
16. Colace one tablet at bedtime prn.
17. Lactulose one tablespoon at bedtime prn.
18. Lomotil as needed.
19. Vitamin D 50,000 units one time a week on Mondays.
PHYSICAL EXAMINATION: The patient's vital signs are as
follows: In the Emergency Department, her temperature is
97.9, blood pressure is 137/45, pulse is 74, breathing at 11,
and sating 94% on room air. General: She is awake, alert in
no acute distress. HEENT: Normocephalic, atraumatic.
Oropharynx with moist mucous membranes. She has alopecia.
Neck: No jugular venous distention. Cardiovascular:
Regular, rate, and rhythm, II/VI systolic murmur at the right
sternal border. No rubs or gallops. Lungs: There were
bibasilar crackles right greater than left. Abdomen: Soft,
nontender, nondistended, normal bowel sounds. There is a PD
catheter, surrounding dry erythema and scab. Chest: There
is a hemodialysis catheter also with the site clean, dry, and
intact without signs of infection. Extremities: Trace edema
bilaterally. Skin: Bilateral shin erythema with ulcers in
various stages of healing. Neurological: Decreased sensory
perception in both feet.
LABORATORY DATA ON ADMISSION: The patient had the following
laboratory data: She had a white blood cell count of 9.1,
hematocrit of 35.4, and platelets of 349. MCV is 101. Her
differential was 72% polys, 20% lymphocytes, and 5%
monocytes, 2% eosinophils. Her Chem-7 was as follows sodium
141, potassium 5.4, chloride 98, total CO2 17, BUN 16,
creatinine 9.3, and glucose 303. Calcium 9.9, magnesium 1.9,
phosphorus 9.0.
Patient had a negative chest x-ray. TSH of 9.4 at this time.
The patient had an ALT of 29, AST of 38, alkaline
phosphatase of 197, T bilirubin of 0.2, and lipase 56.
She had blood cultures which were done, but not finalized at
the time of her discharge. She was acetone negative.
Electrocardiogram showed on admission: Sinus rhythm at 74
beats per minute with peaked T waves in V2, V3, and V4.
Possible left axis deviation.
HOSPITAL COURSE:
1. Endocrine: The patient was initially placed on insulin
drip for a blood glucose greater than 500 and a small anion
gap. Her gap rapidly closed, and the patient subsequently
had a blood glucose as low as 40. She was administered an
amp of D50 and sent to the Medical Intensive Care Unit for q1
hour glucose monitoring, where her glucose normalized
overnight to 120 by the time of discharge. She required
regular doses of subQ insulin per regular sliding scale. She
was also administered her 20 units of Lantus during her stay.
The patient was found to have an elevated TSH, but her
Synthroid dose was not changed as we left it up to her
primary care physician as an outpatient. The etiology of the
patient's hyperglycemia is not known. There was no obvious
infection found, and perhaps it is related to dietary
indiscretion or change in her medication.
2. Cardiovascular: The patient had presented with
hypotension at home and lightheadedness. She occasionally
suffers from hypotension as she has extremely labile blood
pressure and was placed on midodrine by her primary care
physician to smooth out her hypotensive episodes. On
arrival, the patient was normotensive and remained that way
during the hospital stay with the exception of one brief
episode of a drop to systolic blood pressure in the 60s in
the Intensive Care Unit when she was asymptomatic.
The patient has a history of atrial fibrillation. She had
several episodes in the Medical Intensive Care Unit of atrial
fibrillation with a rapid ventricular rate and a right bundle
branch block. Patient was continued on her Coumadin and her
amiodarone. The patient on the day of discharge had no
further episodes of atrial fibrillation.
3. Renal: The patient is an end-stage renal disease patient
on peritoneal dialysis and hemodialysis. She was seen by the
Renal Consult Service and underwent peritoneal dialysis
overnight in the Medical Intensive Care Unit, she was also
found to be hyperkalemic, which she is slightly at baseline.
She was given Kayexalate as she is in ARC and cannot use
Lasix, and allowed minimal IV fluid resuscitation because she
is in ARC.
The patient was told to continue all her renal medications,
and resume her peritoneal dialysis and hemodialysis schedule
upon discharge.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: Home.
DISCHARGE DIAGNOSES:
1. Hyperglycemia of uncertain etiology.
2. Atrial fibrillation.
3. End-stage renal disease on PD and HD.
4. Hypothyroidism.
5. Labile blood pressure.
DISCHARGE MEDICATIONS:
1. Midodrine 10 mg po tid.
2. Reglan 10 mg po qid.
3. Levoxyl 75 mcg po q day.
4. Nephrocaps one cap q day.
5. Renagel 800 mg one tablet tid.
6. PhosLo 667 mg one tablet [**Hospital1 **] with lunch and dinner.
7. Amiodarone 200 mg po q day.
8. Neurontin 100 mg po tid.
9. Protonix 40 mg po q day.
10. Coumadin varying dose currently on 2.5 mg po q day.
11. Epogen 1200 units subQ biw.
12. Humalog insulin-sliding scale.
13. Lantus insulin 20 units every evening.
14. Compazine 10 mg prn.
15. Senokot two tablets at bedtime prn.
16. Colace one tablet at bedtime prn.
17. Lactulose one tablespoon at bedtime prn.
18. Lomotil as needed.
19. Vitamin D 50,000 units one time a week on Mondays.
FOLLOW-UP PLAN: The patient is to followup with her primary
care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) **] within two weeks of discharge.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D.
Dictated By:[**Last Name (NamePattern1) 11801**]
MEDQUIST36
D: [**2201-6-1**] 15:44
T: [**2201-6-3**] 13:34
JOB#: [**Job Number 19743**]
ICD9 Codes: 2767, 2762 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3437
} | Medical Text: Admission Date: [**2138-6-22**] Discharge Date: [**2138-6-29**]
Date of Birth: [**2082-6-3**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
Motor vehicle crash
Major Surgical or Invasive Procedure:
Chest tube thoracostomy
History of Present Illness:
The patient is a 56 yo M non-restrained driver involved in a
motor vehicle crash and transported by air to [**Hospital1 18**]. There was a
20-40 minute extraction, and [**4-19**] feet of intrusion into
passenger compartment noted. A person in the other vehicle was
killed. The patient was noted to have a GCS 15 on scene. He was
evaluated and stabilized in the trauma bay and underwent
imaging. A chest tube was placed for a right PTX.
Past Medical History:
Knee arthritis
Diverticulitis
Social History:
EtOH
Family History:
N/C
Physical Exam:
97.2 R 105 118/64 24 94%RA
Odor of EtOH noted
PERRL, EOMI
trachea midline
CTAB
tachy, regular
MAE x 4
distal pulses: L DP palp, R DP nonpalp, R PT dopplerable
normal rectal tone, guaiac neg
back w/o step-off or deformity
Pertinent Results:
[**2138-6-22**] 08:18PM HCT-36.9*
[**2138-6-22**] 03:47PM HCT-33.6*
[**2138-6-22**] 10:27AM HCT-36.2*
[**2138-6-22**] 06:38AM GLUCOSE-363* UREA N-10 CREAT-0.8 SODIUM-138
POTASSIUM-4.5 CHLORIDE-102 TOTAL CO2-20* ANION GAP-21*
[**2138-6-22**] 06:38AM CALCIUM-7.6* PHOSPHATE-3.4 MAGNESIUM-1.5*
[**2138-6-22**] 06:38AM WBC-21.1* RBC-4.35* HGB-13.5* HCT-38.4*
MCV-88 MCH-30.9 MCHC-35.0 RDW-13.1
[**2138-6-22**] 06:38AM PLT COUNT-162
[**2138-6-22**] 06:38AM PT-13.0 PTT-25.2 INR(PT)-1.1
[**2138-6-22**] 03:05AM TYPE-[**Last Name (un) **] PH-7.30*
[**2138-6-22**] 03:05AM GLUCOSE-369* LACTATE-5.9* NA+-137 K+-3.6
CL--102 TCO2-18*
[**2138-6-22**] 03:05AM HGB-14.2 calcHCT-43 O2 SAT-92 CARBOXYHB-8*
MET HGB-0
[**2138-6-22**] 03:05AM freeCa-1.01*
[**2138-6-22**] 02:50AM UREA N-11 CREAT-0.8
[**2138-6-22**] 02:50AM AMYLASE-33
[**2138-6-22**] 02:50AM ASA-NEG ETHANOL-250* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2138-6-22**] 02:50AM URINE HOURS-RANDOM
[**2138-6-22**] 02:50AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2138-6-22**] 02:50AM WBC-25.5* RBC-4.50* HGB-14.1 HCT-39.5* MCV-88
MCH-31.2 MCHC-35.6* RDW-13.0
[**2138-6-22**] 02:50AM PLT COUNT-207
[**2138-6-22**] 02:50AM PT-13.0 PTT-26.4 INR(PT)-1.1
[**2138-6-22**] 02:50AM FIBRINOGE-226
[**2138-6-22**] 02:50AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.021
[**2138-6-22**] 02:50AM URINE BLOOD-LGE NITRITE-NEG PROTEIN-500
GLUCOSE-1000 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2138-6-22**] 02:50AM URINE RBC->50 WBC-[**7-26**]* BACTERIA-MOD
YEAST-NONE EPI-0-2 RENAL EPI-[**1-5**]
[**2138-6-22**] 02:50AM URINE GRANULAR-[**7-26**]*
.
CT head: IMPRESSION: No evidence of acute intracranial
hemorrhage or shift of normally midline structures.
.
CT C-spine: IMPRESSION: No evidence of acute fracture or
spondylolisthesis.
.
CT torso: IMPRESSION:
1. Moderate-sized right pneumothorax. Likely lung contusions.
Followup recommended.
2. Non-displaced right eighth, ninth and 10th rib fractures.
3. Hypodensity within the liver consistent with contusion.
4. Right adrenal hemorrahge versus mass. Follow-up imaging
recommended for further evaluation. Discussed with Dr. [**First Name (STitle) 67020**]
[**Name (STitle) 58703**] at 10am [**2138-6-22**].
5. Possible small splenic laceration at the dome, with a tiny
amount of fluid around the spleen.
6. No evidence of active extravasation.
7. 1.3-cm likely plaques seen in the aorta at approximately the
level of the bifurcation.
8. Spondylosis and degenerative change is seen within the lower
lumbar spine.
.
CTA chest: IMPRESSION:
1. No evidence of acute aortic injury.
2. Moderate-to-large right-sided pneumothorax, larger when
compared to study performed half an hour earlier.
3. Multiple right rib fractures.
4. Likely lung contusions, follow-up recommended.
5. Increased lung opacities consistent with edema or aspiration.
6. Nondisplaced manubrium fracture.
.
Shoulder XR: : No evidence of acute fracture or dislocation
within the right shoulder. Right rib fracture and right-sided
chest tube seen.
.
Brief Hospital Course:
The patient was admitted to the Trauma Service to the T-SICU. A
chest tube was placed for the R PTX. The Acute Pain Service was
consulted and an epidural catheter was placed for analgesia for
the rib fractures. He was placed on a CIWA scale to monitor and
treat any symptoms of withdrawal. His hematocrit remained
stable. On HD 2 he spiked to 103.2 and CXR revealed pneumonia.
He was started on Levaquin. A sputum culture grew out strep
pneumoniae. The epidural catheter was removed and he was
transitioned to PO pain meds. He was transferred to the floor,
diet was advanced, and he worked with PT/OT. He continued to
have an oxygen requirement with SaO2 88% on ambulation. He was
afebrile x 72 hours. Prior to discharge he was ambulating
without oxygen and maintaining an SaO2>91%. He will return to
the Trauma Clinic for follow up. He will be maintained on RISS
until he completes the course of Levaquin, at which time
transition to oral agents would be appropriate (interaction
between Levaquin and OHAs can cause profound hypoglycemia).
Medications on Admission:
None
Discharge Medications:
1. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
3. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 6 days.
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
5. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
8. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO three times a
day: hold for sedation.
9. Insulin Regular Human Injection
Discharge Disposition:
Extended Care
Facility:
[**Location 54284**]
Discharge Diagnosis:
Motor vehicle crash
Closed head injury
Grade II splenic laceration
Grade II intraparenchymal liver bleed
Rib fractures
Pneumothorax
Pneumonia
Glucose intolerance
Discharge Condition:
Good
Discharge Instructions:
1. Take medications as prescribed.
2. Follow up with Trauma Clinic in 2 weeks, call for
appointment: [**Telephone/Fax (1) **].
3. Call your doctor or go to the ER for any of the following:
uncontrollable pain, fever > 101.4, trouble breathing, abdominal
pain, or other troubling concerns.
4. Use the incentive spirometer at least 3 times an hour while
awake.
Followup Instructions:
As above.
ICD9 Codes: 5070 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3438
} | Medical Text: Admission Date: [**2141-8-16**] Discharge Date: [**2141-8-19**]
Service: MEDICINE
Allergies:
Nsaids/Anti-Inflammatory Classifier
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
somnolence, dyspnea on exertion
Major Surgical or Invasive Procedure:
none
History of Present Illness:
84 year old female with CAD, CHF, COPD, DMII, presented to PCP's
office yesterday complaining of increased daytime somnolence,
DOE in past couple of days (although son states a month). In
her PCP's office she was also noted to be feeling poorly with
dyspnea on exertion after walking several steps. Her son also
reported that she has been getting salt putting it on her food.
Her dose of lasix was increased from 40mg to 60mg and a Chem7
was done which showed an elevated bicarb. Her PCP referred her
to ED with concern for resp acidosis. Patient difficult to get
a history from given bipap, although she is also a poor
historian per the son. She denies chest pain, palpitations,
abdominal pain, fevers, chills, diarrhea. In her PCP's office
she noted increased PND, orthopnea but I was unable to elicit
this history. On previous admission in [**2136**], her pCO2 was noted
to be in the low 60's - unclear what baseline is, however, as
this was also an admission for COPD exacerbation.
.
ED: CXR without infiltrate or edema. ABG was 7.29/76/151 and
7.31/73/59. She was given a dose of steroids for concern of
COPD flare.
Allergy: NSAIDs - azotemia
Past Medical History:
PAST MEDICAL HISTORY:
1. Congestive heart failure in [**2124**]. Her ejection fraction
was found to be 40%.
2. Coronary artery disease.
3. History of an anterior-IMI in 9/[**2137**].
4. Diabetes type 2.
5. Congestive obstructive pulmonary disease.
6. Hypertension.
7. Obesity.
8. Degenerative joint disease.
9. Status post total abdominal hysterectomy.
10. Anemia, baseline hematocrit 31.
11. Chronic renal failure, baseline creatinine 1.1-1.5
12. History of being guaiac positive.
13. Meningioma.
.
MEDICATIONS ON ADMISSION:
ALBUTEROL SULFATE 90MCG--1-2 puffs QID prn
ASPIRIN E.C. 325 po qday
ATENOLOL 100MG po qday
ATROVENT 18MCG--2 puffs [**Hospital1 **]
COLCHICINE 600 MCG po qday
K-DUR 20MEQ po qday
LASIX TABLETS 40MG po qday
LISINOPRIL 40MG po qday
SERTRALINE HCL 50 MGpo qday
Social History:
She has VNA services. She has four sons and lives with one of
her sons. She is a widow and uses Life Line.
Family History:
Non-contributory
Physical Exam:
Vitals: Afebrile HR 47 BP 144/52 RR 17 100% bipap 40%
Gen: awake with bipap on, appears uncomfortable, but no acute
distress
HEENT: anicteric, unable to assess pupillary responses [**2-23**] mask,
OP clear, MMM
Neck: no JVD
CV: S1, S2, regular, bradycardic, no appreciable murmurs
Pulm: CTA-anteriorly
Abd: Normoactive bowel sounds, soft, ND/NT, no rebound or
uarding
Ext: baseline RLE >> LLE. warm with 1+ distal pulses
bilaterally.
Neuro: awake, but unable to provide history [**2-23**] bipap mask on.
Moving all extremities
Pertinent Results:
[**2141-8-16**] WBC-4.3 RBC-4.11* Hgb-12.3 Hct-35.9* MCV-87 MCH-30.0
MCHC-34.4 RDW-14.2 Plt Ct-157 Neuts-54.0 Lymphs-35.9 Monos-6.1
Eos-3.5 Baso-0.4
[**2141-8-16**] Glucose-175* UreaN-31* Creat-1.4* Na-143 K-4.4 Cl-102
HCO3-33* AnGap-12 Calcium-9.5 Phos-3.7 Mg-2.2
[**2141-8-15**] 01:00PM BLOOD ALT-20 AST-19 AlkPhos-85 TotBili-0.4
.
[**2141-8-16**] 08:14PM BLOOD proBNP-1344*
[**2141-8-16**] 08:14PM BLOOD CK(CPK)-53 CK-MB-NotDone cTropnT-<0.01
.
[**2141-8-15**] BLOOD Cholest-203* Triglyc-80 HDL-75 CHOL/HD-2.7
LDLcalc-112
[**2141-8-15**] 01:00PM BLOOD %HbA1c-7.4*
[**2141-8-15**] 01:00PM BLOOD TSH-0.71
.
[**2141-8-16**] 10:10PM BLOOD Type-ART FiO2-100 O2 Flow-2 pO2-151*
pCO2-76* pH-7.29* calTCO2-38* Base XS-7 AADO2-503 REQ O2-83 (On
40% bipap/5peep)
[**2141-8-16**] 11:45PM BLOOD Type-ART PEEP-5 FiO2-30 pO2-59* pCO2-73*
pH-7.31* calTCO2-39* Base XS-6 Intubat-NOT INTUBA
Vent-SPONTANEOU
[**2141-8-17**] 02:19AM BLOOD Type-ART pO2-120* pCO2-68* pH-7.29*
calTCO2-34* Base XS-3
.
[**2141-8-19**] 06:40AM BLOOD WBC-7.8 RBC-3.81* Hgb-11.5* Hct-34.5*
MCV-91 MCH-30.3 MCHC-33.4 RDW-14.3 Plt Ct-167
[**2141-8-19**] 06:40AM BLOOD Plt Ct-167
[**2141-8-19**] 06:40AM BLOOD Glucose-120* UreaN-37* Creat-1.2* Na-142
K-4.7 Cl-105 HCO3-32 AnGap-10
[**2141-8-19**] 06:40AM BLOOD Calcium-9.2 Phos-3.5 Mg-2.4
[**2141-8-17**] 06:23AM BLOOD Type-ART Temp-35.6 Rates-/18 O2 Flow-2
pO2-62* pCO2-67* pH-7.33* calTCO2-37* Base XS-5
Intubat-INTUBATED
[**8-16**] CXR: no acute cardiopulm process
CHEST (PORTABLE AP) [**2141-8-16**] 11:10 PM
No evidence of CHF or pneumonia.
Brief Hospital Course:
Briefly, 84 year old female with CAD, CHF, COPD, DMII, presented
to PCP's office 2d ago complaining of increased daytime
somnolence, DOE in past couple of days, though family reports
symptoms have been more longstanding. Because of DOE with a few
steps in PCP office and Chem7 was done which showed an elevated
bicarb, she was sent ED with concern for resp acidosis. Pt. was
admitted to ICU for BIPAP after gas showing acidosis of
7.29/76/151 in ED. In a previous admission in [**2136**] had pCO2 of
65 in the setting of COPD exacerbation, and elevated bicarb. has
been longstanding per OMR. CXR was clear on admission.
.
Pt. initially given IV steroids/azithro for COPD exacerbation in
ICU, but withdrawn as resp. acidosis at baseline. Pt. stable in
ICU, hydrated for ARF, and transferred to floor on [**8-18**] with
baseline respiratory function and mental status. She continued
to be stable on the floor and was discahrged the next morning.
1. Resp Acidosis - appears to be chronic given pCO2 of approx
70, pH 7.31 and bicarb elevated at 33. Will check ABG after
trial of bipap. Could also consider whether patient may benefit
from bipap at night. Pt. to follow up with Dr. [**First Name (STitle) **] [**Name (STitle) **]
as outpt.
.
2. ?COPD flare - initially given solumedrol iv q8, standing and
prn Albuterol/Atrovent Nebs, Azithromycin and bipap. Patient
was not very wheezy on exam, and steroids/abx. were withdrawn
quickly as pt.'s respiratory status was determined to be
longstanding.
.
3. CHF - Patient has a history of CHF, but does not appear
clinically volume overloaded on exam. Suspect that increased
resp symptoms more likely COPD exacerbation. BNP checked and
elevated at 1300. Will resume increased lasix dose of 60mg po
qday as per PCP.
.
4. CV: continued beta-blocker, afterload reduction with ACEI,
and lasix at 60mg dose. cardiac enzymes were negative with no
EKG changes from prior. Continue ASA.
.
5. CRI - Creatinine 1.4 appears to be baseline. Avoid NSAIDs.
.
6. Depression - Continued sertraline.
.
7. Diabetes - Did not require insulin or oral hypoglycemics.
.
FULL CODE - per discussion with patient's son, [**Name (NI) **] [**Name (NI) **]
Medications on Admission:
ALBUTEROL SULFATE 90MCG--1-2 puffs QID prn
ASPIRIN E.C. 325 po qday
ATENOLOL 100MG po qday
ATROVENT 18MCG--2 puffs [**Hospital1 **]
COLCHICINE 600 MCG po qday
K-DUR 20MEQ po qday
LASIX TABLETS 40MG po qday
LISINOPRIL 40MG po qday
SERTRALINE HCL 50 MGpo qday
Discharge Medications:
1. oxygen Sig: One (1) liter Nasal continuous: to keep o2
saturations above 93%.
Disp:*4 qs* Refills:*5*
2. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Insulin Regular Human 100 unit/mL Solution Sig: One (1) qs
Injection ASDIR (AS DIRECTED).
6. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed for wheezing.
9. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
10. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
Disp:*2 qs* Refills:*2*
11. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for pain, fever.
Disp:*30 Tablet(s)* Refills:*0*
12. K-Dur 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab
Sust.Rel. Particle/Crystal PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] Family & [**Hospital1 1926**] Services
Discharge Diagnosis:
Chronic Obstructive Pulmonary Disease
Congestive Heart Failure
Diabetes Type II
Hypertension
_________________________________
Chronic Renal Failure
Discharge Condition:
good, ambulating with help, tolerating POs
Discharge Instructions:
Please seek medical attention if you develop worsening shortness
of breath, chest pain, lightheadedness or dizziness.
Please take all medications as prescribed. We have not changed
any of your medications other than adding home oxygen to your
regimen
Please follow up with Dr. [**Last Name (STitle) **] (through [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]) at
your appt. next friday at 3:20. Please also call Dr. [**First Name (STitle) **]
[**Name (STitle) **], whose card you have, to follow up your pulmonary
function tests and lung function.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 278**] [**Last Name (NamePattern1) 279**], [**Name12 (NameIs) 280**] Date/Time:[**2141-8-25**] 3:40
Provider: [**First Name8 (NamePattern2) 278**] [**Last Name (NamePattern1) 279**], [**Name12 (NameIs) 280**] Date/Time:[**2141-9-14**] 2:20
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7323**], M.D. Date/Time:[**2141-12-12**] 11:10
Follow up with Dr. [**First Name (STitle) **] [**Name (STitle) **], whose card you have
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
ICD9 Codes: 2762, 5849, 496, 4280, 5859, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3439
} | Medical Text: Admission Date: [**2109-4-12**] Discharge Date: [**2109-4-15**]
Date of Birth: [**2062-9-18**] Sex: M
Service: MEDICINE
Allergies:
Clindamycin
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
Dialysis
History of Present Illness:
46 y/o Ethiopian male hx T1DM, HIV, ESRD (secondary to
nephrolithiasis, htn and T1DM) previously on HD since [**7-14**], has
been on PD intermittently for several months, most recently
started PD 3d PTA, last HD [**4-8**], removed 5kg) and peripheral
neuropathy presents with dyspnea by EMS from dialysis (had PD
overnight). Pt notes SOB since last night, + cough with clear
sputum, + PND. No fever/chills/diarrhea/n/v/dysuria. + abd
pain around PD stie with deep inspirationUsual SBP 150-180-
baseline per OMR notes x 2 months. No recent diet or medication
changes.
.
ED course: Temp 97.1, BP 215/95, HR 72, Sat 99% on 2l, started
on nipride drip, titrated to 2mcg/kg/min, BP improved to 177/91.
Initial K 7.5, hemolyzed, repeat K 5.0.
Past Medical History:
- Type 1 diabetes
- HIV (boosted atazanavir, lamivudine, stavudine), dx'd [**2096**]
- ESRD on HD, planned change to peritoneal dialysis in near
future, on transplant list (clinical study for HIV/solid organ
transplant)
- Recent hospitalizations for Serratia bacteremia (presumed
source AV graft) most recently treated with 6 week course
meropenem
- History of schistosomiasis
- Restless leg syndrome
- Peripheral neuropathy on gabapentin
- S/p cholecystectomy
Social History:
Moved from [**Country 4812**] in [**2091**]. Lives with wife in [**Location (un) 538**].
Works in support services for a law firm. Denies any alcohol or
IV drug use. Quit smoking last year; previous 30 pack-year
history.
Family History:
Non-contributory.
Physical Exam:
T 97.2 HR 72 BP 188/84 RR 12 99% 2L NC
General: appears to be more comfrtable, speaks in full
sentences, NAD
HEENT: anicteric, OP clear
Neck: No LAD or difficult to see JV
CV: RRR, Normal S1, S2 without m/r/g.
Pulm: crackles [**12-12**] way up b/l, no wheezes
Abd: LLQ with PD catheter appears clean, although no dressing in
place, soft, ND, ND, no HSM
Ext: 2+ edema nonpitting b/l, 2+ distal pulses
Neuro: CNs II-XII grossly intact. A/O x 3.
Skin: No rash
Pertinent Results:
[**2109-4-12**] 06:25AM WBC-4.6 RBC-2.90* HGB-10.6* HCT-31.7*
MCV-109* MCH-36.6* MCHC-33.5 RDW-16.5*
[**2109-4-12**] 06:25AM NEUTS-63.6 LYMPHS-21.8 MONOS-6.6 EOS-7.6*
BASOS-0.3
[**2109-4-12**] 06:25AM CALCIUM-8.7 PHOSPHATE-5.8* MAGNESIUM-2.8*
[**2109-4-12**] 06:25AM cTropnT-0.21* proBNP-[**Numeric Identifier 94326**]*
[**2109-4-12**] 06:25AM GLUCOSE-92 UREA N-96* CREAT-13.2*# SODIUM-137
POTASSIUM-7.5* CHLORIDE-97 TOTAL CO2-24 ANION GAP-24*
.
CT w/o contrast:
CT OF THE CHEST: Compared to prior CT from [**2109-3-26**], there
is almost mareked improvement in the diffuse bilateral
peribronchiolar opacities. Since the last exam, there is
interval developmen of a wedge-shaped area of consolidation
within the left lung base, which may represent a pneumonia,
however given its shape cannot exlude infarction. Again seen are
small bilateral pleural effusions, not significantly changed.
The heart and pericardium are unremarkable. Small mediastinal
lymph nodes are seen which do not meet CT criteria for
pathologic enlargement.
The visualized upper abdomen is unremarkable. Bone windows
demonstrate no suspicious lytic or sclerotic lesion. Surgical
clips are seen adjacent to the right crus of the diaphragm. A
right subclavian central venous catheter is seen with tip in the
distal SVC.
IMPRESSION: Compared to the prior CT from [**2109-3-26**], there
is marked improvement of the previously noted peribronchiolar
opacities within both lungs. However, there is development of a
new wedge-shaped opacity within the left lower lobe concerning
for pneumonia versus infarction. Stable bilateral small pleural
effusions.
.
CTA [**2109-4-14**]:
CT OF THE CHEST WITHOUT AND WITH IV CONTRAST: 10-mm hypodense
focus in the left thyroid lobe. No filling defects are noted
within the main pulmonary artery and its branches. The
previously described wedge-shaped opacity in the left lung base
is not seen on the current study. A rounded small pleural- based
opacity in the posterior aspect of the left lung base is seen
and unchanged when compared to a study dated [**2109-4-13**]. The
airways are patent to the segmental levels, bilaterally. Small
mediastinal and axillary lymph nodes, not pathologically
enlarged by CT criteria are again noted, unchanged. Heart and
great vessels are unchanged. No evidence of pericardial
effusions. Emphysematous changes are again seen. Diffuse mild
bilateral ground-glass opacities are unchanged when compared to
a prior study.
The liver demonstrates two small hypodensities measuring 9 mm
and 1.7 cm in segment V and VIII, respectively previously
characterized as hemagioma.
BONE WINDOWS: No suspicious lytic or sclerotic lesions are
identified.
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Interval resolution of the left lower lobe wedge-shaped
opacity.
Brief Hospital Course:
A&P: 46 yo M hx T1DM, HIV, ESRD p/w dyspnea, elevated BP, low
grade fevers and cough.
.
# SOB and HTN: The patient presented to the ED with fluid
overload and hypertensive urgency and was started on a nipride
drip. On transition to the inpatient setting he was converted to
a labetalol drip to avoid buildup of cyanide biproducts while he
awaited hemodialysis. His dyspnea was well controlled on
reaching the floor and remained well controlled throughout his
hospital stay. His hypertension continued to be an issue
following his first dialysis session, despite the removal of 5.2
L of fluid during that session. He was continued on labetalol
drip to maintain SBP < 180 with 160 as target. Following his
second dialysis treatment on hospital day 2, he weighed 57kg,
which was considered his new dry weight. For improved BP
control, he was started on 20 mg Lisinopril per recommendation
of the renal team. He also continued his outpatient regimen of
160 diovan [**Hospital1 **] and 50 atenolol QD. Although his pressure was
better controlled, he still had breaks into the 180s and his
pressure control will need to be optimized as an outpatient.
.
Renal: The patient had recently transitioned from hemodialysis
to peritoneal dialysis, which was apparently insufficient,
resulting in fluid overload, hypertension and admission. The
patient was discharged with plans to resume hemodialysis at his
previous hemodialysis center under the care of his outpatient
nephrologist. His next hemodialysis treatment was scheduled for
Wed. [**4-17**].
.
HIV: The patient's HAART regimen was continued.
.
Anemia: Continue epogen at HD.
.
# Fevers: The patient briefly spiked a fever on [**4-13**] and
underwent non-con CT of the chest. He had increasing cough as
well. Sputum and blood cultures were negative. The patient's
non-con Chest CT demonstrated a peripheral wedge shaped opacity,
and the patient was started on vancomycin and zosyn, given his
relative immunosuppression and his recent hospitalization with
full course of levofloxacin. A follow-up CTA was done to rule
out PE and showed complete resolution of the wedge shaped area,
which presumably was simply atelectasis. However, the lung was
not entirely clear, and it was felt prudent to continue an [**7-19**]
day course of IV antibiotics. For this reason, the patient was
dosed one gram of ceftazadine and one gram of vancomycin
following his dialysis on [**Last Name (LF) 766**], [**4-15**] and he was written a
prescription to receive one gram of vancomycin and one gram of
ceftazadine after each of his dialysis sessions on [**4-17**] and
[**4-19**]. (and then the course would end). On the day of
discharge, the patient's nasal viral swab returned positive for
parainfluenza virus. As discussed with ID, the patient's CT and
clinical findings could all be explained by parainfluenza virus,
but there was also a significant chance for bacterial
superinfection. Thus, the antibiotic course was planned as
described above.
.
He was also scheduled for followup with his infectious disease
physicians on [**4-23**].
.
Medications on Admission:
Gabapentin 100 mg tid
Atenolol 50 mg PO daily
Valsartan 160mg [**Hospital1 **]
Compazine PRN
Insulin (NPH 10 U [**Hospital1 **] and Regular 5 U QAM)
Tenofovir 300 mg PO QSAT
Ritonavir 100 mg p.o. daily
Atazanavir 300 mg p.o. daily
Stavudine (Zerit) 20 mg PO QHD DAYS after HD
Lamivudine (Epivir) 25 mg PO after HD on HD days
Discharge Medications:
1. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
2. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1)
Tablet PO QSAT (every Saturday).
3. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
4. Atazanavir 150 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
5. Stavudine 20 mg Capsule Sig: One (1) Capsule PO Q24H (every
24 hours).
6. Lamivudine 10 mg/mL Solution Sig: Twenty Five (25) mg PO
DAILY (Daily): Take orally after hemodialysis on hemodialysis
days. .
7. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Valsartan 160 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Prochlorperazine 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every
6 hours) as needed for Nausea.
11. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed.
12. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
Disp:*20 Capsule(s)* Refills:*2*
13. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: per
regimen Subcutaneous twice a day.
14. Ceftazidime 1 g Recon Soln Sig: One (1) Intravenous at
dialysis for 2 doses: Patient should receive 1 gram of
ceftazadime administered at his dialysis center after dialysis
on [**4-17**] and [**4-19**]. .
Disp:*2 doses* Refills:*0*
15. Vancomycin 1,000 mg Recon Soln Sig: One (1) g Intravenous at
dialysis for 2 doses: 1 gram, to be given after dialysis at 5/9
and [**4-19**].
Disp:*2 doses* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
End stage renal disease requiring regular hemodialysis
Parainfluenza viral infection
HIV
Hypertensive urgency
Volume overload
Discharge Condition:
Good
Discharge Instructions:
You were admitted with elevated blood pressure and respiratory
difficulty which improved with dialysis. However, your blood
pressure continues to be elevated at times throughout the day.
You will need to work with your clinic physicians to improve
your blood pressure. Elevated blood pressures for a long period
of time with increase your risk of stroke and heart disease.
.
You have a cough and imaging of your chest showed that you may
have a small infection. For this you need to have IV antibiotics
(ceftazadine and vancomycin) administered at your next two
dialysis sessions on Wednesday [**4-17**] and Friday [**4-19**]. You
have been given prescriptions for these two antibiotics and your
physician at dialysis has been informed.
.
In addition, you should check your temperature on a daily basis
and any time that you feel sick. If you have a temperature
greater than 100.4 that does not resolve quickly, you should
call your primary care physician.
.
You had testing for TB during this hospitalization which was
negative. One of your tests is still pending. If this test is
positive, you will be contact[**Name (NI) **]. Your physicians at [**Hospital3 **]
also will have access to these results when you come in for
appointments.
.
You will need regular dialysis. Your next dialysis [**Hospital3 648**]
is scheduled for Wednesday, [**4-17**] at 6:45 AM. It is vital that
you do not miss [**First Name (Titles) **] [**Last Name (Titles) 648**].
.
Please keep your other appointments listed in the appointments
section. These doctors [**Name5 (PTitle) **] help [**Name5 (PTitle) **] with your blood pressure.
.
You have been started on a new blood pressure medication called
lisinopril. You should take this medication as prescribed, and
continued taking your other blood pressure medications.
Followup Instructions:
DIALYSIS at your regular dialysis center: Wednesday, [**4-17**] at
6:45 AM.
.
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Doctor Last Name 9406**] Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2109-4-23**]
10:00
.
Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2109-5-14**] 9:10
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
Completed by:[**2109-5-8**]
ICD9 Codes: 486, 4280, 5856, 3572 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3440
} | Medical Text: Admission Date: [**2117-3-18**] Discharge Date: [**2117-3-24**]
Date of Birth: [**2050-2-11**] Sex: M
Service:
ADMISSION DIAGNOSIS: Abnormal stress exam with abnormal
coronary artery catheterization.
DISCHARGE DIAGNOSES:
1. Status post coronary artery bypass graft x2 vessel redo
on [**2117-3-19**].
2. Severe chronic history of coronary artery disease.
CONSULT: Physical therapy
HISTORY AND PHYSICAL EXAM: Mr. [**Known firstname **] [**Known lastname **] is a 67-year-old
man who speaks mostly Portugese with a history of multiple
prior interventions to the left circumflex artery and history
of coronary artery bypass graft in [**2109**], as well as
percutaneous transluminal coronary angioplasty and RCA in
[**2114**] with a history of progressive rest angina, orthopnea and
paroxysmal nocturnal dyspnea in the setting of a positive
MIBI. In [**2097**], he noted the initial onset of his angina he
was evaluated with coronary catheterization in [**2098-12-10**] as well as [**2106-12-11**], [**2109-7-11**], [**2114-7-11**]
and finally [**2117-3-4**] he had a MIBI during which he
was able to exercise for six minutes to a peak heart rate of
128 and blood pressure of 184/80. At this time, he
experienced chest tightness, but an electrocardiogram was
uninterpretable because of digoxin baseline abnormalities.
MIBI revealed an ejection fraction of 37% in the inferior
wall defecting reversibility. He was begun on Imdur one week
prior to admission and he had a slight decrease in frequency
of his symptoms as a result. Currently, he has been having
very poor exercise tolerance with shortness of breath, chest
tightness with walking in the house.
The patient denies edema and lightheadedness, but reports
two-pillow orthopnea and occasional paroxysmal nocturnal
dyspnea. He has a long history of bilateral claudication and
he gets symptoms after walking five minutes at a slow pace.
Coronary artery disease risks are cholesterol, diabetes and
family history. He has not had a history of hypertension,
nor a history of smoking.
PAST MEDICAL HISTORY:
1. Elevated lipids.
2. Myocardial infarction.
3. Bilateral claudication.
4. In [**February 2098**] a percutaneous transluminal coronary
angioplasty to the LAD and LCX, in 12/90 percutaneous
transluminal coronary angioplasty to the LCX and OM, in 2/93
percutaneous transluminal coronary angioplasty to LCX and OM,
[**7-/2114**] percutaneous transluminal coronary angioplasty to the
RCA.
PAST SURGICAL HISTORY:
1. [**7-/2109**] coronary artery bypass graft with vein graft to the
obtuse marginal 2.
2. Abdominal aortic aneurysm repair in [**2110**].
3. Femoral popliteal bypass.
ALLERGIES: He has no known drug allergies, no shellfish and
no dye allergies.
MEDICATIONS:
1. Humulin 45 NPH units subcutaneous q a.m. and 4 units
subcutaneous q p.m.
2. Regular insulin 4 units [**Hospital1 **].
3. Lasix 120 mg [**Hospital1 **].
4. Zestril 20 mg qid.
5. Trental 400 mg tid.
6. Procardia XL 30 mg qd.
7. Pravachol 20 mg qd.
8. Aspirin 325 mg po qd.
REVIEW OF SYSTEMS: Negative for cerebrovascular accident,
transient ischemic attack and melena.
SOCIAL HISTORY: He is married and lives with his wife who
works for the school system in the dietary department.
LABS: His white blood cell count was 10.7. His hematocrit
was 37.2. His PTT was 12.6. His platelet count was 190.
Sodium 142, potassium 4.6, chloride 103, bicarbonate 26, BUN
24, creatinine 1.4.
PHYSICAL EXAM:
GENERAL: He is a moderately obese male with no apparent
distress, however he was obviously anxious.
HEAD, EARS, EYES, NOSE AND THROAT: Within normal limits.
LUNGS: Clear. He had a healed sternal scar.
HEART: Regular rate and rhythm.
ABDOMEN: Soft with an aortobifemoral scar. He had right
saphenectomy vein harvest scar and a right femoral popliteal
scar.
EXTREMITIES: Left lower extremity had no major varicosities.
SKIN: Okay. There was no edema.
His pulses were 2+ carotids bilaterally without bruits.
Radials were 2+ bilaterally and there was no palpable DP
pulse on either the right or the left.
NEUROLOGIC: Nonfocal.
IMAGING: His electrocardiogram demonstrated a regular rate
with a bundle branch block. There were global T-wave
changes.
The patient was admitted therefore to undergo a coronary
artery bypass grafting. This was a redo procedure. He had a
left internal mammary artery to left anterior descending and
saphenous vein graft to the distal LAD performed. This was
done by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] and the patient was transported in
the atrial paced mode from the Operating Room to the
Cardiothoracic Intensive Care Unit on Neo-Synephrine drip
with a mean arterial pressure of 58, CVP of 13, PAD of 15,
[**Doctor First Name 1052**] of 20.
The patient was weaned to extubation on postoperative day #1.
The site was advanced. On postoperative day #2 he was pan
cultured for a fever of 101.5??????. He was improved later on
that day. His chest tubes were removed. He was diuresed.
Follow up of his cultures revealed no growth in the blood or
urine cultures. There was only oropharyngeal flora in the
sputum. His chest x-ray demonstrated small bilateral pleural
effusions. Swan was in place. There was no pneumothorax
seen on either side. [**Female First Name (un) 3408**] saw the patient and
recommended changes in his insulin.
On postoperative day #3, the patient was found to be very
upset. This was reported by the patient later on and his
daughter to be reaction to Percocet and has been seen in the
past. The patient was therefore taken off of all pure
narcotic agents and placed on strictly Tylenol for pain
control. He was supplemented with Nubain, a narcotic
agonist-antagonist medication. His exercise capacity was
good and he was seen ambulating in the [**Doctor Last Name **] multiple times
during the day. The patient was seen by physical therapy and
found to have a slight increase in his systolic blood
pressure over his resting systolic blood pressure while he
was exercising. He has a sliding scale provided by the
[**Hospital 3408**] [**Hospital 982**] Clinic. On postoperative day #5, he had
been ambulating sufficiently in the [**Doctor Last Name **] and was seen by
physical therapy. They noted an increase in his systolic
blood pressure during ambulation over his resting systolic
blood pressure and plans were made to increase his Lopressor
dose to 50 mg po bid from 25 mg po bid. Plans were therefore
made to discharge the patient.
DISPOSITION: Discharge to home.
DISCHARGE CONDITION: Good
DISCHARGE MEDICATIONS:
1. Lasix 120 mg po bid.
2. Zestril 20 mg po qd.
3. Procardia XL 30 mg po qd.
4. Pravachol 20 mg po qd.
5. ASA 81 mg po qd.
6. Lopressor 50 mg po bid.
7. Tylenol 1 gm po q8h prn pain.
8. NPH insulin 40 units subcutaneous q a.m., 50 units
subcutaneous q hs.
9. Sliding scale of regular insulin. 0 to 100 give nothing,
100 to 150 2 units, 151 to 200 3 units, 201 to 250 4 units,
251 to 300 5 units, 301 to 350 6 units, 351 to 400 7 units
and greater than 400 10 units and call the primary M.D.
FOLLOW UP INSTRUCTIONS: The patient is to follow up with
wound check at the Far Six Nursing Area in approximately one
week. He should follow up with his primary care physician in
one to two weeks and he should make arrangements to follow up
with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for a postoperative wound check with
the attending surgeon in approximately four weeks.
[**First Name8 (NamePattern2) 2053**] [**Last Name (NamePattern1) 2052**], M.D. [**MD Number(1) **]
Dictated By:[**Last Name (NamePattern1) 13391**]
MEDQUIST36
D: [**2117-3-24**] 13:01
T: [**2117-3-24**] 13:19
JOB#: [**Job Number 27894**]
ICD9 Codes: 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3441
} | Medical Text: Admission Date: [**2173-8-3**] Discharge Date: [**2173-8-8**]
Date of Birth: [**2114-1-5**] Sex: M
Service: MEDICINE
Allergies:
clindamycin HCl
Attending:[**First Name3 (LF) 23497**]
Chief Complaint:
Weakness and fatigue
Major Surgical or Invasive Procedure:
None
History of Present Illness:
59M w/pmhx CHF (last EF 55-60%), afib, elevated LFTs, chronic LE
wounds (recent admission for cellulitis on [**6-14**]), hx of PE and
atrial thrombus, presented to clinic today for F/U. Pt had hx of
multiple missed appointments and F/U labs were drawn today.
Reported losing ~20lbs within the past month. Pt appeared
euvolemic and had extensive chronic LE ulcerations (pt was seen
in vascular clinic immediately prior to general medicine
appointment and was started on Keflex).
Referred to ED due to hyponatremia/[**Last Name (un) **] found on labs.
On presentation to the emergency Department the patient reports
that he has had occasional exertional shortness of breath,
reports no symptoms at rest. He denies chest pain at any point.
He reports that due to neuropathy he hasn't felt any pain in his
leg ulcers but notices that they are significantly more
erythematous and draining more fluid. Additionally he reports
that he has not taken any of his A. fib medications for several
days.
In the ED his initial vitals were 98.4 130 90/52 18 100. An EKG
showed afib @ 115, NA, lateral minimal stdep likely demand
related. no STE. He recieved 1L NS and was restarted on his
metorolol and diltiazem. His digoxin was held.
Past Medical History:
CARDIAC HISTORY:
- Afib - noted first during admission [**1-/2171**]; initial TEE CV
aborted due to left atrial thrombus; s/p DCCV [**2171-4-11**].
- Systolic CHF/nonischemic dilated cardiomyopathy - thought due
to tachymyopathy. Recent EF 40% ([**3-/2171**])
- PFO (noted on TEE)
- HTN
Other Past History:
- Pulmonary embolus (noted on CT [**1-/2171**])
- Anxiety
- S/p hernia repair, pt describes complicated course of what
sounds like dehiscence and redo x2 with mesh placement, last in
12/[**2168**].
- Seasonal allergies
Social History:
He is single and lives alone. He worked as a painter at [**Hospital1 **]
[**Location (un) 620**], still out of work. He is a lifetime nonsmoker and
denies illicit drug use. he does drink approximately [**12-28**] bottle
of wine about 3 times weekly and "a few beers" from time to time
with friends.
Family History:
Father: h/o CVA
Mother: h/o heart disease, arrythmia and had a pacer. Deceased
82yo.
Physical Exam:
ADMIT EXAM:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, 2+ pulses, no clubbing, s/p DP amutation of left
great toe, venous stasis dermatitis with possible super
infection bilaterally
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
DISCHARGE EXAM:
VS: 99.7 112/62 100 18 96% RA
Gen: awake, alert, resting comfortably in chair, NAD
HEENT: sclera anicteric, MMM
CV: RRR
Lungs: CTAB, no wheezes/rales/rhonchi
Abd: bowel sounds present, soft, NT, ND
Ext: bilateral pedal edema, venous stasis changes, legs wrapped
in ACE bandages
Pertinent Results:
IMAGING:
CXR [**2173-8-3**] -
FINDINGS AND IMPRESSION: The lungs are clear. No pleural
effusion, pulmonary
edema or pneumothorax is present. Mild cardiomegaly is
unchanged.
MICRO/PATH:
[**2173-8-3**] BLOOD CULTURES X 2 - no growth to date after 5 days.
ADMIT LABS:
[**2173-8-2**] 04:15PM BLOOD WBC-15.1* RBC-3.29* Hgb-10.5* Hct-30.6*
MCV-93 MCH-31.9 MCHC-34.2 RDW-15.6* Plt Ct-289
[**2173-8-2**] 04:15PM BLOOD Neuts-93* Bands-0 Lymphs-5* Monos-1*
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2173-8-2**] 04:15PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-NORMAL
[**2173-8-2**] 12:30PM BLOOD PT-15.7* INR(PT)-1.5*
[**2173-8-2**] 04:15PM BLOOD UreaN-60* Creat-3.4*# Na-120* K-4.6
Cl-80* HCO3-24 AnGap-21*
[**2173-8-2**] 04:15PM BLOOD Glucose-102*
[**2173-8-2**] 04:15PM BLOOD ALT-33 AST-36 CK(CPK)-46* AlkPhos-162*
TotBili-0.9
[**2173-8-2**] 04:15PM BLOOD Albumin-3.6 Calcium-9.1 Cholest-141
RELEVANT LABS:
[**2173-8-3**] 12:25AM BLOOD WBC-12.7* RBC-3.08* Hgb-10.0* Hct-28.8*
MCV-94 MCH-32.5* MCHC-34.7 RDW-15.8* Plt Ct-272
[**2173-8-3**] 05:13AM BLOOD WBC-10.7 RBC-2.99* Hgb-10.0* Hct-28.1*
MCV-94 MCH-33.3* MCHC-35.5* RDW-15.7* Plt Ct-224
[**2173-8-3**] 12:25AM BLOOD Neuts-82.3* Lymphs-10.2* Monos-6.3
Eos-0.9 Baso-0.3
[**2173-8-3**] 05:13AM BLOOD Plt Ct-224
[**2173-8-3**] 12:25AM BLOOD Glucose-104* UreaN-58* Creat-3.0* Na-118*
K-4.6 Cl-85* HCO3-20* AnGap-18
[**2173-8-3**] 05:13AM BLOOD Glucose-91 UreaN-55* Creat-2.5* Na-119*
K-4.5 Cl-86* HCO3-24 AnGap-14
[**2173-8-3**] 07:00AM BLOOD Glucose-132* UreaN-58* Creat-2.8* Na-120*
K-4.0 Cl-85* HCO3-22 AnGap-17
[**2173-8-3**] 02:00PM BLOOD Glucose-131* UreaN-55* Creat-2.3* Na-124*
K-4.1 Cl-89* HCO3-23 AnGap-16
[**2173-8-3**] 07:53PM BLOOD Glucose-136* UreaN-52* Creat-2.0* Na-123*
K-5.6* Cl-91* HCO3-22 AnGap-16
[**2173-8-3**] 12:25AM BLOOD ALT-33 AST-35 LD(LDH)-333* AlkPhos-163*
TotBili-0.8
[**2173-8-3**] 05:13AM BLOOD ALT-29 AST-32 LD(LDH)-283* AlkPhos-146*
TotBili-0.9
[**2173-8-3**] 02:00PM BLOOD ALT-25 AST-25 LD(LDH)-265* AlkPhos-137*
TotBili-0.7
[**2173-8-3**] 12:25AM BLOOD proBNP-1588*
[**2173-8-3**] 02:00PM BLOOD proBNP-1666*
[**2173-8-3**] 12:25AM BLOOD ALT-33 AST-35 LD(LDH)-333* AlkPhos-163*
TotBili-0.8
[**2173-8-3**] 05:13AM BLOOD ALT-29 AST-32 LD(LDH)-283* AlkPhos-146*
TotBili-0.9
[**2173-8-3**] 02:00PM BLOOD ALT-25 AST-25 LD(LDH)-265* AlkPhos-137*
TotBili-0.7
[**2173-8-3**] 12:25AM BLOOD proBNP-1588*
[**2173-8-3**] 02:00PM BLOOD proBNP-1666*
[**2173-8-3**] 07:00AM BLOOD Calcium-8.3* Phos-3.8 Mg-1.5*
[**2173-8-3**] 02:00PM BLOOD Albumin-3.2* Calcium-8.0* Phos-3.6 Mg-2.6
[**2173-8-3**] 07:53PM BLOOD Calcium-8.0* Phos-3.6 Mg-2.5
DISCHARGE LABS:
[**2173-8-8**] 06:10AM BLOOD WBC-10.0 RBC-2.65* Hgb-8.4* Hct-25.6*
MCV-97 MCH-31.9 MCHC-33.0 RDW-15.2 Plt Ct-252
[**2173-8-8**] 06:10AM BLOOD Glucose-99 UreaN-16 Creat-0.9 Na-134
K-4.2 Cl-97 HCO3-27 AnGap-14
[**2173-8-8**] 06:10AM BLOOD Calcium-8.5 Phos-3.6 Mg-1.6
[**2173-8-8**] 06:10AM BLOOD PT-15.0* PTT-28.2 INR(PT)-1.4*
Brief Hospital Course:
59 year old male with a past medical history of systolic
congestive heart failure (last EF 55-60%), atrial fibrillation
on coumadin, transaminitis secondary to cirrhosis, chronic lower
extremity stasis dermatitis (recent admission for cellulitis on
[**2173-6-14**]), history of pulmonary embolus and atrial thrombus who
presented from clinic with with a significant hyponatremia,
elevated lactate, and acute kidney injury.
#. HYPONATREMIA: Etiology was likely hypovolemic hyponatremia in
the setting of over-aggressive diuretic use and decreased
dietary intake of sodium. Patient had started dieting, eating
less salt and drinking more water. He presented with
hypotension and tachycardia. Patient also presented with acute
kidney injury, elevated lactate, fractional excretion of sodium
less than 1, low urine sodium, and elevated creatinine and BUN
all suggesting hypovolemic hyponatremia as the etiology. While
in the MICU his sodium was corrected with normal saline and his
urine and serum sodium trended. Once his sodium was trending
upward he was transferred to the medicine floor. His torsemide
was held and then restarted on [**8-7**] on an every other day dosing
schedule, and he should follow up with his PCP for repeat lab
testing.
# HYPOTENSION / TACHYCARDIA - Though initially concerned for
SIRS/sepsis because of leukocytosis on admission, and possible
source of infection being cellulitis from chronic venous stasis
ulcers. CXR, UA, blood cultures were all negative for signs of
infection. He did not have fever of systemic signs of
infection. Initially he met systemic inflammatory response
syndrome criteria with a possible source. He was started on
vancomycin and unasyn empirically. On re-evaluation he remained
afebrile with no constitutional symptoms concerning for sepsis.
His vancomycin and unysin was discontinued and keflex was kept
on per his vascular physicians prescription. Hypotension was
likely a result of extracellular volume depletion in the setting
of overdiuresis and salt restriction as above, with a reactive
tachycardia. Metoprolol, digoxin, and diltiazem were held for
hypotension but restarted as his pressures tolerated them. He
was monitored on telemetry and was not shown to have any atrial
fibrillation with RVR. However, he had asymptomatic sinus
tachycardia to the 130-160s during physical therapy. This was
likely because his home medications were held, and his
tachycardia improved upon restarting digoxin, metoprolol, and
diltiazem at his home doses. Torsemide was restarted on an
every other day dosing schedule.
#. ATRIAL FIBRILLATION: Chronic issue. On coumadin, metoprolol,
diltizem, and digoxin at home. In the MICU, he became mildly
hypotensive (sbp in 90s, not requiring pressors) so his
metoprolol and diltiazem were reduced in dose. Upon trasnfer to
floor, blood pressure was stable after resuming home meidcations
and metoprolol was uptitrates in setting of tachycardia,
particularly with exertion with PT. He should follow up with his
PCP regarding titration of his rate control. His INR was
subtherapeutic, so his warfarin was increased to 6mg. Digoxin
was continued and level was not toxic.
#. Acute kidney injury: Likely prerenal and related to
hypoperfusion in the setting of hypotension. creatinine improved
with holding torsemide and administration of IVF. His creatine
and BUN were trended and his creatine trended downward with IV
fluids.
#. STASIS DERMATITIS WITH POSSIBLE SUPER IMPOSED CELLULITIS:
While in the MICU he did not spike a fever or appear overtly
septic by exam or review of systems. His leukocytosis
normalized. The decision was made to leave him on his outpatient
dose of keflex however pending follow-up with his vascular
physician.
#. CIRRHOSIS: This is a diagnosis that is currently undergoing
outpatient workup. He did not appear hypervolemic and this was
not likely related to the etiology of his hyponatremia. He
denies alcohol abuse and is reportedly planning on undergoing a
liver biopsy to further characterize his liver disease. His
liver function was monitored while in the MICU and remained
stable, and no further management of his possible cirrhosis was
performed.
TRANSITIONAL ISSUES:
-Vascular, renal, and hepatic follow-up.
-Should f/u with PCP regarding torsemide dosing which was
decreased to every other day. He should be evaluated for less
aggressive diuresis if has bump in creatinine.
-He should follow up with his PCP and cardiology regarding
titration of his metoprolol and diltiazem for rate control.
-Warfarin increased to 6mg at discharge as his INR was 1.4
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from [**Month/Year (2) 581**].
1. Warfarin 2 mg PO DAILY16
2. Torsemide 50 mg PO DAILY
3. OxycoDONE (Immediate Release) 5 mg PO BID:PRN pain
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE HS
6. Diltiazem Extended-Release 180 mg PO DAILY
7. Digoxin 0.125 mg PO DAILY
8. Cephalexin 500 mg PO Q6H
Discharge Medications:
1. Cephalexin 500 mg PO Q6H
2. Digoxin 0.125 mg PO DAILY
3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
4. OxycoDONE (Immediate Release) 5 mg PO BID:PRN pain
5. Oxycodone SR (OxyconTIN) 20 mg PO Q12H
6. Torsemide 20 mg PO EVERY OTHER DAY
please hold for SBP <100
RX *Demadex 20 mg 1 tablet(s) by mouth every other day Disp #*15
Tablet Refills:*0
7. Warfarin 6 mg PO DAILY16
8. Metoprolol Succinate XL 100 mg PO DAILY
RX *metoprolol succinate 100 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
9. Diltiazem Extended-Release 180 mg PO DAILY
10. Outpatient Lab Work
Please check INR [**2173-8-9**] and send results to [**Company 191**] [**Hospital 3052**]. Phone [**Telephone/Fax (1) 2173**].
Discharge Disposition:
Home With Service
Facility:
Allcare VNA
Discharge Diagnosis:
Primary: Hyponatremia, acute kidney injury
Secondary: Atrial fibrillation, chronic systolic congestive
heart failure
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 10840**],
You were treated at [**Hospital1 18**] for low sodium and decreased kidney
function. Your low sodium and decreased kidney function were
likely caused by a combination of not eating and drinking as
much as you used to, as well as your torsemide diuretic. As we
gave you fluid and discontinued your torsemide, your sodium
level improved. Please restart your torsemide, but at a lower
dose. Take 20 mg every other day until you see your
cardiologist and primary care doctor. You should take your next
dose on Monday [**2173-8-9**].
Your kidney function also improved with IV fluids, and is now
normal.
Please have your INR checked on Tuesday [**2173-8-10**]. You may need
adjustment in your coumadin dose. For now, you should take 6 mg
per day as your INR is low.
Please keep the appointments listed below.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Department: CARDIAC SERVICES
When: FRIDAY [**2173-8-13**] at 11:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2003**], NP [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: VASCULAR SURGERY
When: MONDAY [**2173-9-13**] at 10:45 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 20205**], MD [**Telephone/Fax (1) 20206**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: [**Hospital3 249**]
When: WEDNESDAY [**2173-8-18**] at 1:30 PM
With: Dr. [**First Name4 (NamePattern1) 2184**] [**Last Name (NamePattern1) 2185**] in the [**Company 191**] POST [**Hospital 894**] CLINIC
Phone: [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] South [**Hospital **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Notes: This appointment is with a hospital-based doctor as part
of your transition from the hospital back to your primary care
provider. [**Name10 (NameIs) 616**] this visit, you will see your regular primary
care doctor in follow up.
Completed by:[**2173-8-8**]
ICD9 Codes: 5849, 2761, 4254, 5715, 4280, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3442
} | Medical Text: Admission Date: [**2129-9-7**] Discharge Date: [**2129-10-25**]
Date of Birth: [**2087-11-5**] Sex: M
Service: MICU
CHIEF COMPLAINT: The patient is a 41 year old morbidly obese
gentleman who came to the hospital in the setting of
cellulitis of the left leg with hypotension requiring fluid
resuscitation and desaturation.
HISTORY OF PRESENT ILLNESS: The patient is a 41 year old
with a history of diabetes mellitus, morbid obesity, asthma,
obstructive sleep apnea and coronary artery disease. He was
admitted to the [**Hospital3 4527**] Hospital in [**Location (un) 620**] on
[**2129-9-4**], for cellulitis and sepsis. He had cut his left leg
with a saw blade on [**2129-9-2**], and subsequently developed
erythema of the leg.
On [**2129-9-4**], he awoke with fever, chills and rigors and went
to [**Hospital3 4527**] where he was noted to have a temperature
of 104 degrees and also appeared to be uncomfortable and
short of breath. His saturations were 92% in room air and
improved to 97 to 98% with four liters nasal cannula. His
blood pressure at that time ranged from 120/60 to 150/90. He
was admitted to the Intensive Care Unit in the [**Hospital3 29718**].
For the left leg cellulitis, he was started on Vancomycin,
Clindamycin and Levofloxacin. His blood pressure
subsequently dropped to 80 systolic and the patient was
started on Neo-Synephrine infusion and had aggressive fluid
resuscitation. The left leg cellulitis seemed to improve and
the Neo-Synephrine was weaned off.
On [**2129-9-6**], the patient was noted to have increasing
respiratory distress. Chest x-ray showed evidence of
pulmonary edema which was treated with Lasix. There was some
response initially but the respiratory distress was not
relieved. He was placed on CPAP and then a nonrebreathing
mask but the saturations were still in the low 90s with
arterial oxygen tension of 62 to 74 mmHg. At this point, the
patient was transferred to the [**Hospital1 188**].
In the MICU, he was intubated by awake fiberoptic intubation.
Oxygenation seemed to improve with assist control ventilation
and the FIO2 was gradually weaned from 80% to 60% oxygen.
PAST MEDICAL HISTORY:
1. Morbid obesity.
2. Type 2 diabetes mellitus with increasing insulin
requirement, diabetic neuropathy.
3. Chronic pain with possible opioid dependence.
4. Hypertension since age of 19.
5. Coronary artery disease.
6. Obstructive sleep apnea requiring CPAP for more than ten
years.
7. Asthma.
8. Osteoarthritis.
PAST SURGICAL HISTORY:
1. Quadriceps tendon repair in [**2125**].
2. Carpal tunnel release, bilaterally.
3. Status post hydrocele repair which was complicated by
postoperative cellulitis.
4. Status post left ankle surgery.
MEDICATIONS ON ADMISSION:
1. Levofloxacin 500 mg intravenously once a day.
2. Avandia one q8hours.
3. Celexa 40 mg twice a day.
4. Vancomycin two grams twice a day.
5. Clindamycin 600 mg intravenously q8hours.
6. Verapamil 480 mg twice a day.
7. Aspirin 81 mg once a day.
8. Tylenol 1000 mg p.r.n.
9. Motrin 800 mg q8hours.
10. Percocet two tablets q6hours.
11. Rhinocort p.r.n.
12. Flovent and Serevent inhalers as required.
13. Neo-Synephrine.
14. [**Doctor First Name **].
15. Oxymetazoline.
16. Remeron 30 mg h.s.
17. Mexiletine 400 mg twice a day.
18. Tegretol 150 mg twice a day.
19. Neurontin 1200 mg q8hours.
20. Heparin 10,000 subcutaneous b.i.d.
21. Zestril 40 mg b.i.d.
ALLERGIES: Cephalosporins and Morphine Sulfate.
FAMILY HISTORY: Father has hypertension. Mother had
emphysema at the age of 63.
SOCIAL HISTORY: The patient lives alone. He is on
disability. He smokes a pipe or cigar occasionally. No
history of ethanol or intravenous drug use.
PHYSICAL EXAMINATION: Temperature is 98.9, heart rate 100
beats per minute, normal sinus rhythm, blood pressure 86/33
and respiratory rate was 30. After intubation he was
ventilated on pressure support of 20 with a PEEP of 10 and he
was on 100% oxygen. He was sedated with Propofol and
Lorazepam. The pupils are equal, reactive to light.
Extraocular movements are intact. Neck was obese, unable to
see the jugular venous pressure. Pulmonary - There was no
wheeze. Distant breath sounds are heard. Crackles at the
bases. Cardiac - regular heart sounds, S1 and S2, sounds
distant, no murmur appreciated. The abdomen is obese, soft,
nontender, bowel sounds heard, abdominal wall was edematous.
Extremities 3+ peripheral edema left leg, torso edematous
with palpable pulses. Skin - erythema left ankle above the
cut. Neurologic - alert and appropriate despite the low
oxygen saturation.
LABORATORY DATA: White cell count was 12.2, hematocrit 36.6,
platelets 211,000. Sodium 143, potassium 3.9, chloride 99,
bicarbonate 31, blood urea nitrogen 26, creatinine 0.7, blood
sugar 136. Creatinine kinase was 96 and troponin was
negative. Arterial blood gases on 100% oxygen pH 7.47, pCO2
47, pO2 90.
Chest x-ray was of poor quality and diffuse alveolar
infiltrate suggestive of pulmonary edema and congestive heart
failure. could not rule out adult respiratory distress
syndrome.
Ultrasound of the lower limbs showed normal compressibility
of the lower limb veins which was negative for deep vein
thrombosis.
Electrocardiogram shows normal sinus rhythm with normal axis,
with no evidence of ischemia.
HOSPITAL COURSE:
1. Cardiac - Hemodynamic instability requiring inotropics
initially. He was monitored with a PA catheter. The
inotropes were gradually weaned. After the initial course of
hemodynamic instability, there was a face of hypertension
where the blood pressure was difficult to control requiring
increasing the doses of the antihypertensive medications.
There was one episode of fast atrial fibrillation with
hemodynamic instability which required cardioversion.
2. Pulmonary - The patient required awake fiberoptic
intubation for control of airway. Initially the oxygen
requirements were very high with FIO2 of 1.
Over a period of time, the oxygenation was weaned from 100%
to 60 to 40%. During this two to three week period, the
oxygenation was labile and this was treated by intense
physical therapy and nebulizers. The oxygenation gradually
improved.
Percutaneous tracheostomy was performed on [**2129-9-27**]. The
oxygenation improved gradually and for the past two weeks,
there has been no evidence of respiratory distress. Adequate
oxygenation was maintained over the tracheostomy mask with
40% oxygen. The saturations are 100% and the carbon dioxide
levels have been ranging from 35 to 45 mmHg during this time.
3. Renal - Aggressive diuresis during the MICU stay. The
patient was treated with Lasix 20 to 80 mg p.r.n. and a
negative balance of one liter to 1.5 liters was maintained to
wean from the ventilator. There was one episode of prerenal
failure which improved spontaneously and he did not require
dialysis or hemofiltration during his stay in the MICU.
4. Gastrointestinal - Due to the long-standing diabetes
mellitus, he was prone for recurrent gastroparesis. He
tolerated only forced pyloric feeds. There was one episode of
coffee ground vomitus but the patient had a stable hematocrit
and therefore did not need an endoscopy.
5. Endocrine - Very large insulin requirements and poorly
controlled diabetes mellitus. The patient had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
consultation and he was started on U-500 regular insulin, now
has a better blood sugar control.
6. Hematology - The patient's hematocrit has been stable
during his MICU stay and he did not require any transfusions
during the hospital stay.
7. Infectious disease - Methicillin resistant Staphylococcus
aureus positive and positive blood cultures. Methicillin
resistant Staphylococcus aureus positive fungal cystitis. He
was Methicillin resistant Staphylococcus aureus positive in
sputum on [**2129-10-19**]. Clostridium difficile positive on
[**2129-9-10**], and on [**2129-10-6**]. This is being treated with Flagyl
at present. On [**2129-10-17**], the C. difficile toxin assay was
negative.
8. Musculoskeletal - Back pain which has gradually resolved
and received physical therapy.
9. Nutrition - The patient required prolonged parenteral
nutrition due to the gastroparesis but now he has a
postpyloric tube and he is on enteral feeds.
10. Prophylaxis - He is on Heparin 5000 units subcutaneous
b.i.d., on Protonix 40 mg intravenously once a day.
MEDICATIONS ON DISCHARGE:
1. Flagyl 500 mg nasogastric b.i.d., today is day 17 of a 21
day course.
2. Haldol 2 mg nasogastric b.i.d.
3. Fentanyl patch 25 mcg per hour.
4. Aspirin 81 mg nasogastric once a day.
5. Remeron 30 mg nasogastric h.s.
6. Heparin 5000 units subcutaneous b.i.d.
7. Celexa 10 mg nasogastric b.i.d.
8. Lopressor 100 mg nasogastric three times a day.
9. Zestril 40 mg nasogastric once a day.
10. PhosLo two tablets nasogastric twice a day.
11. Nystatin swish and spit topical b.i.d.
12. Reglan 20 mg intravenous three times a day.
13. Lorazepam 2 mg p.r.n. h.s.
14. Albuterol and Atrovent nebulizers as required p.r.n.
q.i.d.
15. Lotrimin cream between toes b.i.d.
16. Trapidil to rash in the left lower limb b.i.d.
17. Half strength Respalor plus 80 grams ProMod as tube feeds
with a goal of 70 cc/hour.
18. U-500 regular insulin, 0.12 ccs or 12/100 q8hours
subcutaneous.
19. Sliding scale Humalog as required.
DISCHARGE STATUS: The patient is ready for transfer to
rehabilitation facility, probably [**Hospital1 **], in the near
future.
CONDITION ON DISCHARGE: He is alert, awake and afebrile. He
has stable blood pressure and is in normal sinus rhythm. The
patient is comfortable with tracheostomy mask with 40%
oxygen. He needs suction regularly and he has a good cough.
He is awake and oriented, follows simple instructions,
communicates by nodding. He can move all his limbs.
He had a swallowing study done and trial but he failed this
assessment because of aspiration of colored water and
aphonia. He also had an ENT consultation in this regard and
the cords are able to move but he is unable to phonates due
to no leak around the tracheostomy tube. The tracheostomy
tube was not changed for fenestrated tube due to anatomical
difficulty and relatively young tracheostomy tract.
The patient is prone for gastroparesis. It is very essential
to check the position of the feeding tube tip periodically
and be certain that it is postpyloric.
The patient was assessed for a percutaneous endoscopic
gastrostomy placement or jejunostomy tube placement, but
these procedures could not be performed either by
gastroenterology or interventional radiology because of the
body mass.
The patient's admission weight was 197 kilograms and his
discharge weight as of today is 158 kilograms.
The exact date of discharge and the facility to which the
patient will be discharged is unclear but once this is
finalized, there will be an addendum to this discharge
summary.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**]
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2129-10-24**] 18:56
T: [**2129-10-24**] 19:29
JOB#: [**Job Number 29719**]
ICD9 Codes: 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3443
} | Medical Text: Admission Date: [**2206-7-27**] Discharge Date: [**2206-8-8**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2751**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
n/a
History of Present Illness:
[**Age over 90 **]F w/PMHx of suspected bronchoalveolar carcinoma, CKD [**2-16**], CHF,
Afib, DM2 on insulin, renal artery stenosis, brought in by EMS
from nursing home due to respiratory distress. The patient was
noted to have progressive respiratory distress with a sat of 88%
on nasal cannula, as well as a fingerstick blood sugar in the
500s this morning with poor response to 10 units of insulin.
Notably, patient was admitted at [**Hospital 3278**] medical center [**Date range (1) 61239**]
for dyspnea, a-fib with RVR, COPD exacerbation, CHF exacerbation
In the ED, initial VS were: 98.8 77 145/57 26 99% 15L. Patient
was found to be hypoxic with poor response to full face mask. He
also spiked to [**Age over 90 **]F, given tylenol with good response. He was
tachypneic, with increased work of breathing and started
empirically on vanc/zosyn for HAP. PE could not be ruled out
with a CT chest as patient had elevated Cr (1.9) so he was
started on a heparin drip. He was given 10 units of insulin at
rehab, and 10 more units in the ED with subsequent fingersticks
in the 200s.
On arrival to the MICU, patient was on BIPAP, saturating 98% on
minimal settings.
Past Medical History:
CHF with diastolic dysfunction, EF 55% in [**2-/2206**]
CAD w/ h/o positive stess test
Afib
HTN [**1-16**] renal artery stenosis
DM2, not on insulin
COPD
Renal artery stenosis s/p stent to R RA
Duodenal ulcer
H/o c. diff colitis
Social History:
Came from [**Location (un) **] Health rehab facility, gets most of his care
at [**Hospital 3278**] Medical center. Per [**Hospital1 3278**] records, no history of EtOH
or illicit drug use. Remote significant tobacco use.
Family History:
[**Name (NI) **] sister with colorectal cancer
Physical Exam:
Exam on Admission:
Vitals: T:97.1 BP:126/51 P:67 R:26 O2:98 on BIPAP
General: Alert, no acute distress
HEENT: Sclera anicteric, injected with hemmorhage on left, on
BIPAP
Neck: supple, distended neck veins
CV: Irregular rate, non-tachy, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Crackles bilaterally at bases
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: Onychomycosis present b/l at toes, DP present, no edema
Neuro: Catontonese speaking, moving all 4 extremities
Discharge exam - unchanged from above, except as below:
Neck: No JVD
CV: Irregular rhythm, normal rate
Lungs: CTAB
Neuro: Cantonese speaking, appropriate and follows commands with
interpreter
Pertinent Results:
Labs on Admission:
[**2206-7-27**] 06:40PM BLOOD WBC-9.9 RBC-4.99 Hgb-13.9 Hct-42.8 MCV-86
MCH-27.8 MCHC-32.4 RDW-15.2 Plt Ct-241
[**2206-7-27**] 06:40PM BLOOD Neuts-82.2* Lymphs-14.8* Monos-2.4
Eos-0.2 Baso-0.3
[**2206-7-27**] 09:00PM BLOOD PT-12.1 PTT-26.1 INR(PT)-1.1
[**2206-7-27**] 06:40PM BLOOD Plt Ct-241
[**2206-7-27**] 06:40PM BLOOD Glucose-470* UreaN-32* Creat-1.9* Na-134
K-4.0 Cl-94* HCO3-20* AnGap-24
[**2206-7-27**] 06:40PM BLOOD estGFR-Using this
[**2206-7-27**] 06:40PM BLOOD CK(CPK)-72
[**2206-7-27**] 06:40PM BLOOD CK-MB-1 proBNP-6839*
[**2206-7-27**] 06:40PM BLOOD cTropnT-0.04*
[**2206-7-27**] 06:40PM BLOOD Calcium-8.7 Phos-3.7 Mg-2.2
[**2206-7-27**] 07:01PM BLOOD pO2-68* pCO2-31* pH-7.44 calTCO2-22 Base
XS--1 Comment-GREEN TOP
[**2206-7-27**] 07:01PM BLOOD Lactate-5.7*
Labs on Discharge:
[**2206-8-8**] 04:42AM BLOOD WBC-8.6 RBC-4.49* Hgb-12.6* Hct-38.9*
MCV-87 MCH-28.2 MCHC-32.5 RDW-16.1* Plt Ct-175
[**2206-8-8**] 04:42AM BLOOD Glucose-112* UreaN-17 Creat-1.2 Na-139
K-3.6 Cl-107 HCO3-23 AnGap-13
Imaging:
Chest XRay ([**2206-7-27**]): "Left basilar opacification likely
reflects a combination of a small pleural effusion and adjacent
atelectasis. Infection, however, is not excluded. Hazy
opacification within the mid lung fields bilaterally is
nonspecific, and could reflect an infectious or inflammatory
process. Mild pulmonary edema is considered less likely."
[**Month/Day/Year **] ([**2206-7-28**]): "The left atrium is mildly dilated. 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%). There is considerable
beat-to-beat variability of the left ventricular ejection
fraction due to an irregular rhythm/premature beats. Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated at the sinus level. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Trivial mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion."
Bilateral lower extremity ultrasound ([**2206-7-28**]): "No evidence of
deep vein thrombosis in either right or left lower extremity."
Microbiology:
BC ([**2206-7-27**]): No growth
Urine legionella antigen ([**2206-7-28**]): No growth
MRSA screen ([**2206-7-28**]): Negative
[**2206-8-6**] 2:13 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT [**2206-8-7**]**
C. difficile DNA amplification assay (Final [**2206-8-7**]):
CLOSTRIDIUM DIFFICILE.
Positive for toxigenic C. difficile by the Illumigene
DNA
amplification. (Reference Range-Negative).
Brief Hospital Course:
[**Age over 90 **] year old male with a history of diastolic heart failure,
atrial fib/flutter, and chronic obstructive pulmonary disease
who was admitted with dyspnea likely secondary to an
exacerbation of his heart failure in the setting of atrial
flutter with rapid ventricular response.
# Acute on chronic diastolic heart failure: The patient
presented in acute hypoxic respiratory failure, for which he
initially required supplemental oxygen with 15L nasal cannula
and was later transitioned to BiPAP, for which he was admitted
to the MICU. Possible etiologies for his respiratory failure
were thought to include CHF exacerbation, pneumonia, PE, COPD
exacerbation, or progression of his underlying cancer. CHF
exacerbation was considered the most likely diagnosis given his
elevated BNP, pulmonary congestion on x-ray, known diastolic
dysfunction, and respiratory distress. CXR found evidence of
pulmonary congestion. [**Age over 90 **] showed an LEVF of >55%, unchanged from
prior. He initially presented with an elevated lactate, which
improved after a 500cc bolus. However, he continued to be volume
overloaded, and was diuresed with IV lasix with improvement in
his symptoms. Over the first 24 hours, his oxygen requirement
decreased and he was successfully weaned from bipap. Afterload
reduction was achieved with diltiazem (initially via a diltiazem
drip). Health care associated pneumonia was also considered
considered as a source of his symptoms given that he had an
isolated fever to 101F in the ED. He was started empirically on
vancomycin/zosyn/azythroycin, but this was discontinued after
four days because he remained afebrile and did not have a
leukocytosis or findings suggestive of PNA on CXR. To evaluate
for PE, he underwent LENIs and [**Age over 90 **], both of which were negative.
Given his elevated Cr, we did not pursue a CTA. He was given
standing atrovent nebulizers for a possible COPD exacerbation.
After transfer to the floor, the patient had an episode of
hypertension, tachycardia and flash pulmonary edema and required
IV lasix and his diltiazem was increased for further rate
control and blood pressure control. His diltiazem was restarted
and titrated to achieve a heart rate of <100, as discussed
below. Furosemide was restarted at 20mg PO daily prior to
discharge. Given his renal function and adequate blood pressure
control on diltiazem alone, ACEi and [**Last Name (un) **] were not initiated.
# A fib: He was started on a diltiazam drip and metorprolol IV
to optimize rate control. His HR remained stable in the 70-100s
on this regimen. He was eventially weaned off of the diltiazam
drip and transitioned to metoprolol 25mg po BID. However, he did
not tolerate this well, and IV diltiazem was required for rate
control. He was transitioned to PO diltiazem with IV pushes as
necessary, before adequate rate control was obtained. His
discharge dose was diltiazem extended-release 240mg daily. He
persistently remained in atrial flutter this admission. He does
not appear to be chronically anticoagulated at home given his
high risk for falls, this was discussed with his PCP. [**Name10 (NameIs) **] found
no evidence of thrombus, normal cardiac output, and normal
atrial size. TSH was also normal.
#Clostridium difficile colitis: Patient had loose watery stools
this admission and C. diff PCR was positive. He was started on
metronidazole and will be discharged on a 14 day course of this
antibiotic.
# Supraventricular Tachycardia (SVT): On [**2206-7-31**] the patient
developed tachycardia to 130's with no visible P waves and a
narrow complex QRS that was interepreted as SVT. He was given
beta blockers and two doses of adenosine with subsequent
conversion into atrial flutter with variable conduction.
Diltiazem was then continued with good rate and rhythm control.
# Hypertension: His hypertension was initially managed with
nitroglycerin drip, which was eventenually weaned. He was
started on captopril while in the hospital for afterload
reduction, and was stopped due to renal impairment. He was
restarted on half of his home dose of furosemide on the floor
for diuresis and afterload reduction. Of note, the patient
developed SBPs in the 190s when agitated, which often resulted
in flash pulmonary edema. His blood pressure was well
controlled on diltizazem and Lasix at discharge.
# [**Last Name (un) **]: His creatinine wasi nitially near his baseline of
1.6-1.8, as documented in [**Hospital1 3278**] records. His kidney function was
monitored during diuresis, and he required repletion of
potassium and phosphate. At discharge, creatinine had improved
to 1.2.
# Diabetes mellitus: Initially had blood glucose 500 at rehab
facility. He received 20units total on the day of admission,
which decreased his blood sugar to the 200s. He was maintiained
on an insulin sliding scale with no adverse effects. At
discharge, he was restarted on glipizide 2.5mg PO daily, with
instructions for his family members to check his glucose before
breakfast and after dinner daily until visiting his PCP.
# Rule out Tuberculosis: On admission, the patient's x-ray was
concerning for miliary TB. Records from [**Hospital1 3278**] were obtained that
confirmed that he had been ruled out for TB via broncioalveolar
lavage and sputum culture.
# Goals of care: The primary team, along with a Cantonese
translator, met with the patient, health care proxy, and family,
and confirmed the patient's desire to be DNR. He would like to
continue to have the option to be intubated at this time. Their
primary goal was for the patient to return home and the
appropriate services were arranged to facilitate this.
# HTN/Renal Artery Stenosis s/p stent placemement: Hypertension
was managed with diltiazem. He was discharged with diltiazem and
Lasix, he did not require any other blood pressure agents.
# Incidental findings: There is some displacement of the lower
cervical trachea to the left, suspicious for thyroid mass on the
right. Upon reviewing records from [**Hospital1 3278**], the patient has a
known thyroid mass. After discussion with his PCP, [**Name10 (NameIs) **] had
been a discussion about this and the decision was made not to
intervene on this mass.
#Code status: The patient was DNR but OK to intubate throughout
his admission.
#Transitions of care:
- will need further titration of his diltiazem for rate control
- continue to discuss the indication for anticoagulation
givenhis atrial fibrillation
- will continue a 14 day course of Flagyl as an outpatient
- follow up on [**Hospital1 **] finger stick blood sugars and titrate oral
hypoglycemics for further diabetes management
- follow up on thyroid mass with possible biopsy, if within
goals of care
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from [**Location (un) **] health rehab.
1. Aspirin 81 mg PO DAILY
2. Diltiazem Extended-Release 240 mg PO DAILY
3. Furosemide 40 mg PO DAILY
4. Ipratropium Bromide MDI 1 PUFF IH Q4H:PRN wheeze
5. GlipiZIDE 2.5 mg PO BID
6. Mirtazapine 7.5 mg PO HS
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Timolol Maleate 0.25% 1 DROP BOTH EYES [**Hospital1 **]
RX *timolol maleate 0.25 % 1 drop both eyes twice daily [**Hospital1 **] #*5
Milliliter Refills:*0
3. Ipratropium Bromide MDI 1 PUFF IH Q4H:PRN wheeze
4. Mirtazapine 7.5 mg PO HS
5. Medical equipment
Hospital bed. Diagnosis: chronic diastolic heart failure(ICD-9
428.32)
6. Diltiazem Extended-Release 240 mg PO DAILY
7. Furosemide 20 mg PO DAILY
Hold for SBP <100
8. GlipiZIDE 2.5 mg PO DAILY
Hold for blood sugar <80
9. MetRONIDAZOLE (FLagyl) 500 mg PO TID Duration: 13 Days
RX *metronidazole 500 mg 1 tablet(s) by mouth Three times daily
[**Hospital1 **] #*39 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 1952**], [**Location (un) 86**]
Discharge Diagnosis:
Primary:
Acute on chronic diastolic heart failure
Atrial flutter with rapid ventricular response
Clostridium difficile colitis
Secondary:
Diabetes Mellitus Type 2
Coronary artery disease
Hypertension
Chronic obstructive pulmonary disease
Renal artery stenosis
Duodenal ulcer
Glaucoma
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Known lastname 3443**],
You were recently admitted to [**Hospital1 18**] with difficulty breathing.
While you were here, we performed tests that suggest that your
heart failure was worsened by a fast heart rate. We restarted
you on your home diltiazem to get better control of your heart
rate, and we gave you medications to control your blood pressure
and remove the fluid from your lungs. You were also started on
an antibiotic for an infection of your colon, which you should
take as prescribed. This will be expected to cause a lot of
diarrhea for the next 1-2 weeks. It is important to NOT TAKE
medications such as Imodium, loperamide or Lomotil during this
time.
While you are at home, please make sure to weigh yourself daily,
and if you notice a 3 pound increase in weight, contact your
primary care physician.
In addition, we changed your oral diabetes medication, and you
will now take glipizide 2.5 miligrams every day. Please be sure
to check your fingerstick blood sugar before breakfast and after
dinner everyday until you see your primary care physician. [**Name10 (NameIs) **]
your doctor if the numbers are consistently over the 200 in the
morning or over 300 after meals.
It was our sincere pleasure to take care of you while you were
in the hospital. Please do not hesitate to contact us with any
questions, comments or concerns.
With Warm Regards,
Your Inpatient Medicine Team
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] K.
Address: [**Last Name (un) 4805**], [**Location (un) **],[**Numeric Identifier 2900**]
Phone: [**Telephone/Fax (1) 4806**]
***I have left a message with the office stating you need a
follow up appt and to call you with an appt. If you dont hear
from them by tomorrow, please call them directly to book.
ICD9 Codes: 2762, 2760, 4280, 496, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3444
} | Medical Text: Admission Date: [**2172-10-23**] Discharge Date: [**2172-10-25**]
Date of Birth: [**2125-12-9**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7223**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
cardiac catheterization
History of Present Illness:
This 46 year old gentleman with PMH of HTN, lipids, and tobacco
use was in his usual state of health until the end of [**2172-7-26**]
when he developed a cough with congestion with low grade fevers.
He was treated with a Z-Pack with improvement until 2-3 weeks
later when he developed a dry cough and dyspnea with exertion,
such as climbing stairs or walking 30 feet. He previously had no
exercise limitations. He attributed these symptoms to a
persistent viral infection. Additionally, he experienced
progressive PND at night. Also has Finally, however, he was
becoming short of breath with only minimal exertion, and decided
to seek medical evaluation. He saw his PMD who referred him for
cardiac workup. Additionally at that time he was diagnosed with
new onset DM2.
.
An echocardiogram was done on [**2172-10-21**] and demonstrated a dilated
left ventricle with severe global systolic dysfunction with an
EF of approximately 10-15%. He had severe MR and mild TR and a
dilated left atrium. He was referred to [**Hospital1 18**] for diagnostic
cath to evaluate the etiology of his heart failure.
Past Medical History:
Hypertension - poorly controlled, not on meds
Hyperlipidemia - took a statin briefly, d/c'ed [**2-28**] palpitations
tobacco abuse ([**1-28**] ppd x 35 years)
DM2 - newly diagnosed on [**10-22**], not started on any meds
back surgery (? laminectomy) 7 years ago
collarbone, rib fracture in MVA [**2169**]
nasal surgery for deviated septum 2 years ago
Social History:
Originally Portuguese, moved to USA 20 years ago. Married, works
as a software project manager. Has one 7 year old son. [**Name (NI) **]
travel to [**Country **] 1.5 years ago, last travel to [**Country **] 5 years
ago. Drinks 2 glasses of wine and 1 glass of scotch daily.
Smokes [**1-28**] ppd x 35 years.
Family History:
No history of udden cardiac death or heart disease in the
family. Father died of ?liver cancer
Physical Exam:
PHYSICAL EXAMINATION:
VS: T: 98.4 BP: 112/89 P: 108 RR: 21 Sat O2: 95% RA
Gen: pleasant, NAD, A+O x 3
HEENT: NC/AT, MMM. PERRLA, sclerae anicteric.
Neck: Jugular veins flat, no HJR. No thyroid nodules appreciated
Cor: RR, tachycardic. no m/r/g, no extra sounds appreciated
Resp: inspiratory crackles at bases bilaterally R>L
Abd: S/NT/ND, + BS
Ext: WWP, no C/C/E. R groin no buits or hematoma. Pulses 2+ at
radial and DP
Skin: no lesions
Pulses:
Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Pertinent Results:
[**2172-10-23**] ADMISSION LABS
CBC:
WBC-6.4 RBC-4.87 Hgb-15.6 Hct-45.0 MCV-92 MCH-31.9 MCHC-34.6
RDW-14.9 Plt Ct-310
.
COAGS:
PT-12.4 PTT-21.7* INR(PT)-1.1
.
CHEM:
Glucose-176* UreaN-16 Creat-1.1 Na-137 K-4.6 Cl-100 HCO3-27
AnGap-15 TotProt-7.3 Calcium-9.7 Phos-4.5 Mg-2.2
.
[**10-23**] CARDIAC CATH
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease (LCX had an occluded [**First Name8 (NamePattern2) **]
[**Last Name (un) **] that filled via collaterals. The RCA was diffusely
diseased with proximal/mid vessel subtotal occlusion. The distal
RCA filled via collaterals from the left system).
2. Severely elevated right and left-sided filling pressures due
to known
severe cardiomyopathy.
3. left ventriculography was deferred due to #2.
4. Unsuccessful PCI of the subtotally occluded RCA complicated
by a
Grade I dissection.
.
CHF WORKUP LABS:
Brief Hospital Course:
1. Acute systolic heart failure: His echo finding of global
systolic dysfunction with EF 10-15% in conjunction with only
mild CAD and sudden onset of HF sxs makes ischemic etiologies of
cardiomyopathy unlikely. His work up for non-ischemic
cardiomyopathy was as follows: HIV neg, Fe studies wnl, TSH wnl.
SPEP/UPEP pending. His recent viral illness suggests a viral
etiology. In addition, his history of ETOH use is also
concerning for ETOH induced CM. He was diuresed with IV lasix,
with significant improvement of his symptoms. He was discharged
with lasix 20 PO and with instructions for follow up in [**Hospital 1902**]
clinic. He was also advised on ETOH cessation.
.
2. CAD: He has several cardiac risk factors including poorly
controlled HTN, hyperlipidemia, tobacco use, and DM. C. cath
demonstrated 2 vessel dz. His RCA PCI was complicated by
dissection. He was treated with medical management with ASA,
BB, ACE-I, and statin. See below for specific risk factor
modifications.
.
3. Hyperlipidemia: He was found to have an LDL 170. He was
started on pravastatin as he reported "muscle aches" on lipitor.
He tolerated the pravastatin during this hospitalization.
.
4. DM: He was found to have hyperglycemia. He was started on
FSG qid and on glipizide 2.5. His HgbA1c was pending on
discharge. He was counselled on following a diabetic diet and
checking his FSG with meals.
.
5. Tobacco dependence: He was counselled on smoking cessation.
He was interested in attempting cessation at this time and
wished for assistance. He was discharged with a prescription of
Chantix and with instructions to start his prescription 1 week
prior to his set quit date. He will follow with his PCP for
progress on smoking cessation.
.
Medications on Admission:
HOME MEDS: (All started [**2172-10-22**])
Aspirin 81mg daily
Lasix 20mg daily
Lisinopril 2.5mg daily
Discharge Medications:
1. Chantix 0.5(11)-1(3X14) mg Tablets, Dose Pack Sig: One (1)
Tablets, Dose Pack PO once a day.
Disp:*1 Dose Pack* Refills:*2*
2. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Pravastatin 20 mg Tablet Sig: Four (4) Tablet PO HS (at
bedtime).
Disp:*120 Tablet(s)* Refills:*2*
4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
6. Glipizide 2.5 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1)
Tab,Sust Rel Osmotic Push 24hr PO twice a day.
Disp:*60 Tab,Sust Rel Osmotic Push 24hr(s)* Refills:*2*
7. Glucose Meter, Disp & Strips Kit Sig: One (1)
Miscellaneous check FSGs TID with meals.
Disp:*1 kit* Refills:*0*
8. Glucose strips Sig: One (1) qACHS.
Disp:*qs 1 month* Refills:*2*
9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Cardiomyopathy of unclear etiology
2 vessel coronary artery disease
Diabetes mellitus
Discharge Condition:
stable
Discharge Instructions:
You were diagnosed with a cardiomyopathy. The most likely
etiology of you cardiomyopathy is viral versus alcohol use. You
should refrain from further alcohol use, as this may exacerbate
your heart failure.
.
It is very important that you take all medications as
prescribed. You were started on Aspirin, Carvedilol, Lisinopril
for your heart. You were also started on Lasix for diuresis. In
addition, you were started on glipizide for your diabetes. You
were also prescribed chantix for assistance with smoking
cessation. You should take the chantix as prescribed, starting
1 week prior to your quit date. Your smoking cessation progress
should be followed by your primary care provider. [**Name10 (NameIs) **] were
given instructions on checking your finger sticks.
.
Please return to the emergency department or see your PCP is you
have any chest pain, shortness of breath or worsening lower
extremity swelling.
.
You should have a repeat ECHO in about six weeks. Dr. [**First Name (STitle) 437**] in
the heart failure clinic will direct your future care for your
heart failure.
Followup Instructions:
Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 27187**], to have your
glucose and electrolytes checked in the next week. TEL:
[**Telephone/Fax (1) 3658**]. Dr. [**Last Name (STitle) 27187**] should also follow your progress
with your smoking cessation.
.
Please also follow up with Dr. [**First Name (STitle) 437**] in the heart failure clinic
in the next week. You should call for an appointment. TEL ([**Telephone/Fax (1) 48042**]. It is important that you follow up with him within
the next 1 week to evaluate for possible progression of your
congestive heart failure.
.
Completed by:[**2172-10-25**]
ICD9 Codes: 4254, 4280, 9971, 4240, 4019, 2724, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3445
} | Medical Text: Admission Date: [**2173-10-5**] Discharge Date: [**2173-10-10**]
Date of Birth: [**2120-3-3**] Sex: F
Service: MEDICINE
Allergies:
Lisinopril / Oxycodone
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
Fevers, chills, sweats, ?sepsis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
53 y/o F with antiphospholipid syndrome on warfarin and ESRD [**1-12**]
lupus nephritis on HD since [**2167**] now s/p renal txp in [**2173-2-8**]
on immunosuppression, referred to ED from primary care office
where she presented with fevers and chills x three weeks. She
also told her providers in the primary care clinic that she has
been vomiting and having abdominal pain and urinary frequency.
She had reportedly not been eating well, but denied dysuria. In
PCP's office today, she was febrile to 103.2 orally, with HR of
116 and BP of 115/80. She was described as lethargic and sleepy
for most of the visit, but easily aroused. Exam was notable for
vital signs as above, cool extremities and tenderness over LLQ
and RLQ over her transplanted kidney. She was sent to the ED to
evaluate for an intra-abdominal, genitourinary, or respiratory
source of SIRS/sepsis.
In the ED, triage vital signs were 100.5, 116, 125/74, 18, 97%
RA. Exam notable for rigoring, tachycardia, 2/6 systolic murmur,
+RLQ TTP without rebound tenderness or guarding. She was
reportedly AAO x2. Labs notable for INR 2.9, lactate 1.1.
Non-contrast CT abd/pelvis showed a malpositioned foley catheter
but no explanation for fevers. There was no perinephric
stranding or abscess. Ultrasound of the transplanted kidney
showed increased resistive indices but no hydronephrosis or
perinephric fluid collections. The patient was given two liters
of IVF, and one amp of D50 for hypoglycemia. She was given 1g
each of vancomycin, cefepime, and acetaminophen. A third liter
of NS was started prior to transfer to the MICU. Transplant
surgery was consulted, and did not feel she needed urgent
surgical intervention. Transfer VS per verbal report were temp
102, HR 120, RR 19, 99% RA, 96/59.
Upon arrival to the MICU, the patient had a low-grade fever to
100.2. She says she is feeling much better than earlier, and her
shaking and chills have stopped. She denies ever having had a
cough or dyspnea. Denies urinary frequency, polyuria, or
difficulty voiding. Denies abdominal pain, nausea, vomiting,
diarrhea, or constipation. She was started on D5NS at 120 cc/hr.
Past Medical History:
-LUPUS
-ANTIPHOSPHOLIPID SYNDROME
-ESRD [**1-12**] LUPUS NEPHRITIS s/p DCD txp [**2-17**] (recent creat 2.3)
(Postop course was complicated by SVC syndrome requiring
reintubation MRV showed bilateral brachecephalic vein occlusion
on [**2173-2-19**]. She underwent venoplasty and stent placement of
the Right subclavian vein, brachiocephalic and SVC. Post
procedure she was started on heparin gtts and transitioned to
Coumadin)
-THYROID NODULE [**2159**]
-ANGIOEDEMA [**2172-10-21**]
-HYPERTENSION
-HYPERCHOLESTEROLEMIA
Social History:
Born in [**Country 2045**]. She was widowed in 6/[**2169**]. She lives alone in
[**Location (un) **], with 1 son nearby. [**Name2 (NI) **] other 3 children are still in
[**Country 2045**]. She denies any tobacco, ethanol or illicit drug use.
Family History:
Significant for a maternal uncle with hypertension; otherwise
denies any family history of heart disease, cancer or diabetes.
Mother died of unclear causes when patient was 7 yo. Father died
of unclear causes in [**2152**].
Physical Exam:
VS: Temp:100.2 BP:116/51 HR:103 (regular) RR:17 O2sat:100% RA
GEN: pleasant, comfortable, NAD. Sitting up in bed.
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no
supraclavicular or cervical lymphadenopathy, no jvd
RESP: CTA b/l with good air movement throughout. No wheezes or
crackles.
CV: RR, S1 and S2 wnl, no m/r/g
ABD: Well-healed surgical scar over RLQ. Softly distended, +NABS
x4, nt, no masses or hepatosplenomegaly. No TTP over LLQ, RLQ,
or elsewhere. No rebound tenderness or guarding.
EXT: no c/c/e
SKIN: + hypopigmented patch over right shoulder extending
medially and inferiorly to mid-back, with interspersed
hyperpigmented papules (reportedly chronic birthmark). no
rashes/no jaundice/no splinters
NEURO: AAOx3. CN II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated
RECTAL: Deferred
Pertinent Results:
Initial Labs:
[**2173-10-5**] 10:48AM WBC-5.3# RBC-3.71* HGB-11.1* HCT-32.5* MCV-88
MCH-29.9 MCHC-34.1 RDW-15.6*
[**2173-10-5**] 10:48AM NEUTS-81* BANDS-4 LYMPHS-5* MONOS-8 EOS-0
BASOS-1 ATYPS-1* METAS-0 MYELOS-0
[**2173-10-5**] 10:48AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-OCCASIONAL
[**2173-10-5**] 10:48AM PLT SMR-NORMAL PLT COUNT-195
[**2173-10-5**] 10:48AM PT-29.0* PTT-31.7 INR(PT)-2.9*
[**2173-10-5**] 10:48AM tacroFK-3.9*
[**2173-10-5**] 10:48AM ALBUMIN-3.9
[**2173-10-5**] 10:48AM LIPASE-23
[**2173-10-5**] 10:48AM ALT(SGPT)-13 AST(SGOT)-32 LD(LDH)-338* ALK
PHOS-67 AMYLASE-146* TOT BILI-0.6
[**2173-10-5**] 10:48AM GLUCOSE-38* UREA N-27* CREAT-2.5* SODIUM-133
POTASSIUM-4.4 CHLORIDE-97 TOTAL CO2-22 ANION GAP-18
[**2173-10-5**] 11:49AM LACTATE-1.1
[**2173-10-5**] 05:20PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.012
[**2173-10-5**] 05:20PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-75
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2173-10-6**] 12:00PM BLOOD WBC-3.3* RBC-3.01* Hgb-9.0* Hct-26.7*
MCV-89 MCH-30.0 MCHC-33.9 RDW-15.7* Plt Ct-131*
[**2173-10-7**] 04:55AM BLOOD WBC-2.8* RBC-3.01* Hgb-9.0* Hct-26.3*
MCV-88 MCH-30.1 MCHC-34.4 RDW-15.7* Plt Ct-146*
[**2173-10-8**] 05:55AM BLOOD WBC-2.5* RBC-3.16* Hgb-9.5* Hct-27.7*
MCV-88 MCH-30.1 MCHC-34.3 RDW-15.7* Plt Ct-170
[**2173-10-9**] 07:05AM BLOOD WBC-1.9* RBC-3.16* Hgb-9.5* Hct-27.6*
MCV-87 MCH-30.0 MCHC-34.4 RDW-15.8* Plt Ct-198
[**2173-10-10**] 06:00AM BLOOD WBC-1.6* RBC-3.30* Hgb-9.8* Hct-28.8*
MCV-87 MCH-29.8 MCHC-34.0 RDW-15.5 Plt Ct-199
Microbiology:
blood cx: [**10-5**]
Blood Culture, Routine (Preliminary): e coli
GRAM NEGATIVE ROD(S). PRELIMINARY SENSITIVITY.
SENSITIVITIES: MIC expressed in MCG/ML
_____________________________________________________
GRAM NEGATIVE ROD(S)
|
AMIKACIN-------------- S
AMPICILLIN------------ S
AMPICILLIN/SULBACTAM-- S
CEFEPIME-------------- S
CEFTAZIDIME----------- S
CEFTRIAXONE----------- S
CIPROFLOXACIN--------- S
GENTAMICIN------------ S
MEROPENEM------------- S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ S
stool toxin: [**10-5**] c diff positive
Imaging:
CXR: [**10-5**] No acute pulmonary process. Stable chest x-ray exam
Renal U/S: [**10-5**]
No evidence of hydronephrosis or perinephric fluid collection.
Increased resistive indices since prior exam in [**Month (only) 216**],
correlate with renal function.
CT abdoman/ pelvis: [**10-5**]
1. No acute findings in the abdomen or pelvis to explain
patient's fevers,
within the limits of this non-contrast enhanced technique.
2. Tip of the Foley catheter within the distal ureter of the
transplanted
kidney causing mild hydroureteronephrosis. No perinephric
collections or
masses. No evidence for abscess.
3. Fecal loading in the rectum without bowel obstruction
Brief Hospital Course:
*Please note that pt left against medical advice*
.
.
53 y/o immunosuppressed female s/p renal transplant in [**Month (only) 958**]
[**2172**], presenting from PCP's office with three weeks of chills,
now with documented fevers tachycardia, borderline hypotension,
and hypoglycemia.
.
1. Sepsis secondary to ecoli bacteremia: On presentation, meet
SIRS criteria with fevers, tachycardia and mild bandemia from
suspected infectious source especially given immunosuppression.
Pancultured in the emergency department and placed on empiric
broad-spectrum antibiotics with vancomycin and cefepime. To
evaluate for etiology, CXR and CT scan of abdomen was performed
with no apparent abnormality besides stool impaction in the
rectum. Urinalysis did have minimal blood and white blood
cells, but culture returned negative. Stool cx returned
positive for cdiff and patient was started on flagyl. Blood cx
from [**10-5**] grew pansensitive ecoli and antibiotics were
subsequently narrowed to ciprofloxacin (and flagyl). The most
likely source of ecoli bacteremia was thought to be
translocation from gut in setting of mild colitis. The patient
was transiently hypotensive in the emergency department, but
responded to fluid boluses. With antibiotic therapy, she
defervesced, tachycardia resolved, and subjective complaints of
chills improved. Surveillance blood cx from [**10-6**] were negative
for 48 hrs, pt was continued on cipro/flagyl but developed
leukopenia and flagyl was discontinued (bc can contribute to
leukopenia) and changed to PO vancomycin. Authorization for PO
vanco could not be obtained over the weekend and pt decided to
leave against medical advice in lieu of waiting for vanco
authorization. Pt was advised to continue vanco for 2 weeks more
after completing 2 week course of cipro. She has outpt f/u in
transplant clinic to have WBC count checked (in addition to INR
and tacro levels, as below). At time of discharge, pt was
abebrile >72 hrs, had no diarrhea, no abd pain, no N/V. Of note,
mycophenolate mofetil was discontinued as well prior to
discharge given leukopenia. Bactrim and valcyte, though also can
cause leukopenia, were continued as pt has been on these for a
long time without complications. Most likely leukopenia was due
to recent initiation of flagyl, and should improve on
cipro/vanco regimen. MMF was held until follow up as this may
have been contributing to her neutropenia.
.
2. ESRD s/p transplant: History of lupus nephritis s/p renal
transplant on cellcept, tacrolimus and prednisone. Baseline
creatinine is in the 1s, but has been slowly increasing since
[**Month (only) 205**] and has been as high as 2.7 in the recent past. Etiology
of developping renal insufficiency is unclear: CT scan with no
evidence of obstruction, urinalysis without active sediment to
suggest recurrent lupus nephritis. The patient may have chronic
volume depletion, she is on bactrim for PCP [**Name9 (PRE) **] which may
artifactually increase creatinine. Also, it is unclear whether
she is compliant with her immunosuppressants at home. A renal
biopsy may be pursued as an outpatient. During hospitalization,
renal function was trended daily and patient continued on
immunosuppressants with bactrim for PCP [**Name Initial (PRE) **]. Daily tacrolimus
levels were also followed with level adjusted as needed. Goal
level [**7-20**], tacro level 6.4 at discharge, per renal consult
continued 2mg [**Hospital1 **] dosing of tacrolimus. Cellcept was
discontinued prior to discharge given leukopenia (as above). Pt
has f/u in renal transplant clinic to have tacro levels
rechecked and to check WBC count, will modulate
immunosuppression regimen based on those results.
.
3. Antiphospholipid syndrome: on longterm anticoagulation with
warfarin for history of APLS (Anticardiolipin Ab's showing
elevated IgG and normal IgM in [**3-17**] and [**7-17**]) with multiple
prior thrombotic occlusions of dialysis fistula. PT/INR followed
daily with warfarin supratherapeutic on [**10-6**] to 4.7. INR at
2.9 to 2.1 on discharge (goal [**1-13**]). Coumadin was restarted at
1mg daily with f/u day after discharge to check INR levels and
to adjust coumadin accordingly.
.
4. SLE: Outpatient rheumatology notes indicate patient
diagnosed in [**2165**] and initially seen at [**Hospital1 112**] lupus clinic. Last
[**Hospital1 18**] rheumatology clinic visit [**1-20**], documenting history of
lupus nephritis and AVN of ankles with last documented [**Doctor First Name **]
positive 1:160 in [**2169**], though dsDNA Ab's have been negative
when checked since [**2171**]. No findings on history or physical
consistent with lupus flair.
.
5. Hypertension: Pt has history of hypertension treated with
metoprolol only, with past systolic blood pressure measurements
documented in the 110-140 range, per OMR. Documented BP's in ED
generally in low 100s, with IVF infusion. Given systemic HTN,
home metoprolol initially held but restarted prior to discharge.
.
6. Hyperlipidemia: Last lipid panel in [**2172-9-10**], with TC
144, HDL 39, LDL 81, TG 120. Not currently receiving treatment,
but was taking simvastatin through [**2172-3-11**].
.
7. Hyponatremia: Mild, without alterations in mental status.
Likely poor PO intake over past days-weeks would suggest
hypovolemic hyponatremia. Improved following IVF bolus in
emergency department.
.
8. Osteoporosis: Last bone densitometry scan in [**2173-4-10**],
consistent with osteoporosis, in setting of chronic
glucocorticoid therapy and hyperparathyroidism.
Medications on Admission:
1. Mycophenolate Mofetil 1000 mg PO BID
2. Acetaminophen 650 mg PO/NG Q6H:PRN fever, pain
3. PredniSONE 5 mg PO/NG DAILY
4. CefePIME 1 g IV Q24H
5. Sulfameth/Trimethoprim SS 1 TAB PO/NG DAILY
6. Cinacalcet 30 mg PO DAILY
7. Tacrolimus 2 mg PO Q12H
8. Famotidine 20 mg PO/NG Q24H
9. ValGANCIclovir 450 mg PO DAILY
10. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H
11. Warfarin 1 mg PO/NG DAILY16
Discharge Medications:
1. Outpatient Lab Work
Please have your INR checked at [**Hospital3 **] ([**Company 191**]) on
Monday, [**10-11**]. Please fax to [**Telephone/Fax (1) 3534**].
2. Outpatient Lab Work
Please have your tacrolimus level, CBC, and INR checked at renal
transplant clinic on [**10-18**].
3. cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
5. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. valganciclovir 450 mg Tablet Sig: One (1) Tablet PO EVERY
OTHER DAY (Every Other Day).
8. warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day:
please have your INR checked on [**10-11**].
9. tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
10. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
11. glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day.
12. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 11 days.
Disp:*11 Tablet(s)* Refills:*0*
13. vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 25 days.
Disp:*100 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
E coli bacteremia
C diff
.
Secondary:
SLE
Antiphospholipid antibody
s/p renal transplant
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You are leaving the hospital against medical advice.
.
You were admitted to [**Hospital1 18**] with fevers and chills. You were
found to have bacteria from your blood (E. coli) which likely
came from your bowel tract. You have an infection in your bowels
called C diff which can be contracted while on immunosuppression
and during hospitalizations. You are being treated for both
infections with antibiotics. Your kidney function improved with
fluids. Your INR level has been higher than optimal because your
antibiotics can interfere with coumadin. We held your coumadin,
but restarted it before your discharge, INR should be closely
monitored when you leave the hospital. Please follow up with
the coumadin clinic tomorrow.
.
We have made the following changes to your medications:
Decrease your tacrolimus to 2mg twice a day
Take cipro for 11 more days (last day = [**10-20**])
Take vancomycin for 25 more days (last day = [**11-3**])
Stop taking mycophenolate mofetil (cellcept) until you follow up
with the kidney transplant doctors
Continue to take coumadin 1mg daily, but have your INR checked
at [**Hospital 191**] [**Hospital3 **] on [**10-11**] to make sure it is
therapeutic
Followup Instructions:
The following appointments have been scheduled for you:
.
Please have your INR checked at [**Hospital 191**] [**Hospital3 **] on
Monday, [**10-11**].
.
Department: [**Hospital3 249**]
When: MONDAY [**2173-10-18**] at 9:30 AM
With: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: WEST [**Hospital 2002**] CLINIC
When: MONDAY [**2173-10-18**] at 1 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2540**], RN [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Please follow up with the kidney transplant doctors, who will
contact you with an appointment.
Completed by:[**2173-10-10**]
ICD9 Codes: 2761, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3446
} | Medical Text: Admission Date: [**2184-12-9**] Discharge Date: [**2184-12-18**]
Date of Birth: [**2128-11-9**] Sex: M
Service: Vascular Surgery
CHIEF COMPLAINT: Left calf claudication with occluded left
leg bypass graft.
HISTORY OF PRESENT ILLNESS: A 56-year-old white male with
coronary artery disease, status post myocardial infarction,
coronary artery bypass graft and redo coronary artery bypass
graft, AICD, with diabetes, hypertension, peripheral vascular
disease status post bilateral fem-[**Doctor Last Name **] dacron graft complained
of increased calf claudication left greater than right and
burning pain from the left knee to the foot.
The patient had an ultrasound done in the Emergency Room at
an outside hospital approximately six days prior to
admission, which showed, per patient, that the graft was
patent.
Patient was seen in the office on [**2184-12-9**] and admitted for
further evaluation and treatment.
PAST MEDICAL HISTORY:
1. Coronary artery disease: Myocardial infarction, coronary
artery bypass graft, redo coronary artery bypass graft,
PTCA/stent.
2. Congestive heart failure, ejection fraction of 30%.
3. Nonsustained ventricular tachycardia in [**2184-5-1**].
4. Diabetes diagnosed two years ago; with neuropathy.
5. Hypertension.
6. Hypercholesterolemia.
7. Gastroesophageal reflux disease.
8. Depression.
9. Psoriasis.
10. Peripheral vascular disease.
PAST SURGICAL HISTORY:
1. Coronary artery bypass graft x3 at [**University/College 14925**]in
[**2180**].
2. PTCA of the LAD in [**2181-3-31**].
3. Redo coronary artery bypass graft in [**2181**].
4. Sternal rewire [**2182-3-2**].
5. PTCA and stent of the right coronary artery in [**2184-3-1**].
6. AICD [**2184-5-31**].
7. Left femoral to above-the-knee popliteal with dacron
bypass graft on [**2184-7-12**].
8. Right common femoral artery to the above-the-knee
popliteal bypass graft with dacron in [**2184-8-1**].
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: Patient lives with his wife. [**Name (NI) **] quit
smoking cigarettes. He does not use alcohol. He ambulates
independently.
ALLERGIES: Patient is allergic to Glucophage which caused
congestive heart failure and hospitalization in the Intensive
Care Unit.
ADMISSION MEDICATIONS:
1. Insulin 75/25 22 units subQ q am.
2. Insulin 75/25 20 units subQ q supper.
3. Digoxin 0.125 mg po q day.
4. Imdur 90 mg po q day.
5. Lisinopril 40 mg po q day.
6. Lopressor 100 mg po bid.
7. Lasix 120 mg po bid.
8. Ecotrin 325 mg po q day.
9. Zantac 150 mg po bid.
10. Gabapentin 800 mg po q am.
11. Zoloft 20 mg po q day.
12. Vicodin prn pain.
13. Oxazepam prn.
PHYSICAL EXAMINATION: General: Drowsy white male in no
acute distress. Awakens easily. Skin is warm and dry.
Patches of psoriasis on the face, arms, knees, and anterior
legs. HEENT: Normocephalic. Pupils are equal, round, and
reactive to light and accommodation. Tongue is midline.
Neck: No lymphadenopathy or thyromegaly. Chest clear
bilaterally. AICD palpable in the left upper chest. Heart:
regular, rate, and rhythm. Abdomen is obese, nontender.
Bowel sounds present. Extremities: Right groin clean, dry,
and intact. No hematoma. Left toes slightly cooler than
right. Rubor present. Neurological examination: Grossly
intact. Motor strength intact. Ankle flexion and extension
normal. Pulse examination: Carotid pulses 1+ bilaterally.
Radial pulses 2+ bilaterally. Femoral pulses, popliteal
pulses are dopplerable bilaterally. Dorsalis pedis on the
right is dopplerable. Right PT has no Doppler signal. Left
dorsalis pedis has no dopplerable signal. Left PT has a
Doppler signal present.
ADMISSION LABORATORIES: White blood cells is 10.6,
hematocrit is 38.6, platelets of 341,000. PT is 12.2, PTT
21.4, INR is 1.0. Sodium is 141, potassium is 4.6, chloride
is 96, CO2 is 32, BUN is 35, creatinine is 1.2, glucose is
148.
ELECTROCARDIOGRAM: Electrocardiogram showed a normal sinus
rhythm with a rate of 64. No significant changes from
[**2184-8-16**] electrocardiogram.
HOSPITAL COURSE: The patient was admitted to the hospital
following an aortogram with bilateral leg run-off with
ultrasound guidance. The arteriogram confirmed that both
grafts were occluded.
On [**2184-12-10**], the patient underwent an uneventful left common
femoral to above-the-knee popliteal bypass graft with a
reverse right basilic vein. Postoperatively, the patient's
feet were warm. Patient had strong Doppler signals at his
left pedal pulses.
On postoperative day #1, the patient's pulse examination had
deteriorated. He was taken to the operating room for a
thrombosed graft. He was re-explored and the proximal
anastomosis was redone. At the end of surgery, the patient's
left foot was warmer than his right. He had a triphasic left
posterior tibial Doppler signal. He was maintained on IV
Heparin infusion. He received perioperative Kefzol.
On [**2184-12-13**], postoperative day #3 and two, patient was
scheduled to be transferred from the VICU to floor status.
Beta blockade was resumed. He was continued on IV Heparin
and anticoagulation with Coumadin for his bypass graft was to
start. However, patient had an episode of hypotension with a
systolic blood pressure in the low 70s. He was asymptomatic.
His electrocardiogram showed no changes. His CK MB band
started at 19, 14, and then 13, which corresponded to a MB
index of 1.4%. Patient's troponin peaked at 24.5 and then
subsequently went down to 20.9 indicating a non-ST elevation
myocardial infarction.
Cardiology service was consulted. Patient was transfused
with packed red blood cells for hematocrit of 25. Pressors
were recommended if necessary, but were not needed for
patient to maintain his pressure after transfusion. IV
Heparin was continued. Addition of aspirin was recommended.
A loading dose of Plavix was given and followed by 75 mg of
Plavix po q day was started.
Cardiac catheterization was considered, but not recommended.
Patient was asymptomatic and he had just had a cardiac
catheterization in [**2184-5-1**]. An outpatient stress test
four weeks after discharge was booked.
The remainder of patient's postoperative course was
uneventful. He was followed by the [**Last Name (un) **] Endocrine Service
to manage his insulin requirement. During hospitalization,
patient's 75/30 insulin was supplemented with NPH insulin and
a sliding scale of regular insulin. At discharge, [**Last Name (un) **]
recommended resuming patient's 75/25 insulin with 18 units at
breakfast and 22 units at supper.
Anticoagulation with Coumadin for his bypass graft was
started. His goal INR was 2-2.5. Patient was to have PT/INR
draws Monday, Wednesday, Friday by the VNA with results
called to Dr.[**Name (NI) 1720**] office. ................... and
Coumadin dose adjusted accordingly.
At time of discharge, patient's left leg incision was clean,
dry, and intact. He had a warm foot. His right arm incision
was clean, dry, and intact. There was minimal arm swelling.
Patient was to followup in the office for staple removal two
weeks after discharge. He was to followup with the
Cardiology service one week after discharge to followup for
his perioperative myocardial infarction and also for
adjustment of cardiac medications as necessary.
DISCHARGE MEDICATIONS:
1. Coumadin 2.5 mg po q day.
2. Insulin 75/25 18 units subQ q am.
3. Insulin 75/25 22 units subQ presupper.
4. Glipizide 10 mg po q day.
5. Plavix 75 mg po q day.
6. Digoxin 0.125 mg po q day.
7. Lopressor 75 mg po bid.
8. Lisinopril 10 mg po q day.
9. Lasix 120 mg po q day.
10. Aspirin 325 mg po q day.
11. Zocor 20 mg po q day.
12. Zoloft 200 mg po q day.
13. Neurontin 800 mg po q am.
14. Neurontin 1600 mg po q pm.
15. Fluocinonide 0.05% topically [**Hospital1 **].
16. Vicodin 5/500 1-2 tablets po q4h prn pain.
CONDITION ON DISCHARGE: Satisfactory.
DISPOSITION: Home with VNA services.
DIAGNOSES:
1. Ischemic left foot with occluded left fem-[**Doctor Last Name **] dacron
graft: Left common femoral to above-the-knee popliteal
bypass graft with reverse right basilic vein.
2. Thrombosis of fem-[**Doctor Last Name **] vein graft: Re-exploration and redo
of proximal anastomosis on [**2184-12-11**].
SECONDARY DIAGNOSES:
1. Perioperative myocardial infarction.
2. Severe coronary artery disease, SV CABG, SV redo CABG, SV
AICD.
3. Diabetes.
4. Hypertension.
5. Hypercholesterolemia.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3409**]
Dictated By:[**Last Name (NamePattern1) 3954**]
MEDQUIST36
D: [**2185-1-25**] 22:56
T: [**2185-1-26**] 04:01
JOB#: [**Job Number **]
ICD9 Codes: 9971, 4280, 3572, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3447
} | Medical Text: Admission Date: [**2146-2-19**] Discharge Date: [**2146-2-21**]
Date of Birth: [**2098-2-13**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
Neck Wound
Major Surgical or Invasive Procedure:
Neck exploration
Left carotid artery repair
Esophagoscopy
Bronchoscopy
Left greater saphenous vein angioplasty closure of left common
carotid
History of Present Illness:
41 y/o male who is transferred from [**Hospital3 15402**] for a Zone 2 neck
injury that occured after a stab wound to the neck. Pt. was
high on cocaine and unable to recall how injury occurred. In
ambulance pt. w/ ? of posturing and sizure activity. Pt.
received 5 L. crystalloid and 2 units blood. Pt. intubated in
ED.
Past Medical History:
Pt. denies
Social History:
Cocaine use
Family History:
Unknown
Physical Exam:
Afebrile hr 70s, 106/70 bagged w/ 99% sat
Gen: paralyzed
HEENT: PERRLA
Neck: trachea midline, mild L neck swelling w/ laceration
Chest: CTAB, no injury noted
Back: No deformity or step-off
Abd: soft, NTND
Rectal: no tone, guiac negative
Pelvis: stable
Ext: no obvious injury
Pertinent Results:
CXR: ETT 5 cm above carina, no ptx, mediastinum 9 cm
Brief Hospital Course:
Pt. transferred from OSH for zone 2 neck wound with carotid
defect on CTA. Pt. intubated and taken to the OR from the ER.
Pt. had left neck exploration w/ left common carotid
arteriorotly and primary repair of posterior wall of CCA,
primary repair of disscestion w/ tacking sutures, left GSV
angiplasty closure of Left CCA, resection of left groin LN.
Post op pt. went to unit and was extubated [**2146-2-19**] p.m. Pt.
called out to floor on [**2146-2-20**]. Pt. had bronchoscopy and EGD
that were unremarkable. Pt. tolerating POs. Both groin site
and neck healing well. Vascular followed pt. and felt that pt.
was okay to be d/c on [**2146-2-21**] and will follow up with Vasc. in 2
weeks for staple and stitch removal. Pt. to be d/c w/ pain
control.
Of note, team saw patient for morning rounds and discussed the
plan for the morning. We were going to stop telemetry and then
get some discharge paperwork for patient. Discussed outpatient
pain control and the need to take an aspirin a day, along with
the need to follow up with both the vascular surgeons who
performed the surgery and the trauma service. Pt. expressed
understanding. However, prior to discharge, pt. eloped from
hospital without prescriptions for pain control and was not
given formal written instructions prior to leaving. [**Name (NI) 1094**] mother
did call the hospital later that evening and the nurse gave the
discharge instructions over the phone and encouraged the patient
to call himself for further instructions. Hopefully, pt. will
follow up to have wounds evaluated and staple and sutures
removed.
Medications on Admission:
Unknown
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
Neck Wound
Left carotic artery injury
Discharge Condition:
Good
Discharge Instructions:
Do not soak any of your wounds. It is okay to shower, and then
you should pat yourself dry. Do not do any heavy lifting or
straining. Call your doctor or go the emergency room if you
have increased pain, swelling in the neck, shortness of breath,
difficulty breathing, difficulty or inability to swallow, pus
draining from the wounds, nausea, vomiting, fevers, chills, or
any other changes in your medical condition that concern you.
You will need to have the staples and stitches removed in two
weeks at vascular clinic. You should continue taking aspirin.
Followup Instructions:
You need to follow up with Dr. [**Last Name (STitle) **] in the next 1-2 weeks.
You should call the vascular clinic [**Telephone/Fax (1) 8343**] to make an
appointment. You will also need to follow up in the trauma
clinic in 2 weeks. Call [**Telephone/Fax (1) 6449**] tomake an appoinment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
ICD9 Codes: 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3448
} | Medical Text: Admission Date: [**2176-12-12**] Discharge Date: [**2176-12-19**]
Date of Birth: [**2112-8-28**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Septra Ds / Lipitor / Pravachol / Wheat Flour / Dairy
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2176-12-12**] Three Vessel Coronary Artery Bypass Grafting utilizing
the left internal mammary to left anterior descending artery
with vein grafts to obtuse marginal and PLV.
History of Present Illness:
Mrs. [**Known lastname 20821**] is a 64 year old female with recent complaints of
exertional chest pain and shortness of breath. She also admits
to lower extremity edema and palpitations. Following an abnormal
ETT, she underwent cardiac catheterization which revealed severe
three vessel coronary artery disease. Based upon these findings,
she was referred for surgical revascularization.
Past Medical History:
Coronary Artery Disease
Insulin Depedent Diabetes Mellitus
Hypertension
Hyperlipidemia
History of Ulcerative Colitis
Abnormal LFTs, Cholelithiasis
Asthma
Osteopenia
Cataracts - s/p surgery
History of Palpitations
History of RLE Trauma
Tonsillectomy
Cesarean Sections
Social History:
Quit tobacco 41 years ago. Denies ETOH. Unemployed. Married,
lives with husband.
Family History:
Denies premature coronary artery disease.
Physical Exam:
Vitals: BP 155-164/65, HR 79, RR 16
Height 61 inches, Weight 187 pounds
General: WDWN obese female in no acute distress
HEENT: Oropharynx benign, EOMI
Neck: Supple, no JVD
Lungs: CTA bilaterally
Heart: Regular rate and rhythm, normal s1s2, no murmur
Abdomen: Soft, nontender with normoactive bowel sounds
Ext: Warm, no edema
Pulses: 2+ distally
Neuro: Alert and oriented, CN 2- 12 grossly intact, no focal
deficits noted
Pertinent Results:
[**2176-12-19**] 04:30AM BLOOD WBC-13.5* RBC-3.16* Hgb-9.6* Hct-28.4*
MCV-90 MCH-30.6 MCHC-34.0 RDW-14.6 Plt Ct-421#
[**2176-12-19**] 04:30AM BLOOD Plt Ct-421#
[**2176-12-15**] 02:32AM BLOOD PT-15.0* PTT-32.8 INR(PT)-1.3*
[**2176-12-19**] 04:30AM BLOOD Glucose-99 UreaN-24* Creat-1.1 Na-142
K-3.6 Cl-102 HCO3-30 AnGap-14
CHEST (PORTABLE AP) [**2176-12-16**] 12:25 PM
CHEST (PORTABLE AP)
Reason: s/p ct removal ?ptx
[**Hospital 93**] MEDICAL CONDITION:
64 year old woman with s/p cabg
REASON FOR THIS EXAMINATION:
s/p ct removal ?ptx
HISTORY: Chest tube removal, to evaluate for pneumothorax.
FINDINGS: In comparison with the study of [**12-13**], the left chest
tube has been removed and there is no definite pneumothorax.
Endotracheal, nasogastric, and Swan-Ganz catheter have all been
removed. Residual right IJ sheath is seen. The atelectatic
changes at the left base have decreased.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname 247**] [**Hospital1 18**] [**Numeric Identifier 20822**] (Complete)
Done [**2176-12-12**] at 9:42:15 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
Division of Cardiothoracic [**Doctor First Name **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2112-8-28**]
Age (years): 64 F Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Abnormal ECG. Chest pain. Coronary artery disease.
Hypertension.
ICD-9 Codes: 402.90, 786.51, 440.0
Test Information
Date/Time: [**2176-12-12**] at 09:42 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5209**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW2-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: 40% to 45% >= 55%
Aorta - Ascending: 2.5 cm <= 3.4 cm
Aortic Valve - Peak Gradient: 5 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 3 mm Hg
Findings
LEFT ATRIUM: Normal LA size. No spontaneous echo contrast or
thrombus in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. Good (>20 cm/s) LAA
ejection velocity.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No spontaneous
echo contrast in the body of the RA. A catheter or pacing wire
is seen in the RA and extending into the RV. No ASD by 2D or
color Doppler. Prominent Eustachian valve (normal variant).
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Normal LV wall thickness. LV cavity
normal for BSA. Mild regional LV systolic dysfunction.
RIGHT VENTRICLE: Mild global RV free wall hypokinesis.
AORTA: Normal aortic diameter at the sinus level. Simple
atheroma in aortic root. Normal ascending aorta diameter. Simple
atheroma 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: Three aortic valve leaflets. Mildly thickened
aortic valve leaflets. No AS. Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. Trivial MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets.
Moderate [2+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with physiologic PR.
PERICARDIUM: Trivial/physiologic 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 patient received antibiotic prophylaxis. The
TEE probe was passed with assistance from the anesthesioology
staff using a laryngoscope. No TEE related complications.
patient.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
PRE-CPB:1. The left atrium is normal in size. No spontaneous
echo contrast or thrombus is seen in the body of the left atrium
or left atrial appendage. No spontaneous echo contrast is seen
in the body of the right atrium.
2. No atrial septal defect is seen by 2D or color Doppler.
3. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal for the patient's body size.
There is mild regional left ventricular systolic dysfunction
with mild global free wall hypokinesis. LVEF= 45%
4. There are simple atheroma in the aortic root. There are
simple atheroma in the ascending aorta. There are simple
atheroma in the aortic arch. There are complex (>4mm) atheroma
in the descending thoracic aorta.
5. There are three aortic valve leaflets. The aortic valve
leaflets are mildly thickened. There is no aortic valve
stenosis. Trace aortic regurgitation is seen.
6. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen.
7. The tricuspid valve leaflets are mildly thickened. Moderate
[2+] tricuspid regurgitation is seen.
8. There is a trivial/physiologic pericardial effusion.
POST-CPB: On infusion of phenylephrine. Preserved LV function
post cpb. LVEF is 45%. Trace MR, AI. TR is now 1+. Aortic
contour is preserved post decannulation.
Brief Hospital Course:
Mrs. [**Known lastname 20821**] was admitted and taken directly to the operating
room where Dr. [**Last Name (STitle) **] performed coronary artery bypass grafting
surgery. For surgical details, please see seperate dictated
operative note. Following the operation, she was brought to the
CVICU for invasive monitoring. Within 24 hours, she awoke
neurologically intact and was extubated without incident. Due to
a postoperative anemia, she was transfused with packed red blood
cells to maintain hematocrit near 30%. It took several days to
wean from Milrinone. She otherwise maintained stable
hemodynamics and eventually transferred to the SDU on
postoperative day five. She was followed closely by [**Last Name (un) **] to
assist in the management of her Insulin dependent diabetes
mellitus, and her insulin pump was reinserted on [**12-18**]. She was
ready for discharge home on POD#8. She had a right groin wound
that will require wet to dry packing, and is being continued on
keflex for one week for some erythema aurrounding her vein
harvest incisions.
Medications on Admission:
Novalog Insulin Pump, Aspirin 325 qd, Asacol 1600 tid, Advair,
Albuterol prn, [**Doctor First Name **] 180 qd, Lasix 20 qd, Zantac 150 [**Hospital1 **],
Crestor 10 qd, Flonase, Atenolol 25 qd, Preservision 2 tabs [**Hospital1 **],
Lutein 200 qd, KCL 20 meq qd, MVI
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Four
(4) Tablet, Delayed Release (E.C.) PO TID (3 times a day).
Disp:*360 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. Crestor 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 Disk with Device(s)* Refills:*0*
7. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*0*
8. insulin pump
9. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) for 7 days.
Disp:*21 Capsule(s)* Refills:*0*
10. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days.
Disp:*14 Tablet(s)* Refills:*0*
11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for 7
days.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
12. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day: after
1 week of 40 mg [**Hospital1 **].
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] VNA, [**Hospital1 1559**]
Discharge Diagnosis:
Coronary Artery Disease - s/p CABG
Postoperative Anemia
Insulin Depedent Diabetes Mellitus
Hypertension
Hyperlipidemia
History of Ulcerative Colitis
Abnormal LFTs, Cholelithiasis
Discharge Condition:
Stable
Discharge Instructions:
1)Please shower daily. No baths. Pat dry incisions, do not rub.
2)Avoid creams and lotions to surgical incisions.
3)Call cardiac surgeon if there is concern for wound infection.
4)No lifting more than 10 lbs for at least 10 weeks from
surgical date.
5)No driving for at least one month.
6)Please remove leg staples on [**2177-1-2**].
Followup Instructions:
Dr. [**Last Name (STitle) **] in [**2-22**] weeks, call for appt
Dr. [**Last Name (STitle) **] in [**12-22**] weeks, call for appt
Dr. [**First Name (STitle) **] in [**12-22**] weeks, call for appt
Completed by:[**2176-12-19**]
ICD9 Codes: 2851, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3449
} | Medical Text: Admission Date: [**2174-4-20**] Discharge Date: [**2174-5-6**]
Date of Birth: [**2148-1-31**] Sex: F
Service:
The remainder of the dictation will be done by the next
intern.
CHIEF COMPLAINT: Refractory AML.
HISTORY OF PRESENT ILLNESS: This is a 26-year-old female
with progressive AML diagnosed [**3-9**] status post 7 + 3 x2,
most recently [**3-10**] complicated by prolonged aplasia
approximately 32 days with appendicitis/typhlitis, who
represents with 7 + 3 reinduction to be followed by
preparation for mismatched allo-BMT.
Since recent discharge on [**2174-4-13**], patient has been followed
by Dr. [**First Name (STitle) 1557**] in clinic with progressively increased from a
white count of 4800 with 80% blasts on discharge to 61,700
and 98% blasts on [**4-19**], the day prior to admission. She has
been treated with increases of Hydrea 1 gram q.d. to 3 grams
q.d. on admission.
Currently, patient describes progressive increase in fatigue
without fevers, chills, sweats, shortness of breath, cough,
chest pain, or extremity pain. She reports nausea with
medications relieved by Ativan without any new right lower
quadrant abdominal pain or discomfort. Patient denies recent
bruising, bleeding, or headache/changes in mental status.
ALLERGIES: No known drug allergies. Vancomycin has in the
past been reported to cause rash, that is false. AmBisome
causes diaphoresis, severe nausea, vomiting, and chills. Has
been avoided as needed.
PAST MEDICAL HISTORY: Progressive AML diagnosed [**3-9**]. See
history of present illness for details.
MEDICATIONS:
1. Hydrea 3000 mg b.i.d.
2. Prednisone 20 mg p.o. q.d.
3. Levaquin 500 mg p.o. q.d.
4. Flagyl 500 mg p.o. t.i.d.
5. Ativan 0.5 1-2 tablets p.o. q.4-6h. prn anxiety and
nausea. Hickman line care.
SOCIAL HISTORY: Patient lives with family in [**Location (un) 1468**], I
believe.
FAMILY HISTORY: No known history of leukemia.
VITAL SIGNS: T current 97.7, 110, 114/66, 20, and 99% on
room air.
PHYSICAL EXAM: In no apparent distress, alert and oriented
times three. Patient was anicteric. Pupils are equal,
round, and reactive to light and accommodation. Extraocular
muscles are intact. Moist oral mucosa. No oral petechiae or
hemorrhages. No lymphadenopathy. Lungs are clear to
auscultation bilaterally. Heart: Tachycardic, regular
rhythm, normal S1, S2, no murmurs, rubs, or gallops. Abdomen
was soft, nontender, nondistended without rebound or
guarding, no hepatosplenomegaly was noted. No clubbing,
cyanosis, or edema, 2+ pulses bilaterally.
PERTINENT LABORATORY VALUES: White blood cell count of 69.2
with 93% blasts, hematocrit 27.0, platelets 339. Chem-7 was
unremarkable. LFTs were unremarkable. Uric acid was 2.9.
RELEVANT STUDIES: He had a [**4-12**] abdominal CT, which showed
persistent inflammatory phlegmon surrounding appendix to
cecal tip. The small fluid collection was undrainable.
She had an echocardiogram [**3-2**], which showed an EF of 65%.
Normal study.
Micro data: Blood cultures drawn [**4-18**] are pending.
In summary, this is a 26-year-old female with resistant and
progressive AML readmitted for 7 + 3 reinduction to be
followed by Cytoxan/TBI and mismatched MUD allo-BMT.
SUMMARY OF HOSPITAL COURSE:
1. AML: Patient was reinduced with idarubicin and cytarabine
7 + 3 with appropriate reduction in her white blood cell
count. She remained neutropenic at the time of this
dictation [**2174-5-6**] with pancytopenia. She was treated with
supportive care with blood and platelets, and remained on
neutropenic precautions given the appropriate mouth care,
repletion of electrolytes, bowel regimen, pain control, etc.
At this point in time, the decision to proceed with allo-BMT
was pending. The recommendations of the attending physicians
had not been decided at this time. Please see additional
dictation summary for further treatment of the patient's AML.
2. Fever and neutropenia: Patient was intermittently febrile
throughout her hospital course while she was on neutropenic.
She was treated with broad-spectrum antibiotics for a known
right lower quadrant inflammatory process, and was treated
with Flagyl, voriconazole, meropenem, Vancomycin, acyclovir,
and most recently ciprofloxacin. Patient continued to spike
fevers through antibiotic treatments. She had been cultured
on multiple occasions with negative culture data to date.
She has been followed with serial abdominal exams and CAT
scans of her abdomen.
Most recently she had a CT of the torso on [**2174-5-5**], which
showed no disease within the chest with a small stable
pulmonary nodule. However, her CT of her abdomen and pelvis
showed progression of her extensive inflammatory changes
involving the appendix. No drainable fluid collections,
however, there was free fluid within the right pelvis.
Additionally, the patient has noticed some interval change in
her abdomen with sensation of fullness within her right lower
quadrant, though she continues to deny pain. Consequently at
this time, given her limited options, she has been seen by
Surgery. However, surgery in this instance has not been
recommended. We will continue to treat her with
broad-spectrum antibiotics with the understanding that her
counts will not recover at this time without transplant.
3. FEN: The patient remained NPO throughout her hospital
stay. She was started on TPN and continued to have her
electrolytes repleted by scale.
ADDENDUM: Please see next dictation by the following intern
for complete details on the rest of her hospital course.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4380**], M.D. [**MD Number(1) 10999**]
Dictated By:[**Last Name (NamePattern1) 1303**]
MEDQUIST36
D: [**2174-5-6**] 17:42
T: [**2174-5-9**] 06:50
JOB#: [**Job Number 47831**]
ICD9 Codes: 7907, 5849, 4254 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3450
} | Medical Text: Admission Date: [**2103-5-31**] Discharge Date: [**2103-6-5**]
Service: Medicine
HISTORY OF PRESENT ILLNESS: The patient is a 79 year old
male who came from an outside hospital status post three
bloody stools. He was orthostatic with a hematocrit of 22.8.
During his stay at the outside hospital, he was given a total
of 20 units of packed red blood cells, 16 units of platelets
and 10 mg of vitamin K and four bags of fresh frozen plasma
to correct his INR. He was also on Coumadin. Nasogastric
lavage did not have any coffee-grounds in it. He was scoped
and had small polyps that were not bleeding. A red tag scan
was negative and a repeat scan after melanotic stool showed
uptake throughout his entire colon. He was scoped the next
day, which showed a friable cecum without bleeding. He was
transferred to [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] for
angiography.
PAST MEDICAL HISTORY: 1. Cerebrovascular accident in [**2102-5-11**] with left paralysis, since resolved. 2.
Myelodysplastic syndrome with pancytopenia. 3. Gastric
ulcers. 4. Chronic renal insufficiency. 5. Coronary
artery disease, status post myocardial infarction in [**2098**],
status post coronary artery bypass grafting in [**2097**]. 6.
Hypertension. 7. Congestive heart failure. 8. Type 2
insulin dependent diabetes mellitus. 9. Questionable
gastrointestinal bleed. 10. Peripheral vascular disease.
11. Alcohol abuse, last drink [**2074**]. 12. Malignant
gastrointestinal polyp in [**2096**], subsequent scopes have been
negative. 13. Transurethral resection of prostate. 14.
Cataract surgery. 15. Helicobacter pylori in [**2103-2-8**].
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON ADMISSION: Zantac, NPH, Actose, Coumadin,
Altace, Lasix, folate, pyridoxine, iron sulfate and
multivitamins.
PHYSICAL EXAMINATION: On physical examination on transfer to
the medical team from the Medical Intensive Care Unit, the
patient had a temperature of 97.8, pulse 81, blood pressure
135/56 and oxygen saturation 99% in room air. General:
Pleasant male in no acute distress. Head, eyes, ears, nose
and throat: Anicteric sclerae, oropharynx clear, moist
mucous membranes. Neck: No jugular venous distention.
Cardiovascular: Regular rate and rhythm, no murmurs. Lungs:
clear to auscultation bilaterally. Abdomen: Soft,
nontender, positive bowel sounds. Extremities: No peripheral
edema.
LABORATORY DATA: Upon transfer, white blood cell count was
2.1, hemoglobin 11.1, hematocrit 32.4, platelet count 72,000,
sodium 136, potassium 4.2, chloride 111, bicarbonate 16, BUN
20, creatinine 1, platelet count 212,000, prothrombin time
14.6, partial thromboplastin time 35.5 and INR 1.4.
HOSPITAL COURSE: 1. Gastrointestinal: The patient was
transferred from the outside hospital for possible
angiography. He was admitted to the Medical Intensive Care
Unit for close observation. There was no evidence of further
bleeding since his arrival here, with a stable hematocrit and
no melena. Therefore, angiography was not performed. A
repeat tagged red blood cell scan, to look for a fistula, was
negative.
The patient was transferred to the medicine service and,
again, his hematocrit remained stable. He was able to
tolerate oral intake and was discharged to follow up for a
repeat colonoscopy in six to eight weeks. Coumadin,
non-steroidal anti-inflammatory drugs and aspirin were
discontinued and he was to await further instructions from
his gastroenterology doctor as an outpatient concerning these
medications.
2. Cardiovascular: The patient remained stable.
3. Fluids, electrolytes and nutrition: The patient was able
to tolerate oral intake and his diet was eventually advanced
to a diabetic diet without difficulty.
DISCHARGE DIAGNOSIS:
Gastrointestinal bleed of unknown source.
DISCHARGE MEDICATIONS:
Zantac.
NPH.
Actose.
Altace.
Lasix.
Folate.
Pyridoxine.
Iron sulfate.
Multivitamins.
DISCHARGE INSTRUCTIONS: 1. Call to schedule a follow-up
colonoscopy. 2. Avoid aspirin and aspirin-like products.
3. Do not take Coumadin. 4. [**Month (only) 116**] resume normal activities.
5. Call doctor [**First Name (Titles) 151**] [**Last Name (Titles) **] greater than 101, increased pain,
weakness, nausea, vomiting and/or blood in stool.
[**First Name11 (Name Pattern1) 2515**] [**Last Name (NamePattern4) 4517**], M.D. [**MD Number(1) 4518**]
Dictated By:[**Name8 (MD) 4385**]
MEDQUIST36
D: [**2103-10-23**] 01:29
T: [**2103-10-23**] 14:37
JOB#: [**Job Number **]
ICD9 Codes: 4280, 412, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3451
} | Medical Text: Admission Date: [**2121-10-13**] Discharge Date: [**2121-10-16**]
Date of Birth: [**2049-3-5**] Sex: M
Service: OTOLARYNGOLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7729**]
Chief Complaint:
L parotid mass
Major Surgical or Invasive Procedure:
L parotidectomy
History of Present Illness:
72M with h/o L parotid mass. FNA revealed malignant cells. Pt
presents for elective left parotidectomy.
Past Medical History:
DM
CAD s/p CABG
h/o atrial fibrillation
HTN
CRI w/Cr 2.0
h/o SCC L leg/R ear
Social History:
Occasional EtOH, no tobacco
Family History:
NK
Physical Exam:
NAD
EOMI, nares patent, oropharynx clear without exudates/erythema
L face and neck incision intact without overlying erythema or
swelling. Neck otherwise flat and soft.
CN VII intact to testing
Pertinent Results:
[**2121-10-13**] 03:48PM GLUCOSE-160* UREA N-43* CREAT-1.9* SODIUM-139
POTASSIUM-5.1 CHLORIDE-108 TOTAL CO2-23 ANION GAP-13
[**2121-10-13**] 03:48PM CK(CPK)-38
[**2121-10-13**] 03:48PM CK-MB-2 cTropnT-<0.01
[**2121-10-13**] 03:48PM CALCIUM-8.5 PHOSPHATE-3.1 MAGNESIUM-1.7
[**2121-10-13**] 03:48PM DIGOXIN-1.6
[**2121-10-13**] 03:48PM WBC-7.3 RBC-4.15* HGB-12.6* HCT-37.4* MCV-90
MCH-30.5 MCHC-33.8 RDW-15.0
[**2121-10-13**] 03:48PM PLT COUNT-159
[**2121-10-13**] 02:18PM TYPE-ART PO2-325* PCO2-44 PH-7.34* TOTAL
CO2-25 BASE XS--2 VENT-CONTROLLED
[**2121-10-13**] 02:18PM GLUCOSE-197* LACTATE-2.1* NA+-137 K+-5.4*
CL--106
[**2121-10-13**] 02:18PM HGB-13.7* calcHCT-41
[**2121-10-13**] 02:18PM freeCa-1.17
Brief Hospital Course:
Pt underwent a left parotidectomy. Intraoperatively, anesthesia
noted that the patient was likely in atrial flutter. He was kept
intubated overnight as anesthesia was concerned regarding the
need for reintubation as the patient has a h/o of difficult
intubation and required a fiberoptic intubation for this
operation. Postoperatively, he was transferred to the MICU where
he was electrically cardioverted successfully. He was stable
overnight and on POD 1, he was extubated without difficulty.
He tolerated po intake, and remained in normal sinus rhythm. On
POD 2 he continued to do well and remained in NSR. He was
transferred to the floor. Cardiology recommended no further
interventions for Mr. [**Known lastname 23657**] regarding his episode of
a-fib/a-flutter.
On POD 3, his JP drain was discontinued and he was discharged
home in good condition.
1. L parotidectomy
-pt did well post operatively
-L JP drain removed prior to discharge
-CN VII intact
-pathology pending
2. A-fib/a-flutter
-started intra-op, pt electrically converted in the MICU and
remained in NSR for the remainder of his hospital stay
-cardiology recommended no further intervention above pt's home
dose of digoxin and atenolol
3. DMII
-BS well controlled during his stay with regular insulin SS and
glargine
4. Dispo
-discharged to home
-pt to f/u with Dr. [**Last Name (STitle) 1837**]
Medications on Admission:
digoxin, atenolol, diovan, nitrodur, amaryl, glargine, lipitor
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
2. Keflex 500 mg Capsule Sig: One (1) Capsule PO three times a
day for 5 days.
Disp:*15 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Left parotid mass
Discharge Condition:
good
Discharge Instructions:
Please take your antibiotcs as directed. Do not drive while
taking pain medications. Please call the clinic or come to the
emergency room if you have fever or increased swelling and pain
in your neck.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 1837**] in [**7-6**] days. Call
[**Telephone/Fax (1) 7732**] for an appointment.
ICD9 Codes: 5859, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3452
} | Medical Text: Admission Date: [**2143-3-1**] Discharge Date: [**2143-3-8**]
Date of Birth: [**2095-1-14**] Sex: M
Service: MEDICINE
Allergies:
Latex
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Tylenol overdose/encephalopathy
Major Surgical or Invasive Procedure:
none
History of Present Illness:
48 y/o male w/ a hx of HCV cirrhosis, who was transferred to
[**Hospital1 18**] from ICU at [**Hospital3 2737**] for altered mental status,
noted to have a tylenol level of 51 at [**Hospital3 2737**], no
tylenol level checked at [**Last Name (LF) **], [**First Name3 (LF) **] OSH records, he received IV
mucomyst there 150mg/kg over 50min , then 50mg per/kg over 4
hours, then 100mg/kg over 16 hours.
.
Pt was originally brought to [**Hospital3 2737**], because of
domestic dispute with wife, where he made homicidal threats
against her. Patient has reportedly had past psych admits to
[**Last Name (LF) 2025**], [**First Name3 (LF) **] attain records.
.
Pt transferred to [**Hospital1 18**] late on [**3-1**] out of concern for tylenol
toxicity, concern for impending liver failure, possible SBP
reported abd tenderness and fever to 101 at osh, and MS changes
(encephalopathy vs. frank psychosis). Of note pt is no longer
active on transplant list, because of both suicidal and
homicidal ideation.
.
MICU course: During micu stay patient received, ceftriaxone 1mg
x one dose, 8400mg of mucomyst. Team felt that he was unlikely
to have SBP, and was not treated as such. No paracentesis. Pt
was continued on Nadolol, rifaximin, lactulose, prn haldol and
risperidol. Patient extremely aggitated at times, still
endorsing suicidal and homicidal ideation "against his wife".
Other times calm, but w/ loose associations, admits to olfactory
hallucinations, and reported to at times respond to internal
stimuli.
.
.
(FOR MORE DETAILS SEE MICU ADMIT NOTE BELOW)
Reason for transfer: Tylenol overdose/encephalopathy
.
HPI: 48 year old male with HCV cirrhosis presenting altered
mental status and tylenol overdose. The patient has known
cirrohosis and has been considered for transplant in the past,
but is not currently listed due to a psychiatric
hospitalization. He has been seen recently in the liver clinic
for fluid accumulation and had his diuretics and diet adjusted.
.
The patient arrives to [**Hospital1 18**] and is not responding to history
questions. History is obtained from the OSH records. The patient
was taken to the ED after a domestic altercation with homicidal
ideation, with a specific desire to injure his wife. [**Name (NI) **] asked to
be restrained because he felt like he wanted to kill someone,
but did not know why. He denied hallucinations. During the ED
work up, he was found to have a Tylenol level of 51. He
reporedly taking acetaminophen nightly for insomnia for an
unspecified period of time and an unspecified amount. Some
reports indicate he was taking Tylenol PM to aide with sleep. He
was treated with activated charcoal and mucomyst (started 62.5
cc/hr started at 9 am on [**2143-3-1**], stopped, likely at transfer at
8 pm), and his Tylenol level improved. Ammonia level at
admission was 5, and coagulation profile was at baseline, so it
was not suspected that the patient was in fulminant failure. He
did report persistent ascites, though compliance with his
diuretics is unclear. [**Name2 (NI) **] was scheduled for ultrasound guided
paracentensis, but was started on ceftriaxone empirically.
Psychiatry saw the patient and felt he was depressed and started
him on Celexa and recommended decreasing his Risperdal. He was
transferred for further care at [**Hospital1 18**].
Past Medical History:
Past Medical History:
-Cirrhosis: from HCV infection. Complicated by variceal bleed
([**2138**]) w/p EGD and banding last in [**11-24**], ascites on diuretics,
hyponatremia, and hepatic encephalopathy. Had been listed for
transplant at [**Hospital1 2025**], but removed after psychiatric hospitalization
for SI/HI. Last seen in liver clinic by Dr. [**Last Name (STitle) 497**] [**2143-2-23**]. Last
colonoscopy in [**11-24**]. Reported baseline coagulopathy, with INR
between [**1-20**].
-Hypertension
-Pancytopenia
-Depression, Anxiety
-GERD
Social History:
Social history: married with 1 daughter, smokes 1.5 ppd. + h/o
etoh (sober X 3 years) and drugs (intranasal cocaine), but
apparently quit in [**2138**]. On disability
Family History:
Denies liver disease in family.
Physical Exam:
PE:
vitals: T98.3, BP 108/51, HR 50s-60s, RR 18, 98% on RA
General: tangential, responsive to name, intermittently answers
questions, responds to internal stimuli,
HEENT: no icterus, EOMI
Car: RRR
Resp: CTAB-ant/lat, would not cooperate with further exam
Abd: + BS, distended, soft,
Ext: no LE edema 2+ DP, No asterixis
NEURO: CN 2-12 intact, normal strength, nl sensory exam, equal
reflexes through out.
Skin: jaundice
Pertinent Results:
ADMISSION LABS:
[**2143-3-2**] 03:26AM BLOOD WBC-3.4* RBC-3.14* Hgb-10.2* Hct-31.2*
MCV-100* MCH-32.5* MCHC-32.7 RDW-18.2* Plt Ct-15*#
[**2143-3-2**] 03:26AM BLOOD Neuts-64.9 Lymphs-25.6 Monos-8.1 Eos-1.0
Baso-0.4
[**2143-3-2**] 03:26AM BLOOD PT-19.3* PTT-43.2* INR(PT)-1.8*
[**2143-3-2**] 03:26AM BLOOD Glucose-85 UreaN-11 Creat-1.0 Na-132*
K-3.5 Cl-98 HCO3-27 AnGap-11
[**2143-3-2**] 03:26AM BLOOD ALT-40 AST-117* LD(LDH)-304* AlkPhos-149*
TotBili-5.0*
[**2143-3-2**] 03:26AM BLOOD Albumin-2.5* Calcium-8.6 Phos-3.6 Mg-1.7
[**2143-3-4**] 03:09AM BLOOD VitB12-1889* Folate-15.7
[**2143-3-2**] 03:26AM BLOOD TSH-0.40
[**2143-3-2**] 03:26AM BLOOD Acetmnp-NEG
[**2143-3-3**] 04:37AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
DISCHARGE LABS:
[**2143-3-8**] 05:50AM BLOOD WBC-2.7* RBC-3.04* Hgb-9.9* Hct-30.1*
MCV-99* MCH-32.7* MCHC-33.0 RDW-19.1* Plt Ct-20*
[**2143-3-8**] 05:50AM BLOOD Neuts-71.4* Lymphs-21.7 Monos-5.3 Eos-1.2
Baso-0.3
[**2143-3-8**] 05:50AM BLOOD Plt Ct-20*
[**2143-3-8**] 05:50AM BLOOD Glucose-92 UreaN-10 Creat-0.9 Na-131*
K-3.8 Cl-97 HCO3-28 AnGap-10
[**2143-3-8**] 05:50AM BLOOD ALT-35 AST-101* LD(LDH)-272* AlkPhos-145*
TotBili-3.9*
[**2143-3-8**] 05:50AM BLOOD Albumin-2.5* Calcium-8.2* Phos-3.2 Mg-2.1
[**2143-3-4**] 03:09AM BLOOD VitB12-1889* Folate-15.7
[**2143-3-6**] 03:53PM BLOOD Ammonia-22
[**2143-3-6**] 04:00PM BLOOD TSH-1.1
[**2143-3-3**] 04:37AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
EEG [**3-7**]
OBJECT: PSYCHOSIS AND DELIRIUM. ? SEIZURES.
.
REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **]
.
BACKGROUND: Included a well-formed 9 Hz alpha frequency in
posterior
areas bilaterally during wakefulness.
HYPERVENTILATION: Produced no activation of the record.
INTERMITTENT PHOTIC STIMULATION: Produced no activation of the
record.
SLEEP: The patient appeared to remain awake throughout the
recording.
CARDIAC MONITOR: Showed a generally regular rhythm.
IMPRESSION: Normal EEG in the waking state. There were no focal
abnormalities or epileptiform features.
CT HEAD W/O CONTRAST [**2143-3-3**] 3:26 PM
.
NON-CONTRAST CT HEAD: There is no evidence of infarction,
hemorrhage, shift of normally midline structures, or edema. The
imaged paranasal sinuses and mastoid air cells are unremarkable.
The osseous structures are unremarkable.
.
IMPRESSION: Normal study.
ECHO [**2-28**]
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%) Right ventricular chamber size and free wall
motion are normal. The ascending aorta is mildly dilated. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is borderline pulmonary artery systolic hypertension.
There is no pericardial effusion.
RADIOLOGY Final Report
.
CTA ABD W&W/O C & RECONS [**2143-2-28**] 12:37 PM
.
There are stigmata of chronic liver disease with nodular,
atrophied liver and moderate amount of perihepatic and
perisplenic ascites. Spleen is enlarged. There are varices seen
within the splenic hilum, perigastric and paraesophageal region.
Recanalized paraumbilical vein is noted. There is a single
hepatic hypodensity, which is too small to characterize, but
likely a benign cyst, without change on delayed phase imaging.
Decompressed gallbladder is noted. There is no biliary
dilatation. Moderate amount of mesenteric edema is evident,
likely on the basis of increased portal pressures. Portal vein
remains patent. Hence, the hepatic arterial anatomy is
conventional and patent.
.
No dilated loops of bowel.
.
PELVIS: There is a fat-containing umbilical hernia.
.
Kidneys enhance and excrete contrast symmetrically. There is a
left renal cyst. The bowel loops are decompressed. Nondistended
bladder is seen in the deep pelvis. There is a small amount of
pelvic ascites. Atherosclerotic calcifications.
No focal osseous lesions.
IMPRESSION: Stigmata of chronic liver disease including
cirrhotic shrunken liver, ascites, recanalized umbilical vein,
splenomegaly and varices. Conventional hepatic arterial anatomy.
Patent portal vein. No suspicious focal hepatic lesions.
Brief Hospital Course:
IMPRESSION:
48 y/o male w/ HCV cirrhosis, ESLD, w/ hx of varices and
encephalopathy who presents from OSH, w/ tylenol ingestion, and
likely psychosis. Continued homicidal ideation toward wife and
son and suicidal ideation. EEG normal [**3-7**].
.
Patient would likely be discharged to rehab if not for his
endorsement of voices telling him to kill his wife with a knife.
Patient endorses these voices at different times of the day at
other times he denies them.
.
# Homicidal ideation w/ ? Psychosis vs. Delirium: Pt appears to
be responding to internal stimuli. MMSE very high, Still
endorses voice that tell him to kill his wife and son w/ a
knife. He denies that he would actually do this. He has no
active plans of Suicide or murder. These symptoms come and go
during the day. Psychiatry feels that the waxing and [**Doctor Last Name 688**] does
not fit entirely with a primary psychiatric disorder. However
patient is atypical for hepatic encephalopathy. Cont to monitor
for improvement with long term plans of trial of inpatient psych
evaluation. Patient needs to have all psychiatric comorbitidies
controlled for him to be considered for liver transplant.
.
Also of note, wife and son were notified of these homicidal
ideations on [**3-7**]. Patient was continued on the following psych
medications, Citalopram 10mg daily, Risperidone 3mg po bid,
0.5mg risperidone PRN, Haldol 5-10mg IV q4PRN. Pt was calm for
the 48 hours prior to transfer to [**Hospital1 **] 4.
.
# Encephalopathy: Patient does not appear encephalopathic,
ammonia 22, no asterixis, MMSE very high today, perfect on
serial sevens, and memory. Patient not currently
encephalopathic, but will become so if he does not continue his
current dose of rifaximin/lactulose
.
#Transient Hypotension: Pt was noted to have, transient sbp of
86 after receiving spironolactone and nadolol with in 30min of
one another. On recheck 15min later patients blood pressure was
96/50 baseline. We suggest that patient receive 40 of lasix in
the morning, spironolactone at noon and nadolol at night.
.
# Cirrhosis: INR is stable at patient's baseline per records,
continue to trend. Patient with ascites, and unclear if
compliant with diuretics. Continue aldactone and Lasix.
Continued on nadolol dose reduced from 40mg to 20mg for history
of esophageal varices. INR at baseline. Platelet count 22. Felt
that patient did not have SBP clinically. MELD score near
baseline at MELD 19. Patient follows with Dr. [**Last Name (STitle) 497**] from the
liver service at [**Hospital1 18**].
.
#Tylenol ingestion: history consistent with daily tylenol
ingestion on a cirrhotic liver, though exact dose/intent/timing
is unclear. [**Name2 (NI) **] received NAC infusion with 5 additional
hours for 16 hours at 17.5 mg//kg/hr dosing as well as NAC
infusion at [**Hospital3 2737**] prior to transfer
.
# Thrombocytopenia: Nadir of 15 this hospital stay continue to
monitor, at transfer platelets were 20. Platelet transfusions
are likely only accumulate in spleen.
.
#Anemia: HCT 28-30 pt is near baseline. Probably related to
anemia of chronic disease given liver disease.
.
#Leukopenia: Stable, likely related to liver disease.
.
#. Chronic back pain: continue oxycontin. Reduced dose from 40mg
[**Hospital1 **] to 20mg [**Hospital1 **], during hospital stay.
.
#. GERD: continue protonix
.
#. FEN: low salt diet. Hyponatremia of 130s at baseline.
.
#. PPx: Avoided heparin sq, as patient all ready coagulopathic.
.
#. Access: PIV
.
#. Code: Full
.
# Dispo: Depending on psych issues.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8952**] [**MD Number(1) 8953**]
1.
Medications on Admission:
Medications (per Dr.[**Name (NI) 948**] Notes)
Lasix 20 mg [**Hospital1 **]
Lactulose 45 cc tid
Reglan 5 mg po tid
Nadolol 20 mg daily
Omeprazole 20 mg daily
oxycontin 60 mg [**Hospital1 **]
rifaximin 400 mg tid
risperdal 1 mg [**Hospital1 **]
aldactone 100 mg daily
Thiamine 100 mg daily
Vitamin K 100 mcg daily
.
Medications at transfer:
Lactulose 30 ml q8h
Lasix 40 mg daily
Aldactone 100 mg daily
Nadolol 40 mg daily
Protonix 40 mg [**Hospital1 **]
Oxycontin 60 mg [**Hospital1 **]
Xanax 0.25 mg daily
Ceftriaxone 1 gm IV daily
Thiamine 100 mg daily
Risperdal 0.5 mg [**Hospital1 **]
NAC
Folate 1 mg po daily
Celexa 10 mg daily
Ativan
Family history:
Discharge Medications:
1. Lactulose 10 gram/15 mL Syrup Sig: Forty Five (45) ML PO QID
(4 times a day).
2. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
4. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. Risperidone 0.5 mg Tablet Sig: One (1) Tablet PO PRN (as
needed) as needed for agitation.
6. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: Two (2)
Tablet Sustained Release 12 hr PO QHS (once a day (at bedtime)).
7. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: Two (2)
Tablet Sustained Release 12 hr PO DAILY (Daily).
8. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
9. Risperidone 1 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
10. Nadolol 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO qam.
12. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY AT
NOON ().
13. Haloperidol Lactate 5 mg/mL Solution Sig: One (1) Injection
Q4H (every 4 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] 4
Discharge Diagnosis:
Primary Diagnosis.
1. End Stage Liver Disease(Cirrhosis)
2. Psychosis NOS
3. Enchephalopathy
4. Delirium
5. Tylenol toxicity
6. Homicidal Ideation
.
Secondary Diagnosis
1. Hepatitis C
2. Thrombocytopenia
3. GERD
4. Leukopenia
5. Hx of varices
6. Chronic lower back pain
Discharge Condition:
stable, normotensive SBP 100
Discharge Instructions:
Mr. [**Known lastname **] you were transferred to [**Hospital1 18**] from [**Hospital3 2737**] out
of concern for your mental status changes and your high tylenol
levels. While you were at [**Hospital3 2737**] at while you were at
[**Hospital1 18**] you received mucomyst which helped protect your liver from
tylenol toxicity.
.
There was also intial concern that you might have an infection
in your abdomen, but this was felt not to be the case by the
team. You were still very confused when you were in the ICU. You
needed medications to help calm you down.
.
You were given medications to help control any confusion caused
from your liver disease. You had a test called an RPR which rule
out any syphyllis causing your confusion. You had an EEG which
did not show any seizure activity. You did not have any
infection in your urine.
.
You continued to hear voices and be confused during your
hospitalizations. You repeatedly stated that you heard a voice
telling you to kill your wife, your son and yourself. As a
result we are transitioning you to a psychiatry facitilty to
determine if you have a primary psychiatric problem on top of
your other liver issues, and to further assess if you are a
danger to yourself or others.
Followup Instructions:
Please follow up with your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]
[**Telephone/Fax (1) 22166**] once you are discharged from the hospital.
.
Please contact the [**Hospital1 18**] liver center on discharge from the
hospital.
.
Please keep the following appointments.
.
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8753**], MD Phone:[**Telephone/Fax (1) 1387**] Date/Time:[**2143-3-12**]
2:00
ICD9 Codes: 5715, 2875, 2761 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3453
} | Medical Text: Admission Date: [**2156-6-24**] Discharge Date: [**2156-7-2**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
hypoxia and hypotension
Major Surgical or Invasive Procedure:
right femoral line placement
History of Present Illness:
[**Age over 90 **]F with [**Hospital 10224**] medical problems including diastolic CHF (EF
55%), CAD, CRI, Afib who presented to ED in acute respiratory
distress. The patient was recently hospitalized several times at
[**Hospital1 2177**], including in [**2156-5-9**], during which time she underwent
cardiac catheterization for CHF, s/p stent to 90% mid-LAD
lesion. Most recently, pt was in hospital [**Date range (1) 10232**] for CHF
exacerbation. Pt reports doing well at home since discharge but
does report mild URI Symptoms (rhinorrhea and nonproductive
cough) and some "sweats" during the past few nights (but no
"sweats" during the day).
.
For the past 1-2 days, the pt missed all of her medications
including lasix because her daughter, who keeps track of her
medications, was out of town. Last night, the patient was
breathing comfortably when she was going to bed but awoke at
midnight with diaphoresis and shortness of breath which improved
somewhat with albuterol and pt was able to fall back asleep. Pt
then awoke numerous times throughout the night due to SOB and
this progressed despite using albuterol MDIs so pt called EMS.
.
EMS noted BP 180/110, HR 104, RR 32, sat 94% on NRB. En route to
ED, received 3 SL NTG and 80 IV lasix with minimal improvement
and only diuresed 200 cc. In [**Name (NI) **], pt was unable to speak in full
sentances. CXR confirmed increased perihilar haziness and
interstitial prominence, bilateral effusions consistent with CHF
but also with right lung haziness concerning for PNA. Pt was
placed on nitro gtt, given 2 mg morphine, Levofloxacin and
Ceftriaxone for empiric coverage and placed on BIPAP. Pt felt
symptomatically improved with BIPAP, then changed to 50%
ventimask with sats low 90s, ABG 7.39/40/101. Pt then admitted
to [**Hospital Unit Name 153**] for further monitoring.
.
Upon arrival to [**Name (NI) 153**], pt reported feeling "much better" and her
breathing was "almost normal." Pt denied F/C, diarrhea (is in
fact constipated), CP, palpitations, orthopnea (sleeps on 2
pillows but prefers to sleep flat), PND, or increased LE edema.
Denied dietary indiscretions. Denied DOE & is able to walk
(w/walker) about her apt w/o stopping.
.
ICU course:
~ Respiratory distress thought to be multifactorial with
pulmonary edema secondary to discontinuation of lasix being the
main triggering factor. Other factors included COPD exacerbation
in setting of volume overload and possible pneumonia. Her
pneumonia was treated with ceftriaxone and azithromycin which
was later changed to levaquin/azithro. She was started on
solumedrol and standing nebulizers. Pt had several episodes of
respiratory distress, all of which improved with nebs and BiPAP.
She was given prn Lasix with a goal of keeping patient one
liter negative per day.
~ Her BP ran low thought to be due to poor forward flow but she
was never on pressors.
~ Creatinine rose and urine output fell despite lasix. Urine
lytes revealed a FeNa of <1% indicating that pt's CHF was likely
contributing to poor renal perfusion. Further lasix doses were
held given that pt appeared intravascularly dry.
~ Pt's hct remained low during her ICU but pt refused PRBC
transfusion because of an episode of respiratory distress that
the pt had after receiving a transfusion at [**Hospital1 2177**].
Past Medical History:
-CHF- ECHO [**12-12**] EF 50-55% with mild MR [**First Name (Titles) **] [**Last Name (Titles) 10225**]
-Coronary Artery Disease- s/p atheterization [**2153**]: Left dominant
system; PCI LCx, LPDA, 50% RCA
-Paroxysmal Atrial Fibrillation- treated w/ amiodarone, off
coumadin due to risk of falls
-Asthma
-s/p thyroid sx
-Diverticulitis
-Hypercholesterolemia
-Right Hip Fracture
-History of [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tears
-Chronic Renal Insufficiency- baseline creatinine low 2's
Social History:
-The patient lives alone but with full-time aide. Daughter is
main caregiver in terms of administering medications. Ambulates
with a walker. Smoked in her teens but none since. Rare EtOH
use.
Family History:
Non-contributory
Physical Exam:
temp 98, BP 113/50 (90-120/40-60), HR 80 (60-80), R 20, O2 94%
on 3 L n/c
I/O: 900/650, total ICU LOS: +3.2L
Gen: NAD, able to speak in full sentences
HEENT: PERRL, EOMI, MMM
Neck: JVP 2 cm below angle of mandible
CV: irreg irreg, grade 2-3/6 systolic murmur at apex
Chest: poor movement of air, crackles B
Abd: +BS, slightly tender and distended
Groin: femoral line site intact, no erythema or tenderness noted
Ext: no edema, 1+ DP
Neuro: Alert and Oriented, good cognitive function. Right eyelid
sightly drooped; right leg, right hand, left hand 5/5 strength;
left leg 4/5 strength; no DTR on left patella; downgoing toes
bilaterally.
Pertinent Results:
**(at admission)
-WBC 13.9, 54N, 42L, 2M, 3E
-Hct 31.4, Plt 579
-Na 141, K+ 4.3, Cl 105, bicarb 21, BUN 24, creat 2.0
-CXR in ED: cardiomegaly; prominent pulm vasculature; L-lung
with diffuse haziness throughout; flat diaphragm w/small bilat
pleural effusions.
-ECG: sinus @ 83 bpm, L-axis, LBBB pattern, no ST/TW-changes
compared to old.
-ABG @ 6 pm: 7.36/41/361 on hi-flow FM
-CK 54->51; MB not done; TropT 0.03->0.04.
-INR 1.0
.
** CXR: Findings consistent with CHF with small bilateral
pleural effusions.
.
** ECHO:
The left atrium is elongated. The right atrium is moderately
dilated. There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity size is normal. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Overall left ventricular systolic function is
low normal (LVEF 55%). [Intrinsic left ventricular systolic
function may be more depressed given the severity of valvular
regurgitation.] Right ventricular chamber size and free wall
motion are normal. The ascending aorta is mildly dilated. The
aortic valve leaflets are moderately thickened. There is mild
aortic valve stenosis. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Moderate (2+)
mitral regurgitation is seen. [Due to acoustic shadowing, the
severity of mitral regurgitation may be significantly
UNDERestimated.] The tricuspid valve leaflets are mildly
thickened. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
Brief Hospital Course:
[**Age over 90 **] yr old female with hx of CAD, dCHF, COPD, anemia, CRF
admitted for respiratory distress.
.
1. Respiratory Distress: Etiology likely multifactorial
including acute pulm edema, asthma/bronchospasm and
tracheobronchomalacia. There was initally concern for pneumonia
so she was given several days of ceftriaxone and azithromycin
for CAP. These were stopped once it was clear that she had no
pneumonia. There was also a question of upper airway
obstruction given pt's multiple prior intubations so PFTs were
done but were unrevealing as pt was unable to cooperate with
testing. A CT of the trachea showed moderate to severe
tracheobronchomalacia. Given her tracheobronchomalacia and CHF,
she was given BiPAP at night in the ICU to relieve episodes of
respiratory distress. She was started on steroids for a COPD
flare but these were stopped soon after her transfer to the
floor. She was continued on her flovent and nebs. To treat her
CHF, she was diuresed gently in the ICU but this was held once
her creatinine started to rise. Diuresis was reinitiated on the
floor and she diuresed approximately one liter per day. On HD
#7, she was breathing comfortably on room air.
.
2. CHF: An echocardiogram during this admission showed an EF of
55% but an E/A ratio of 2.8 indicating diastolic heart failure.
As above, she was diuresed to her dry weight and she was
continued on her beta-blocker.
.
3. Paroxysmal Afib: Pt has not been coumadinized in past due to
risk for falls. She was rate controlled with metoprolol and she
continued her amiodarone.
.
4. CAD: Pt with recent cath with stent to LAD. Pt did not
report any chest pain and on admission, her cardiac enzymes were
flat x 3. ECG unchanged but LBBB pattern so could mask subtle
changes. She was continued on her ASA, plavix, BB and statin.
.
5. Acute on chronic renal failure/oliguria: On admission, pt's
creatinine was at baseline of 2.0 but with diuresis, her
creatinine started to rise and urine output dropped. A FeNa
indicated prerenal azotemia so she was given gentle fluid
boluses to maintain urine output. Once her creatinine
stabilized, she was again diuresed and her urine output remained
>25cc/hr.
.
6. Normocytic Anemia: Baseline hct appears to be 27-28 and pt
slightly lower than baseline at 25. Given her CAD, we preferred
to transfuse to >30 but pt refused given resp distress following
a transfusion at [**Hospital1 2177**]. Iron studies on this admission indicate
iron def anemia so she was started on iron. She should start
epogen as an outpatient.
.
7. UTI: UA was grossly positive with bacteria and yeast. She
was started on treatment with cefpodoxime and her foley was
discontinued.
.
8. Diarrhea: Due to diarrhea, c. difficile was checked and found
to be positive so she was treated with Flagyl, which she must
continue after discharge for seven more days.
.
9. Disposition: Per family meeting on [**6-24**], pt expressed her
desire to be DNR/DNI but then when the medical team accepting
the pt asked her again, she stated that she would like to have
the breathing tube if necessary to keep her alive until she can
see her great-grandchildren. Per the daughter's request, a
palliative care consult was placed and the pt restated that she
was not ready for DNR/DNI yet. The patient is being discharged
to an extended care facility (Scherrill).
Medications on Admission:
-Advair 500/50 1 puff [**Hospital1 **]
-Albuterol prn
-Plavix 75 qd
-Lipitor 20 qd
-amiodarone 200 qd
-ASA 325 qd
-metoprolol 50 [**Hospital1 **]
-lasix 60 qd
-levothyroxine 75 mcg qd
-Flonase 2 sprays qd
-MVI
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): hold for loose stools.
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
hold for loose stools.
5. Levothyroxine Sodium 88 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed: hold for loose stools.
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
10. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
Two (2) puffs Inhalation [**Hospital1 **] (2 times a day).
11. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
12. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
every 4-6 hours as needed for shortness of breath or wheezing.
13. Lasix 40 mg Tablet Sig: 1.5 Tablets PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
Diastolic congestive heart failure, ejetion fraction 55%
Emphysema
Tracheobronchomalacia
Acute on Chronic Renal Failure
Urinary Tract Infection
Clostridium Difficile Colitis
[**Female First Name (un) 564**] of the groin
Secondary:
Paroxysmal Atrial Fibrillation
Coronary Artery Disease, status post stent of the Left Anterior
Descending
Iron Deficiency Anemia
Discharge Condition:
Good, breathing well on room air
Discharge Instructions:
Take all medications as prescribed and go to all follow-up
appointments. Call your PCP or go to the ED if you experience
worsening shortness of breath, chest pain, fevers, chills or
anything else that concerns you. Walk only with the help of an
ambulatory device.
Followup Instructions:
Please follow-up with your PCP [**Name Initial (PRE) 176**] 1-2 weeks of discharge
ICD9 Codes: 2720, 5849, 5990, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3454
} | Medical Text: Admission Date: [**2154-6-15**] Discharge Date: [**2154-6-18**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
Bradycardia
Major Surgical or Invasive Procedure:
Pacemaker Placement
History of Present Illness:
84 yo man with spinal stenosis and a cardiac history significant
for hyperlipidemia and stable asymptomatic RBBB, who initially
presented to an OSH for elective laminectomy on [**6-14**]. The
patient had been in his USOH until [**Month (only) 958**], walking [**2-12**] miles per
day with no CP, SOB, palpitations, lightheadedness or syncope,
when his back pain became unbearable and he elected to undergo
laminectomy. Following surgery on [**6-14**], the patient was noted to
be bradycardic to 20s on the morning of POD#1 but remained
asymptomaticand otherwise hemodynamically stable. He was
initially thought to be in complete heart block by EKG but that
impression was later revised to 2:1 heart block.
He was transferred to [**Hospital1 18**] for further evaluation and for
possible pacemaker placement, and on admission continued to deny
any history of CP/SOB/DOE, dizziness, syncope, palpitations or
orthopnea.
Past Medical History:
Hyperlipidemia
Stable RBBB, LAD on past EKGs; no cardiac interventions
L3 - L5 stenosis with pseudoclaudication s/p laminectomy [**2154-6-15**]
Hyperlipidemia, on statin
BPH, nocturia x3, on flomax
GERD
PTSD, stable per records
s/p L Knee arthroscopy
s/p benign neck tumor excision [**2147**]
Social History:
Married, retired truck driver and former milkman
-Tobacco history: 35 pack-year history, quit 39 years ago
-ETOH: "Occasional"
Family History:
- Brother with CAD and [**Name (NI) 21418**]
- Brother with pacemaker
- Father with pacemaker
- Mother with heart disease
Physical Exam:
VS: T= 98.8, BP= 114/50, HR= 45, RR= 22, O2 sat= 96%
.
GENERAL: WDWN male in NAD, comfortable and conversant. Oriented
x3. Mood, affect appropriate.
.
HEENT: Well-healed scar over occipital scalp from "war wound,"
otherwise 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 at 30 degrees.
.
CARDIAC: PMI located in 5th intercostal space, 2cm left of
midclavicular line. Irregular rhythm but 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: Trace pedal edema. No c/c. No femoral bruits.
.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+
Pertinent Results:
LABS
[**2154-6-18**] 06:25AM BLOOD WBC-7.1 RBC-3.80* Hgb-11.4* Hct-33.5*
MCV-88 MCH-30.0 MCHC-34.1 RDW-13.3 Plt Ct-187
[**2154-6-15**] 05:44PM BLOOD Neuts-79.5* Lymphs-13.4* Monos-6.2
Eos-0.7 Baso-0.2
[**2154-6-18**] 06:25AM BLOOD Plt Ct-187
[**2154-6-18**] 06:25AM BLOOD PT-13.8* PTT-27.3 INR(PT)-1.2*
[**2154-6-18**] 06:25AM BLOOD Glucose-121* UreaN-27* Creat-1.2 Na-138
K-3.9 Cl-103 HCO3-25 AnGap-14
[**2154-6-18**] 06:25AM BLOOD Calcium-8.6 Phos-2.5* Mg-1.8
[**2154-6-15**] 05:44PM BLOOD TSH-1.2
===========
Studies
===========
TTE [**2154-6-17**]
The left atrium is dilated. No atrial septal defect is seen by
2D or color Doppler. There is mild symmetric left ventricular
hypertrophy with normal cavity size and global systolic function
(LVEF>55%). The right ventricular cavity is dilated with
depressed free wall contractility. The aortic root is mildly
dilated at the sinus level. 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. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion.
Compared with the report of the prior study (images unavailable
for review) of [**2149-4-24**], the right ventricle appears dilated
with depressed function and there is mild pulmonary artery
systolic hypertension seen.
CHEST PA AND LATERAL ([**2154-6-18**])
REASON FOR EXAM: 84-year-old man with status post pacer,
evaluate for lead
position.
Since yesterday, left-sided dual-chamber pacemaker ends in
expected position.
There is no pneumothorax. The aorta is tortuous. Basilar
opacities are
likely due to atelectasis. Minimal elevation of the right
hemidiaphragm is
unchanged. There is no other change.
The study and the report were reviewed by the staff radiologist.
ECG ([**2154-6-16**])
Sinus bradycardia with probable Wenckebach Mobitz Type I A-V
block. Right
bundle-branch block. Non-specific ST-T wave abnormalities. No
previous
tracing available for comparison.
Brief Hospital Course:
This is an 84 yo man with spinal stenosis and a cardiac history
significant for hyperlipidemia and stable RBBB, s/p elective
laminectomy and developed bradycardia and hypotension on POD#1,
with heart block on EKG, and was then transferred to [**Hospital1 18**] for
further evaluation and treatment.
.
RHYTHM: EKG and tele tracings today show dropped beats with
various conduction patterns including 2:1 block and a likely
Type I second degree AV Block/Wenkebach pattern. The patient
remained asymptomatic throughout these episodes while monitored
on telemetry. A medication related conduction abnormality was
considered, but felt to be unlikely given that his amlodipine
had been held at [**Hospital1 7145**] for low BP prior to the onset of heart
block and he had recieved no other nodal blocking agents. Prior
EKGs pre-op show stable 1st-degree HB, RBBB and left-axis
deviation without LVH which was concerning for LAFB, and
probably Type I Wenkebach 2nd degree HB. There is no prior
record of bradycardia, and the 2:1 block with low HR on
admission was concerning for possible progression of his
conduction disease. A TSH was checked and was within normal
range, and thus given the patient's extensive fascicular
conduction disease, a pacemaker was placed on [**2154-6-17**]. The
patient was given antibiotics pre and post procedure. He will
continue on levoflox for 3 days after discharge. His CXR showed
proper placement of his pacemaker. The patient will have
follow-up with Dr. [**Last Name (STitle) **] on [**7-3**]. The patient was called at
his home to let him know of the scheduled appointment.
.
CORONARIES: No hx of CAD, no sx of ACS. On baby aspirin daily at
home, which was continued. On admission, the patient's
amlodipine, spironolactone and cozaar were held given that he
remained normotensive to slightly hypotensive. He was continued
on his statin throughout this hospitalization. The amlodipine
was restarted on discharge given normotensive to hypertensive
pressures.
.
PUMP: No hx of CHF; last echo [**2149**] showed normal EF. Clinically
slightly volume up, on spironolactone at home. Initially the
patient's spironolactone was held given his low/normal blood
pressures on arrival. A TTE on [**6-17**] confirmed a LVEF of >55%.
.
CRF: Cre stable since [**2149**] at 1.5-1.6, and remained stable
throughout this hospitalization.
.
BPH: The patient was continued on his tamulosin during his
hospitalization.
Medications on Admission:
HOME MEDICATIONS:
.
Amlodipine 5 mg PO daily
Spironolactone 25 mg PO daily
Pravastatin 20 mg PO daily
Omeprazole 20 mg PO daily
ASA 81 mg PO daily
Flomax 0.4 mg daily
Cozaar 50 mg daily
Vitamin E daily
.
MEDICATIONS ON TRANSFER FROM [**Year (4 digits) 7145**]
.
Trazodone 100 mg po qHS
Dilaudid 0.5-1.0 mg IM q3h for breakthrough pain
Aspirin 81 mg PO daily
Cefazolin 1g PO q8h
Pravastatin 20 mg PO daily
Omeprazole 20 mg PO daily
Multivitamin 1 tab PO daily
Senna 2 tabs PO qHS
APAP 650 mg PO q4H PRN: pain
Discharge Medications:
1. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for back pain.
6. Tylenol-Codeine #3 300-30 mg Tablet Sig: 1-2 Tablets PO every
six (6) hours as needed for severe pain: Do not take more than
12 tabs in 24 hours.
Disp:*20 Tablet(s)* Refills:*0*
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO once a day as
needed for constipation.
8. Colace 100 mg Capsule Sig: One (1) Capsule PO once a day as
needed for constipation.
9. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day.
10. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Primary: Heart Block (Wenkebach), status post pacemaker
placement
Secondary:
L3 - L5 stenosis with pseudoclaudication status post laminectomy
[**2154-6-15**]
Hyperlipidemia
Benign prostic hypertrophy
Gastroesophageal reflux disease
Post traumatic stress disorder
Status post Left Knee arthroscopy
Status post benign neck tumor excision [**2147**]
Discharge Condition:
Stable. Discharge VS: T 98.3, BP 145/85, HR 68, RR 16, SaO2
98-100%RA
Discharge Instructions:
You were transferred to this hospital becuase you developed a
slow heart rhythm following your back surgery. You were seen by
our electrophysiologists who determined you needed a pacemaker
which was placed without any complications.
NEW MEDICATIONS:
- Levofloxacin is an antibiotic medication that you should take
for the next 3 days to avoid infection from your recent
procedure
- Senna and Colace are medications that help relieve
constipation
- You should take Acetaminophen (Tylenol) for your back pain,
and use the prescription for Tylenol #3 if the regular Tylenol
is not enough.
STOP Taking:
Cozaar
Spironolactone
When you get home, please call your back surgeon, Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 40740**], from the [**Hospital6 2910**] to make a
follow-up appointment. His phone number is ([**Telephone/Fax (1) 40741**].
Followup Instructions:
- Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Telephone/Fax (1) 40742**] ([**2155-7-3**]:45am) [**Month (only) 7145**]
- Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16258**], PCP. [**Name Initial (NameIs) **]: [**Telephone/Fax (1) 19196**]. Date/Time:
[**7-3**], 1:15
- Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 40740**], [**Name12 (NameIs) 7145**] surgery. Phone: ([**Telephone/Fax (1) 40741**]
Completed by:[**2154-6-18**]
ICD9 Codes: 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3455
} | Medical Text: Admission Date: [**2188-1-8**] Discharge Date: [**2188-1-15**]
Date of Birth: [**2168-12-28**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
s/p Motor vehicle crash
Major Surgical or Invasive Procedure:
[**1-8**] I & D and ORIF right patella fracture
History of Present Illness:
19 yo female restrained driver s/p motor vehicle crash; +
passenger fatality. She was taken to an area hospital and
subsequently transferred to [**Hospital1 18**] to to her extensive injuries.
Past Medical History:
Denies
Family History:
Noncontributory
Pertinent Results:
[**2188-1-8**] 09:30PM HCT-24.7*
[**2188-1-8**] 06:56PM ALT(SGPT)-680* AST(SGOT)-604* CK(CPK)-171*
ALK PHOS-34* AMYLASE-3 TOT BILI-0.7
[**2188-1-8**] 06:56PM PT-13.4 PTT-25.9 INR(PT)-1.1
[**2188-1-8**] 07:50AM GLUCOSE-190* UREA N-12 CREAT-0.5 SODIUM-139
POTASSIUM-4.3 CHLORIDE-111* TOTAL CO2-24 ANION GAP-8
[**2188-1-8**] 07:50AM WBC-6.2 RBC-2.61* HGB-8.0* HCT-22.3* MCV-86
MCH-30.7 MCHC-35.9* RDW-13.0
[**2188-1-8**] 07:50AM PLT COUNT-256#
[**2188-1-8**] 12:09AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2188-1-8**] 04:58AM TYPE-ART PO2-183* PCO2-39 PH-7.40 TOTAL
CO2-25 BASE XS-0
[**2188-1-8**] CT ABDOMEN WITH IV CONTRAST: There is a grade 4 liver
laceration involving approximately 60% of the right lobe of the
liver, and extending just slightly into the left lobe of the
liver. This extends up to the inferior vena cava, which is not
clearly severed, although high clinical suspicion should be
maintained given the stellate configuration and extent of
laceration. In comparing the arterial phase chest scan to the 45
second delay abdominal scan, a hyperdense focus in the hepatic
dome demonstrates increase in size, with increase in density of
the surrounding hematoma(10:55, 11:12). This is consistent with
active extravasation. There is hemoperitoneum, with high-
density fluid surrounding the right lobe of the liver.
Hemoperitoneum tracks inferiorly into the pelvis.
The spleen, pancreas, adrenal glands, kidneys, ureters, large
bowel, and small bowel are unremarkable. There has been previous
appendectomy. There is no intra-abdominal air to suggest
perforation.
IMPRESSION: Grade 4 liver laceration with active extravasation
of IV contrast near the hepatic dome, with associated
hemoperitoneum.
[**2188-1-8**] Outside images:
CT C-SPINE WITHOUT IV CONTRAST: There is no fracture or
malalignment. There is no evidence of prevertebral soft tissue
swelling. Intervertebral discs maintain normal height. The
imaged lung apices are unremarkable.
IMPRESSION: No fracture or malalignment.
[**2188-1-8**]
FEMUR (AP & LAT) RIGHT; TIB/FIB (AP & LAT) RIGHT; ANKLE (AP,
MORTISE & LAT) RIGH; FOOT 2 VIEWS RIGHT; HEEL (AXIAL & LATERAL)
RIGHT Clip # [**Clip Number (Radiology) **]-IMPRESSION:
1. Comminuted fracture of the patella with superior and somewhat
medial
displacement of multiple fracture fragments.
2. Markedly comminuted fracture of the calcaneus. Nondisplaced
fractures of the talus and cuboid. Recommend CT for more
complete assessment.
Brief Hospital Course:
She was admitted to the trauma service. Orthopedics was
immediately consulted given her injuries; she was taken to the
operating room for irrigation debridement, right knee joint,
including arthrotomy; open reduction internal fixation right
patella; irrigation debridement, open patella fracture and
closed treatment, right calcaneus. There were no intraoperative
complications. Postoperatively she was transferred to the trauma
ICU where she remained for several days. Serial hematocrits were
followed very closely given her significant liver injury. Her
hematocrits remained relatively stable with a Hct of 30 on day
prior to discharge.
She was eventually transferred to the regular nursing unit where
she continued to progress. Her pain was managed effectively with
oral narcotics and her diet was advanced. She was evaluated by
Physical therapy and was recommended for home with services.
Social work was also involved providing emotional support to
patient and her family.
Medications on Admission:
Denies
Discharge Medications:
1. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30) ML's
PO twice a day as needed for constipation.
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every [**2-25**]
hours as needed for pain.
6. Enoxaparin 40 mg/0.4 mL Syringe Sig: Forty (40) MG
Subcutaneous DAILY (Daily).
Disp:*30 MG* Refills:*1*
7. Zolpidem 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as
needed for insomnia.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
s/p Motor vehicle crash
Grade IV liver laceration
Right open patella fracture
Right closed calcaneal fracture
Right nondiplaced talus/cuboid fractures
Small right anterior 4th rib fracture
Acute blood loss anemia
Discharge Condition:
Hemodynamically stable, tolerating a regular diet, pain
adequately controlled.
Discharge Instructions:
DO NOT participate in any contact sports or physical activity
for the next 6 weeks that may cause injury to your abdominal
region because of your liver injury.
Go to the nearest Emergency room immediately if you should
become dizzy, feel faint or lightheaded as this could be a sign
that you are having internal bleeding from your liver injury.
Keep the hinged knee brace on at all times, you may take it off
only when performing hygiene. DO NOT bend your knee at all.
Return to the Emergency room for fevers, chills, shortness of
breath, chest pain, nausea, vomitng. diarrhea and/or any other
symptoms that are concerning to you.
Followup Instructions:
Follow up next Thursday in [**Hospital **] clinic with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],
PA. Call [**Telephone/Fax (1) 1228**] for an appointment.
Follow up in 2 weeks with Dr. [**Last Name (STitle) **], Trauma Surgery for
evaluation following your liver injury. Call [**Telephone/Fax (1) 600**] for an
appointment.
Completed by:[**2188-4-30**]
ICD9 Codes: 2851, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3456
} | Medical Text: Admission Date: [**2157-1-21**] Discharge Date: [**2157-1-25**]
Service: MEDICINE
Allergies:
Penicillins / Aspirin / Demerol / Droperidol
Attending:[**First Name3 (LF) 4654**]
Chief Complaint:
acute shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms [**Known lastname 4610**] is a [**Age over 90 **] year old woman with a medical history
significant for hypertension and a series of orthopedic
surgeries, but without a known CHF or CAD diagnosis, who comes
today with a two day history of feeling increasingly fatigued
and short of breath.
Starting on Thursday she noticed increasing cough and shortness
of breath. Thursday night ([**1-20**]) she had a difficult time
sleeping because of severe cough; she required three pillows to
decrease her cough and dyspnea. Today she also had a headache
and had mild nausea. She denies any chest pain or chest
tightness or palpitations. This evening, she used her emergency
alert button to summon 911 to bring her to the hospital today
after her shortness of breath worsened to the point of
intolerability.
She says she has been requiring more pillows to sleep on for
about the last month. On reflection she later also realized that
she has been having periodic sweats for about six weeks; however
she has taken her temperature during a number of these episodes
and generally finds it to be in the 96-97 range??????i.e., generally
lower than expected rather than febrile.
She??????s had no recent travel. As part of her past occupation as a
medical social worker she has often been tested for TB and her
last PPD was 1.5 years ago, which was negative. She has two cats
at home, but no other pets; no children at home. Her partner has
been sick for the last week or so, with a cough and what Ms
[**Known lastname 4610**] feels was likely a pneumonia, to which her partner is
often susceptible. Both Ms [**Known lastname 4610**] and her partner got flu
vaccinations this year.
In the ED her vitals were: 101.8 , 127, 173/74, RR 31, 100% on
NRB She received:Nitro drip; 80 mg Lasix x1; 325 mg ASA; 1 gm
ceftriaxone; 750 mg IV levofloxacin; 650 mg Tylenol; morphine 1
mg x2.
On arrival in the MICU her vitals were T 99.6, HR 101, BP
127/64, RR 26, O2 sat 96% on BiPAP FiO2 40%, PEEP 5.
Review of System: Constitutional: Fatigue, No(t) Fever, had
fever in ED but denies subjective fever symptoms, Weight loss
over past 1 week
Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t)
Edema
Respiratory: Cough, Dyspnea, Tachypnea, Wheeze
Gastrointestinal: No(t) Abdominal pain, Nausea, No(t) Emesis,
No(t) Diarrhea, (+) Constipation
Genitourinary: Foley
Endocrine: No(t) History of thyroid disease
Neurologic: Headache
Allergy / Immunology: Influenza vaccine
Pain: No pain / appears comfortable
Past Medical History:
Hypertension
3 hip replacement operations; 1 knee replacement
s/p appy
chronic back pain
Social History:
Occupation: retired medical social worker
Drugs: denies
Tobacco: denies; however, long-time partner is heavy smoker w
COPD, smokes in house
Alcohol: glass of wine w dinner most nights
Other: Originally from [**Location (un) **]. Partner ([**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 174**] [**Telephone/Fax (1) 109477**])
is HCP, and the couple has been together since [**2112**]. Pt does
basic ADLs including cooking all meals for both of them.
Family History:
Non-contributory
Physical Exam:
T: 37.6 ??????C HR: 89 BP: 115/49 RR: 22 O2sat: 96% 3 liters nasal
cannula
Eyes / Conjunctiva: PERRL
Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal); I did
not appreciate a murmur in this rhonchorous exam
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Crackles : , Wheezes : , Rhonchorous: ). Right posterior lower
lung field with broncial breath sounds and decreased percussion
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: pulses present x4; right hand has fifth finger and
fourth finger arising from same place in hand (pt states this is
congenital)
Skin: Warm
Neurologic: Attentive, Responds to: easily interactive with
examiner, Oriented (to): time, place, situation, Movement: Not
assessed, Tone: Not assessed
Pertinent Results:
ON ADMISSION:
[**2157-1-21**] 06:35PM WBC-18.6* RBC-4.78 Hgb-15.0 Hct-43.6 MCV-91
MCH-31.5 MCHC-34.5 RDW-14.2 Plt Ct-230
[**2157-1-21**] 06:35PM Neuts-85.1* Lymphs-11.3* Monos-2.9 Eos-0.4
Baso-0.3
[**2157-1-21**] 06:35PM PT-13.9* PTT-26.9 INR(PT)-1.2*
[**2157-1-21**] 06:35PM Glucose-149* UreaN-19 Creat-0.8 Na-142 K-4.7
Cl-101 HCO3-26
[**2157-1-21**] 06:35PM ALT-22 AST-32 AlkPhos-84 TotBili-0.4
[**2157-1-21**] 06:35PM Albumin-4.8 Calcium-10.2 Phos-4.0 Mg-1.7
[**2157-1-21**] 06:35PM proBNP-4648*
[**2157-1-22**] 04:31AM LD(LDH)-538*
CARDIAC ENZYMES
[**2157-1-22**] 04:31AM CK-MB-NotDone CK(CPK)-59 cTropnT-0.01
[**2157-1-21**] 06:35PM CK-MB-NotDone CK(CPK)-39 cTropnT-<0.01
LACTATE TREND
[**2157-1-21**] 06:49PM BLOOD Lactate-2.3*
[**2157-1-22**] 03:40AM BLOOD Lactate-1.3
STUDIES:
[**2157-1-25**] Echocardiogram:
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. There is moderate to severe global left ventricular
hypokinesis with more severe hypokinesis of the septum and
inferior wall (LVEF = 25-30 %). 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
ascending aorta is mildly dilated. The aortic valve leaflets (3)
are mildly thickened. There is no aortic valve stenosis. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. The left ventricular inflow pattern suggests a
restrictive filling abnormality, with elevated left atrial
pressure. There is no pericardial effusion
[**2157-1-22**] CT CHEST:
Patchy opacities in the lingula and right lower lobe which given
associated bronchiectatic change and may represent aspiration vs
pneumonia. Ground-glass opacity in a similar distribution as
well as the right upper lobe is nonspecific, however, can be
seen with bronchioalveolar carcinoma and thus recommend
three-six month followup to ensure resolution/stability.
[**2157-1-21**] CXR: Evidence of mild fluid overload. No pleural
effusion or overt cardiomegaly.
[**2157-1-21**] EKG: Sinus tachycardia with left bundle-branch block.
No previous tracing available for comparison.
Brief Hospital Course:
Ms. [**Known lastname 4610**] is a highly functioning [**Age over 90 **] year old woman PMH
hypertension admitted fatigue and dyspnea found to have
community acquired pneumonia.
1. Community acquired pneumonia: Multifocal pneumonia on CT scan
with infilrate in RUL, RLL and lingula with 23% bandemia. This
is most likely cause of presenting symptoms of dyspnea and
respiratory distress. In the emergency department she was felt
to have pulmonary edema clinically and on chest xray and was
briefly on BIPAP and treated with lasix. In addition she had a
BNP of 4648. She was admitted to the ICU given her requirement
for BIPAP which was quickly weaned and she was transferred to
the medical floor the following day. She ruled out for
influenza with nasal aspirate. In addition, she ruled out for
myocardial infarction with cardiac enzymes x3. She was treated
with levaquin and improved clinically and was discharged to
complete a 7 day course. She will need a repeat CT scan in [**4-8**]
months to ensure resolution of her infiltrates. On discharge
she had an ambulatory oxygen saturation of 96%.
2. Acute on chronic heart failure: She had two episodes during
her admission with hypoxia, diffuse crackles and dyspnea which
improved with lasix and nebulizers consistent with pulmonary
edema. No chest pain or EKG changes at the time. Possible flash
pulm edema. Echocardiogram showed systolic dysfunction with an
EF of 25-30% thought likely to hypertensive vs ischemic
cardiomyopathy. In addition, she had evidence of severe
diastolic dysfunction on her echocardiogram as well. She was
started on low dose lisinopril on discharge and continued on
metoprolol, aspirin and simvastatin to be titrated by her
primary care doctor.
3.Left Bundle branch block - no reported cardiac history or old
EKG to compare. Likely due to CAD given evidence of
cardiomyopathy on echocardiogram. She was continued on ASA, BB,
statin and started on an ACEI.
4. Hematuria: Most likely associated with foley catheter trauma
as she was asymptomatic. Urine culture with 10,000-100,000
coagulase positive staph which was not felt to be indicative of
a urinary tract infection. She will need repeat UA as am
outpatient to ensure that hematuria resolves.
5. Hypertension - Decent control on admission with systolic
blood pressure averaging about 140. She was continued on
atenolol and started on low dose lisinopril as discussed above.
6. CODE: DNR/DNI confirmed with patient
Medications on Admission:
simvastatin 40 daily
gabapentin 800 mg TID
nortryptiline 20 mg HS
oxybutynin 5 mg HS
omeprazole 20 mg 2x daily, 30 minutes before breakfast and
dinner
asa 81
xalatan 2.50 ml OU both eyes HS
timolol 1 drop in R eye in AM
senna 2 tabs [**Hospital1 **]
MVI
Ca+vitD
Glucosamine, Echinacea, ginkgo biloba
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO three times
a day.
3. Nortriptyline 10 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
4. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Oxybutynin Chloride 5 mg Tablet Sig: Two (2) Tablet PO QHS
(once a day (at bedtime)).
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
9. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic
DAILY (Daily).
10. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
12. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
13. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
Disp:*120 ML(s)* Refills:*0*
14. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
15. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 3 days: to complete 7 day course.
Disp:*9 Tablet(s)* Refills:*0*
16. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six
(6) hours as needed for pain.
17. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
18. Outpatient Lab Work
Please check chem 7 panel on [**2156-2-4**], results to go to patient
primary care doctor, Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 20035**]
Discharge Disposition:
Home With Service
Facility:
Americare at Home Inc
Discharge Diagnosis:
Community Acquired Pneumonia
Diastolic and systolic heart failure
.
Secondary diagnoses:
Hypertension
Discharge Condition:
Good, 96% with ambulation
Discharge Instructions:
You were admitted to the hospital for shortness of breath. You
were found to have a pneumonia and you were treated with
antibiotics and your symptoms improved. You had a Cat Scan of
your chest which showed that you have a pneumonia. You will
need a repeat Cat scan in [**4-8**] months to follow up and be sure
the infiltrates have resolved. Please discuss this with your
primary care doctor.
You had an echocardiogram (ultrasound of your heart) which
showed that you have weakened heart muscle possible due to long
standing hypertension. We have started you on a medicine called
lisinopril to help protect your heart. Your doctor will need to
follow your blood pressure and kidney function on this medicine.
Medications:
1. You will need to continue to take levofloxacin to complete
seven days of antibiotics.
2. You have been started on lisinopril to help protect your
heart.
No other changes were made to your medications.
Please follow up with your primary care doctor.
Please call your doctor or return to the hospital if you
experience chest pain, worsening of your breathing, fevers or
other worrisome symptoms.
Followup Instructions:
You have an appointment schedule to follow up with your PCP [**Last Name (NamePattern4) **].
[**Last Name (STitle) **] on [**2-7**] at 3:10. Please call [**Telephone/Fax (1) 20035**] if you
need to reschedule this appointment.
Please talk with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 51794**] a
repeat Cat Scan of your chest in [**4-8**] months to be sure that the
pneumonia has resolved.
[**First Name8 (NamePattern2) **] [**Name8 (MD) 474**] MD [**MD Number(2) 4658**]
ICD9 Codes: 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3457
} | Medical Text: Admission Date: [**2198-5-8**] Discharge Date: [**2198-5-15**]
Date of Birth: [**2158-1-9**] Sex: F
Service:
CHIEF COMPLAINT: Murmur found on examination.
HISTORY OF PRESENT ILLNESS: The patient is a 40 year-old
female from [**Country 32814**] who presented there with a complaint of
severe headache. On workup she was found to have a murmur
and subsequent evaluation revealed a dilated ascending aorta.
She presented for aortic arch replacement.
PAST MEDICAL HISTORY: Tonsillectomy as a child.
MEDICATIONS: Atenolol 25 mg po q day.
ALLERGIES: No known drug allergies.
HO[**Last Name (STitle) **] COURSE: The patient underwent a Bentall procedure
with a mechanical valve on [**2198-5-8**] by Dr. [**Last Name (Prefixes) **]. She
tolerated the procedure well and was transferred to the CSRU
postoperatively. She was transfused blood on postoperative
day zero. She was extubated on postoperative day one. She
was stable thereafter and was ready for transfer to the floor
on postoperative day two. While on the floor she had a
routine postoperative course and made slow progress toward
recovery. She was Coumadinized for the valve. She was then
deemed ready for discharge on postoperative day six.
MEDICATIONS ON DISCHARGE: Lopressor 50 mg po b.i.d., Lasix
20 mg q.d. for one week, K-Ciel 20 milliequivalents q.d. for
one week, Colace 100 mg b.i.d., Protonix 40 mg q.d., Percocet
one to two tablets q 4 to 6 hours prn, Coumadin 5 mg q.d.
FO[**Last Name (STitle) 996**]P: INR to be checked by Dr. [**Last Name (STitle) 8173**]. She will
follow up also with Dr. [**Last Name (Prefixes) **] in four weeks.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 2209**]
MEDQUIST36
D: [**2198-6-6**] 14:05
T: [**2198-6-7**] 09:43
JOB#: [**Job Number 40437**]
ICD9 Codes: 4241 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3458
} | Medical Text: Admission Date: [**2174-6-3**] Discharge Date: [**2174-6-21**]
Date of Birth: [**2120-8-24**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Osteomyelitis.
Major Surgical or Invasive Procedure:
CT-guided aspiration of right AC joint ([**6-6**]).
L BKA on [**2174-6-8**] and revision of L BKA on [**2174-6-16**]
Right shoulder debriment and joint washout on [**2174-6-8**] and on
[**2174-6-16**]
History of Present Illness:
Mr. [**Known lastname **] is a 53-year-old male with past medical history
significant for poorly controlled type II diabetes, known
cardiomyopathy (EF 10-15%), HTN, and CAD who initially presented
to outside hospital on [**5-31**] with AMS, fall at home, and HHNK
requiring an insulin drip for glucose levels up to 591. Also
treated for hyperkalemia to 6.8. Patient is now off of insulin
drip and back on [**Hospital1 **] NPH with humalog SSI.
He was also found to be newly in afib, controlled with diltiazem
drip. He was also treated with carvedilol and lisinopril. He was
temporarily on digoxin, which was reportedly stopped due to
recent hyperkalemia, although appears to have been given on day
of transfer.
The patient has a chronic known left heel osteomyelitis and
ulcer which probes all the way through to the calcaneus and
appeared gangrenous and malodorous with subcutaneous gas on
x-ray. His calcaneus was also shown to be entirely fracture on
x-ray. He was placed on IV Vancomycin/Zosyn and he was seen by
vascular / podiatry teams at OSH who offered amputation there
but family prefers [**Hospital1 18**] podiatry service where patient sees Dr.
[**Last Name (STitle) **] regularly.
??bacteremic with Gram pos cocci
Of note, patient had a debridement on [**6-1**] and likely had an
arterial bleed as he had severe bleeding requiring 4 units PRBCs
and 2 units FFP as well as local torniquets to control bleeding.
He had been on SC heparin for DVT prevention at time of
debridement which was then held. Vascular study showed no
arterial flow abnormalities.
.
He also complained of right sided shoulder pains which triggered
an orthopedic consult. There was concern for septic joint but
imaging revealed no significant fluid to tap. However, there was
evidence of air in the local subcutaneous tissue around right
shoulder and follow-up CT scan of shoulder showed some evidence
of air in SC tissue as well as air inside shaft of clavicle per
OSH reports.
.
Initial labs were also remarkable for Cr 2.5 but slowly
recovered to Cr 1.07 with IV fluids by time of transfer. Also
noted to have tbili of 2.2, tropT of 0.04.
.
On arrival to the ICU, patient's initial VS were: T 101.2 P 104
BP 133/111 R 29 O2 sat 96%,3L. He remembers going to the
hospital for being confused, but is unclear of the other
details. He currently complains of shoulder pain on the right,
denies foot pain.
Past Medical History:
-Type II diabetes mellitus c/b neuropathy, bilat Charcot foot.
A1c 11.6 on admission to OSH.
-Chronic left heel ulcer
-status post Right [**3-16**] toe amputation
-Gout
-EtOH cardiomyopathy with EF 10-15% at OSH
-Hypertension
-CAD
Social History:
Lives with mother, on disability. States he "thinks" he is
taking all of his medications and could not name them.
- Tobacco: Denies.
- Alcohol: Heavy drinking on weekends, 1-2 bottles of wine
nightly sometimes
- Illicits: denies
Family History:
father with lupus
Physical Exam:
Vitals: T 101.2 P 104 BP 133/111 R 29 O2 sat 96%,3L.
General: Alert and oriented x3 , no acute distress, slow speech
HEENT: PERRL, sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: irregular 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: foley in place, draining yellow urine
NEURO: CNs [**3-25**] in tact, sensation decreased over [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) **]: TTP over anterior and lateral right glenohumeral joint with
point tenderness at lateral edge of clavicle. Patient has pain
with attempts to abduct arm and exam limited from pain, no
significant warmth or erythema appreciated. limited ROM.
Ext: bilateral Charcot joints, right foot with toes [**3-16**]
amputated, toenail fungus bilaterally and 1+ edema over legs
bilaterally below the knees, left foot wrapped in thick
dressings
Pertinent Results:
OSH Labs [**6-2**]:
WBC 16.8, HCT 29, Hgb 10.1, Plts 168
Na 133, K 4.4, Cl 102, HCO3 23, BUN 39, Cr 1.07
Ca 7.5, phos 3.5, Mg 2.2
albumin 1.9
total bilirubin 2.2, AST 86, ALT 49, ALP 212
.
Vanco trough = 11.1
Digoxin level 1.8
.
OSH EKG: NSR, incomplete LBBB, no ST changes, rate 90
ADMISSION LABS:
[**2174-6-4**] 01:51AM BLOOD WBC-14.2*# RBC-3.52* Hgb-10.7* Hct-33.6*
MCV-95# MCH-30.3 MCHC-31.8 RDW-17.4* Plt Ct-184
[**2174-6-4**] 01:51AM BLOOD Neuts-87.9* Lymphs-7.5* Monos-3.7 Eos-0.5
Baso-0.4
[**2174-6-4**] 01:51AM BLOOD PT-15.1* PTT-33.8 INR(PT)-1.3*
[**2174-6-4**] 01:51AM BLOOD ESR-104*
[**2174-6-8**] 06:08AM BLOOD Ret Aut-3.4*
[**2174-6-4**] 01:51AM BLOOD Glucose-146* UreaN-35* Creat-1.1 Na-137
K-4.5 Cl-106 HCO3-25 AnGap-11
[**2174-6-4**] 01:51AM BLOOD ALT-48* AST-66* AlkPhos-211* TotBili-1.7*
[**2174-6-4**] 01:51AM BLOOD Albumin-2.0* Calcium-7.5* Phos-3.5 Mg-2.1
[**2174-6-8**] 06:08AM BLOOD Hapto-284*
[**2174-6-11**] 08:12AM BLOOD calTIBC-142* VitB12-[**2106**]* Ferritn-556*
TRF-109*
[**2174-6-4**] 11:00AM BLOOD %HbA1c-9.3* eAG-220*
[**2174-6-5**] 04:36AM BLOOD TSH-2.2
[**2174-6-4**] 01:51AM BLOOD CRP-206.6*
[**2174-6-4**] 01:51AM BLOOD Digoxin-2.0
[**2174-6-5**] 10:42AM BLOOD Lactate-1.1
CARDIAC ENZYMES:
[**2174-6-16**] 06:09PM BLOOD cTropnT-0.05*
[**2174-6-17**] 07:14AM BLOOD cTropnT-0.08*
INFLAMMATORY MARKERS:
[**2174-6-4**] 01:51AM BLOOD ESR-104*
[**2174-6-11**] 07:15AM BLOOD ESR-95*
[**2174-6-11**] 08:12AM BLOOD ESR-117*
[**2174-6-4**] 01:51AM BLOOD CRP-206.6*
[**2174-6-11**] 08:12AM BLOOD CRP-90.6*
MICROBIOLOGY:
# BLOOD CULTURE ON [**6-4**] X 2, [**6-5**], [**6-6**]: NO GROWTH
# OHS LAB WAS GROWING: [**Month/Year (2) 8974**]
#[**2174-6-5**] 1:16 pm STOOL CONSISTENCY: LOOSE Source:
Stool.
**FINAL REPORT [**2174-6-6**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2174-6-6**]):
Feces negative for C.difficile toxin A & B by EIA.
#[**2174-6-6**] 3:00 pm TISSUE RIGHT CLAVICLE BONE BIOPSY.
**FINAL REPORT [**2174-6-11**]**
GRAM STAIN (Final [**2174-6-6**]):
REPORTED BY PHONE TO [**Location (un) **] [**Doctor Last Name **] @ 1750 ON [**6-6**] - [**Numeric Identifier 65017**].
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
TISSUE (Final [**2174-6-11**]):
STAPH AUREUS COAG +. SPARSE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
GRAM NEGATIVE ROD(S). 1 COLONY ON 1 PLATE.
UNABLE TO IDENTIFY FURTHER.
SENSITIVITIES: MIC expressed in
MCG/ML
__________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
ANAEROBIC CULTURE (Final [**2174-6-10**]): NO ANAEROBES ISOLATED.
#[**2174-6-6**] 3:00 pm TISSUE RIGHT CLAVICLE BONE BX RECD IN
SYRINGE.
**FINAL REPORT [**2174-6-12**]**
GRAM STAIN (Final [**2174-6-6**]):
REPORTED BY PHONE TO [**Location (un) **] [**Doctor Last Name **] @ 1750 ON [**6-6**] - [**Numeric Identifier 65017**].
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
TISSUE (Final [**2174-6-12**]):
STAPH AUREUS COAG +. SPARSE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # 296-1274H
[**2174-6-6**].
ANAEROBIC CULTURE (Final [**2174-6-10**]): NO ANAEROBES ISOLATED.
# [**2174-6-8**] 11:35 am JOINT FLUID JOINT FLUID RT ELBOW.
SPECIMEN LEAKED IN TRANSIT . A SMALL AMOUNT REMAINS AROUND
THE
SYRINGE CAP. PLANTED TO A CHOCOLATE AND BLOOD PLATE
ONLY.
**FINAL REPORT [**2174-6-11**]**
GRAM STAIN (Final [**2174-6-8**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2174-6-11**]): NO GROWTH.
.
# [**2174-6-8**] 3:09 pm
TISSUE RIGHT CLAVICLE.
**FINAL REPORT [**2174-6-12**]**
GRAM STAIN (Final [**2174-6-8**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
TISSUE (Final [**2174-6-11**]):
STAPH AUREUS COAG +. MODERATE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # 296-1274H [**2174-6-6**].
ANAEROBIC CULTURE (Final [**2174-6-12**]): NO ANAEROBES ISOLATED.
# [**2174-6-16**] 4:39 pm FLUID,OTHER RIGHT KNEE FLUID.
GRAM STAIN (Final [**2174-6-16**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2174-6-19**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
# [**2174-6-16**] 4:39 pm FLUID,OTHER RIGHT KNEE FLUID.
GRAM STAIN (Final [**2174-6-16**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2174-6-19**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
# [**2174-6-18**] 5:10 pm URINE Source: Catheter.
URINE CULTURE (Preliminary):
ENTEROBACTER CLOACAE. >100,000 ORGANISMS/ML..
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROBACTER CLOACAE
|
CEFEPIME-------------- 4 S
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ 4 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 2 S
TRIMETHOPRIM/SULFA---- <=1 S
.
IMAGES/STUDIES:
AT OHS:
-------
[**6-3**] Upper EXT CT W/O Contrast/ R Shoulder:
air without significant fluid in the soft tissues and within the
clavicle. In the absence of an iatrogenic source of this air it
is considered most likely to be an infection and related to
findings of the patient's foot.
.
[**6-2**] Left LEG Arterial Doppler : normal arterial flow , ABI
1.21
.
[**5-31**] left foot x-ray: gas in soft tissues, calcaneal fracture
[**5-31**] CXR - mild evidence of CHF, no fractures in shoulder and
no PNA
.
[**6-1**] TTE: moderate LVH, mild elevation right sided heart
pressures at 27-32mmHg, 1+ TR, 1+ MR, EF 10-15%
.
AT [**Hospital1 18**]:
---------
ECG: Sinus rhythm. Short P-R interval. Non-diagnostic Q waves in
leads I and aVL. RSR' pattern in lead V1. Since the previous
tracing of [**2174-6-4**] sinus rhythm is now present. The QRS width is
narrower. ST-T wave abnormalities have resolved.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
89 120 96 362/412 66 6 60
.
FOOT 2 VIEWS LEFT [**2174-6-5**]:
Extensive gas collections in the soft tissues, both at the
plantar
and dorsal aspect of the foot. Increasing assessment of cortical
structures
in the region of the calcaneus (where a non-recent fracture line
has newly
appeared), in the talus and at the distal metatarsal bone of the
first digit.
Known extensive hallux valgus deformity with degenerative
changes. Healing
fracture deformities of the third to fifth metatarsal bones. Pes
planus
deformity.
Overall, the changes are consistent with ongoing multifocal
osteomyelitis,
complicated by a pathologic calcaneal fracture and gas
collections in the soft tissues.
.
ECHO on [**2174-6-6**]:
Conclusions
The left atrium is markedly dilated. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity is moderately dilated.
Overall left ventricular systolic function is moderately
depressed (LVEF= 30-35 %) with global hypokinesis and regional
inferior akinesis. No masses or thrombi are seen in the left
ventricle. There is no ventricular septal defect. with mild
global free wall hypokinesis. The ascending aorta is mildly
dilated. 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. No mass or
vegetation is seen on the mitral valve. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion.
.
KNEE (2 VIEWS) RIGHT [**2174-6-10**]:
FINDINGS: Diffuse soft tissue swelling is present as well as a
possible
suprapatellar joint effusion. Degenerative changes are present
in the knee,
but there is no evidence of acute fracture or dislocation.
.
UNILAT UP EXT VEINS US RIGHT [**2174-6-15**]:
[**Doctor Last Name **]-scale and Doppler images of the left subclavian, right
subclavian and right IJ, right axillary, cephalic, and brachial
veins were
obtained. There was wall-to-wall flow with normal response to
compression and augmentation in all visible veins.
IMPRESSION: No right upper extremity DVT.
.
UNILAT LOWER EXT VEINS RIGHT [**2174-6-15**]:
FINDINGS: [**Doctor Last Name **]-scale and Doppler images of the left and right
common femoral,right superficial femoral, right popliteal and
right proximal calf veins were obtained. There was wall-to-wall
flow with normal response to compression and augmentation in all
visible veins.
IMPRESSION: No DVT in the right lower extremity.
Brief Hospital Course:
53-year old man with poorly controlled diabetes, atrial
fibrillation, CHF, cardiomyopathy, and new fevers and
leukocytosis in the setting of left heel osteomyelitis and
ulcer, and septic right shoulder, s/p left BKA. Overall
improving on Nafcillin. S/p revision of L BKA and right shoulder
washout.
MICU/HOSPITAL COURSE:
Patient initially admitted to MICU for concern for bleed, sepsis
in setting of osteo. No septic physiology seen on admission, no
evidence of active bleeding. Longstanding left foot ulcer with
recent imaging at OSH showing osteomyelitis per reports. Per
review of records, patient with chronic wounds over same foot
with prior I&D procedures and debridements. Recent attempted
debridement was complicated by excessive bleeding felt to be
arterial. Patient followed closely by Dr. [**Last Name (STitle) **] in podiatry.
Patient was seen by ortho, podiatry, and vascular surgery for
workup of his left foot ulcer. Patient also with R shoulder pain
worrisome as OSH imaging with air in surrounding soft tissues.
Patient with additional imaging showing changes consistent with
osteomyelitis and possible septic arthritis of the AC joint.
Patient maintained on vanco/cefepime for antibiotics with
continued fevers up to 102.4. Pt overall improving on IV
antibiotic. His blood culture from the OHS were + for [**Last Name (LF) 8974**], [**First Name3 (LF) **]
his antibiotic was changed to Nafcillin. He also had L below
knee amputation which was most likely source of infection. His
right shoulder was edematous and painful, ortho evaluated
patient and he was found to have osteomyelitis on his right
clavicle which was also growing [**First Name3 (LF) 8974**]. He had right shoulder
washout and a wound vac placed at the site. Post-op he did well,
except for worsening renal fx this was thought to be due to
diuresing. His lasix was held and he was given fluids. He went
to the OR for the second time on [**6-16**] for BKA revision and
right shoulder washout. Post-op he had A-fib with RVR requiring
additional meds and fluids. His Renal fx continued to worsen. He
had renal eval. This was again thought to be due to pre-renal
causes, either hypovolemia or lack of forward flow due to CHF.
He was given hydration followed by diuresis and his creatine has
been trending down for the last few days as listed below.
.
# Bacteremia/osteomylitis: This a complicated patient with
multiple comorbidities and multiple sources including gangrenous
left foot and septic right shoulder. TTE showed no evidence of
vegations. Pt's blood cult from OHS grew Coag + Staph. He had
left BKA and right shoulder washout on [**6-8**]. His right clavicle
is growing [**Month/Year (2) 8974**]. He has a right shoulder wound vac. The drsg
[**Name5 (PTitle) 4801**] be changed every 3 days for a total of 6 weeks. ID is
currently following patient. His antibiotics were changed to
nafcillin Q4hrs IV (day 1 was on [**2174-6-9**]) for a total of 6
weeks. He will need to follow as outpatient and will need to
have weekly labs as listed in the d/c instructions. Pt initially
refused to have TEE done and then agreed to have it done under
anesthesia while in to OR for the BKA revision. TEE was
scheduled with anesthesia to be done while in the OR, but
unfortunately pt had refused to go to the OR for the last 2 days
and this was not done. All his blood cultures since admission
have been negative. He has been afebrile for the last several
days. He has a PICC on his left AC which was placed under IR on
[**2174-6-13**]
.
His right knee had a area of effusion and he was complaining of
worsening pain, but no erythema noted. Ortho saw patient. Right
knee xray showed diffuse soft tissue swelling, as well as a
possible suprapatellar joint effusion. Degenerative changes are
present in the knee, but there is no evidence of acute fracture
or dislocation. They did a joint tap, and there was no growth on
the fluid.
.
Antibiotic summary:
Patient was initially placed on vanc, cefepime, Flagyl for a few
days and was then switched to Nafcillin 2gm Q4hrs (Day 1 on
[**6-9**]) x 6 wks for [**Month/Year (2) 8974**].
.
RECS:
- ORTHO RECS: continue wound vac on right shoulder for 6 weeks,
change drsg Q 3 days wound vac drsg [**Last Name (NamePattern4) **] 125mmHG continuous sx
(high setting of 3). He will following up with ortho on [**7-21**].
OT will need to work with pt for right arm lymphedema. He should
wear compression sleeve or ace-wrap as needed for edema.
- BKA: Vascular surgery will follow on [**7-18**]- the staples should
not be removed until then. He should be encouraged to have left
knee bending and extending while in bed. He should be eval by
PT.
- ID: nafcillin Q4hrs IV (day 1 was on [**2174-6-9**]) for a total of
6 weeks. He will need to follow as outpatient and will need to
have weekly labs as listed in the d/c instructions.
.
#Pain Management: Pt was on high dose of pain meds at home prior
to hospital admission, oxycodone 20mg Q 3-4hrs as needed at home
for his left foot pain. He was started on oxycontin dose
increased from 20mg [**Hospital1 **] to 30mg on [**2174-6-13**], and to 40mg [**Hospital1 **] on
[**6-21**]. Pain has been well controlled on current regimen.
- Oxycontin 40mg [**Hospital1 **]
- oxycodone 5-10mg Q4hrs PRN
.
# Edema: pt with worsen R UE edema as well as R LE edema. This
is most likely due to fluid overload since we were holding
diuretics due to worsening renal fx. U/S negative for DVT. The
right arm edema may also due lymphatic drainage obstruction r/t
clavicular osteomyelitis. Overall improving with diuresing.
Placed compression sleeve on right arm. PT/OT to help with lymph
drainage. Monitor distal pulses
.
#[**Last Name (un) **]: His creatinine peaked at 3.4 on [**6-16**] and has been
improving for the last few days to 1.7 today (baseline at
admission 1.1-1.2). Prior urine lytes showed FeNa was <1% c/w
pre-renal causes. Fe urea was 33, also likely due to pre-renal
causes. Had been NPO for extended period of time while awaiting
surgery, then aggressively volume resuscitated. Continues to
make good amounts of urine. He also had 80mg of IV lasix on
[**6-18**] with -4.4 L, then had 40mg of IV lasix for the last 2 days
with good UO. He will continue on his home dose of lasix 40mg PO
Qday. He will need to have creatine and lytes monitor daily
until creatine stable.
.
#CHF/CMY: Prior records note ETOH cardiomyopathy. Last EF per
OSH is 10-15%. Echo [**6-6**] revealed improved LVEF of 30-35%.
Appears to be fluid overloaded on exam as noted above, likely
due to fluids post-op and for initially holding home lasix due
to worsening in the renal fx. Overall improving with diuresing
over the last few days. He denies any SOB or orthopnea. Holding
lisinopril 2.5mg daily due to initial hypotension and [**Last Name (un) **].
Consider restarting once creatine stable. Continue digoxin
0.125mg and coreg at 6.25mg [**Hospital1 **]. His dig level will need to be
rechecked. His last level was low; however he is now on sinus
rhythm. Continue lasix at 40mg PO daily as noted above.
.
# Atrial fibrillation: At admission pt had A-fib with RVR and
transient hypotension. This is a new diagnosis. Likely triggered
by new infection. Post op on [**6-16**] pt had episode of A-fib with
RVR w/ HR in 140s. He was given metoprolol IV and additional
dose of coreg overnight with the HR returning to 80s. He rhythm
converted to sinus. He was started on anti-coagulation, coumadin
5mg on [**6-19**], once he was cleared by ortho and vascular surgery.
His anti-coagulation regimen should be readdressed with his PCP
in the future since this is a new diagnosis.
-Continue coumadin on [**6-19**] at 5mg PO, continue to check INR and
to adjust coumadin dose as needed. INR goal (2.0-3.0)
-Continue Coreg 6.25mg [**Hospital1 **] and Dig 0.125mg QD
.
# UTI: pt with new UTI, + E.coli that is only resistant to
Ceftriaxone. On cipro 500mg PO Q12hrs started on [**6-19**] for at
total of 10 days. Currently on day [**4-20**]. Foley d/ced on [**6-20**].
Pt voiding without any difficulty. He denies having any GU
symptoms. He will need repeat UA/urine culture after antibiotics
to confirm that infection has cleared.
.
#Type II diabetes mellitus: patient presented at OSH with
elevated glucose levels to 591 which were likely due to his poor
medication compliance issues. Fingersticks under excellent
control on SS. Holding home PO medications until infection
resolved
-QID FSGs
-diabetic diet
-NPH 230 units with breakfast and 20 units with dinner
-Humalog SS
.
# Anemia: Hct trended down over this admission worse after
surgery down to 23, likely due to left BKA bleeding, although
this is macrocytic. This could also be related to hx of ETOH
use. His retic count was sl. elevated at 3.4% and his direct
bili is also sl. elevated at 0.7. B12 elevated and iron studies
consistent with anemia of chronic inflammation. This is likely
due to multifactorial anemia. Hct currently stable at 28.7, not
actively bleeding. Hct responded to PRBC transfusion the last
one was yesterday, he had a total of 4 units during this
admission. He currently on multivitamins and folate. He will
need to have HCT checked daily until stable. He should also be
monitored for signs of bleeding.
.
# ETOH history: Poor historian and unclear how muuch ETOH intake
at home. He did not show any signs of withdraw, social worker
was consulted and was following pt during this hospitalization.
Continue MVI, thiamine and folate daily
.
# Prophylaxis: Pneumoboot and on heparin for PPx of DVT
.
# Access: PICC on left AC
.
# Communication: Patient, Dr. [**Last Name (STitle) 23608**] at OSH: [**Telephone/Fax (1) 65018**].
Also patient's mother [**Name (NI) **] #[**Telephone/Fax (1) 65019**]
# Code: Full (discussed with patient)
# Disposition: LTAC
.
Medications on Admission:
Medications at home (per OSH, unverified):
Glipizide
Percocet 10/325 [**Hospital1 **]
.
Medications at transfer:
APAP 325-650mg q4h prn
Zolpidem 5mg qhs prn
Docusate 100mg [**Hospital1 **]
Florastor 250mg [**Hospital1 **] (probiotic)
MVI daily
Morphine 2-4mg IV prn
Oxycodone-APAP 5mg/325mg 1-2 tabs q4h prn
Thiamine 100mg daily
Folate 1mg daily
Vancomycin 1gm daily
Erythropoietin 40,000 units SC qweek
Insulin NPH 20 units [**Hospital1 **] plus humalog sliding scale
Pip-tazo 3.375gm IV q6h or ?2.25gm q8h
Carvedilol 6.25mg [**Hospital1 **]
Lisinopril 2.5mg daily
Lorazepam 1-2mg q2h prn
Vitamin C 500mg [**Hospital1 **]
Zinc 220mg daily
?Heparin 5000 units SC q8h (said stopped but still on [**Month (only) 16**])
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: [**2-12**] Capsules PO BID (2
times a day): PLease hold for loose BM or diarrhea.
2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. NPH Insulin Human Recomb 100 unit/mL Suspension Sig: Twenty
(20) units Subcutaneous twice a day: 12 units at breakfast and
12 units at dinner.
6. Humalog 100 unit/mL Solution Sig: One (1) injection
Subcutaneous QAC and HS: Please follow slidding scale.
7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
9. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain: Please hold for sedation and RR<12
.
13. OxyContin 40 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO twice a day: Please hold for
sedation and RR<12
.
14. Carvedilol 3.125 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day): hold for sbp<100 or HR <60
.
15. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
16. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
17. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush: PICC,
heparin dependent: Flush with 10mL Normal Saline followed by
Heparin as above daily and PRN per lumen.
18. Nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: One (1)
Intravenous Q4H (every 4 hours): Day 1 [**2174-6-9**]. He will need
antibiotics for a total of 6 weeks.
19. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day: Please
hold for SBP<100.
20. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
21. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours): For UTI for total of 10 days, last day on
[**6-30**].
22. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 671**] [**Hospital 4094**] Hospital - [**Location (un) 86**]
Discharge Diagnosis:
Primary:
-[**Location (un) 8974**] bacterimea
-L BKA
-Right shoulder (clavicular)osteomyelitis
-A-fib with RVR (new onset)
-Poorly controlled DM II
.
Secondary:
HTN
Cardiomyopathy with CHF (LVEF 30-35%)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the [**Hospital1 18**] for left foot bone infection and
high glucose. Unfortunately, you were found to have gangrene in
your left foot and you needed to have an left below the knee
amputation. You were also found to have infection in the bone of
the right shoulder. You were evaluated by orthopedics and you
had debriment of the wound and placement of a vaccum wound
dressing. You will need to have this dressing on for a total of
6 weeks and it will need to be changed every 3 days. You were
also found to have bacterial growth in your blood, called
Methecillin Sensitive Staph Aureus ([**Hospital1 8974**])and you were started on
IV nafcillin. You also had a PICC line (an IV line tht can stay
for long periods of time) placed in your left arm. You will need
to stay on IV Nafcillin for at least 6 weeks and you will need
to have follow-up with infectious diseases. You had echo
cardiogram which did not show bacterial growth in your valves,
however we recommended that you had a tras-esophageal
echocardiogram and you had initially refused. You were then
scheduled to have once you were anesthesia, but given that you
refused to go the procedure for 2 days we were unable to have
that done while you were underanesthesia. You will need to
continue to have blood cultures done to make sure that is no
more bacteria in your blood.
Your kidney function has also gotten worse, this was thought to
be due to dehydration and to fluid retition. You started to
improved with IV fluids, blood transfusion and lasix (diuretic
that helps you get rid of fluid). Your red blood count was low
and this was thought to be due to bleeding after the procedure
and chronic inflammation. You were given transfusion of red
blood cells. You were heart rate was fast and you were found to
have A-fib. You were given medications to control your heart
rate and you were also started on coumadin. This was only
started on [**2174-6-19**] due to
We have made the following changes to your medications:
-Holding glipizide until your infections resolves and you go
home
-Changed Percocet for oxycodone as needed for pain
-Started you nafcillin antibiotic
-Started on coumadin
-Started on Ciprofloxacin HCl 500 mg every 12 hours for urinary
tract infection for a total
DISCHARGE INSTRUCTIONS FOLLOWING BELOW OR ABOVE KNEE AMPUTATION
.
This information is designed as a guideline to assist you in a
speedy recovery from your surgery. Please follow these
guidelines unless your physician has specifically instructed you
otherwise. Please call our office nurse if you have any
questions. Dial 911 if you have any medical emergency.
.
ACTIVITY:
.
There are restrictions on activity. On the side of your
amputation you are non weight bearing until cleared by your
Surgeon. You should keep this amputation site elevated when ever
possible.
.
You may use the other leg to assist in transferring and pivots.
But try not to exert to much pressure on the amputation site
when transferring and or pivoting.
No driving until cleared by your Surgeon.
.
PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:
.
Redness in or drainage from your leg wound(s) .
.
Watch for signs and symptoms of infection. These are: a fever
greater than 101 degrees, chills, increased redness, or pus
draining from the incision site. If you experience any of these
or bleeding at the incision site, CALL THE DOCTOR.
.
Exercise:
.
Limit strenuous activity for 6 weeks.
.
Do not drive a car unless cleared by your Surgeon.
.
Try to keep leg elevated when able.
.
BATHING/SHOWERING:
.
You may shower immediately upon coming home. No bathing. A
dressing may cover you??????re amputation site and this should be
left in place for three (3) days. Remove it after this time and
wash your incision(s) gently with soap and water. You will have
sutures, which are usually removed in 4 weeks. This will be done
by the Surgeon on your follow-up appointment.
.
WOUND CARE:
.
Sutures / Staples may be removed before discharge. If they are
not, an appointment will be made for you to return for staple
removal.
.
When the sutures are removed the doctor may or may not place
pieces of tape called steri-strips over the incision. These will
stay on about a week and you may shower with them on. If these
do not fall off after 10 days, you may peel them off with warm
water and soap in the shower.
.
Avoid taking a tub bath, swimming, or soaking in a hot tub for
four weeks after surgery.
.
MEDICATIONS:
.
Unless told otherwise you should resume taking all of the
medications you were taking before surgery. You will be given a
new prescription for pain medication, which can be taken every
three (3) to four (4) hours only if necessary.
.
Remember that narcotic pain meds can be constipating and you
should increase the fluid and bulk foods in your diet. (Check
with your physician if you have fluid restrictions.) If you feel
that you are constipated, do not strain at the toilet. You may
use over the counter Metamucil or Milk of Magnesia. Appetite
suppression may occur; this will improve with time. Eat small
balanced meals throughout the day.
.
CAUTIONS:
.
NO SMOKING! We know you've heard this before, but it really is
an important step to your recovery. Smoking causes narrowing of
your blood vessels which in turn decreases circulation. If you
smoke you will need to stop as soon as possible. Ask your nurse
or doctor for information on smoking cessation.
.
Avoid pressure to your amputation site.
.
No strenuous activity for 6 weeks after surgery.
.
DIET :
.
There are no special restrictions on your diet postoperatively.
Poor appetite is expected for several weeks and small, frequent
meals may be preferred.
.
For people with vascular problems we would recommend a
cholesterol lowering diet: Follow a diet low in total fat and
low in saturated fat and in cholesterol to improve lipid profile
in your blood. Additionally, some people see a reduction in
serum cholesterol by reducing dietary cholesterol. Since a
reduction in dietary cholesterol is not harmful, we suggest that
most people reduce dietary fat, saturated fat and cholesterol to
decrease total cholesterol and LDL (Low Density Lipoprotein-the
bad cholesterol). Exercise will increase your HDL (High Density
Lipoprotein-the good cholesterol) and with your doctor's
permission, is typically recommended. You may be self-referred
or get a referral from your doctor.
.
If you are overweight, you need to think about starting a weight
management program. Your health and its improvement depend on
it. We know that making changes in your lifestyle will not be
easy, and it will require a whole new set of habits and a new
attitude. If interested you can may be self-referred or can get
a referral from your doctor.
.
If you have diabetes and would like additional guidance, you may
request a referral from your doctor.
.
FOLLOW-UP APPOINTMENT:
.
Be sure to keep your medical appointments. The key to your
improving health will be to keep a tight reign on any of the
chronic medical conditions that you have. Things like high blood
pressure, diabetes, and high cholesterol are major villains to
the blood vessels. Don't let them go untreated!
.
Please call the office on the first working day after your
discharge from the hospital to schedule a follow-up visit. This
should be scheduled on the calendar for seven to fourteen days
after discharge. Normal office hours are 8:30-5:30 Monday
through Friday.
.
PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR
QUESTIONS THAT MIGHT ARISE
Followup Instructions:
Department: VASCULAR SURGERY
When: MONDAY [**2174-7-18**] at 11:40 AM
With: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: ORTHOPEDICS
When: THURSDAY [**2174-7-21**] at 10:00 AM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: THURSDAY [**2174-7-21**] at 10:20 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1984**], MD [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
ICD9 Codes: 7907, 5990, 3572, 4280, 5849, 4019, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3459
} | Medical Text: Admission Date: [**2164-5-21**] Discharge Date: [**2164-5-27**]
Date of Birth: [**2083-4-7**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Codeine
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Chest Pain/Dyspnea
Major Surgical or Invasive Procedure:
Coronary Artery Bypass Graft x 2 (Lima to LAD, SVG to PDA)
History of Present Illness:
81 y/o female with known coronary artery disease and a recent
increase in symptoms. Cardiac Catheterization revealed 3 vessel
disease and now presents for surgical revascularization.
Past Medical History:
Hypertension
Hypercholesterolemia
Peripheral Vascular Disease s/p Left CEA [**2153**]
Chronic Obstructive Pulmonary Disease
OS Blindness
s/p Appendectomy
s/p Hysterectomy
Social History:
Retired, Lives alone.
60+ yrs or [**1-30**] ppd (>100pkyrhx), Quit 1 month ago
Quit drinking ETOH 15 yrs ago
Family History:
?Mother with CAD
Physical Exam:
VS: 60 20 118/74 112/69 64" 124#
General: Frail, elderly caucasian female in NAD w/ mild SOB @
rest.
Skin: Warm, dry w/ mild darkening/yellowing of face/fingers
HEENT: NC/AT OS blindness, OP benign
Neck: Supple, FROM -JVD, +Carotid Bruits
Chest: Bibasilar rales
Heart: RRR, +S1S2, 2/6 SEM
Abd: Soft, NT/ND +BS
Ext: Warm, Well-perfused, 1+ edema, -varicosities 2+ BFA, 1+
BDP, 1+ PT
Pertinent Results:
Echo [**2164-5-21**]: PRE BYPASS: The left atrium is mildly dilated.
Overall left ventricular systolic function is low normal (LVEF
50-55%). Resting regional wall motion abnormalities include mild
hypokinesis of the anteroseptal wall and apex. There are complex
(>4mm) atheroma in the descending thoracic aorta. The aortic
valve leaflets (3) are mildly thickened. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild to moderate ([**1-30**]+) mitral regurgitation is seen.
POST BYPASS: Biventricular systolic function remains unchanged
from prebypass. MR is now mild (1+). Remaining study is
otherwise unchanged from prebypass
CXR [**5-25**]: Improvement of mild pulmonary edema. Small bilateral
effusions. Improving left basilar atelectasis.
[**2164-5-21**] 10:34AM BLOOD WBC-13.5*# RBC-3.06*# Hgb-8.9*#
Hct-26.1*# MCV-85 MCH-29.1 MCHC-34.2 RDW-14.3 Plt Ct-119*#
[**2164-5-23**] 01:54AM BLOOD WBC-18.1* RBC-3.19* Hgb-9.2* Hct-27.1*
MCV-85 MCH-28.8 MCHC-33.9 RDW-14.9 Plt Ct-163
[**2164-5-25**] 10:50AM BLOOD WBC-12.0* RBC-3.30* Hgb-9.5* Hct-28.8*
MCV-87 MCH-28.9 MCHC-33.2 RDW-15.3 Plt Ct-242
[**2164-5-26**] 05:05AM BLOOD WBC-10.2 Hct-27.5*
[**2164-5-21**] 10:34AM BLOOD PT-19.5* PTT-45.5* INR(PT)-1.9*
[**2164-5-24**] 05:08AM BLOOD PT-15.4* PTT-33.4 INR(PT)-1.4*
[**2164-5-21**] 11:17AM BLOOD UreaN-6 Creat-0.5 Cl-110* HCO3-21*
[**2164-5-24**] 07:19PM BLOOD Glucose-162* UreaN-12 Creat-0.7 Na-133
K-3.4 Cl-97 HCO3-25 AnGap-14
[**2164-5-26**] 05:05AM BLOOD UreaN-10 Creat-0.5 K-4.1
[**2164-5-26**] 05:05AM BLOOD Mg-1.7
Brief Hospital Course:
Following pre-operative work-up as an outpatient, Ms. [**Known lastname 67248**] was
a same day admit and brought to the operating room on [**2164-5-21**].
She underwent a coronary artery bypass graft x 2 by Dr. [**Last Name (Prefixes) **]. Please se op note for surgical details. Following surgery
she was brought to the CSRU in stable condition on
Neo-Synephrine. Later on op day, patient was weaned from
sedation, awoke neurologically intact and was extubated. Chest
tubes and epicardial pacing wires were removed per protocol. She
was started on Beta Blockers and diuretics. She was gently
diuresed towards her pre-operative weight during her post-op
course. All inotropes were weaned, she remained in the CSRU
until post-operative day three and was then transferred to the
cardiac surgery step-down floor. Physical therapy worked with
patient during entire post-op course for strength and mobility.
Over the next several days patient appeared to be recovering
quite well with stable labs, vs, and physical exam. She cleared
level 5 and was finally discharged on post-op day six with vna
and the appropriate follow-up appointments.
Medications on Admission:
Aspiriin 325mg qd, Atenolol 100mg qd, Lipitor 20mg qd, Norvasc
10mg qd, Betagen eye drops OD
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day
for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
Disp:*35 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Hospice and VNA
Discharge Diagnosis:
Coronary artery disease s/p Coronary Artery Bypas Graft x 2
([**2164-5-21**])
Hypercholesterolemia
Hypertension
Peripheral Vascular Disease
Discharge Condition:
Stable
Discharge Instructions:
Take all medications as prescribed.
Seek medical attention if you experience fever, chills, nausea,
vomiting, increased pain, or shortness of breath.
Do not lift anything heavier than 10 lbs for 4 wks.
Do not drive for 4 wks.
[**Last Name (NamePattern4) 2138**]p Instructions:
Please call Dr. [**Last Name (STitle) **] [**Last Name (Prefixes) 2546**] office at [**Telephone/Fax (1) 170**] within the
next few days for a follow-up appointment in 4 weeks.
Please call your Primary Care Physician within the next few days
to schedule a follow-up appointment for general assessment and
monitoring of LFT's (on statin).
Completed by:[**2164-5-28**]
ICD9 Codes: 496, 4019, 2720, 4439 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3460
} | Medical Text: Admission Date: [**2178-1-1**] Discharge Date: [**2178-1-6**]
Date of Birth: [**2102-6-17**] Sex: F
Service: NEUROLOGY
Allergies:
Percocet / Codeine
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Left hemiparesis, decreased level of consciousness
Major Surgical or Invasive Procedure:
Right hemicraniectomy
Intubation
History of Present Illness:
75 year old right handed woman with a history of CAD, HTN,
obesity, hyperlipidemia, atrial fibrillation, currently off
coumadin due to GI bleeds, Sytolic CHF (LVEF 40-45%) was last
seen well when she went to bed last night. This morning at 9:30
am she was found was on the floor by her mother, mumbling a few
words and not being able to move the left side of her body. They
immediately called EMS who brought her here. Of note, patient
has a history of colonic AVM that has led her to several
hospitalizations due to GI bleed. In [**2175**] she developed atrial
fibrillation and was started on coumadin by her PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 2450**]. As
another gastrointestinal hemorrhage occured one year
ago([**2176-12-31**]), it was decided to stop coumadin.
Past Medical History:
-Hypertension
-Coronary artery disease: s/p MI X 2 ([**2142**] and [**2159**]) s/p LCX
stent ([**2159**])--complicated by pericarditis, pleural effusion.
Last cath [**2173**] with LCX 80% restenosis treated with angioplasty
and placement of cypher DES.
-DVT s/p IVC filter and completed course of coumadin
-High cholesterol
-Atrial fibrillation
-Osteoarthritis
-GIB: recurrent LGIB. Last colonoscopy [**3-30**] with AVMs--treated
-s/p bilateral rotator cuff surgery
-s/p hysterectomy
Social History:
Divorced mother of 2 children (son, daughter). Quit tob [**2159**]
(smoked [**12-26**] ppd x 40 years). Occasional alcohol, no drugs.
Retired inspector. Lives in Mission [**Doctor Last Name **]. She lives with her
mother, brother, son, cousin, and granddaughter.
Family History:
There is no family history of premature coronary artery disease
or sudden death
Physical Exam:
T-96 BP-166/68 HR-73 RR-15 100O2Sat
Gen: Lying in bed, obese
HEENT: NC/AT, moist oral mucosa
Neck: No tenderness to palpation, normal ROM, supple, no carotid
or vertebral bruit
Back: No point tenderness or erythema
CV: irregular, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema
Neurologic examination:
Mental status: Awake and alert, partly cooperative with exam,
She can mumble a few words, however, it is difficult to
understant.She was oriented to place, and date, nodding
confirming them. Speech is nonfluent; normal comprehension (she
followed commands such as pointing to the ceiling, squeezing the
hand, repetition is impaired. Patient would tend to look to the
left side of the room and she made a few mistakes when I tested
touching one or two arms and asking how many arms I was
touching. with some evidence of left sided neglect.
Cranial Nerves:
Pupils equally round and reactive to light, 4 to 2 mm
bilaterally. Visual fields are not able to test. Extraocular
movements intact bilaterally, no nystagmus. Sensation intact
V1-V3. Left UMN facial weakness. Hearing intact to finger rub
bilaterally. Palate elevation symmetrical. Sternocleidomastoid
and trapezius normal bilaterally. Tongue midline, movements
intact
Motor:
Normal bulk bilaterally. Increased tone on left leg. No observed
myoclonus or tremor
No pronator drift
[**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IP H Q DF PF TE TF
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
L 0 0 0 0 0 0 1 3 2 2 2 3 2 3
Sensation: Intact to light touch, pinprick, vibration and
proprioception throughout. No extinction to DSS
Reflexes:
Biceps 2+ BL; Triceps 2+ BL; Brachrad. 3+ BL, patellar trace BL;
Achilles 0 BL
Upgoing left toe
Coordination: Finger tap normal on right side; could not perform
on the right side due to weakness.
Gait: not tested
Brief Hospital Course:
The patient is a 75 year old woman with a history of atrial
fibrillation off Coumadin given history of GI bleeds related to
colonic AVM, hypertension, and hyperlipidemia who presented
after being found down with left hemiparesis and decreased level
of consciousness. Physical exam on admission was significant for
being awake but somnolent, dysarthria, left sided neglect, left
hemiparesis, and upgoing toe on the left. CT Head showed an
acute right MCA territorial infarct. Given her somnolence and
size of her right MCA infarct with potential to swell, she was
admitted to the NeuroICU. She was continued on an ASA 325 mg
daily, and her blood pressure was allowed to auto-regulate (and
ranged 130-180 overnight). MRI/MRA brain/neck performed at
approximately [**9-3**] pm on the day of admission ([**1-1**]) showed acute
right MCA infarct with no hemorrhage or shift of midline
structure and decreased flow in the right ICA and complete
occlusion of the right MCA
at its M1 segment. The patient's GCS began to decrease at
approximately 3 am on Day 2 of admission ([**1-2**]), with decreased
responsiveness. This was initially thought to be due to her
respiratory status. At 4:40 am, she was reevaluated by neurology
and found to have a fixed and dilated R pupil at 6 mm, no
corneal reflex on the right, and no gag. Repeat Head CT at 5:19
am showed showed new hemorrhagic conversion within the
extensive, virtual-complete right MCA territorial infarction,
which, along with worsening cytotoxic edema, caused
significantly increased mass effect, with severe leftward
subfalcine and right uncal and impending downward transtentorial
herniation. She was thought to have a malignant MCA infarct due
to recanalization and reperfusion causing hemorrhage. She was
intubated and given Mannitol 20% 150 g IV x1. Her son was
notified, and neurosurgery was consulted who performed an
emergent right hemicraniectomy on the morning of [**1-2**]. She was
hypotensive during the hemicraniectomy requiring pressors. A
repeat head CT/CTA after the hemicraniectomy showed continued
midline shift and increased size of the hemorrhage. She was
started on Dilantin after the procedure, and her ASA was
discontinued. A family meeting was held with the patient's son
(who was present) and daughter (via the telephone), and they
were informed about the patient's grim prognosis. The patient's
daughter wanted to continue care until she was able to come to
[**Location (un) 86**] from [**State 3908**]. The patient was started on Mannitol IV q6
hr.
The patient was made CMO after family meeting and expired a few
hours later.
Medications on Admission:
pantoprazole 40mg
lisinoprol 40mg
colchicine 0.6 mg
isosorbide mononitrate 30mg
senna
docusate
allopurinol 100mg
furosemide 80mg [**Hospital1 **]
Hydralizine 25mg [**Hospital1 **]
crestor 40mg
aspirin 325mg
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
Completed by:[**2178-1-20**]
ICD9 Codes: 431, 5990, 4280, 4019, 4589, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3461
} | Medical Text: Admission Date: [**2124-7-19**] Discharge Date: [**2124-7-23**]
Date of Birth: [**2056-12-2**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Aortic valve replacement ([**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] Mechanical) on [**7-19**]
History of Present Illness:
Very nice 67 year old gentleman with history of heart murmur
since childhood. In preparation for hip replacement surgery, he
was referred to Dr. [**Last Name (STitle) **] for evaluation of his systolic murmur.
Work-up revealed severe aortic stenosis necessitating surgical
management prior to his hip replacement. He has thus been
referred to Dr. [**Last Name (STitle) **] for surgical management. He admits to
only mild shortness of breath with activity.
Past Medical History:
Chronic pain
Obese
Depression
Hypertension
?Sleep apnea
OA left hip/knee
sq. cell skin CA
colon polyps
Social History:
Occupation: Retired
Last Dental Exam:[**5-13**]
Lives with:alone Race: Caucasian
Tobacco: never ETOH:rare
Enrolled in any clinical/research study? no
Family History:
Father died of MI at 72 and father's brother died of MI at 55
Mother died of cancer.
Physical Exam:
Physical Exam:
Pulse: 76 reg
Resp: O2 sat:
B/P Right: 128/76 Left: 130/80
Height: 71" Weight: 250#
General:
Skin: Dry [x] intact [x] flaky with mutiple patches of pink
areas
of skin from treatments for CA and precancerous lesions
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [] no JVD noted
Chest: Lungs clear bilaterally [x];healed acne scars
Heart: RRR [x] Irregular [] Murmur 4/6 SEm heard throughout
precordium and radiating to carotids
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+
obese abd, healed abd scars
Extremities: Warm [x], well-perfused [x] Edema none
Varicosities: None [x]
Neuro: Grossly intact, nonfocal exam, MAE [**5-9**] strengths
Pulses:
Femoral Right: 1+ Left: 1+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 1+
Carotid Bruit : murmur radiates bilaterally to carotids
Pertinent Results:
[**2124-7-21**] 04:50AM BLOOD WBC-14.3* RBC-3.46* Hgb-11.7* Hct-33.3*
MCV-96 MCH-33.9* MCHC-35.2* RDW-13.5 Plt Ct-120*
[**2124-7-21**] 04:50AM BLOOD PT-17.2* INR(PT)-1.5*
[**2124-7-21**] 04:50AM BLOOD Glucose-100 UreaN-23* Creat-1.5* Na-136
K-4.3 Cl-101 HCO3-25 AnGap-14
[**2124-7-21**] 04:50AM BLOOD Mg-2.2
Pre-CPB:
No spontaneous echo contrast is seen in the left atrial
appendage.
There is severe symmetric left ventricular hypertrophy. Overall
left ventricular systolic function is normal (LVEF>55%). with
mild global free wall hypokinesis.
The ascending aorta is moderately dilated. There are simple
atheroma in the descending thoracic aorta.
There are three aortic valve leaflets. 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 moderately thickened. Moderate
(2+) mitral regurgitation is seen.
There is no pericardial effusion.
Post-CPB:
The patient is on low dose phenylephrine, AV paced.
There is a prosthetic aortic valve in place, well-seated with no
leak and no AI. Mean gradient = 16 mmHg.
Good biventricular systolic fxn.
MR is now trace to 1+.
Aorta intact.
Other parameters as pre-bypass.
Dr [**Last Name (STitle) **] present and aware.
[**2124-7-22**] 07:00AM BLOOD WBC-12.8* RBC-3.98* Hgb-13.2* Hct-38.0*
MCV-96 MCH-33.1* MCHC-34.6 RDW-13.5 Plt Ct-191#
[**2124-7-23**] 06:30AM BLOOD PT-26.2* PTT-47.8* INR(PT)-2.5*
[**2124-7-22**] 07:00AM BLOOD PT-21.1* PTT-35.1* INR(PT)-2.0*
[**2124-7-22**] 07:00AM BLOOD Glucose-133* UreaN-23* Creat-1.4* Na-136
K-4.2 Cl-98 HCO3-28 AnGap-14
Brief Hospital Course:
The patient was admitted and brought to the operating room on
[**2124-7-19**] where he underwent aortic valve replacement with a 23mm
St. [**Male First Name (un) 923**] mechanical valve as detailed in the operative report.
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for monitoring and recovery. POD 1 found the patient
extubated, alert and oriented and breathing comfortably. He was
neurologically intact and hemodynamically stable off inotropic
and vasopressor support. Chest tubes and pacing wires were
discontinued without complication. The patient was transferred
to the telemetry floor on POD 1. Anti-coagulation was initiated
with coumadin and heparin for the mechanical valve. Beta
blocker was started and the patient was gently diuresed toward
his preoperative weight. The physical therapy service was
consulted for post-operative strength and mobility. The patient
progressed through the cardiac surgery pathway without
complication and was discharged to home with VNA on POD 4 with
appropriate follow-up instructions.
Medications on Admission:
Wellbutrin 150mg [**Hospital1 **]
Atenolol 25mg Daily
tylenol PM prn pain
Aspirin 81mg QD
amoxicillin prn dental
Discharge Medications:
1. Outpatient Lab Work
INR to be drawn on [**7-25**] with results called to the office of
Dr.[**First Name8 (NamePattern2) 1692**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 28436**] ([**Telephone/Fax (1) 82111**]. INR goal for aortic
valve replacement is 2.5-3.5.
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Bupropion HCl 75 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever/pain.
6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
Dose will change daily for goal INR 2.5-3.5, Dr. [**Last Name (STitle) 28436**] to
manage.
Disp:*30 Tablet(s)* Refills:*2*
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
Two (2) Tab Sust.Rel. Particle/Crystal PO once a day for 2
weeks.
Disp:*28 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day
for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 2203**] VNA
Discharge Diagnosis:
aortic stenosis
s/p aortic valve replacement this admission
Discharge Condition:
good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month, and while taking
narcotics
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
See your PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 1692**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 28436**] ([**Telephone/Fax (1) 82111**] in [**1-7**]
weeks.
See your cardiac surgeon Dr. [**First Name (STitle) **] [**Name (STitle) **] ([**Telephone/Fax (1) 11763**] in [**4-10**]
weeks.
INR to be drawn on [**7-25**] with results called to the office of
Dr.[**First Name8 (NamePattern2) 1692**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 28436**] ([**Telephone/Fax (1) 82111**]. INR goal for aortic
valve replacement is 2.5-3.5. Plan confirmed with [**Doctor First Name **] on
[**2124-7-21**].
Completed by:[**2124-7-23**]
ICD9 Codes: 4241, 4019, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3462
} | Medical Text: Admission Date: [**2202-10-17**] Discharge Date: [**2202-10-22**]
Date of Birth: [**2143-12-3**] Sex: M
Service: NEUROLOGY
Allergies:
Vicodin / Roxicet / Sirolimus
Attending:[**First Name3 (LF) 1032**]
Chief Complaint:
Mental status changes
Major Surgical or Invasive Procedure:
Endotracheal intubation
Lumbar puncture with moderate sedation
Radial arterial line insertion
History of Present Illness:
58y/o RHM with history of liver transplant, Hepatitis C, chronic
renal disease and multiple asymptomatic strokes, presented with
sudden decline in his mental status. His wife witnessed him be
struggling get out from bed, decline in his
awareness. His wife spoke to him with appropriate condition
around 6:05PM. Around 6:25PM, she heard that the patient started
to say non-sence, act inappropriately, unable to exchange
conversation. His wife recalled some "shaking" at the right arm.
He was brought into [**Hospital1 18**] ED above time and Neurology was
consulted for code stroke.
In ED, while Neurology was examining patient, he developed right
arm, leg clonic seizure with head deviation and gaze deviation
toward to left. He responded with moan when his name was called,
then developed left arm clonic seizure (secondary
generalization) and became unresponsive. Ativan 2mg IV was given
to stop. Patient was intubated subsequently to have further
neuroradiological evaluation.
HPI ADDENDUM:
Further history was obtained from the patient's wife the morning
following his admission. She reports the patient was well until
returning from a same-day-surgical procedure on [**10-14**] for repair
of left eye retinal detachment. The patient was vague with his
reported symptoms, but complained of "feeling lousy" with poor
appetite and fatigue. He did not eat or drink very much Friday
or Saturday following. On Saturday evening he began to vomit
quite frequently. They had a small breakfast Sunday morning and
the patient was still feeling unwell, but altogether normal per
his wife. She left for a few hours during the day, returned home
and heard him yelling out of frustration after having dropped
something in his room, however the yelling continued and she
went to see him and noted that he had a great amount of
difficulty getting himself upright to the edge of his bed. She
then noted his right arm was shaking. He was brought to [**Hospital1 18**] ED
where the above described event occurred.
Past Medical History:
- ETOH/HCV cirrhosis s/p Liver Transplant [**2195**] on
immunosuppression. Course c/b recurrent hep C viremia, CRI, LFT
abnl, acute rejection and hepatic artery thrombosis ([**2196**])
- Polymyositis - diagnosed in [**2196**] after hepatic artery
thrombosis, Bx showed inflammatory myositis
- HTN
- CRI (baseline 2.0)
- DM on insulin - post-transplant, related to steroid treatment
- IVDU
- Multiple strokes - [**2195**] prior to transplant left corona
radiata
and posterior putaminal infarct, periventricular white matter
disease. [**8-12**] MRI with evidence of chronic cerebellar infarcts.
- Seizure - single event 3 days prior to transplant while in
hospital. However chart review reveals pt may have had seizures
associated with prior infarcts in [**2195**].
Social History:
Lives with his wife. Does not smoke. Quit ETOH use several years
prior to transplant.
Family History:
No FH of stroke or neurological disease
Physical Exam:
Vitals: T ? HR 64, reg BP 243/123 RR 17 SO2 97% r/a
Gen:NAD.
HEENT:MMM. Sclera clear. OP clear. Extra ear canals, ear drums
clear.
Neck: No Carotid bruits
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
Abd: Horizontal surgical scar. Soft, flat, no tenderness
Ext: No arthralgia, no deformities, no edema
Neurologic examination:
MS- Opening eyes to voice. Non-verbal. Vocalize non identifiable
sound. No following command.
CN- Pupils left sclera injected, surgical. Right pupil also
surgical. Left gaze preference. Left head turning. No facial
droop with grimacing. Gag+. Cough+.
Motor/Sensory- Normal bulk. R foot clonus x7-9 beats. Left
negative. No
withdrawal at R arm, leg, L leg. Withdrawal at R arm.
Response to the noxious stimuli at left arm. None at right arm,
leg and left leg.
Reflexes: B T Br Pa Ankle
Right 2 2 2 3 3
Left 2 2 2 2 2
Toes were upgoing at the right, down at the left.
Coordination:Unable to examine due to inattention.
Meningeal sign: Negative Brudzinski sign. No nuchal rigidity.
Pertinent Results:
ADMISSION LABS:
138 99 42 AGap=18
------------<140
3.9 25 2.3
estGFR: 29/36 (click for details)
11.2 >15.9/46.6< 127
N:64.7 L:24.7 M:9.9 E:0.6 Bas:0.2
PT: 11.7 PTT: 31.0 INR: 1.0
Head CT:
No hemorrhage.
Head MRI/MRA: MRA: The intracranial vertebral and internal
carotid arteries and their major branches appear normal with no
evidence of significant stenosis, occlusion, or aneurysms. MRI:
Unchanged appearance of punctate hemorrhagic areas in bilateral
cerebral hemispheres and brainstem suggestive of chronic
process. Amyloid angiopathy is one of the conditions that can
predispose to tiny punctate hemorrhages. No acute hemorrhage,
masses, infarct.
Brief Hospital Course:
Mr. [**Known lastname 2809**] is a 58 year old gentleman s/p liver transplant
related to chronic HCV infection, myopathy (? steroid induced),
history of prior multiple asymptomatic embolic infarcts prior to
transplantation, who presents with three day prodrome of general
malaise, poor appetite, nausea/vomiting, followed by acute
change in mental status with witnessed partial complex seizure
in the [**Hospital1 18**] ED.
1) Neuro:
* SEIZURE - Initially a code stroke was called in the ED, but CT
imaging and later, MRI, showed no evidence of acute infarction.
Initial labs notable for presence of only serum benzodiazepines
on tox screening and acute on chronic renal failure. Etiology of
seizure was thought to be areas of prior cortical infarcts in
setting of gastrointestinal illness. The patient was intubated
in the emergency department and promptly extubated at 2am in the
Neuro ICU the same evening. The morning following admission the
patient's examination was notable for marked encephalopathy. He
was changed from phenytoin to oxcarbazepine (Trileptal) given
multiple long term side effects of phenytoin, and with normal
hepatic function, but renal impairment and keppra did not seem a
wise choice. Lumbar puncture was attempted with light sedation
without success. It was re-attempted with fentanyl and midazolam
for monitored conscious sedation and revealed 1 WBC, 0 RBC,
normal protein and glucose. He was transferred to the floor
after an EEG done on the [**7-18**] revealed no
abnormalities and showed a normal background.
* ENCEPHALOPATHY - On the floor, the patient's exam was notable
for continued encephalopathy, but he was evidently not
delerious. His main abnormalities were frontal dysfunction (as
exhibited by impulsiveness, stimulus-bound behaviors,
desinhibition, bilateral grasp and palmomental reflexes, a
marked inability to switch mindset) and memory (as exhibited by
anososgnosia, orientation to place and time, as well as not
imprinting new information, and working memory (the patient
stayed in-task, and had sufficent attention to perform, but
couldn't complete the tasks). Clinically he continued to improve
slowly but surely, an EEG done on [**10-21**] showed 7 Hz background,
but otherwise normal. Per his wife, his level of cognitive
functioning at home was high, as for example he was able to
discuss politics.
2) Cardio:
* NSTEMI - Patient was noted to have elevated troponin enzymes
to 0.31 with EKG without ischemic changes. He was started on
aspirin, beta blocker, atorvastatin. Cardiology consultation was
obtained and additionally recommended echocardiogram which
revealed moderate symmetric left ventricular hypertrophy, no
focal wall motion abnormalities (poor data quality though),
LVEF>55%, mild aortic valve stenosis. His NSTEMI was thought
related to demand related ischemia in the setting of
catecholamine surge associated with seizure. He should be
scheduled for an exercise stress test as an outpatient.
3) FEN
* Acute Renal Failure - Patient's has prior hepato-renal
syndrome now with baseline creatinine of 1.9-2. Admission
creatinine notable for 2.4. He was noted to have low urine
output. He received vigorous IV hydration with improved Cr to
1.6, however this was likely a sampling error because all the
lines of his cellcount were down on this blooddraw as well,
repeat labs showed a creat of 2.0 and his [**Hospital1 **] back to the old
values. His medications were renally dosed. He was started on
Thiamine, Folate and MVI.
4) Liver transplantation
Transaminase levels on admission were WNL. Hepatology
consultation was obtained and recommended continuing with his
prior regimen of immunosuppressive agents. No changes were made.
5) ID
A broad spectrum of CSF studies were sent despite the normal
cell count. Varicella PCR and CMV PCR negative, remainder
pending. MRSA isolation negative. VRE swab negative.
Cryptococcal antigen GRAM STAIN, FLUID CULTURE, FUNGAL
CULTURE-PRELIMINARY,ACID FAST CULTURE, VIRAL CULTURE were all
(preliminary) negative.
6) PPx, reactivation and reconditioning
For prophylaxis, he was put on Heparin, pneumoboots, TEDs, and
PT and OT were consulted to evaluate and treat him.
Medications on Admission:
Prograf 1mg [**Hospital1 **]
Imuran 50mg [**Hospital1 **]
Cellcept (mycophenidate mofetil) 1000mg [**Hospital1 **]
bactrim
metoprolol 50mg [**Hospital1 **]
Clindagel
asa 81mg daily
fosamax 35mg q fri
marinol 5mg qpm and qhs
simethicone 80mg [**Hospital1 **]
calcum 500mg + D [**Hospital1 **]
Ambien (zolpidem) 5mg qhs
doxazosin 1.5mg qhs
hydroxyzine hcl 50mg [**Hospital1 **]
ritalin 15mg qam
remeron 7.5 qhs
prilosec 20mg daily
Effexor 37.5mg daily
Florinef 0.1mg daily
Lasix 20mg daily
Kayexylate
Lipitor 10mg daily
Lisinopril 5mg daily
Percocet one tab qid prn
Cosopt one drop to left eye [**Hospital1 **]
Alphagan 0.15% to left eye [**Hospital1 **]
Ofloxacin 0.3% eye drop to left eye qid
Prednisolone 1% eye drop to left eye qid
Homatropine 5% eye drop to left eye [**Hospital1 **]
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
3. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
4. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
twice a day.
5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
6. Alendronate 35 mg Tablet Sig: One (1) Tablet PO QFRI (every
Friday).
7. Doxazosin 1 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime).
8. Hydroxyzine HCl 25 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
9. Venlafaxine 37.5 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
10. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
12. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO MWF (Monday-Wednesday-Friday) as needed for ppx.
13. Oxcarbazepine 300 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
14. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
15. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q 12H
(Every 12 Hours).
16. Ofloxacin 0.3 % Drops Sig: One (1) Ophthalmic four times
daily ().
17. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic QID (4 times a day).
18. Homatropine HBr 5 % Drops Sig: One (1) Ophthalmic twice
daily ().
19. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
20. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
21. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
22. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
23. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
24. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at
[**Hospital6 1109**] - [**Location (un) 1110**]
Discharge Diagnosis:
Complex partial seizure with secondary generalization.
Discharge Condition:
Stable, improving cognitively.
Discharge Instructions:
You have been admitted with an epileptic seizure, most likely
related to small scars in your brain from old small strokes,
possibly in the setting mild dehydration. After this you have
been confused for a while, which is not unusual with a fragile
brain, a post-seizure state and a lot of medications on board.
Your medications such as Remeron and Methylphenidate have been
temporarily discontinued - please follow up with your doctor to
perhaps reverse these changes when you are back to your
baseline.
Please take all medications as directed, and attend all your
follow-up appointments. If you experience any signs or symptoms
of concern, please contact your doctor immediately, or in case
of urgency go directly to the emergency room - for example in
case of recurrence of seizures.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2202-11-17**] 8:40
Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2202-12-14**] 4:10
Provider: [**Name10 (NameIs) 8741**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2202-12-14**]
4:30
Provider: [**First Name8 (NamePattern2) 539**] [**Last Name (NamePattern1) 540**] MD Phone:[**Telephone/Fax (1) 541**]
Date/Time:[**2202-11-17**] 2:30
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD, [**MD Number(3) 1041**]
ICD9 Codes: 5849, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3463
} | Medical Text: Admission Date: [**2101-9-15**] Discharge Date: [**2101-9-21**]
Date of Birth: [**2050-6-14**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
Chief Complaint:hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is a 51 y.o male with h.o colon cancer widely mets to lungs
s/p ileostomy, mucous fistula, transferred from [**Hospital 1562**]
Hospital for further eval. Per report, pt noticed clogging,
cloudy outpt from his urostomy tubes 1-2 days ago and 1 episode
of vomiting. He also reportedly denied change in ileostomy
outpt, but was noted to have cloudy outpt from his R.nephrostomy
tube.
.
While at [**Name (NI) 1562**], pt noted to have dirty u/a. Afeb, BP 128/68,
HR 120's, sat 96% on RA at ~9am. Upon transfer was noted to have
BP 84/54, HR 113, sat 100% on 2L. CXR with "L.sided white out".
.
In [**Hospital1 18**] ED, initial vitals T-99.4, 95/61, hr 121, 16, 100% on
2L-cold, clammy on presentation. On exam decreased bowel sounds
on L.side. The patient's abdomen was non-tender, non-distended,
and had b/l nephrostomy tubes with cloudy/turbid outpt.
Upon transfer to the MICU the patient was started on
phenylephrine for pressor support briefly. His coverage was
broadened to cefepime/vanc/cipro. The patient mental status and
hemodynamics improved. Discussions with the patient and sister
resulted in a DNR/DNI discussion. As the patient is now stable
with a diagnosis of urosepsis, organism to be determined he is
called out to the medical floor.
.
At the time of transfer to the general medicine floors, the
patient is resting comfortably with pain controlled. He is
concerned about the cleanliness of his enviroment and the
temperature of his new room.
.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, abdominal pain, nausea, vomiting,
diarrhea, constipation, melena, hematochezia
Past Medical History:
Metastatic Colon CA: lung, liver, kidneys, bone, throat.
Chronic pain
GERD
Social History:
Pt lives in [**Location **], formerly lived in Hospice facility. Denies
smoking, ETOH, drug use. Ambulates with a cane.
Family History:
Non-contributory
Physical Exam:
Admission physical exam:
Vitals:T. 99.5, BP 101/54, HR 133, RR 22 sat 98% 4L
General: writing in pain, moaning
HEENT: Nc/AT, EOMI, anicteric, poor dentition.
Neck: supple
Lungs: b/l ae, diminished BS, anteriorly.
CV: Regular rate and rhythm, normal S1 + S2, tachycardic
Abdomen: +bs, +multiple areas of tubing/fistula etc.
urine-cloudy.
GU: no foley
Ext: warm, well perfused, 2+ pulses
neuro: somnolent, answers some questions AAOx1
Pertinent Results:
Admission laboratories:
[**2101-9-15**] 03:58PM BLOOD WBC-11.9* RBC-3.65* Hgb-10.7* Hct-33.2*
MCV-91 MCH-29.3 MCHC-32.2 RDW-15.6* Plt Ct-272
[**2101-9-15**] 03:58PM BLOOD Neuts-92.2* Lymphs-5.9* Monos-1.2*
Eos-0.5 Baso-0.1
[**2101-9-18**] 10:11AM BLOOD PT-12.3 PTT-27.7 INR(PT)-1.0
[**2101-9-15**] 03:58PM BLOOD Glucose-98 UreaN-24* Creat-1.2 Na-136
K-3.6 Cl-102 HCO3-24 AnGap-14
[**2101-9-16**] 03:37AM BLOOD ALT-24 AST-39 LD(LDH)-651* AlkPhos-238*
TotBili-0.6
[**2101-9-16**] 03:37AM BLOOD Albumin-2.5* Calcium-7.3* Phos-3.3
Mg-1.2*
[**2101-9-15**] 03:58PM BLOOD calTIBC-229* Ferritn-880* TRF-176*
Iron-9*
[**2101-9-16**] 03:37AM BLOOD TSH-0.93
[**2101-9-15**] 04:13PM BLOOD Lactate-1.6
Urinalysis:
[**2101-9-15**] 04:30PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.017
[**2101-9-15**] 04:30PM URINE Blood-MOD Nitrite-POS Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2101-9-15**] 04:30PM URINE RBC-21-50* WBC->50 Bacteri-MANY
Yeast-NONE Epi-0-2
EKG ([**2101-9-15**]): Artifact is present. Sinus tachycardia. Normal
tracing. Compared to the previous tracing there is no
significant change.
Rate PR QRS QT/QTc P QRS T
116 130 70 314/412 61 8 8
Imaging:
CT of the chest/pelvis/abdomen ([**2101-9-15**]):
CT OF THE CHEST WITHOUT IV CONTRAST: A left subclavian catheter
terminating
in the right atrium is noted. There is no axillary, mediastinal,
supraclavicular adenopathy. There is an 8 mm right thyroid lobe
nodule. The patient LUL collapse with a left hilar mass. There
are multiple bilateral pulmonary nodules, consistent with known
history of malignancy, metastatic lung cancer. Evaluation of
hilar structures is limited given lack of IV contrast, however,
there is fullness adjacent to the left upper lobe bronchus with
suggestion of a mass measuring 1.9 x 2.6 cm, may relate to
patient's known malignancy (2:19). There are innumerable
bilateral pulmonary nodules, largest in the right lower lobe,
measuring 2.3 x 1.3 cm and 2.0 x 1.9 cm. There are bilateral
pleural effusions. There is right lower lobe consolidation may
reflect atelectasis given enhancement.
CT OF THE ABDOMEN WITHOUT IV CONTRAST: Livery demonstrates fatty
infiltration. The gallbladder, spleen, pancreas are within
normal limits. The right adrenal demonstrates a mass, measuring
2.1 x 1.6 cm, suspicious for adrenal metastases. There are
multiple mesenteric lymph nodes, in the
gastrosplenic ligament, measuring up to 1.2 cm and may reflect
metastatic
nodes. The patient has an indwelling vena caval filter. There
are bilateral nephrostomy tubes. The right kidney is otherwise
unremarkable. The leftkidney demonstrates mild hydronephrosis
and hydroureter, could be due to clogged PCN tube, which is
appropriately positioned in the renal pelvis. There is no
intraperitoneal free fluid or free air.
There is a left paramedian colostomy. There is a right lower
quadrant
ileostomy. Small amount of contrast is noted in the small bowel.
CT OF THE PELVIS WITHOUT IV CONTRAST: There is marked soft
tissue thickening and fullness in the deep pelvis effacing the
normal fat planes and limiting differentiation between bladder,
prostate and residual rectum. It extends from the sacral
promontry to the pubic symphysis. There is no inguinal or
pelvicsidewall adenopathy. The largest inguinal lymph node on
the right measures up to 1 cm.
OSSEOUS STRUCTURES: There are no osteolytic or osteosclerotic
lesions.
IMPRESSION:
1. Innumerable pulmonary nodules, right adrenal metastases,
mesenteric nodes, pelvic soft tissue mass, left peri hilar mass,
and left upper lobe collapse, findings consistent with
metastatic lung cancer.
2. A hydronephrotic left kidney with percutaneous nephrostomy
tube in situ
and moderate left hydronephrosis and hydroureter possibly due to
compression/infiltration from the pelvic mass and clogged PCN
tube.
3. Bilateral Pleural effusions and RLL atelectasis.
4. Fatty Liver
Culture data:
[**2101-9-17**] 2:44 pm URINE Source: Kidney LEFT NEPHROSTOMY.
**FINAL REPORT [**2101-9-20**]**
URINE CULTURE (Final [**2101-9-20**]):
PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 8 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM------------- 2 S
PIPERACILLIN---------- 32 S
PIPERACILLIN/TAZO----- 64 S
TOBRAMYCIN------------ <=1 S
[**2101-9-17**] 2:45 pm URINE Source: Kidney RIGHT NEPHROSTOMY.
**FINAL REPORT [**2101-9-19**]**
URINE CULTURE (Final [**2101-9-19**]):
YEAST. 10,000-100,000 ORGANISMS/ML..
PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES PERFORMED ON CULTURE # 279-0219P [**2101-9-17**].
Brief Hospital Course:
Assessment and Plan: Pt is a 51 y.o male with h.o colon ca who
presents with hypotension found to have sepsis due to UTI.
.
1. Sepsis due to UTI: The patient was stabilized in the ICU with
IV fluids and broad spectrum antibiotics including Vancomycin,
Zosyn, and Cipro. Repeat lactates were normal. Although his
SBP~80, the patient was mentating well initially, but then grew
more somelent. His status improved with antibiotic treatment,
intravenous fluids and brief pressor treatment with Neo. Once
stabilized, he was transferred to the general medicine floors.
The patient had a positive urinanalysis and urine cultures
revealed Pseudomonas growing in both of his nephrostomy tubes
which is sensitive to Cefepime. Vancomycin and Cipro were
discontinued in light of the sensitivities. While on the floors
the patient was normotensive and afebrile without any complaints
of shortness of breath, fevers, chills, or abdominal pain.
Of note, his right nephrostomy bag also grew yeast on the urine
culture. Since he is on antibiotic treatment, he was not covered
for yeast. Once his antibiotic course ends on [**10-6**], if he is
still growing yeast in his urine, one could consider treatment
for his yeast.
The patient had bouts of tachycardia to 120s during his stay on
the floors which responded to high 90s with fluid boluses. He
did not have any episodes of hypoxia, hemoptysis or chest pain
concerning for PE. His pain was well controlled. Of note, the
patient says that he has a baseline tachycardia.
2. Metastatic colon cancer: A CT scan of the chest, abdomen and
pelvis revealed extensive metastases. The patient is s/p bowel
resections with a colostomy, stoma and bilateral nephrostomies.
The patient stated that he is full code and wants chemotherapy
for his disease. Contact was made with the primary oncologist
who thought in [**Month (only) **]/[**Month (only) 205**] that he was not a good candidate for
further chemotherapy treatment. His pain regimen was changed
while in the hospital to Fentanyl patch 100 mg, lidocaine patch,
Morphine Sulfate 4.5 mg SL Q2H:PRN pain, Morphine SR 90 mg PO
Q8H pain, Gabapentin 600 mg PO TID, Naproxen 250 mg PO Q12H:PRN
and Tylenol PRN. He stated that his home pain regimen sedated
him too much.
.
3. Leaking right nephrostomy tube: Interventional radiology
evaluated the tube and said that the tube was not currently
leaking. It might have been leaking secondary to either kinking
or increased debris. Once the debris was flushed, it was not
leaking. If the tube leaks, then interventional radiology would
have to be contact[**Name (NI) **].
.
4. Anemia of chronic disease and iron deficiency anemia: The
patient remains and lab values reveal an anemia of chronic
disease and iron deficiency anemia. His Fe/TIBC ratio is less
than 5% and his iron levels are low (Fe=9). He was started on
iron supplementation. His hematocrit remained stable (Hct on
discharge=28.2).
.
5. Chronic Prednisone use: The patient is on his home dose of
prednisone. He states that his prednisone helps his neuropathy,
but the his primary care physician and oncologist do not know
why he takes prednisone. The use needs to be addressed for its
immunosuppressive effects, especially in light of his recent
infection.
Outpatient followup:
1. Address goals of care for his metastatic cancer.
2. Once antibiotic treatment ends on [**10-6**], check a urine
culture. If the culture still has yeast growing, contact a
physician to consider treating the yeast.
3. Address the reason why the patient uses prednisone.
Medications on Admission:
tylenol prn
ativan q4hrs
roxanol 20mg/ml, 4.5ml SL Q2hrs for pain
naproxen 220 [**Hospital1 **]
zofran
MSIR 90mg q3hrs prn
fentanyl 100mcg/patch
neurontin 600mg QID
lidoderm 5% patch
omeprazole 20mg daily
KCL 40meq in am
zoloft 100mg daily
prednisone 10mg [**Hospital1 **]
Neurontin 600 mg Tab Oral
Discharge Medications:
1. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6HR:PRN
as needed for fever or pain: Do not exceed 4 grams per day.
2. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO q4HR: PRN as
needed for anxiety.
3. Roxanol Concentrate 20 mg/mL Solution Sig: 4.5 mL PO Q2HR:PRN
as needed for pain: Sublingually.
4. Naproxen Sodium 220 mg Tablet Sig: One (1) Tablet PO BID:PRN
as needed for pain. Tablet(s)
5. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q4HR:PRN as needed for nausea.
6. BenGay Ultra Strength [**2102-6-9**] % Cream Sig: One (1)
application Topical PRN as needed for pain: Please apply to
right knee.
7. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
8. Gabapentin 600 mg Tablet Sig: One (1) Tablet PO three times a
day.
9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
10. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
One (1) Capsule, Sustained Release PO once a day.
11. Sertraline 100 mg Tablet Sig: One (1) Tablet PO once a day.
12. Prednisone 10 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
13. Bacid Capsule Sig: Two (2) Capsule PO twice a day.
14. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) patch Topical once a day.
15. MS Contin 30 mg Tablet Sustained Release Sig: Three (3)
Tablet Sustained Release PO every eight (8) hours.
16. Morphine Concentrate 20 mg/mL Solution Sig: Four (4) mg PO
Q2H (every 2 hours) as needed for pain.
17. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
18. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
19. Docusate Sodium 50 mg/5 mL Liquid Sig: Five (5) mL PO BID (2
times a day).
20. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
21. Cefepime 1 gram Recon Soln Sig: One (1) Recon Soln Injection
Q8H (every 8 hours) for 15 days.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 9188**] care and Rehab Ctr
Discharge Diagnosis:
Primary:
1. Sepsis due to UTI
.
Secondary
1. Metastatic colon cancer
2. Anemia
Discharge Condition:
Stable. On room air. Pain well controlled. Ambulating with
assistance.
Discharge Instructions:
You came to the hospital because you were not feeling well. You
were found to have an infection with bacteria called Pseudomonas
growing in your urine. You were first in the ICU and then when
stabilized came to the general medicine floors. While on the
general medicine floors, you did not have a fever or low blood
pressure. You will leave with an antibiotic called Zosyn which
will treat your infection.
.
Your right nephrostomy tube started to leak while in the
hospital. The interventional radiologist came to evaluate you
and said that your tube was fine. It was probably leaking due to
a kink in the tube. If it happens again, you should unkink the
tube. If you are having problems with the tube, you can call the
interventional radiology department at [**Hospital3 **] [**Telephone/Fax (1) **].
At other hospitals, they also have interventional radiology
departments that would help.
You should come back to the hospital or call your primary care
physician if you have any fevers, chills, abdominal pain,
shortness of breath, or chest pain.
Followup Instructions:
We made an appointment with your oncologist to discuss your
goals of care.
Appointment #1
MD: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **] MD
Specialty: Oncology
Date and time: [**10-3**] at 11am.
Location: [**Location (un) 83209**], [**Apartment Address(1) **]; [**Location 21487**], [**Numeric Identifier 83210**]
Phone number: [**Telephone/Fax (1) 52208**]
ICD9 Codes: 5990, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3464
} | Medical Text: Admission Date: [**2148-12-2**] Discharge Date: [**2148-12-11**]
Date of Birth: [**2066-10-30**] Sex: M
Service: MEDICINE
Allergies:
Ace Inhibitors
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
HD catheter placed [**2148-12-4**]
PICC line placed [**2148-12-4**]
Intubation
History of Present Illness:
The patient is an 82 year old male with a history of CRI being
set up for HD, DM, and HTN who presented after a syncopal
episode. The patient is being transitioned to HD due to
continually worsening renal function. He is followed by Dr.
[**Last Name (STitle) **] of nephrology, with daily kayexalate and frequent
electrolyte monitoring. By report, the patient has not had his
usual daily bowel movements for 3 days and had missed a
scheduled lab check on the day of presentation due to a major
snowstorm that was blanketing the [**Location (un) 86**] metropolitan area at
the time.
On the morning of presentation, the patient awoke nauseous and
not feeling well, got up to go to the bathroom and felt dizzy.
He was witnessed by his family to syncopize, and was
unresponsive for a few minutes. Following the event, he
continued to feel light headed and nauseous. The patient
complained of low back pain throughout the day. It was unclear
if this was due to trauma. EMS was called, evidently after a
pre-syncopal event (per second-hand account of patient??????s
grandson) on the evening of presentation; he had not clearly
worsened during the day before that according to his grandson.
When EMS arrived the patient continued to vomit, his HR was 80,
BP 90/50, and he was taken to [**Hospital3 **].
At [**Hospital3 **], the patient was found to be in a junctional
bradycardia as low as 15; he had a BP 105/70, Cr of 3.5, and K
was 6.5. He got 0.5 of atropine, then 1mg of atropine without
effect. Transcutaneous pacer pads were used, but due to concern
of low blood pressure, no sedation was given, and shocks were
discontinued when they did not capture. The patient was
transferred to [**Hospital1 18**] CCU for transvenous pacing.
On transport, Mr [**Known lastname **]??????s HR remained 18-20 with SBP of 105-147,
with an oxygen saturation of 92% on a NRB. On arrival to the
floor, the patient was found to be minimally responsive with
labored breathing. An ABG was obtained, with a gas of
7.02/43/102, potassium of 7.3, and lactate of 7.0. Ten (10)
units of insulin and 50ml of dextrose were administered. The
patient's breathing became increasingly agonal, and bag
ventilation was intiated. His pulse became thready and systolic
blood pressures dropped into the 60s. Dopamine was started, and
quickly up titrated to 20. The patient was by this time in PEA
arrest and a code blue was called. The patient was ultimately
intubated. With absent pulse, chest compressions were intiated.
The patient received a total of 3 amps of atropine, 2 pushes of
epi, 2g of calcium, and 2 amps of bicarb. The patient regained a
normal HR at 80 and BP of 120/50.
Renal was emergently consulted. A temporary HD line was placed
and CVVH was initiated. He was difficult to ventilate initially
until it was recognized that he had a right mainstem bronchus
intubation; his ETT was pulled back and his oxygenation
improved. Since then, by report he has remained stable on the
ventilator. He had a CT scan of his abdomen for which a
preliminary read suggested colitis and pancreatitis without
contrast extravasation into the peritoneum. When he was
transferred to the MICU he remained on dopamine as a pressor but
the nursing staff were soon able to stop this, after which his
pressures remain stable and MAPS remained >65.
Past Medical History:
Diabetes
Hypertension
CRI for last 3 year, now nearing dialysis, believed [**1-13**] to DM,
HTN,
- LUE AV fistula placed [**6-18**] with poor maturation
- s/p fistulogram and balloon angioplasty of mid outflow vein
stenosis on [**8-19**]
BPH s/p TURP
Anemia [**1-13**] to CKD (baseline Cr 31)
Renal Osteodystrophy
Gout
Social History:
Occupation: Former construction worker in [**Country 3992**]
Drugs: unk
Tobacco: smoked in past, quit 20 yrs ago per family
Alcohol: v occasional EtOH per family
Other: Pt [**Name (NI) 27558**]; lives with daughter in [**Name (NI) 5110**]
Family History:
Father: Died in 50's, unsure of cause
Mother: Died in 80's of MI, no history of renal disease
Physical Exam:
Tmax: 36.6 ??????C (97.8 ??????F)
Tcurrent: 36.5 ??????C (97.7 ??????F)
HR: 84 (33 - 93) bpm
BP: 116/46(69) {86/37(-29) - 171/54(90)} mmHg
RR: 22 (17 - 23) insp/min
SpO2: 100%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 56.6 kg (admission): 56 kg
Respiratory
O2 Delivery Device: Endotracheal tube
Ventilator mode: CMV/ASSIST/AutoFlow
Vt (Set): 400 (400 - 400) mL
RR (Set): 22
RR (Spontaneous): 0
PEEP: 8 cmH2O
FiO2: 60%
RSBI Deferred: Hemodynamic Instability
PIP: 20 cmH2O
Plateau: 18 cmH2O
Compliance: 40 cmH2O/mL
SpO2: 100%
ABG: 7.42/42/200/27/3
Ve: 8.2 L/min
PaO2 / FiO2: 333
Physical Examination
General Appearance: Well nourished
Head, Ears, Nose, Throat: Endotracheal tube, OG tube
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : )
Abdominal: Soft, Distended Non-tender, Bowel sounds faintly
present
Extremities: Right: Trace, Left: Trace
Skin: No rashes/petichiae in limited exam
Neurologic: Responds to: voice, intermittently
Pertinent Results:
On Admission:
[**2148-12-2**] 02:50AM BLOOD WBC-13.7*# RBC-2.91* Hgb-8.6* Hct-26.2*
MCV-90 MCH-29.4 MCHC-32.6 RDW-14.7 Plt Ct-193
[**2148-12-2**] 03:30AM BLOOD Neuts-66.3 Lymphs-29.3 Monos-0.4* Eos-3.4
Baso-0.4
[**2148-12-2**] 03:30AM BLOOD Glucose-606* UreaN-62* Creat-3.4* Na-140
K-5.9* Cl-109* HCO3-20* AnGap-17
[**2148-12-2**] 06:11AM BLOOD ALT-328* AST-293* LD(LDH)-587* AlkPhos-50
TotBili-0.6
[**2148-12-2**] 03:30AM BLOOD Calcium-13.5* Mg-2.1
[**2148-12-2**] 02:58AM BLOOD Type-ART pO2-103 pCO2-48* pH-7.02*
calTCO2-13* Base XS--19
[**2148-12-2**] 02:58AM BLOOD Lactate-7.0* K-7.3*
[**2148-12-2**] 03:40AM BLOOD freeCa-1.62*
.
Imaging:
ECHO on Admission: Normal global and regional biventricular
systolic function. Diastolic dysfunction. Trace aortic
regurgitation.
.
Body CTA: 1. Very severe atherosclerosis of the aorta with
multiple ulcerated plaques and eccentric thrombus. 40% stenosis
of the origin of the celiac artery. Very severe stenosis of the
right common iliac artery. Very severe stenosis of the right
renal artery with atrophic right kidney. Moderately severe left
renal artery stenosis. 2. Edema of the right and transverse
colon, could be related to colitis. No pneumatosis and no free
air. 3. Peripancreatic edema with retroperitoneal free fluid,
could be related to pancreatitis in the appropriate clinical
setting. Gallbladder enhancement and common bile duct
enhancement could also be related to pancreatitis. 4. Small
amount of ascites. 5. Large third duodenum diverticulum. 6.
Nonobstructive right vesicoureteral junction ureterolithiasis.
7. Right upper lobe peribronchial nodules, likely
postinflammatory or postinfectious. Scattered lung nodules,
should be followed in one year to ensure stability. 8. Signs of
anemia. 9. ETT tip less than 1 cm above the carina, should be
pulled back for optimal placement. Foley catheter balloon
inflated in the prostate.
.
CXR: Right PICC terminates in the mid superior vena cava. Heart
size,
mediastinal, and hilar contours are within normal limits. The
lungs
demonstrate no focal areas of consolidation. No definite pleural
effusion. Minimal relatively symmetrical biapical thickening.
Bones are diffusely
demineralized with slight decrease in height of several
vertebral bodies.
IMPRESSION: No evidence of pneumonia.
.
Right upper extremity ultrasound: Thrombus within the right
cephalic vein. No evidence of deep venous thrombus within the
right upper extremity.
.
Right knee: No signs for acute fractures or dislocations.
Mineralization is
within normal limits. There are mild degenerative changes with
spurring of
the medial and lateral compartments as well as of the
patellofemoral and
tibial spines. There is no significant joint effusion. No bony
erosions are
present. Vascular calcifications are seen.
.
Micro:
URINE CULTURE (Final [**2148-12-5**]):
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ <=1 S
.
Labs on Discharge:
[**2148-12-11**] 04:21AM BLOOD WBC-13.3* RBC-3.08* Hgb-8.8* Hct-24.9*
MCV-81* MCH-28.6 MCHC-35.3* RDW-19.9* Plt Ct-411
[**2148-12-10**] 04:48AM BLOOD Neuts-83.9* Lymphs-9.1* Monos-5.8 Eos-1.1
Baso-0.1
[**2148-12-11**] 04:21AM BLOOD Glucose-144* UreaN-63* Creat-2.5* Na-135
K-3.7 Cl-99 HCO3-24 AnGap-16
[**2148-12-4**] 02:51AM BLOOD ALT-100* AST-57* LD(LDH)-246 AlkPhos-30*
TotBili-0.6
[**2148-12-3**] 04:40AM BLOOD Lipase-68*
[**2148-12-11**] 04:21AM BLOOD Calcium-7.5* Phos-4.4 Mg-2.3
[**2148-12-7**] 03:18AM BLOOD calTIBC-207* Ferritn-205 TRF-159*
[**2148-12-5**] 07:27AM BLOOD Vanco-4.5*
Brief Hospital Course:
82 yo M with T2DM, HTN, CKD near ESRD, admitted with syncope,
found to be hyperkalemia with junctional bradycardia, s/p PEA
arrest now recovered after CVVH and HD.
.
MICU/CCU Course according to problem:
# Hypotension: Mr [**Known lastname **] was hypotensive in the CCU, even after his
hyperkalemia and bradycardia were corrected. He had a high
lactate. His CT scan included findings of possible pancreatitis
(supported by high pancreatic enzymes) and colitis (which might
be source of high but now lower lactate). His lactate is
declining which is reassuring; however, his pancreatic enzymes
are rising and fluid balance will need to be watched closely.
Sepsis may have been an underlying issue; cultures are pending.
In the MICU:
* hypotension resolved [**12-2**]-> pt hypertensive
* restarted [**First Name9 (NamePattern2) 3782**] [**Last Name (un) **] and hydralazine, imdur
* persistent hypertension, was started on nitro gtt [**12-4**].
* titrated up PO BP meds and nitro gtt turned off [**12-7**] early
AM.
.
# Bradycardia: Mr [**Known lastname **] was transferred to the [**Hospital1 18**] CCU from
[**Hospital3 **] originally because of bradycardia refractory to
transcutaneous pacing attempts. The bradycardia was in the
setting of severe hyperkalemia, and although he first had a PEA
cardiac arrest requiring resuscitation, his arrythmias resolved
after correction of potassium in the [**Hospital1 18**] CCU. Agree with CCU
assessment that potassium level is likely source of his original
bradycardia and likely his syncopal and pre-syncopal events
described by his family.
* resolved [**12-2**], no new episodes in the MICU; continued to hold
nodal blockers
.
# Hyperkalemia: Patient had failed to get labs checked and
kayexelate was not producing usual BM. Presented with K of 7.3,
and likely etiology of patients arrythmia, which had corrected
with short term interventions. Patient??????s symptoms of dizziness,
nausea, and vomiting likely secondary to uremia/hyperkalemia
given timing, though underlying infection is a possibility. HD
line was placed in CCU and dialysis was conducted.
.
# CKD: Secondary to DM/HTN and being transitioned to HD with
ESRD. Likely contributing to hyperkalemia [**1-13**] ineffective
kayexalate.
* tunneled line placed [**12-4**], last RRT 12/24
.
* [**12-4**] HCT drop in setting of self discontinuation of fem line
(patient pulled out) - CT abd/pelvis negative for intra or
retroperitoneal bleed, received 2 units of PRBCs. Anemia stable
.
# Respiratory Distress: Patient with agonal breathing on
presentation, poor oxygenation with large A-a gradient.
Intubated in setting of PEA arrest.
* extubated w/o complication [**12-3**]
# DM: Patient on glyburide as an outpatient. Patient had glucose
of 606 in CCU with consistent hyperglycemia; may be secondary to
pancreatic injury. Resolved.
.
Hospital course on general medicine floor by problem:
.
# Leukocytosis: Elevated to 17, unclear etiology. Patient
developed low grade fever (T max 100.2). Urine, CXR and blood
culture negative growth. HD and PICC line pulled prior to d/c.
Asymptomatic other than right knee pain. Patient with history of
gout, no erythema or warmness on exam, but uric acid elevated to
8.8. Leukocytosis could have been related to mild gout flare
(see below). Patient was afebrile > 48hr with negative cultures
and decreasing leukocytosis prior to discharge.
.
# Hypertension : Moderately well-controlled 130-40s. Avoiding
increasing nodal blockade in the setting of recent bradycardia.
Started Amlodipine 5 mg this admission. Patient was discharged
on Amlodipine plus prior outpatient medications.
.
# Knee pain: Symptoms have improved. Right knee without warmth,
erythema or tenderness. Full range of motion on exam. Patient
does have history of gout and uric acid is elevated. Avoid any
NSAID treatment for gout due to unstable renal function. Knee
film demonstrated no abnormalities. Pain improved prior to
discharge.
.
# Anemia: The patient dropped his Hct in the setting of losing
his femoral HD line. After 2 units PRBCs has stabilized at 26.
No other evidence of bleeding. Chronic anemia most likely due to
renal disease. Patient on EPO [**2139**] units [**Hospital1 **]/ 2 x weekly while
in house. Discharged on outpatient EPO dose.
.
# Enterococcus UTI: Treated with Ampicillin for 7 day course.
.
# CKD: Acute elevation in creatinine most likely ATN related to
hypovolemia. Chronic renal disease secondary to DM/HTN. Last HD
session on [**12-4**]. Good urine output (> 2 L), lytes in normal
limits therefore temporary HD line was removed. However, was
slowly increasing since stopping dialysis (from 2 to 2.5 over
three days). Mild creatinine increase could have been due to
ibuprofen dose 12/28 for ? gout (ibuprofen was discontinued).
Patient will require very close follow-up with Renal.
.
# PEA Arrest: Likely related to hyperkalemia, presumably from
ESRD. Has recovered very well with no obvious morbidity.
Underlying rhythm was a junctional bradycardia.
Patient was monitored on tele while on the floor.
Medications on Admission:
ALLOPURINOL - 200 mg daily
CALCITRIOL - 0.25 mcg Capsule every Monday and Friday
CINACALCET - 30 mg Tablet once a day
EPOETIN ALFA [PROCRIT] 6000 units (s/c q 6 weeks
FINASTERIDE - 5 mg Tablet - 1 Tablet(s) by mouth daily
FUROSEMIDE - 40 mg Tablet [**Hospital1 **]
GLIPIZIDE - 5 mg daily
LACTULOSE - PRN constipation
LOSARTAN [COZAAR] - 100 mg daily
SEVELAMER HCL [RENAGEL] - 800 mg three times a day with meals
SIMVASTATIN - 20 mg daily
VERAPAMIL - 240 mg Cap,24 hr once a day
Discharge Medications:
1. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO every
monday and friday.
2. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day.
6. Losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO three
times a day: with meals.
8. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Verapamil 240 mg Cap,24 hr Sust Release Pellets Sig: One (1)
Cap,24 hr Sust Release Pellets PO once a day.
10. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
11. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
12. Bacitracin-Polymyxin B 500-10,000 unit/g Ointment Sig: One
(1) Appl Ophthalmic Q8H (every 8 hours).
13. Homatropine HBr 2 % Drops Sig: One (1) Drop Ophthalmic DAILY
(Daily).
14. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*2*
15. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
16. Epoetin Alfa 4,000 unit/mL Solution Sig: 6,000 units
Injection every 6 weeks.
Discharge Disposition:
Home
Discharge Diagnosis:
PEA arrest
Bradycardia
Acute on chronic renal failure requiring emergent dialysis
Hyperkalemia
Urinary tract infection
Hypertension
Discharge Condition:
Good, ambulating.
Discharge Instructions:
You were admitted for passing out. During your hospital stay you
had a cardiac arrest, and was consequently intubated and
transferred to the medical ICU. You were found to have renal
failure and high potassium and was consequently started on
dialysis. Your renal failure improved and you no longer required
dialysis. You were treated for a urinary tract infection.
.
Review your medication list closely. The following changes were
made to your medications:
1. Imdur 90mg daily should be taken for your blood pressure
every day
2. You should also take amlodipine 5mg daily for your blood
pressure
.
Attend all follow up appointments. It is very important you
follow your kidney function closely with your kidney doctor and
primary care doctor.
.
Return to the ER if you experience dizziness, passing out, chest
pain, difficulty breathing, fever, chills or any other
concerning symptoms.
Followup Instructions:
You have an Appt with Dr [**Last Name (STitle) **]: Sunday [**12-15**] at 11:45
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2540**], RN Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2148-12-18**] 8:30
Provider: [**Name10 (NameIs) **] OPTOMETRY Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2149-1-16**]
2:45
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] AV CARE AV CARE [**Location (un) **]
Phone:[**Telephone/Fax (1) 5537**] Date/Time:[**2149-2-3**] 8:30
Completed by:[**2148-12-14**]
ICD9 Codes: 5845, 5990, 2767, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3465
} | Medical Text: Admission Date: [**2159-3-20**] Discharge Date: [**2159-3-21**]
Service: NEUROLOGY
Allergies:
No Allergies/ADRs on File
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Stroke as OSH transfer
Major Surgical or Invasive Procedure:
none
History of Present Illness:
[**Known firstname 2013**] [**Last Name (NamePattern1) **] is an 87 year old right handed woman with a
history of hypertension and Afib who presents aftering being
found unresponsive today. The patient lives in an [**Hospital3 12272**] community and today she apparently didn't show up for a
meal. She was found this eveing laying on her left side,
unresponsive. GCS was 5. She was initially brought to [**Hospital **]
hospital and vitals on arrival were T 99.8, HR 68, RR 32, 94% on
NRB. She was intubated and treated with versed, fentanyl,
dilantin and 1L NS. WBC was 13, Hct 40, PLT 249. She was
transferred to [**Hospital1 18**] for further care.
Past Medical History:
Hypertension
Pacemaker
Atrial fibrillation
Arthritis
? CHF (EF unknown)
No prior strokes
Social History:
Widowed 15 years ago. Lives in [**Hospital3 **]. Her daughter
[**Name (NI) 2411**] is her health care proxy. [**Name (NI) **] smoking, alcohol or
tobacco.
Family History:
Hypertension, brother with malignancy, mother died of stroke in
her 60s, father with stroke in his older age.
Physical Exam:
General: intubated, off sedation
Head and Neck: right [**Last Name (un) 2599**] hematoma, left facial swelling.
Chemosis of the bilateral conjunctive. MM moist.
Pulmonary: Lungs clear to auscultation bilaterally
Cardiac: sounds irregular, mild SEM appreciated.
Abdomen: soft, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: 2+ radial, DP pulses bilaterally.
Skin: entire left side with marked ecchymoses. She has areas of
blistering across her chest and shoulder, with some skin tears.
Neurologic:
Intubated, off sedation. Does not open her eyes or follow
commands, Right pupil ovoid with likely anterior lens
replacement. Left 2mm and reactive. Eyes not deviated at rest.
EOM appear intact. Moves all but the left upper extremity
spontaneously and to noxious. Reflexes 2+ on right, trace on
left. Increased tone in the Bilateral lower extremities, but
left side overall slightly decreased tone than right. Left toe
up.
Pertinent Results:
CT head: Right sided proximal MCA stroke. Atrophy. See official
read on OMR.
Brief Hospital Course:
Patient [**Name (NI) 90247**] was admitted as an OSH transfer after being
found down and having a CT head demonstrate a large Right MCA
stroke. She was a DNR/DNI before arrival but had no
representative with her. She was transferred to [**Hospital1 **] for further
care. Her family was at bedside and after being provided the
appropriate update in terms of clinical status she was made CMO.
Medications on Admission:
Pramipexole .25mg [**Hospital1 **] (?)
Metoprolol 40mg QD
furosemide 40mg daily
lisinopril 5mg daily
tramadol 50mg qhs
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
Passed away
Discharge Condition:
n/a
Discharge Instructions:
n/a
Followup Instructions:
n/a
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
Completed by:[**2159-8-9**]
ICD9 Codes: 4019, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3466
} | Medical Text: Admission Date: [**2169-12-31**] Discharge Date: [**2170-1-5**]
Date of Birth: [**2094-11-9**] Sex: M
Service: [**Year (4 digits) 662**]
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
Femoral line placed
History of Present Illness:
75 y/o M [**First Name3 (LF) **] speaking only PMH ESRD on HD, CAD, PAF, COPD,
HTN who presensts with altered mental status of 2 days duration.
Initially felt to be secondary to percocet use at rehab, but HD
facility was concerned and sent patient to be evaluated. Per
family patient is AOx3 at baseline but has been more confused
recently. Notes slow decline over several days since being at
the rehab. States he was also given a "sleeping pill" the day
before admission. Family did not notice any increased cough,
SOB, or fever.
.
Patient was recently admitted [**Date range (3) 5527**] for left humeral
fracture, hypoxia and inability to care for himself at home. For
left humeral fracture patient was evaluated by ortho who
recommended sling. Hypoxia was felt to be secondary to mild COPD
exacerbation and was treated with aggressive neb therapy and
oral steroids. At time of discharge his O2 sats were 90% on RA
with occasional desats to the high 80s and discharged on 1L NC
to be weaned as tolerated. Patient was discharged to rehab.
.
In the ED, initial VS were: 96.9 86 107/84 22 91. Patient spiked
a temp to 100.2. rectally. CT head demonstrated no
abnormalities. CXR demonstrated right lower lobe infiltrate.
Patient was given levofloxacin and zosyn and 1L NS. A groin CVL
was placed. His LUE was noted to be swollen and echymotic but an
u/s revealed no DVT. Ortho evaluated it in the ED and
recommended continued sling and NWB. He was agitated and
confused, so received 5mg Zyprexa. Vitals on transfer were 98.8
rectal, HR 63, BP 149/52, RR 13, 100% facemask. He would
reportedly desat to upper 80s on 6L NC so he was admitted to the
MICU for further care.
.
On the floor, still mildly agitated and confused. Unable to
obtain further ROS.
Past Medical History:
-ESRD on HD via left AVF from polycystic kidney disease.
HD-M,W,F on [**State **] St in [**Location (un) **]
-Asymptommatic Bradycardia/WCT: [**Company 1543**] single-lead pacemaker
placed
-CAD - cath here in [**2155**] with moderate ramus intermedius disease
(discrete 50% stenosis) and mild diastolic ventricular
dysfunction
-PAF with [**Year (4 digits) 5509**] documented once in the ED in [**3-/2167**]
-ETT [**2153**]: Atypical symptoms in the absence of ischemic ECG
changes or reversible defects by thallium to the acheived low
level of exercise
-Asthma/COPD
-Hypertension
-Prostate CA [**2160**]
-recent left humeral fracture
Social History:
Patient currently lives at rehab but lived alone before (wife
has passed away recently). [**Year (4 digits) 595**] speaking only. Currently
smokes <10 cigs/day for 60yrs, [**1-13**]/wk EtOH, no ilicit drug use.
Family History:
Denies significant family history.
Physical Exam:
Gen: Well appearing elderly man in NAD
Eye: extra-occular movements intact, pupils equal round,
reactive to light, sclera anicteric, not injected, no exudates
ENT: mucus membranes moist, no ulcerations or exudates
Neck: no thyromegally, JVD: flat
Cardiovascular: regular rate and rhythm, normal s1, s2, no
murmurs, rubs or gallops
Respiratory: Clear to auscultation bilaterally, no wheezes,
rales or rhonchi
Abd: Soft, non distended, no heptosplenomegaly,
bowel sounds present. Mildly tender to palpation in RUQ and LLQ.
Extremities: Left arm in sling, painful with movement, warm, 2+
radial pulse, sensation intact, ecchymotic, no cyanosis,
clubbing, joint swelling
Neurological: Alert and oriented x2, CN II-XII intact, normal
attention, sensation normal
Pertinent Results:
Labs during event leading to death:
[**2170-1-5**] INR(PT)-7.8*
[**2170-1-5**] Hct-25.2*
[**2170-1-5**] 06:28PM BLOOD Type-ART pO2-74* pCO2-53* pH-7.21*
calTCO2-22 Base XS--7
[**2170-1-5**] 06:12PM BLOOD Glucose-161* UreaN-66* Creat-5.1*# Na-144
K-6.8* Cl-97 HCO3-20* AnGap-34*
Lactate 11.4
.
Labs on admission:
[**2169-12-31**] 06:50PM BLOOD WBC-10.3 RBC-3.26* Hgb-9.8* Hct-30.5*
MCV-94 MCH-30.1 MCHC-32.1 RDW-17.5* Plt Ct-177
[**2169-12-31**] 06:50PM BLOOD Neuts-95.1* Lymphs-3.5* Monos-1.0*
Eos-0.1 Baso-0.2
[**2169-12-31**] 06:50PM BLOOD PT-19.4* PTT-47.3* INR(PT)-1.8*
[**2169-12-31**] 06:50PM BLOOD Glucose-98 UreaN-33* Creat-3.2*# Na-145
K-3.7 Cl-100 HCO3-32 AnGap-17
[**2169-12-31**] 06:50PM BLOOD ALT-36 AST-43* LD(LDH)-380* AlkPhos-90
TotBili-0.5
.
Other pertinent labs:
[**2170-1-2**] 06:00AM BLOOD Vanco-13.4
[**2170-1-3**] 09:28AM BLOOD Vanco-22.4*
[**2170-1-4**] 05:55AM BLOOD Vanco-21.5*
[**2169-12-31**] 07:01PM BLOOD Lactate-2.2* K-3.7
[**2170-1-1**] 12:06AM BLOOD Lactate-2.0
[**2170-1-5**] 06:28PM BLOOD Lactate-11.4*
[**2170-1-1**] 05:59AM BLOOD ALT-12 AST-42* LD(LDH)-339* CK(CPK)-220*
AlkPhos-49 TotBili-0.5
.
[**2169-12-31**] 06:50PM URINE RBC-21-50* WBC-0-2 Bacteri-OCC Yeast-NONE
Epi-0
[**2169-12-31**] 06:50PM URINE Blood-LG Nitrite-NEG Protein-500
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG
.
[**2169-12-31**] INR(PT)-1.8*, INR(PT)-2.1*, [**2170-1-1**] INR(PT)-1.8*,
[**2170-1-2**] INR(PT)-2.0*, [**2170-1-3**] INR(PT)-2.9*, [**2170-1-4**]
INR(PT)-5.2*, [**2170-1-4**] INR(PT)-4.5*, [**2170-1-5**] INR(PT)-5.1*,
[**2170-1-5**] INR(PT)-7.8*
[**2170-1-3**] Hct-26.4, Hct-27.2* [**2170-1-4**] Hct-28.0*, [**2170-1-4**]
Hct-26.9*, [**2170-1-5**] Hct-25.4*, [**2170-1-5**] Hct-26.1*,
.
[**2169-12-31**] 6:50 pm BLOOD CULTURE
**FINAL REPORT [**2170-1-6**]**
KLEBSIELLA OXYTOCA. FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
KLEBSIELLA OXYTOCA
|
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- 8 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Anaerobic Bottle Gram Stain (Final [**2170-1-1**]):
GRAM NEGATIVE ROD(S).
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5528**] AT 14:08PM ON [**2170-1-1**].
Aerobic Bottle Gram Stain (Final [**2170-1-1**]): GRAM NEGATIVE
ROD(S).
.
[**Date range (3) 5529**] blood cx negative
.
[**2169-12-31**] 6:50 pm URINE Site: CLEAN CATCH
URINE CULTURE (Final [**2170-1-1**]): NO GROWTH.
.
[**2170-1-5**] 3:51 pm STOOL **FINAL REPORT [**2170-1-6**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2170-1-6**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
.
[**2169-12-31**] CT head:
IMPRESSION: No acute intracranial abnormality. No significant
change in
cerebral volume loss and chronic microvascular ischemic changes.
Bilateral
maxillary sinus disease.
.
[**2169-12-31**] Humerus AP/Lat:
LEFT HUMERUS, THREE VIEWS: Evaluation is limited by patient
positioning.
Within this limitation, there is no significant change in the
comminuted left humeral neck fracture with approximately 2 cm of
foreshortening. There is nodislocation. There is no new
fracture. There is subtle soft tissue calcification noted on the
second and third images at the level of the fracture which may
represent early callous formation. No radiopaque foreign body is
identified.
.
[**2169-12-31**] RUE Ultrasound:
IMPRESSION: No evidence of DVT. Exam is limited due to
patient-related
factors.
.
[**2170-1-1**] Abdomen upright:
IMPRESSION: No evidence of obstruction; incomplete assessment
for free air -upright or left lateral decubitus views are
recommended to better assess for perforation.
.
[**2170-1-2**] RUQ ultrasound:
IMPRESSION:
1. Innumerable cysts seen within the liver and right kidney.
2. Focally distended gallbladder at the fundus without signs of
cholecystitis. If clinically indicated, a HIDA scan could be
performed to
further assess for cholecystitis. No gallstone is identified.
3. No biliary dilatation and no ascites in the right upper
quadrant.
.
[**2169-12-31**]:
SINGLE AP VIEW OF THE CHEST: Evaluation is limited by patient
position.
Compared to the prior study, there is increased opacity at the
right lung base concerning for infection. An opacity in the
right upper lung is stable
compared to prior and may represent a calcified granuloma. The
heart is
enlarged and there is a small residual right pleural effusion.
The left
costophrenic angle is excluded from view. A single lead follows
a normal
course from a right-sided battery pack terminating in the
expected position
over the right ventricle. There is a left tunneled internal
jugular catheter terminating at the cavoatrial junction. There
is no pneumothorax. Left humeral fracture better evaluated on
dedicated humeral radiographs.
.
[**2170-1-3**] Video Swallow:
FINDINGS: Barium passed freely through the oropharynx and
esophagus without
evidence of obstruction.
There was aspiration with thin consistency.
.
[**2170-1-5**] CXR:
FINDINGS: As compared to the previous radiograph, the patient
has taken a
better inspiration. There is unchanged extent of the bilateral
basal areas of opacity. However, no opacity has newly occurred
in the interval. Moreover, no evidence of pulmonary edema is
seen. The size of the cardiac silhouette is unchanged. Unchanged
moderate tortuosity of the thoracic aorta, unchanged position of
central venous access line and the right-sided pacemaker.
Brief Hospital Course:
Assessment and Plan:
75 year old [**Month/Day/Year 595**] speaking male with hx of COPD, CAD, and
recent humerus fracture presents with altered mental status and
found to have pneumonia and GNR bacteremia on [**2169-12-31**].
.
#. His hospital course is detailed below. On the evening of
[**2170-1-5**] I was called to evaluated him for "being less
responsive and looking more blue." He was DNR/DNI at the time.
His initial BP was normal and then we were unable to obtain a
blood pressure. O2 sats were being obtained on his forehead as
he was satting higher on his forehead than on his digits earlier
in the day. His initial o2 sat was 90 and then was
unobtainable. He was noted to be in agonal breathing and had
fixed non responsive pupils (minimally responsive pupils per
neuro). A code stroke was immediately called. Fluids were
opened wide. Labs were obtained and notable for pH
7.21 pCO2 53 pO2 74 on non rebreather, lactate of 11.4, WBC
22.4, HCT stable at 25.2, INR of 7.8, and potassium of 6.8 (this
K+ was obtained within 1 min of his death and thus no medication
had been administered). FFP was ordered and brought down to the
CT scanner but arrived within minutes of his death. The patient
was rushed to the CT scanner for a head CT without contrast.
While at the CT scanner he had an episode of bloody emesis. He
died within seconds of his CT scan being completed and the scan
showed no evidence of bleed or stroke. His family members and
his primary care physician were [**Name (NI) 653**] about his death and
declined autopsy. Dr. [**Last Name (STitle) **] was being updated throughout the
code stroke. He likely did from a GI bleed in the setting of a
high INR.
.
#. Klebsiella Bacteremia: His blood cx on [**2169-12-31**] were positive
for pansensitive Klebsiella bacteremia and he was on cefepime.
Subsequent blood cultures were found to be negative from
[**Date range (1) 5530**].
.
# Pneumonia: His CXR showed RUL and RLL PNA. He was being
treated with vancomycin and cefepime given need to cover for HAP
and he was on flagyl for possible HAP. He had a new oxygen
requirement throughout his hospitalization and he was continued
on nebulizers. He was never able to produce a sputum for us.
His blood cx grew Klebsiella as detailed above.
.
#. Elevated WBC: His elevated WBC was thought to be secondary to
PNA and klebsiella bacteremia. He was afebrile for several days
prior to his death. His white count trended up to 23 and then
remained stable between 17-18 until the time of his death when
his WBC was 22.4. His stool was negative for c diff. His
abdominal exam was followed and was benign and he denied
abdominal pain.
.
# Altered Mental Status: His CT scan of his head was negative.
His AMS was likely due to bactermia and PNA. His mental status
improved after he started treatment for his PNA & bacteremia and
then again after narcotic medications & clonazepam were
discontinued. The days prior to his death he was oriented to
himself and his location. The only exception to this was the
evening of [**2170-1-4**] when he received a dose of pain medication
for his broken humerus and he delirius. His family member (who
speaks [**Name (NI) 595**]) noted to me early in the day on [**2170-1-5**] that he
was much clear compared to the evening before and knew where he
was and who he was.
.
# Anemia: His HCT was 30.5 on arrival on [**2169-12-31**]. His HCT
remained stable in the 25-28 range for the several days prior to
his death and his transfusion threshold was<25. Please see
humerus fracture below. On [**2170-1-4**] ortho came to evaluate the
patient as his left arm (where he had humeus fracture) looked
larger and there was concern that he could be bleeding into it
in the setting of his elevated INR. His HCT was followed closely
and was stable. He had no evidence of compartment syndrome on
exam. He was found to be guaiac positive on exam but was having
rare bowel movements. The late morning of his death he had
question of coffee ground emesis. This was discussed with the
attending and it was decided not to place an NG tube in the
setting of a high INR. The patient was started on an IV PPI.
.
# Elevated INR: He was given reduced dosing of coumadin given
that he was on antibiotics. His INR became supratherapeutic on
[**1-4**] to 5.9. On the morning of [**1-5**] his INR was 5.1. His
coumadin was held. In the setting of ? coffee ground emesis
(detailed below under anemia section) on [**1-5**] in AM he was
given vitamin K.
.
# COPD: He was on standing nebs and advair with a clear lung
exam.
.
# ESRD: He received dialysis throughout his hospitalization. He
had one episode of hypotension post dialysis but otherwise
tolerated it well.
.
# Humerus fracture: On [**2170-1-4**] ortho came to evaluate the
patient as his left arm (where he had humerus fracture) looked
larger and there was concern that he could be bleeding into it
in the setting of his elevated INR. His HCT was followed closely
and was stable. He had no evidence of compartment syndrome on
exam. Pain was controlled with tylenol and lidocaine and no
narcotics were given since they were thought to contribute to
his AMS.
.
# Paroxysmal atrial fibrillation: He was continued on home
dronedarone and diltiazem. His coumadin was held in the setting
of his high INR.
.
# Hypertension, benign: He was continue on his home diltiazem,
lisinopril, and valsartan.
.
# Coronary artery disease: He was continued on his home ACE,
[**Last Name (un) **], and aspirin
.
# Dementia: He was continued on his home Aricept.
.
# Depression: He was continued on his home citalopram.
.
# FEN: He was on a puree diet and nectar thick liquids given
concern for aspiration and was followed by speech and swallow.
Medications on Admission:
1. Clonazepam 1 mg PO QHS as needed for insomnia.
2. Citalopram 20 mg PO DAILY
3. Warfarin 5 mg t PO QHS
4. Simvastatin 10 mg PO QHS
5. Donepezil 5 mg PO HS
6. Amylase-Lipase-Protease 60,000-12,000- 38,000 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Capsule, Delayed
Release(E.C.) PO once a day.
7. Montelukast 10 mg PO DAILY
8. Fexofenadine 180 mg PO DAILY
9. Lisinopril 20 mg PO BID
10. Hyoscyamine Sulfate 0.375 mg Capsule, Sust. Release 12 hr
Sig: One (1) Capsule, Sust. Release 12 hr PO BID
11. Valsartan 80 mg PO DAILY
12. Aspirin 81 mg PO DAILY
13. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1)
Capsule PO once a day.
14. Fluticasone-Salmeterol 250-50 mcg [**Hospital1 **]
15. Tiotropium Bromide 18 mcg DAILY
16. Diltiazem HCl 60 mg PO BID
17. Dronedarone 400 mg PO BID
18. Sevelamer Carbonate 800 mg PO TID W/MEALS
19. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Q6H
20. Ipratropium Bromide 0.02 % Q6H
21. Lidocaine 5 %(700 mg/patch) Q24H (every 24 hours)
as needed for shoulder pain.
22. Oxycodone-Acetaminophen 5-325 mg 1-2 Tablets PO
every 4-6 hours as needed for pain
23. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
24. Lactulose (30) ML PO Q8H as needed for constipation.
25. Docusate Sodium 100 mg PO BID
27. Prednisone taper: Now on 20mg qdaily x 2d, then take 10mg
x2d, then stop.
Discharge Medications:
Deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
Deceased
Discharge Condition:
Deceased
Discharge Instructions:
Deceased
Followup Instructions:
Deceased
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
Completed by:[**2170-1-17**]
ICD9 Codes: 486, 5856, 7907, 311, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3467
} | Medical Text: Admission Date: [**2115-3-19**] Discharge Date: [**2115-3-26**]
Date of Birth: [**2062-8-25**] Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Shellfish / Percocet / Codeine / Sulfa (Sulfonamide Antibiotics)
/ Ceclor / Darvocet-N 100 / Flexeril / Dilaudid / Valium /
Zithromax / Ace Inhibitors / doxicycline / Cardizem / Toprol XL
/ Verapamil / Catapres / Atacand / Norvasc / Levaquin / Cipro /
Floxin / Prednisone / Adhesive / Latex
Attending:[**Attending Info 65513**]
Chief Complaint:
Elective Surgery
Major Surgical or Invasive Procedure:
TAH-BSO debulking of ovarian cancer
History of Present Illness:
52 year old female with h/o multiple drug allergies, complex
pelvic mass now s/p TAH-BSO for excision and staging.
.
Patient initally presented to PCP [**Name Initial (PRE) **] abdominal pain and anorexia
several weeks prior to this admission. Pelvic ultrasound
positive for a 7cm cystic mass posterior to the uterus. MRI
showed a 9cm cystic mass arising from the right ovary with
<1.5cm nodes in the perirectal areas and some nodes anterior to
the IVC. CA-125 was 46. Notably, she also has complete
duplication of her lower gynecologic tract including a vertical
vaginal septum and a didelphic uterus/cervix. She presented for
surgery.
Past Medical History:
Asthma, mild
Hypertension
GERD s/p Nissen
Seasonal allergies
Back pain
Carpal tunnel surgery
Ulnar neurosurgery
Achilles tendon repair
Nissen fundoplication
Cholecystectomy
Lithotripsy
Social History:
She smoked, but quit 15 years ago. Denies alcohol or drug
abuse. She works in the Police Department.
Family History:
Breast cancer in paternal aunt and grandmother.
Ovarian cancer, none. Uterine or cervical cancer in her sister.
Physical Exam:
Exam upon admission to ICU:
Vitals: afebrile, 88 87/49 99% on Assist Control
(500/5/16bpm/50%O2)
General: intubated, spontaneously moving all extremities
HEENT: Sclera anicteric, PERRL, MMM, oropharynx clear
Neck: Supple, no JVD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: midline incision w bandage c/d/i, soft, non-distended,
quiet bowel sounds, no guarding
GU: +foley
Ext: cool, 2+ pulses, no clubbing, cyanosis or edema
Pertinent Results:
ADMISSION EXAM:
[**2115-3-19**] 10:46PM TYPE-ART PO2-158* PCO2-46* PH-7.33* TOTAL
CO2-25 BASE XS--1
[**2115-3-19**] 10:46PM LACTATE-3.7*
[**2115-3-19**] 10:26PM GLUCOSE-171* UREA N-15 CREAT-0.7 SODIUM-142
POTASSIUM-4.2 CHLORIDE-109* TOTAL CO2-23 ANION GAP-14
[**2115-3-19**] 10:26PM CALCIUM-8.4 PHOSPHATE-4.0 MAGNESIUM-1.8
[**2115-3-19**] 10:26PM WBC-17.3*# RBC-4.54 HGB-12.9 HCT-38.8 MCV-86
MCH-28.5 MCHC-33.3 RDW-13.5
[**2115-3-19**] 10:26PM NEUTS-92* BANDS-0 LYMPHS-5* MONOS-3 EOS-0
BASOS-0
[**2115-3-19**] 08:28PM TYPE-ART PO2-135* PCO2-39 PH-7.40 TOTAL
CO2-25 BASE XS-0 INTUBATED-INTUBATED VENT-CONTROLLED
[**2115-3-19**] 07:05PM TYPE-ART PO2-187* PCO2-40 PH-7.40 TOTAL
CO2-26 BASE XS-0 INTUBATED-INTUBATED VENT-CONTROLLED
[**2115-3-19**] 07:05PM HGB-11.4* calcHCT-34
[**2115-3-19**] 04:14PM GLUCOSE-115* LACTATE-1.8 NA+-138 K+-2.9*
CL--103
[**2115-3-19**] 04:14PM HGB-11.3* calcHCT-34
DISCHARGE LABS:
[**2115-3-21**] 06:20AM BLOOD WBC-12.8* RBC-4.07* Hgb-11.6* Hct-34.2*
MCV-84 MCH-28.4 MCHC-33.9 RDW-14.2 Plt Ct-200
[**2115-3-22**] 06:20AM BLOOD WBC-9.5 RBC-3.56* Hgb-10.8* Hct-30.0*
MCV-84 MCH-30.4 MCHC-36.1* RDW-14.1 Plt Ct-179
[**2115-3-23**] 05:40AM BLOOD WBC-8.9 RBC-3.71* Hgb-10.6* Hct-31.2*
MCV-84 MCH-28.6 MCHC-34.1 RDW-14.1 Plt Ct-184
[**2115-3-24**] 05:30AM BLOOD WBC-7.4 RBC-3.90* Hgb-11.2* Hct-32.5*
MCV-83 MCH-28.7 MCHC-34.5 RDW-14.0 Plt Ct-230
[**2115-3-25**] 06:10AM BLOOD WBC-6.8 RBC-3.81* Hgb-11.4* Hct-33.6*
MCV-88 MCH-29.8 MCHC-33.9 RDW-13.8 Plt Ct-222
[**2115-3-26**] 06:20AM BLOOD WBC-9.0 RBC-4.26 Hgb-12.7 Hct-35.7*
MCV-84 MCH-29.8 MCHC-35.6* RDW-14.2 Plt Ct-291
[**2115-3-21**] 06:20AM BLOOD PT-13.9* PTT-22.9 INR(PT)-1.2*
[**2115-3-22**] 06:20AM BLOOD Glucose-99 UreaN-8 Creat-0.5 Na-142 K-3.5
Cl-104 HCO3-30 AnGap-12
[**2115-3-23**] 05:40AM BLOOD Glucose-83 UreaN-10 Creat-0.5 Na-141
K-3.5 Cl-103 HCO3-29 AnGap-13
[**2115-3-24**] 05:30AM BLOOD Glucose-89 UreaN-7 Creat-0.5 Na-137 K-3.4
Cl-101 HCO3-28 AnGap-11
[**2115-3-25**] 06:10AM BLOOD Glucose-100 UreaN-7 Creat-0.5 Na-138
K-3.9 Cl-104 HCO3-26 AnGap-12
[**2115-3-26**] 06:20AM BLOOD Glucose-108* UreaN-8 Creat-0.6 Na-140
K-3.8 Cl-104 HCO3-25 AnGap-15
[**2115-3-21**] 03:34AM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
[**2115-3-21**] 3:34 am URINE Source: Catheter.
**FINAL REPORT [**2115-3-22**]**
URINE CULTURE (Final [**2115-3-22**]): NO GROWTH.
Brief Hospital Course:
52 year old female with h/o multiple drug allergies, complex
pelvic mass now s/p TAH-BSO. Please see operative note for
details.
.
[**Hospital Unit Name 153**] Course:
The patient was transferred to the [**Hospital Unit Name 153**] after during her
TAH-BSO. She required 2 U PRBCs intraoperative. Her vitals on
arrival with SBP 70s s/p this blood and 6L LR. Her hypotension
was thought to be secondary to third spacing in the setting of a
protracted abdominal surgery v. medication effect from propofol.
BP improved throughout her stay. She received another 1 U PRBCs
in the ICU, with HCT stable around 36-38. She arrived in the
[**Hospital Unit Name 153**] intubated but was successfully extubated. Her WBC post op
was 17 but she remained afebrile so this was thought to be due
to a stress response to protracted surgery. She received
amp/gent/flagyl intra-operatively but no additional antibiotics
in the [**Hospital Unit Name 153**]. She was kept NPO as there was concern for ileus
post surgery secondary to mobilization of bowl. IV PPI was given
for history of GERD.
She was transferred to the floor the afternoon of POD#1. She was
put on a morphine PCA for pain control. Her diet was advanced on
POD#4 after she had flatus, then to regular on POD#6. Her Hct
was stable. She did have a temperature to 101 on POD#1, and a
urine culture was done and came back normal. Her pain
medications were switched to PO. She became ambulatory. She was
discharged home in good condition on POD #7.
Medications on Admission:
Vitamin D
Asmanex
Triamterene/HCTZ 37.5/25mg po daily
Protonix 40mg po daily
Claritin
Singulair 10mg po daily
Xopenex - hasn't used in months
Discharge Medications:
1. levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:
Three (3) ML Inhalation q 6 hours () as needed for prn
SOB/wheezing.
2. morphine 10 mg/5 mL Solution Sig: 2.5-5 ml PO Q4H (every 4
hours) as needed for pain: each mL has 2mg of morphine. Do not
take more than 5 mL at once.
Disp:*500 ml* Refills:*0*
3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
4. acetaminophen 650 mg/20.3 mL Solution Sig: 20.3 mL PO Q6H
(every 6 hours).
Disp:*2436 mL* Refills:*2*
5. ibuprofen 100 mg/5 mL Suspension Sig: Thirty (30) mL PO Q6H
(every 6 hours).
Disp:*500 mL* Refills:*2*
6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
7. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Asmanex Twisthaler 110 mcg (30 doses) Aerosol Powdr Breath
Activated Sig: One (1) daily Inhalation daily ().
9. Claritin 10 mg Tablet Sig: One (1) Tablet PO once a day.
10. Dyazide 37.5-25 mg Capsule Sig: One (1) Capsule PO once a
day.
Discharge Disposition:
Home
Discharge Diagnosis:
Ovarian cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Nothing in your vagina for 3 months.
No heavy lifting for 6 weeks.
You may shower, but no baths for 3 weeks.
Continue to take acetaminophen and ibuprofen around the clock.
You make take liquid morphine on top of this as needed for pain.
Please also take Colace, a stool softener, twice daily while
taking these medications. You may take Milk of Magnesia for
constipation.
Please stay active while at home.
Please follow-up with your primary care doctor to discuss
management of your other medications.
Restart all your home medications. Hold your blood pressure
medication if you feel dizzy or light-headed.
Followup Instructions:
Provider: [**Name10 (NameIs) 35354**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 5777**]
Date/Time:[**2115-4-1**] 11:30 - Staple removal
Provider: [**Name10 (NameIs) 35354**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 5777**]
Date/Time:[**2115-4-8**] 9:00 - Post-op follow-up
Please call Dr.[**Name (NI) 89880**] office for an appointment to
discuss chemotherapy. His number is ([**Telephone/Fax (1) 34323**].
[**Name6 (MD) 35354**] [**Name8 (MD) **] MD [**MD Number(2) 65515**]
Completed by:[**2115-3-30**]
ICD9 Codes: 5180, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3468
} | Medical Text: Admission Date: [**2159-9-18**] Discharge Date: [**2159-10-1**]
Date of Birth: [**2088-7-13**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2605**]
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pt is a 71 yo F with Down's syndrome and Alzheimer's dementia,
also s/p [**First Name3 (LF) 4448**] who initally presented with fever, cough and
agitation for 2-3 days. Pt reported abdominal pain but no other
complaints. Per nursing home staff, she was eating and drinking
normally with no diarrhea. No known sick contacts. [**Name (NI) **] reports of
sputum. Pt otherwise has been in USOH. Had swallow eval in [**9-2**]
which showed only microaspiration.
.
In the ED the pt was febrile to 101.2. She had a KUB and
abdominal CT, as well as CXR. She was given IV fluids and
swallow study was ordered. She was started on vanco, levo, and
flagyl.
Past Medical History:
Down's Syndrome
Alzheimer's dementia
s/p [**Date Range 4448**]
osteoporosis
rosacea
Raynauds
OCD
Social History:
Pt lives in nursing home. Per chart no tobacco or alcohol. The
pt's guardian ([**Name (NI) **] ARC) from her group home changed her code
status to DNR/DNI for this admission.
Family History:
Unable to obtain.
Physical Exam:
PE: T 96.5 ax BP 95/48, HR 71 RR 12 O2 96% shovel mask wt
103lbs
Gen: sitting up in bed, not following commands, agonal
breathing, audible wheeze.
HEENT: PERRL, NCAT, MMM
Neck: no LAD, ? JVD (unable to assess fully due to mask
ventilation)
Cor: RRR, III/VI systolic murmur heard best at LUSB, s1s2
Pulm: difuse insp and exp wheezing. Poor air movement, decreased
BS at bilateral bases.
Abd: soft, NT, distended, small ventral hernia noted, no HSM,
hyperactive BS.
Ext: mild erythema of hands and wrists. Warm and well perfused.
Neuro: unable to examine
Pertinent Results:
Labs on admission:
[**2159-9-23**] 07:20AM BLOOD WBC-8.8 RBC-3.45* Hgb-11.1* Hct-32.7*
MCV-95 MCH-32.1* MCHC-33.8 RDW-13.6 Plt Ct-287
[**2159-9-23**] 07:20AM BLOOD Plt Ct-287
[**2159-9-22**] 07:05AM BLOOD Glucose-89 UreaN-4* Creat-0.6 Na-134
K-4.1 Cl-101 HCO3-26 AnGap-11
[**2159-9-23**] 07:20AM BLOOD Calcium-7.8* Phos-4.5 Mg-1.7
[**2159-9-23**] 01:33PM BLOOD Type-ART pO2-129* pCO2-52* pH-7.37
calHCO3-31* Base XS-3
[**2159-9-23**] 09:36AM BLOOD Type-ART pO2-55* pCO2-49* pH-7.39
calHCO3-31* Base XS-3
.
CXR: Persistent bilateral pulmonary opacities consistent with
pneumonia, possibly slightly increased right lung base and
decreased on the left side. No pneumothorax.
.
CT abdomen ([**9-19**]): Bibasilar airspace consolidations with small,
bilateral pleural effusions. Otherwise, unremarkable CT of the
abdomen and pelvis.
.
KUB ([**9-19**]): fecal material demonstrated throughout the colon.
Limited study. No definite evidence for bowel obstruction or
free intraperitoneal air.
.
TTE: The left atrium is elongated. There is mild symmetric LVH.
The LV cavity size is normal. Overall LV systolic function is
normal (LVEF>55%). RV chamber size and free wall motion are
normal. The aortic valve leaflets (3) are mildly thickened to
moderately. There is mild aortic valve stenosis. Mild to
moderate ([**12-31**]+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild to moderate ([**12-31**]+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
.
Based on [**2150**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate a moderate risk (prophylaxis
recommended).
.
.
CXR [**9-26**]: Mild-to-moderate pulmonary edema, largely basilar, has
improved and small-to-moderate bilateral pleural effusions are
also smaller compared to [**9-25**]. Severe cardiomegaly
and/or pericardial effusion is stable. A component of pneumonia
particularly in the severely congestive lower lungs cannot be
excluded. Transvenous right atrial and right ventricular pacer
leads in standard placements are unchanged. No pneumothorax.
Brief Hospital Course:
She was admitted, hydrated 3L NS, had KUB and abdominal CT (done
for c/o abd pain) which was neg. On the floor on the first
hospital day, the pt remained afebrile but became quite agitated
and had increased respiratory distress satting in the high 80s,
as well as hypotension to SBP 80/40. She was given 100% O2 by
face mask, and 1.5L fluid bolus, to which she did not respond. A
foley was placed and the patient immediately put out 1L of
yellow urine. Later that evening, she was transferred to the
[**Hospital Unit Name 153**] for increased nursing needs in the setting of low sat and
hypotension. ABG 7.43/30/54 on RA. In the [**Hospital Unit Name 153**], the pt's
hypotension eventually resolved with fluids. She has been
saturating well first on O2 by nasal cannula and then on room
air. She had no more complaints of abdominal pain since the
foley catheter was placed. She had nl BMs. The pt became very
agitated and inconsolably crying and was given zydis, with good
results. The pt then desatted to the 80s on RA and was given
lasix and placed on a shovel mask, which returned her sats to
the high 90s. CXR at that time had revealed worsening CHF.
Repeat CXR the next AM showed improved pulmonary edema and
worsening LLL pneumonia. Pt was transferred back to [**Hospital Unit Name 153**] for
respiratory distress to receive Bipap. Patient did not tolerate
BiPAP and was weaned to face mask.
On the floor her respiratory distress was thought to be PNA with
a component of CHF (and volume overload from 6+L of IVF). For
her institutionally acquired (CAP in nursing home) vs aspiration
pneumonia completed a course of azithro, vanc x 2 days, zosyn x
4 days, and then was transitioned to PO levo and flagyl. She
received 2 days of steroids as well. She received Q6 hour nebs.
She needed soft restraints to keep her Nasal Cannula on. She
also received 2 doses of IV lasix to diurese patient, after CXR
showed significant pulmonary edema.
.
The patient's low-grade fever resolved on the floor. Her
leukocytosis worsened upon transfer so the patient was started
on flagyl IV on [**9-25**] for possible C.diff (loose BMs that morning
as well) and coverage for possible aspiration PNA. The patient
was transitioned to PO levo and flagyl for pneumonia. On
discharge she was satting well on 2L NC. Stool cultures for
C.diff were negative.
.
The patient passed video swallow study on [**9-25**] and was able to
take pureed food and thin liquids. She had good PO intake on
discharge. Aspiration precautions were maintained.
.
Her foley was removed on [**9-29**] with less than 100cc of post-void
residual. On discharge the patient was urinating spontaneously.
.
The patient had a delicate fluid balance while on the floor,
requiring gentle diuresis with lasix. CXR showed signs of
improving CHF. TTE showed good EF and it was found that the
patient meets AHA criteria for endocarditis prophyllaxis. On
the day prior to discharge the patient was over-diuresed and
became hypotensive to 80/50, requiring a 500cc bolus.
.
The patient's donepezil and celexa were restarted once the
patient was taking PO.
.
The patient was DNR/DNI for this admission per guardian.
Communication was with her GB ARC Guardian, [**Name (NI) **] at
[**Telephone/Fax (1) **].
Medications on Admission:
celexa 10 mg PO qday
tylenol 325mg PO prn
Ca carbonate 1000mg PO qday
ASA 81 mg PO qday
aricept 5mg PO qday
trazadone 25mg qhs
Zyprexa PRN
Zosyn
Vanco
Azithromycin
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for fever, pain.
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
3. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
4. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for sob, wheeze.
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily): please crush in pureed food.
6. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily):
please crush in pureed food.
7. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime):
please crush in pureed food.
8. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 4 days.
9. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 4 days.
10. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day) as needed for agitation.
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
12. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
13. Calcium 500 with Vitamin D 500-125 mg-unit Tablet Sig: Two
(2) Tablet PO once a day: please crush in pureed food.
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) 1687**] - [**Location (un) 745**]
Discharge Diagnosis:
Pneumonia
.........
Alzheimer's Dementia
Down's Syndrome
Discharge Condition:
stable - satting 94-99% on 4L NC. tolerating PO well,
ambulating.
Discharge Instructions:
Please return with increased shortness of breath, decreased
blood pressure (SBP <90), fever > 101.5, or any other worrisome
symptoms.
.
Please take all medications as directed.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 719**] Date/Time:[**2159-10-4**]
12:00
.
Provider: [**Name10 (NameIs) **] CALL Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2159-10-18**]
11:45
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2608**] MD, [**MD Number(3) 2609**]
ICD9 Codes: 5070, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3469
} | Medical Text: Admission Date: [**2184-10-10**] Discharge Date: [**2184-10-18**]
Date of Birth: [**2129-2-16**] Sex: M
Service: MEDICINE
Allergies:
Demerol
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
SOB, Syncope
Major Surgical or Invasive Procedure:
none
History of Present Illness:
55 year old male with a PMH of STEMI s/p stent '[**79**] who stopped
his plavix 2 months ago [**2-10**] financial issues, who presents from
[**Hospital3 2737**] with near syncope and SOB.
.
The patient states he was doing yardwork, started walking across
the lawn, felt dizzy and lightheaded for 1 minute and felt like
he was going to pass out. The patient states that this was
nothing like his prior MI. He sat down on his steps where he
"blacked out" for less than 30 seconds and he immediately came
to. FSBG was 168 at that time. His wife called the ambulance
and the patient presented to [**Hospital1 **] where he was worked up for
MI, initial troponin I was .29 and repeat was .6. He was
transfered to [**Hospital1 18**] with concern for ACS on heparin drip.
.
Per patient there has been no recent travel, no smoking, no
prolonged immobilization, though he has been less active at
work.
.
In the ED initial vital signs were 98.5 75 147/86 18 98% 2L NC.
Heparin drip was continued at 1000 unites per hour. CTA
revealed saddle PE, and dopplers revealed a non-obstructive
popliteal clot. No labs were checked and the patient was
admitted directly to the [**Hospital Unit Name 153**]. Vitals at the time of transfer
were 97.8, 70, 151/91, 23, 100 2L
Past Medical History:
Diabtets mellitus, Type II
Hypertension
Hypercholesterolemia
Ruptured Vertebral Disc
Social History:
No alcohol or tobacco use
Family History:
Not relevant
Physical Exam:
General Appearance: Well nourished, Overweight / Obese
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (S1: Normal), (S2: Loud)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : )
Abdominal: Soft, Non-tender, Bowel sounds present, Obese
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent, diffuse scarring
Skin: Warm, Tan
Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Oriented (to): Person, Place, Time, Movement:
Purposeful, Tone: Normal, CNII-XII intact
Pertinent Results:
[**2184-10-10**] 09:30PM BLOOD WBC-10.3 RBC-5.30 Hgb-15.6 Hct-45.3
MCV-86 MCH-29.4 MCHC-34.3 RDW-13.5 Plt Ct-213
[**2184-10-10**] 09:30PM BLOOD PT-13.2 PTT-37.1* INR(PT)-1.1
[**2184-10-10**] 09:30PM BLOOD Glucose-98 UreaN-44* Creat-1.8* Na-140
K-4.0 Cl-106 HCO3-21* AnGap-17
[**2184-10-10**] 09:30PM BLOOD ALT-15 AST-23 LD(LDH)-271* CK(CPK)-204
AlkPhos-76 TotBili-0.4
[**2184-10-10**] 09:30PM BLOOD CK-MB-6 cTropnT-0.09*
[**2184-10-11**] 03:33AM BLOOD CK-MB-5 cTropnT-0.05*
[**2184-10-11**] 12:06PM BLOOD CK-MB-4 cTropnT-0.03*
[**2184-10-10**] 09:30PM BLOOD Calcium-8.8 Phos-4.4 Mg-2.0
Imaging:
[**10-10**] CTA chest:
1. Saddle pulmonary embolus with early evidence of right
ventricular heart
strain. Thrombus burden is very high.
2. Hypoattenuating focus in the left ventricular apex in an area
surrounded
by fibrofatty replaced myocardium is concerning for a left
ventricular apical
thrombus in an area of prior infarct. Further evaluation with
echocardiography is recommended.
[**10-10**] LENI:
Non-occlusive left popliteal vein DVT.
[**10-11**] echo:
Mild focal LV systolic dysfunction consistent with prior mid-LAD
infarction. Early appearance of agitated saline seen in the left
atrium and left ventricle, consistent with a small ASD or PFO.
The right ventricle is probably mildly dilated with borderline
systolic function.
Compared with the prior study (images reviewed) of [**2183-7-19**],
agitated saline was used in the current study and suggests a
small ASD or PFO. The aorta is slightly dilated on the current
study.The right ventricle is mildly dilated/hypokinetic on the
current study. The other findings are similar
Discharge Labs: [**2184-10-18**] 07:30AM
WBC-8.1 RBC-4.85 Hgb-14.1 Hct-41.8 MCV-86 Plt Ct-277
Glucose-160* UreaN-33* Creat-1.7* Na-138 K-4.9 Cl-105 HCO3-21*
AnGap-17
Calcium-9.9 Phos-4.1 Mg-1.9
Brief Hospital Course:
55M presenting with syncope, found to have saddle PE on CTA with
troponin leak.
#Saddle PE, acute: On admission pt was started on weight based
heparin ggt, which was then overlapped with coumadin starting
[**10-11**] with a goal INR [**2-11**]. Patient has remained HD stable
throughout admission, although bradycardic at times, with
excellent oxygenation, no chest pain & no SOB. LENIs show
non-occlusive popliteal vein DVT. TTE suggests small ASD or
PFO, likely visible now given increased right-sided pressures in
the setting of PE. This will need to be adressed in the future
re: potential closing. He will also need age-appropriate cancer
screening in the outpatient setting. an outpt hypercoaguable
workup.
- He will be discharged on Coumadin 5mg, which is the dose he
has been consistently receiving in the hospital. The
[**Hospital3 **] will be in contact with him tomorrow
morning, and will arrange follow-up INR checks. A prescription
for outpatient lab work was given at the time of discharge.
- Of note, CTA, initial echo suggested LV Thrombus. [**10-11**] TTE
shows stable EF at 40-45% (EF at 40-45% in [**July 2183**]). A left
ventricular mass/thrombus cannot be excluded. Cardiology was
consulted who recommed contrast echo for further eval. This did
NOT show any LV thrombus
#Troponin Leak: Most likely right heart strain in the setting
of the PE. Peak trop 0.09 -> 0.05 this AM. EKG unconcerning.
#HTN: Given potential for cardiogenic shock, antihypertensives
were initially held. They were slowly re-introduced with stable
blood pressures. His home medication regimen was resumed prior
to discharge with the exception of Toprol, which was decreased
to 25mg given bradycardia during his hospital stay.
#DM2: Placed on reduced dose 70/30 with HISS coverage. Resumed
to usual dose at discharge.
Medications on Admission:
ASPIRIN - 81 mg po, Delayed Release (E.C.) DAILY
HYDROCHLOROTHIAZIDE - 25 mg po DAILY
LISINOPRIL - 40 mg po DAILY
METOPROLOL SUCCINATE [TOPROL XL] - 50 mg Sust. Rel. 24 hr po
DAILY
AMLODIPINE - 5 mg po DAILY
DOXYCYCLINE MONOHYDRATE - 100 mg Capsule, po BID
GEMFIBROZIL - 600 mg po BID
NITROGLYCERIN
ROSUVASTATIN [CRESTOR] - 20 mg po DAILY
SILDENAFIL [VIAGRA] - 100 mg, 0.5-1.0 Tablets PRN
INSULIN NPH & REGULAR HUMAN [NOVOLIN 70/30] - 100 unit/mL
(70-30)
Suspension - 20 units twice a day or as directed max dose 50 u
per day [**First Name8 (NamePattern2) **] [**Last Name (un) **]
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. doxycycline hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours) for 2 days.
Disp:*3 Capsule(s)* Refills:*0*
5. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
6. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
7. Outpatient Lab Work
Please have your PT/INR checked within two days of discharge.
8. Novolin 70/30 100 unit/mL (70-30) Suspension Sig: Twenty (20)
units Subcutaneous twice a day.
9. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
10. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
11. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Coumadin 2 mg Tablet Sig: 2.5 Tablets PO once a day: Please
take at the same time each day.
Disp:*75 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Acute Pulmonary Embolus
Deep Vein Thrombosis
Patent Foramen Ovale
CAD
Hypertension
Type 2 diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for syncope and found to have a blood clot in
your lung (pulmonary embolus) and blood clot in your leg (DVT).
You were started on heparin to thin your blood. You have been
transitioned to Coumadin. Your INR must be monitored to ensure
a level between [**2-11**]. Avoid any activity that would increase the
risk of bleeding/bruising and eat a consistent diet.
Please follow up with your PCP as scheduled, and have your INR
checked within 2 days of discharge. The [**Company 191**] anticoagulation
service will call you on [**2184-10-19**] to enroll you in their clinic.
Please discuss with them which lab you will be having your blood
drawn at so that the results can be forwarded to their office.
They will be helping to manage your Coumadin dosing going
forward.
Ultrasound of your heart also found an incidental PFO, or small
hole. Please discuss this with your PCP.
The dose of your Toprol was decreased during this
hospitalization due to a low heart rate. Please discuss this
with your PCP. [**Name10 (NameIs) **] other changes were made to your home
medications.
Followup Instructions:
Department: [**Hospital3 249**]
When: THURSDAY [**2184-10-21**] at 1:10 PM
With: Dr. [**First Name4 (NamePattern1) 2184**] [**Last Name (NamePattern1) 2185**] [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
This appointment is with a hospital-based doctor as part of your
transition from the hospital back to your primary care provider.
[**Name10 (NameIs) 616**] this visit, you will see your regular primary care doctor
in follow up.
Department: CARDIAC SERVICES
When: TUESDAY [**2185-1-25**] at 11:30 AM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 2875, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3470
} | Medical Text: Admission Date: [**2168-8-11**] Discharge Date: [**2168-8-13**]
Date of Birth: [**2098-12-13**] Sex: M
Service: MICU
HISTORY OF PRESENT ILLNESS: The patient is a 69 year old man
with a history of hypertension and seizure disorder who was
admitted to the MICU for hypoxia and hypotension. He was in
his usual state of good health until two days prior to
admission when he had the onset of vertigo. Since then, he
increasing lethargy. On the day of admission, he suffered a
syncopal episode which he recalls occurred after vomiting.
He says this was unlike his seizure episodes. He denies head
trauma or loss of consciousness. He also denies fever,
chills, cough, abdominal pain, chest pain, shortness of
breath, hematuria, hematochezia and melena.
evaluation. There he was afebrile and hypotensive with a
systolic blood pressure in the 70s. After three liters of
isotonic intravenous fluids, his blood pressure remained in
the 70s with a heart rate in the 80s to 90s. A nasogastric
tube was placed and lavage was trace positive for blood. An
electrocardiogram was obtained which showed a new right
bundle branch block. The patient's oxygen saturations were
in the 80s in room air but increased to mid 90s on four
liters nasal cannula oxygen.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Seizure disorder since birth, last seizure five years
ago. Generalized tonoclonic seizures.
3. Status post colovesical fistula repair in [**2164**].
4. History of diverticulitis.
MEDICATIONS ON ADMISSION:
1. Primidone 250 mg p.o. t.i.d.
2. Atenolol dose unknown.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: He lives with his wife. [**Name (NI) **] is a retired
restaurant worker and has grown children. The patient smoked
four packs per day for thirty years before quitting in [**2144**].
He denies alcohol use or other drug use.
FAMILY HISTORY: The patient describes several relatives on
his father's side of the family who suffered Alzheimer's
disease. No family history of coronary artery disease,
cancer or diabetes mellitus.
REVIEW OF SYSTEMS: Please see history of present illness.
PHYSICAL EXAMINATION: On admission, vital signs revealed
temperature 98.0, pulse 86, blood pressure 96/52, respiratory
rate 20, oxygen saturation 94% on four liters nasal cannula
oxygen. Head, eyes, ears, nose and throat - The pupils are
equal, round, and reactive to light and accommodation.
Extraocular movements are intact. Bilateral arcus senilis.
Neck - no jugular venous distention, no lymphadenopathy.
Positive retraction. Chest - decreased breath sounds
diffusely with poor air entry. No crackles and no wheezes.
Cardiovascular - normal rate and regular rhythm, no murmurs,
rubs or gallops. Abdomen - soft, nontender, nondistended,
normoactive bowel sounds, no hepatosplenomegaly.
Neurologically, the patient is alert and oriented times
three, but anxious. Cranial nerves II through XII are
intact. Motor strength is 5/5 times four. Deep tendon
reflexes are 1+ and symmetric throughout. No clonus.
LABORATORY DATA: White blood cell count 10.7, hematocrit
47.4, platelets 325,000, 77% neutrophils, 18% lymphocytes, 5%
monocytes. Prothrombin time 13.4, partial thromboplastin
time 27.4. Sodium 145, potassium 3.6, chloride 93,
bicarbonate 28, blood urea nitrogen 44, creatinine 3.2,
glucose 150. Anion gap was 24. Lactate 1.8. ALT 23, AST
49, alkaline phosphatase 114, amylase 96, total bilirubin
0.6. CPK 120, CK MB 1.0, troponin I less than 0.3. Albumin
4.8. Abdomen revealed pH 7.42/45/58.
IMAGING: KUB revealed no free air. Bowel gas pattern
throughout small and large intestines. Chest x-ray revealed
hyperinflated lung fields with flat diaphragms, no
pneumothorax, no infiltrate, appropriate line placement.
Electrocardiogram - normal sinus rhythm, new right bundle
branch block.
HOSPITAL COURSE: The patient's hypoxia, hypotension and new
onset right bundle branch block with new onset syncope were
most worrisome for pulmonary embolism. The patient was
started on Heparin and a VQ scan was obtained because the
creatinine was too high for a CT angiogram. The VQ scan was
low probability. The patient was ruled out for an acute
myocardial infarction. An echocardiogram was also obtained
during this admission which showed hyperdynamic left
ventricle with an ejection fraction of 75%. The right
ventricle had a normal cavity size and normal function. No
evidence of strain. Lower extremity Doppler was also
obtained which showed no clot in his veins.
The patient was started on Dopamine in the Emergency
Department after left subclavian line was placed for blood
pressure support. This was quickly weaned off in the Medical
Intensive Care Unit as the patient's blood pressure responded
well to isotonic fluid resuscitation. Over the course of his
admission after receiving aggressive volume repletion, the
patient's creatinine corrected to 1.6 and his hematocrit
corrected to 35.0.
With a more reassuring creatinine, a CT study of the chest
was obtained with contrast and this was negative for
pulmonary embolism. Pulmonary function tests were also
obtained to identify an etiology for his hypoxia and these
were remarkable for a FEV1/FVC ratio of 70% predicted and
RV/TLC of 118 and a markedly reduced diffusion coefficient of
only 39%. The chest CT was also remarkable for right middle lobe
and right lower lobe cyst formation and interstitial scarring
which are not completely consistent with injury due to tobacco
smoke but more consistent with a pneumoconiosis.
A urine and blood toxicology screen were obtained at the time
of admission to rule out ingestion as the cause of his
hypotension. These were negative except for a positive
barbiturate level which may have been due to sedatives
administered in the Emergency Department.
The patient's antiseizure medication Primidone was held
initially but was then restarted one day after being admitted
and the patient suffered no seizures while in the Medical
Intensive Care Unit. He initially received a dose of
Ampicillin and Gentamicin and Flagyl in the Emergency
Department because they were worried about sepsis as the
cause for his hypoxia and hypotension, however, his clinical
status improved greatly upon receiving aggressive volume
repletion and nasal cannula oxygen and it was felt that both
his history and presentation were inconsistent with an
infectious etiology so antibiotics were discontinued.
The patient's basophil count came back at 3% on [**2168-8-12**].
This was followed up by examining the peripheral blood smear
with a hematology/pathology physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 18081**]. It was his feeling that the smear showed no
evidence of a malignancy. A follow-up differential showed a
basophil count of 0.2%.
The patient's CPKs rose to 465 during his admission, but
serial CPKs after that have returned to the normal range.
On the evening prior to discharge, the patient spiked a
temperature of 101.0. Blood and urine cultures have been
sent off. Stool leukocytes and ova and parasite studies have
also been sent off because it was the feeling of our team
that this illness may have been a severe gastroenteritis that
led to dehydration and volume depletion with subsequent
hypotension.
While on Heparin, the patient suffered mild Foley trauma and
had mild hematuria which appears to be resolving.
CONDITION ON DISCHARGE: The patient is stable and ready for
discharge to home.
DISCHARGE DIAGNOSES:
1. Severe interstial/fibrotic, predominantly lower-lobe,
uncertain etiology (atypical for tobacco- related COPD)
2. Status post severe gastroenteritis.
3. Hypotension secondary to dehydration
4. Epilepsy.
MEDICATIONS ON DISCHARGE: Primidone 250 mg p.o. t.i.d.
FOLLOW-UP:
1. Home oxygen therapy will be arranged by case manager.
2. The patient needs follow-up with pulmonary specialist.
This should be arranged by Dr. [**First Name4 (NamePattern1) **] [**Month (only) 18082**] office.
Dr. [**First Name (STitle) 216**] is the patient's primary care physician.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**], M.D. [**MD Number(1) 2438**]
Dictated By:[**Name8 (MD) 2653**]
MEDQUIST36
D: [**2168-8-13**] 11:40
T: [**2168-8-13**] 16:13
JOB#: [**Job Number 18083**]
ICD9 Codes: 496, 2765, 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3471
} | Medical Text: Admission Date: [**2160-12-26**] Discharge Date: [**2160-12-31**]
Service: MEDICINE
Allergies:
Codeine / Ultram
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
s/p mechanical fall with right femur fracture
Major Surgical or Invasive Procedure:
intubation, R hip hemiarthroplasty
History of Present Illness:
- This is an 85 y/o female with HTN, A fib, HL, COPD, s/p RLL
lobectomy for mycobacterium infection, who presents with a right
femur fracture s/p mechanical fall earlier today. She was out
shopping at [**Company 7546**] earlier today with her family and tripped
over a floor barrier, landing on her right hip. This was a
witnessed fall by her family - per pt and family, no LOC or
hitting of head. Pt denies any preceding dizziness/LH, chest
pain, SOB, palpitations, n/v/. Presented to the ED at 3 pm with
right hip swelling and pain, unable to support weight. She was
found to have a right femur head fracture and was seen by ortho,
plan for OR tomorrow. She now needs medical clearance.
.
At baseline, pt is able to walk [**2-4**] miles comfortably and is
very independent. She can easily climb 2 flights of stair with
groceries. Denies SOB or CP with activity or with rest. Per
daughter, pt had stress test [**10-8**] which was "excellent." No h/o
cardiac intervention. Reports her COPD at baseline, does not use
inhalors.
Past Medical History:
1. Chronic obstructive pulmonary disease, right lower lobe
lobectomy for mycobacterium xenopi infection.
2. Atrial fibrillation, status post two failed
cardioversions.
3. Hypertension.
4. Hypercholesterolemia.
5. Diverticulosis.
6. Status post cholecystectomy.
7. Status post total abdominal hysterectomy, bilateral
salpingo-oophorectomy.
8. Arthritis.
9. Gastroesophageal reflux disease.
Social History:
The patient lives alone on [**Hospital3 **] and visits her daughter who
lives in [**Name (NI) 620**]. Former tobacco use, quit thirty years ago. No
alcohol use. Very active and independent with ADL's. Functional
capacity > 4 mets.
Family History:
noncontributory
Physical Exam:
VS: Tc 98.4, BP 120/72, HR 88, RR 18, SaO2 100%/RA, wt 163.9 lbs
General: Pleasant elderly female in NAD while lying still, AO x
3
HEENT: NC/AT, PERRL, EOMI. No scleral icterus. MMM, OP clear
Neck: supple, no JVD or LAD
Chest: CTA-B, no w/r/r
CV: [**Last Name (un) **], s1 s2 normal, no m/g/r
Abd: soft, NT/ND, NABS, no HSM
Ext: right LE externally rotated, no swelling or lesions noted.
Pulses 2+ b/l
Neuro: AO x 3, non-focal
Pertinent Results:
[**2160-12-26**] 06:35PM BLOOD WBC-11.3* RBC-4.21 Hgb-13.0 Hct-36.6
MCV-87 MCH-30.8 MCHC-35.4* RDW-13.9 Plt Ct-237
[**2160-12-28**] 12:31PM BLOOD Hct-31.9*
[**2160-12-29**] 12:18AM BLOOD WBC-13.6* RBC-3.14* Hgb-9.7* Hct-27.4*
MCV-87 MCH-31.0 MCHC-35.4* RDW-14.0 Plt Ct-199
[**2160-12-29**] 02:22PM BLOOD WBC-8.8 RBC-2.58* Hgb-8.1* Hct-22.7*
MCV-88 MCH-31.5 MCHC-35.9* RDW-13.9 Plt Ct-94*#
[**2160-12-30**] 02:50AM BLOOD WBC-9.5 RBC-3.10* Hgb-9.5* Hct-27.2*
MCV-88 MCH-30.6 MCHC-34.9 RDW-14.4 Plt Ct-103*
[**2160-12-30**] 03:10PM BLOOD Hct-27.2* Plt Ct-134*
[**2160-12-31**] 05:10AM BLOOD WBC-11.1* RBC-3.11* Hgb-9.5* Hct-26.8*
MCV-86 MCH-30.5 MCHC-35.4* RDW-14.6 Plt Ct-168
[**2160-12-26**] 06:35PM BLOOD Neuts-85.8* Lymphs-9.9* Monos-2.6 Eos-1.1
Baso-0.7
[**2160-12-26**] 07:12PM BLOOD PT-12.0 PTT-25.9 INR(PT)-1.0
[**2160-12-31**] 05:10AM BLOOD PT-13.5* PTT-27.6 INR(PT)-1.2*
[**2160-12-26**] 06:35PM BLOOD Glucose-121* UreaN-15 Creat-0.8 Na-135
K-4.2 Cl-95* HCO3-28 AnGap-16
[**2160-12-31**] 05:10AM BLOOD Glucose-114* UreaN-8 Creat-0.4 Na-134
K-3.6 Cl-103 HCO3-21* AnGap-14
[**2160-12-29**] 12:18AM BLOOD CK(CPK)-584*
[**2160-12-29**] 08:15AM BLOOD CK(CPK)-489*
[**2160-12-29**] 02:22PM BLOOD CK(CPK)-385*
[**2160-12-29**] 12:18AM BLOOD CK-MB-10 MB Indx-1.7 cTropnT-0.07*
[**2160-12-29**] 02:22PM BLOOD CK-MB-6 cTropnT-0.07*
[**2160-12-27**] 06:47AM BLOOD Calcium-8.7 Phos-3.2 Mg-1.8
[**2160-12-31**] 05:10AM BLOOD Calcium-8.0* Phos-2.0* Mg-1.8
[**2160-12-30**] 02:50AM BLOOD Hapto-171
[**2160-12-29**] 08:15AM BLOOD Cortsol-35.5*
[**2160-12-29**] 10:55AM BLOOD Cortsol-33.4*
[**2160-12-29**] 12:16PM BLOOD Cortsol-36.8*
[**2160-12-28**] 09:38AM BLOOD Type-[**Last Name (un) **] pO2-76* pCO2-41 pH-7.47*
calTCO2-31* Base XS-5 Intubat-INTUBATED
[**2160-12-28**] 09:38AM BLOOD Glucose-152* Lactate-1.9 Na-128* K-2.8*
Cl-93*
[**2160-12-28**] 09:38AM BLOOD freeCa-1.08*
[**2160-12-31**] 05:10AM BLOOD HEPARIN DEPENDENT ANTIBODIES-PND
.
CT head [**12-30**]: IMPRESSION: No evidence of acute intracranial
hemorrhage. No fracture identified.
CXR [**12-26**]: IMPRESSION: No acute cardiopulmonary abnormalities
identified.
R Hip [**12-26**]: AP PELVIS AND RIGHT HIP, THREE VIEWS: There is a
subcapital fracture of the right femur with slight proximal
displacement of the distal fracture fragment. The right femoral
head appears to articulate with the right acetabulum without
evidence of dislocation. No other fractures are identified. Bony
mineralization is normal. There is slight asymmetry in the right
hemipelvis, which may be related to position. Degenerative
changes are seen at the L5-S1 level. The bowel gas pattern is
within normal limits.
IMPRESSION: Subcapital right femur fracture.
.
CT pelvis: IMPRESSION: No retroperitoneal hematoma. Small
intraabdominal ascites. Fluid surrounding the right hemipelvis
is consistent with patient's recent postoperative status.
.
CXR [**12-29**]: IMPRESSION: New left lower lobe opacity representing
airspace disease versus atelectasis. Stable right-sided
post-operative changes.
Brief Hospital Course:
Patient was admitted to the medicine service for medical
clearance for orthopedic management of her right femur fracture.
(Right femur fx - [**3-6**] mechanical fall. No symptoms or history
suggestive of syncopal episode. Needs OR repair, intermediate
risk surgery. Per ACC guideline, pt falls into minor clinical
predictors with excellent functional capacity. Is medically
clear for OR from cardiac standpoint, no need for additional
testing. Also medically clear from pulmonary standpoint given
baseline COPD and unremarkable CXR. Role of a peri-op BB
controversial in this low-risk pt (minor predictors, excellent
functional capacity, intermediate OR risk).
Patient was made NPO on midnight of HD 2 and taken to the OR
with orthopedics on HD 3. Pt had R hip hemi-arthroplasty with
700 EBL and no other complications noted.
[**Name (NI) **] pt had an episode of hypotension, was difficult to weane
of ventilator and spiked a temperature to 102. She was admitted
to the MICU, started on broad abx with ciprofloxacin for UTI and
also had vancomycin added empirically. She defervesced on this
regimen and fever work-up revealed no other source of infection.
Vancomycin was stopped after 72 hrs. Plan to continue cipro
for 3 additional days for a total of 7 day course.
In addition, post-op course was complicated by hypotension
requiring pressors. She required agressive fluid resuscitation
of about 8 L and 2 Units of PRBC and her hypotension resolved.
Anti-hypertensive medications were initially held and restarted
on [**12-31**].
Initially the pt had rapid atrial fibrillation in the setting of
hypotension and was started on IV digoxin. No change in BP was
noted with better HR control. Digoxin was discontinued with
good HR control throughout remainder of her stay and diltiazem
was restarted at home dose on [**12-31**].
She was maintained on atrovent nebulizer intermittently for COPD
with oxygen saturation around 95% on room air, and minimized
albuterol in the setting of atrial fibrillation. Initial CXR
showed no infiltrate, repeat one at the time of fever showed a
questionable new infiltrate. Pt had no clinical evidence of
pneumonia, consider repeat CXR in a few days to assess
resolution.
During her MICU stay, her platelets were noted to trend down to
94 in the setting of aggressive fluid resuscitation. Heparin
was held and HIT antibody was sent. She was anticoagulated with
fondaparinux and plts increased to 168 on this regimen. She
should be able to resume lovenox anticoagulation for post-op
prophylaxis should the HIT antibody prove to be negative. HCT
was also noted to trend down along with this, hemolysis labs was
negative and abdominal CT showed no RP hepatoma.
Pt was restarted on cardiac diet after hypotension resolved,
tolerated well.
FULL code
Medications on Admission:
1. Plavix 75 mg qd - for afib, previously on coumadin but d/c'd
due to risk with falls
2. ASA 81 mg qd
3. Lipitor 10 mg qd
4. HCTZ 25 mg qd
5. Protonix 40 mg qd
6. Enablex 7.5 mg qd
7. Diltiazem 180 mg qd (per OMR notes, pt unsure of dose)
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
8. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
9. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Ciprofloxacin 400 mg/40 mL Solution Sig: Four Hundred (400)
mg Intravenous Q12H (every 12 hours) for 3 days.
11. Morphine 2 mg/mL Syringe Sig: 0.5 mg Injection Q4H (every 4
hours) as needed.
12. Insulin Regular Human 100 unit/mL Solution Sig: as dir
Injection ASDIR (AS DIRECTED): per sliding scale.
13. Fondaparinux 2.5 mg/0.5 mL Syringe Sig: 2.5 mg Subcutaneous
DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Right Hip fracture
Urinary tract infection
Discharge Condition:
fair
Discharge Instructions:
Please follow-up with your regular doctor once you are out of
rehab or within the next few weeks.
Take your medications as prescribed.
Followup Instructions:
Follow-up with your regular doctor within the next few weeks.
Follow-up with Dr. [**Last Name (STitle) 7376**] (orthopedics) on [**1-9**] 1:20 pm, [**Location (un) 1385**] of [**Hospital Ward Name 23**] building at [**Hospital1 18**].
Completed by:[**2160-12-31**]
ICD9 Codes: 496, 5990, 2851, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3472
} | Medical Text: Admission Date: [**2161-5-29**] Discharge Date: [**2161-7-9**]
Date of Birth: [**2114-11-20**] Sex: M
Service:Transplant Surgery
ADDENDUM: On [**2161-6-13**] the patient underwent orthotopic liver
transplant with Drs. [**Last Name (STitle) **], [**Name5 (PTitle) **] and [**Name5 (PTitle) 955**]. The
anastomosis PHA to right CHA, portal vein was anastomosed to
portal vein, duct was anastomosed to duct, graft type was
cadaveric. The patient tolerated the procedure well with
approximately 3,000 cc of crystalloid given intraoperatively,
14 units of fresh frozen plasma, three units of packed red
cells, two units of platelets with an estimated blood loss of
only 300 cc.
Postoperatively the patient was transferred intubated to the
intensive care unit. He remained intubated until
postoperative day 14, which was [**2161-6-26**].
1. Infectious disease: The patient continued to spike fevers
in the intensive care unit with temperatures to 102-103
through postoperative day seven, at which point the patient
defervesced, remained afebrile with temperatures 97-98
throughout the remainder of his hospitalization. For
immediate postoperative prophylaxis the patient was placed on
Unasyn, valacyclovir, fluconazole, vancomycin, Zosyn and
Bactrim. Vancomycin was continued for a 16-day course, the
Zosyn for a 10-day course. The valacyclovir was changed on
postoperative day ten, [**2161-6-23**], following a CT scan of the
patient's head which revealed temporal lobe enhancement
consistent with possible herpes virus infection. At this
point the patient was changed to acyclovir 800 mg t.i.d.
which he continued throughout the remainder of his
hospitalization. At the time of discharge the patient was
changed back to valacyclovir for prophylaxis. Cultures were
drawn throughout the patient's hospitalization with
temperature spikes. For the most part these remained
negative. One culture came back positive, which was central
venous line, on the 13th, which grew coagulase-negative
Staphylococcus. He was continued on vancomycin for this.
Cultures after that point were negative.
2. Fluids, electrolytes and nutrition: Postoperatively the
patient was begun on TPN for the first four postoperative
days. On postoperative day four the patient was begun on
tube feeds for nutritional support. Throughout his
hospitalization he has remained on a Regular Insulin sliding
scale. At the time of discharge he was placed on glyburide
10 mg b.i.d. Postintubation swallowing study was performed
given that the patient was intubated for a number of weeks
prior to transplant. This demonstrated a failure of bedside
swallow as well as videoscopic examination. The patient was
thought to be a high risk for aspiration. On postoperative
day 27 again a video swallow was repeated. As the patient's
voice became stronger he was able to tolerate swallowing. At
that point he was placed on a diet of nectar-thickened
liquids and soft solids, to avoid thin liquids. At the time
of discharge he is to follow up with the speech and swallow
service in approximately two weeks for reevaluation and
questionable progression of diet.
3. Pulmonary: The patient was intubated on [**2161-6-3**]. He
remained intubated postoperatively until postoperative day
seven at which point he was able to tolerate extubation and
breathe on his own. Numerous chest x-rays remained negative
for pulmonary disease. There was some difficulty with his
oxygenation in his postoperative course; this resolved and
the patient had good oxygenation saturations on room air by
the time of discharge.
4. Neurologic: The patient had an ICP monitor placed almost
immediately preoperatively for his liver transplant. His
ICPs remained stable in the 9-14 range as measured by a
bullet. His ICPs remained stable postoperatively and the
bullet was discontinued postoperatively on postoperative day
two, [**2161-6-16**]. It was discontinued without complications.
Numerous head CT scans obtained during the time in which he
had the bullet demonstrated no evidence of intracranial
bleed. The neurology service continued to follow the patient
through his hospitalization. Postoperatively his
encephalopathy cleared. At the time of discharge he was
mentating well without any problems.
5. Cardiovascular: The patient did have a fair amount of
hypertension postoperatively. Postoperatively in the
intensive care unit the patient's blood pressures ranged from
180 to 202. Over successive days following transfer from the
intensive care unit the patient's blood pressures resumed
with values in the 120s to 130s. He was maintained on a
regimen of hydralazine 20 mg p.o. q. 6 hours, clonidine patch
for control of his hypertension. On [**2161-6-20**] the patient had
an episode of atrial flutter. The cardiology service was
consulted for this and Lopressor was added to his regimen for
rate control. It was felt he may require ablation at some
point postoperatively. The patient on the floor has had no
further episodes of atrial flutter. His rate has been well
controlled. He is to follow up with the cardiology service
post discharge.
6. Lines, drains, tubes: The patient was transferred out of
the operating room with two [**Location (un) 1661**]-[**Location (un) 1662**] drains. These
successfully decreased in output over the first 18 days
postoperatively. The first drain was removed on
postoperative day 12, the second drain was removed on
postoperative day 18. The drain sites remained clean, dry
and intact. Additionally the patient came out of the
operating room with a central venous line. This was also
removed postoperatively before discharge. The patient has a
T-tube in place. This T-tube was clamped on postoperative
day 18 as well. The T-tube site remained clean, dry and
intact by the time of discharge.
7. Renal: The patient's creatinine remained relatively
stable with a value in the 1.1 to 1.7 range. Immediately
postoperatively he was maintained on a Lasix drip for low
urine output and diuresis following approximately a 20-liter
net positive gain immediately postoperatively.
8. Immunosuppression: The patient was begun on CellCept on
postoperative day zero, 1,000 mg b.i.d. and this was
maintained throughout his hospitalization. He was begun on a
Solu-Medrol taper initially with 1 gram of Solu-Medrol given
on postoperative day zero, slowly tapered down to 50 mg of
Solu-Medrol by postoperative day six. He remained on this
until the time of discharge at which time he was changed to
oral prednisone 15 mg p.o. q.d. The patient was also begun
on cyclosporine on postoperative day four. His levels were
maintained in the 300 range. Daily levels were checked and
at the time of discharge the patient was to be discharged on
a dose of 150 mg b.i.d. He is to follow up with the
transplant service for frequent checks of this. Additionally
the patient received two doses of Simulect, one on
postoperative day zero and one on postoperative day four.
9. Hepatology: Initially the patient was maintained on a
dose of hepatitis B immune globulin for the first six days
postoperatively, at which point he was switched over to a q.
week dosing. At the time of discharge he has received two
weeks of a four-week regimen of 10,000 units of hepatitis B
immune globulin. He is to receive two more doses on
Wednesdays post discharge. Additionally for hepatitis B the
patient remained on adefovir 2 mg p.o. q. day. He is to be
discharged on this medication as well.
CONDITION ON DISCHARGE: Good.
DISCHARGE DIAGNOSES:
1. Orthotopic liver transplant.
2. End-stage liver disease secondary to hepatitis B.
3. Insulin dependent diabetes mellitus.
4. Encephalopathy status post intracranial pressure
monitoring.
5. Hypertension.
6. Multiple line infections.
7. Herpes encephalitis.
DISCHARGE MEDICATIONS:
1. Adefovir dipivoxil 2 mg p.o. q. 24 hours.
2. Hydralazine 20 mg p.o. q. 6 hours.
3. Metoprolol 50 mg p.o. b.i.d.
4. Hepatitis B immune globulin 10,000 units IV q. Wednesday
for two weeks.
5. Clonidine TTS patch, one patch transdermal q. Saturday.
6. Bactrim DS one tablet p.o. q. day.
7. Protonix 40 mg p.o. q. day.
8. Valcyte 450 mg p.o. q. day.
9. Fluconazole 400 mg p.o. q. day.
10. Glipizide 10 mg p.o. b.i.d.
11. CellCept 1,000 mg p.o. b.i.d.
12. Prednisone 15 mg p.o. q. day.
13. Cyclosporine 150 mg p.o. b.i.d.
FOLLOW UP: The patient is to follow up as previously
arranged with the transplant surgery service coordinator.
The patient is to be transferred to rehabilitation with a
diet consisting of soft solids and nectar-thick liquids. He
is to follow up with the speech and swallow service
additionally for evaluation of his swallow and questionable
progression of diet.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 02-366
Dictated By:[**Name8 (MD) 16207**]
MEDQUIST36
D: [**2161-7-9**] 04:12
T: [**2161-7-9**] 07:16
JOB#: [**Job Number 33099**]
ICD9 Codes: 5715, 7907 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3473
} | Medical Text: Admission Date: [**2119-12-7**] Discharge Date: [**2120-1-3**]
Date of Birth: [**2050-8-14**] Sex: M
Service: SURGERY
Allergies:
Penicillins / Pollen Extracts
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Incidental finding of cystic neuroendocrine neoplasm.
Major Surgical or Invasive Procedure:
[**2119-12-7**]:
1. Distal pancreatectomy with splenectomy.
2. Ligation of intra-abdominal vessel for control of hemorrhage
(splenic arterial takeoff).
History of Present Illness:
Mr. [**Known lastname **] is a 69-year-old gentleman who has pulmonary issues
including COPD and chronic bronchitis and pulmonary infections.
In the workup of one of his recent bouts with this, a CT scan
was performed and cuts from this revealed a cystic lesion in the
pancreas. This was focused on the tail. He subsequently was
worked up with an endoscopic ultrasound and aspiration of this
tissue revealed a cystic neuroendocrine neoplasm. The features
of this were a size close to 3 cm in diameter along with some
enhancing features suggestive of solid tumor growth and
malignancy. Furthermore, a detailed CT scan the abdomen showed
that he had multiple cystic lesions throughout his liver and
kidneys; but that there was a suspicious-appearing lesion in the
superior pole of the left kidney that might also be a neoplastic
problem. [**Name (NI) **] was admitted for planned distal pancreatectomy.
Past Medical History:
PMHx: pancreatic neuroendocrine tumor, hyperlipidemia, HTN,
asthma, COPD, h/o CVA, HA, obesity, hiatal hernia, renal
insufficiency, renal cyst, liver cysts.
.
PSHx: [**2119-10-31**] EUS, [**2062**] appy; Umbilical hernia repair [**8-7**].
Social History:
Married.
Family History:
Non-contributory
Physical Exam:
Pre-Admission Examination [**2119-11-20**]:
His abdomen is soft, nontender, and nondistended with positive
bowel sounds. He has a well-healed umbilical hernia scar and
appendectomy incision. There is no evidence of recurrent
hernia. He is extremely rotund in the abdomen and would be
considered obese. There is no evidence of any hernias or masses
in his inguinal and genital region. A rectal exam is deferred
today. The rest of his physical exam is entirely normal with
the exception of coarse expiratory rhonchi bilaterally.
.
At Discharge:
AVSS/afebrile.
GEN: Well appearing male in NAD.
HEENT: Sclerae anicteric. O-P clear.
NECK: Supple.
LUNGS: CTA(B)
COR: RRR; nl S1/S2 w/o m/c/r
ABD: Incision with steri-strips c/d/i. BSx4. Soft/NT/ND.
EXTREM: No c/c/e
NEURO: A+Ox3. Non-focal/grossly intact.
Pertinent Results:
On Admission:
[**2119-12-7**] 01:16PM freeCa-1.07*
[**2119-12-7**] 01:16PM HGB-13.5* calcHCT-41
[**2119-12-7**] 01:16PM GLUCOSE-142* LACTATE-1.1 NA+-141 K+-3.8
CL--106
[**2119-12-7**] 01:16PM TYPE-ART PO2-87 PCO2-40 PH-7.42 TOTAL CO2-27
BASE XS-0
[**2119-12-7**] 04:31PM freeCa-0.99*
[**2119-12-7**] 04:31PM HGB-11.7* calcHCT-35
[**2119-12-7**] 04:31PM GLUCOSE-156* LACTATE-2.0 NA+-138 K+-4.5
CL--108
[**2119-12-7**] 05:32PM freeCa-0.87*
[**2119-12-7**] 05:32PM HGB-11.7* calcHCT-35
[**2119-12-7**] 05:32PM GLUCOSE-168* LACTATE-3.1* NA+-139 K+-4.9
CL--114*
[**2119-12-7**] 05:32PM TYPE-ART PO2-311* PCO2-44 PH-7.27* TOTAL
CO2-21 BASE XS--6
[**2119-12-7**] 06:28PM freeCa-0.97*
[**2119-12-7**] 06:28PM HGB-13.7* calcHCT-41
[**2119-12-7**] 06:28PM GLUCOSE-169* LACTATE-3.0* NA+-140 K+-5.5*
CL--113*
[**2119-12-7**] 08:15PM FIBRINOGE-160
[**2119-12-7**] 08:15PM PT-15.1* PTT-29.1 INR(PT)-1.3*
[**2119-12-7**] 08:15PM PLT COUNT-152
[**2119-12-7**] 08:15PM WBC-18.4*# RBC-4.92 HGB-14.4 HCT-43.2 MCV-88
MCH-29.3 MCHC-33.4 RDW-14.9
[**2119-12-7**] 08:15PM estGFR-Using this
[**2119-12-7**] 08:15PM GLUCOSE-204* UREA N-17 CREAT-1.1 SODIUM-142
POTASSIUM-5.8* CHLORIDE-114* TOTAL CO2-22 ANION GAP-12
[**2119-12-7**] 08:58PM freeCa-1.04*
[**2119-12-7**] 08:58PM LACTATE-1.4
[**2119-12-7**] 10:25PM GLUCOSE-253* POTASSIUM-4.8
[**2119-12-7**] 10:38PM freeCa-1.38*
.
Prior to Discharge:
[**2119-12-27**] 06:05AM BLOOD WBC-30.9* RBC-2.78* Hgb-7.9* Hct-24.5*
MCV-88 MCH-28.5 MCHC-32.4 RDW-15.1 Plt Ct-1072*
[**2119-12-27**] 06:05AM BLOOD Glucose-132* UreaN-12 Creat-1.1 Na-136
K-4.2 Cl-100 HCO3-25 AnGap-15
[**2119-12-27**] 06:05AM BLOOD Calcium-8.2* Phos-3.7 Mg-1.9
.
IMAGING:
CTA ABD [**2119-11-20**] (Pre-Admit):
1. 2.6 x 2.4 x 2.7 cm predominantly cystic lesion in the body of
the
pancreas, with a thin periphery of enhancement, and 1.5 x 1.1 cm
nodular area of enhancement along its superior margin. Results
from recent endoscopic FNA biopsy are consistent with a
neuroendocrine lesion, which is concordant with the imaging
findings. No definite evidence of metastatic disease within the
abdomen.
2. Multiple bilateral renal cystic lesions, several of which are
hyperdense. The majority of these are consistent with renal
cysts, and are statistically most likely benign. However, 2.4-cm
left upper pole cystic lesion is more mass-like, enhances
substantially more from the other lesions, and is suspicious for
renal neoplasm. This lesion would be amenable to image-guided
biopsy.
.
[**2119-12-7**] CXR:
ET tube ends at the thoracic inlet, nasogastric tube passes into
the upper stomach, right jugular line tip is at the junction of
brachiocephalic veins. Heart size is normal. Mediastinal
vasculature is engorged but there is no pulmonary edema.
Bibasilar atelectasis is severe, worsened since [**11-20**].
.
[**2119-12-15**] Chest/ABD/PELVIC CT:
1. Post-surgical changes, status post partial pancreatectomy and
splenectomy with small amount of fluid at the pancreatic bed
just at the tip of drainage catheter.
2. Bilateral lower lobe consolidations may represent
aspiration,pneumonia,
or atelectasis.
3. Apparent air in the nondependent portion of the cecum and
proximal ascending colon is unlikely to represent pneumatosis
and likely represents air mixed with fecal material. There is no
portal venous air or free peritoneal air to suggest ischemia.
4. Dilated loops of small bowel with no definite transition
point most likely representing paralytic ileus. Clinical
correlation and follow-up is suggested.
5. Bilateral renal lesions, with the largest measuring 2.4 cm in
the left upper pole which is suspicious for renal neoplasm due
to soft tissue attenuation.
6. Multiple liver hypodensities, likely cysts.
7. Small hiatal hernia.
.
[**2119-12-17**] CHEST/ABD/PELVIC CT:
1. Multifocal bilateral lung consolidations compatible with
pneumonia. This has worsened in the interval.
2. Partial pancreatectomy and splenectomy changes with
inflammatory changes and fluid in the surgical bed. The drain
appears to be in appropriate position. No discrete or drainable
fluid collection is identified on this limited non-contrast
study.
3. Interval worsening small-bowel dilatation with bowel wall
thickening. These findings are concerning for developing partial
small-bowel obstruction, with a transition to normal caliber
near the surgical site. No pneumoperitoneum or portal venous air
is demonstrated.
4. Multiple hepatic cysts.
5. Bilateral renal lesions, some of them dense, which may
represent complicated cyst versus underlying mass lesion. The
need for further evaluation with ultrasound should be determined
on a clinical basis.
6. Diverticulosis with no signs of acute diverticulitis.
.
[**2119-12-19**] ECHO:
Image quality is very limited. The left atrium is elongated. No
atrial septal defect or patent foramen ovale is seen by 2D,
color Doppler or saline contrast with maneuvers. Left
ventricular wall thickness, cavity size, and global systolic
function are normal (LVEF 70%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Right ventricular chamber size and free wall motion
are normal. There are focal calcifications in the aortic arch.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. There is no
pericardial effusion.
IMPRESSION: Suboptimal image quality. This is a nondiagnostic
study - no obvious intracardiac shunt seen during color flow
imaging and air buibble contrast injection, but cannot be
excluded with certainty on the basis of this study
.
[**2119-12-26**] CXR: Bibasilar opacities most consistent with
atelectasis although underlying infiltrate cannot be excluded.
.
PATHOLOGY:
SPECIMEN SUBMITTED: DISTAL PANCREAS, MIDDLE PANCREAS, SPLEEN:
DIAGNOSIS:
I. Middle pancreas (A-B): Benign pancreatic tissue.
II. Distal pancreas, distal pancreatectomy (C-H): Well
differentiated neuroendocrine tumor, See synoptic report.
III. Spleen (I-J): Spleen with congestion; no malignancy
identified.
Pancreas (Endocrine): Resection Synopsis
MACROSCOPIC
Specimen Type: Partial resection, pancreatic tail.
Tumor Site: Pancreatic tail.
Tumor focality: Unifocal.
Tumor configuration:
Circumscribed: Cystic and nodular, partially encapsulated.
Tumor Size
Greatest dimension: 2.5 cm. Additional dimensions: 2.3 cm
x 1.9 cm.
Other organs/Tissues Received: Spleen.
MICROSCOPIC
Functionality type: Pancreatic endocrine tumor, secretory
status unknown.
EXTENT OF INVASION
Primary Tumor: Tumor limited to pancreas.
Regional Lymph Nodes: pN0: No regional lymph node metastasis.
Lymph Nodes
Number examined: 2.
Number involved: 0.
Distant metastasis: pMX: Cannot be assessed.
Margins:
Uninvolved by tumor:
Distance from closest margin: 15 mm, microscopically .
Specified margin: Pancreatic parenchymal margin.
Lymphovascular invasion: Present.
Perineural invasion: Absent.
Mitotic activity: Absent.
Additional Pathologic Findings: None identified.
Comments: The tumor has been characterized previously by
immunohistochemistry (specimen S09-[**Numeric Identifier 83582**]; positive for AE1/AE3,
CAM5.2, Synaptophysin, and chromogranin). The tumor has a
mitotic index of 0-1/50 HPF. The tumor invades into adjacent
pancreatic parenchyma but does not invade peripancreatic soft
tissue.
Clinical: Pancreatic mass.
Gross:
The specimen is received fresh in three containers, all labeled
with the patient's name, "[**Known lastname **], [**Known firstname **]", and the medical record
number.
Part 1 is additionally labeled "middle pancreas." It consists of
an unoriented segment of pancreas with attached blood clot
measuring overall 5 x 3.1 x 2.1 cm. The pancreatic parenchymal
margins are inked in yellow and the outside surface of the
pancreas is inked blue. The specimen is serially sectioned to
reveal soft tan yellow lobulated cut surfaces with no obvious
lesions noted. The specimen is represented as follows: A =
sections of the parenchymal margin, B = representative sections
of pancreas.
Part 2 is additionally labeled "distal pancreas." It consists of
a distal pancreatectomy specimen measuring 4.5 x 3.5 x 2.7 cm
with attached peripancreatic adipose tissue measuring 5 x 1.6 x
1.1 cm. The parenchymal resection margin is inked yellow and
the outer surface of the pancreas is blue inked and the specimen
is sliced horizontally to reveal a solid-cystic mass measuring
2.5 x 2.3 x 1.9 cm, located 2 cm away from the parenchymal
resection margin at its closest approach. The cyst is filled
with a clear serous fluid and contains a focally solid area
measuring 2 x 1.2 x 0.2 cm. The specimen is represented as
follows: C = sections through the parenchymal resection margin,
D = section of the mass in relation to the normal pancreas and
the parenchymal resection margin, E-G = additional
representative sections of mass, H = sections of the
peripancreatic fat containing possible lymph nodes.
Part 3 is additionally labeled "spleen." It consists of a
splenectomy specimen with attached adipose tissue measuring
overall 14.5 x 12.8 x 3.5 cm and weighing 311 grams. The spleen
is serially sliced to reveal maroon brown cut surfaces with no
gross lesions identified. The specimen is represented as
follows: I = sections of hilar fat containing possible lymph
nodes, J = sections of spleen.
.
MICROBIOLOGY:
[**2119-12-26**] URINE URINE CULTURE: No Growth to date - PRELIM.
[**2119-12-26**] BLOOD CULTURE: No Growth to date - PRELIM.
[**2119-12-26**] BLOOD CULTURE: No Growth to date - PRELIM.
[**2119-12-24**] BLOOD CULTURE:No Growth to date - PRELIM.
[**2119-12-24**] CATHETER TIP: NO GROWTH.
[**2119-12-24**] BLOOD CULTURE: No Growth to date - PRELIM.
[**2119-12-21**] BLOOD CULTURE:NO GROWTH.
[**2119-12-21**] BLOOD CULTURE: NO GROWTH.
[**2119-12-19**] BLOOD CULTURE: NO GROWTH.
[**2119-12-19**] URINE URINE CULTURE:NO GROWTH.
[**2119-12-19**] BLOOD CULTURE:NO GROWTH.
[**2119-12-18**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
{YEAST}
[**2119-12-17**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST:
POSITIVE FOR CLOSTRIDIUM DIFFICILE - FINAL.
[**2119-12-16**] BLOOD CULTURE: NO GROWTH.
[**2119-12-16**] URINE URINE CULTURE:NO GROWTH.
[**2119-12-16**] BLOOD CULTURE: NO GROWTH.
[**2119-12-15**] MRSA SCREEN MRSA: NEGATIVE.
[**2119-12-15**] URINE URINE CULTURE:NO GROWTH.
[**2119-12-15**] BLOOD CULTURE: NO GROWTH.
[**2119-12-15**] BLOOD CULTURE: NO GROWTH.
[**2119-12-11**] URINE URINE CULTURE: NO GROWTH.
[**2119-12-7**] MRSA SCREEN MRSA SCREEN: NEGATIVE.
Brief Hospital Course:
The patient was admitted to the General Surgical Service on
[**2119-12-7**] for for planned distal pancreatectomy. On that date,
the patient underwent distal pancreatectomy with splenectomy,
which was complicated by major intraoperative hemorrhage
requiring additional ligation of intra-abdominal vessel for
control of hemorrhage (splenic arterial takeoff). During the
surgery, the patient required the administration of 7000 mL of
crystalloid, 1000mL of 5% albumin, two units of FFP, and 9 units
of packed red blood cells. He remained hemodynamically stable
throughout the procedure(reader referred to the Operative Notes
for details). After the surgery, the patient was admitted to the
TICU, where he arrived NPO with an NG tube, intubated on
mechanical ventilation and neomycin infusion, on IV fluids, with
a foley catheter and two JP drain in place, and a
Dilaudid/Bupivacaine epidural for pain control.
.
While in the TICU, he was treated for hyperkalemia with a return
of his potassium to a baseline of 3.8-4.6. On POD#1, the patient
was successfully extubated. Serial hematocrits remained stable.
He remained hemodynamically stable, and was transferred to the
inpatient floor later that day.
.
Post-operative pain was initially well controlled with the
epidural, which was converted to just a Dilaudid PCA on POD#4.
When tolerating a diet, the PCA was discontinued, and the
patient started on oral pain medications with continued good
effect. The NG tube was discontinued, and the patient started on
clears on POD#5. His diet was progressively advanced as
tolerated to fulls by POD#6. The foley catheter discontinued in
the afternoon of POD#4, six hours after the epidural was
discontinued. As he was unable to void, the foley was replaced,
and he was started on Flomax. Post-splenectomy immunizations
consisting of the Pneumovax, Meningicoccal, and Haemophilus B
vaccines were given on POD#5. At this point, the patient was
being prepared for discharge in the next 1-2 days.
.
On POD#8, the patient went into atrial fibrillation, which could
not be converted on the floor with Metoprolol and Lasix. The
patient was emergently transferred to the TICU for further
evalaution and care. He was intubated, placed on a neomycin
drip, and treated for hyperkalemia. He was able to be extubated
the next day. When hemodynamically stable, he was returned to
[**Hospital Ward Name 121**] 9 on [**2119-12-10**], at which point the NG tube was out, he was
NPO except medications, on IV fluids, the foley was still in
place, and the patient still on the Dilaudid/Bupivacaine
epidural for pain control. While on the floor, his diet had been
advanced to fulls, the epidural was discontinued, and the
patient started on a Dilaudid PCA, and JP amylase levels were
sent.
.
On [**2119-12-15**], the patient again experienced atrial fibrillation,
which could not be converted on the floor. He was cardioverted.
He was transfered back to the TICU, started on a Diltiazem drip,
which was converted to an Amiodarone drip due to hypotension.
Cycled cardiac enzymes were unremarkable. Chest CT revealed
findings consistent with aspiration pneumonia, for which patient
was started on IV Vancomycin and Cefepime. Abdominal/pelvic CT
revealed apparent air in the nondependent portion of the cecum
and proximal ascending colon is unlikely to represent
pneumatosis and likely represents air mixed with fecal material.
There is no portal venous air or free peritoneal air to suggest
ischemia. Dilated loops of small bowel with no definite
transition point most likely representing paralytic ileus. He
developed acute renal failure with a creatinine of 2.4, which
responded well to IV fluid boluses x2 with inproved urine
output. NGT was placed, and immediately 1L bilious fluid was
suctioned. Following the removal of fluid, his SaO2 improved to
low 90s, his nausea resolved, and his abdominal pain decreased
to a [**12-10**]. He required subsequent fluid boluses foe a FENA of
0.1. Repeat Chest/abdominal/pelvic CT on [**2119-12-17**] demonstrated
multifocal bilateral lung consolidations compatible with
pneumonia, which had worsened in the interval. Interval
worsening small-bowel dilatation with bowel wall thickening
concerning for developing partial small-bowel obstruction, with
a transition to normal caliber near the surgical site was also
noted. Also, the patient had been experiencing multiple loose
stools. [**2119-12-17**] C.diff was returned positive, and the patient
was started on PO Vancomycin and Flagyl in addition to IV
Vancomycin and Cefepime. The patient was started on TPN.
.
On [**2119-12-20**], the patient was again returned to [**Hospital Ward Name 121**] 9 in stable
condition. He was NPo with an NG tube, on IV fluids and TPN,
continued on IV Vancomycin, Flagyl, and Cefepime as well as PO
Vancomycin, a foley was in place, and he received acetaminophen
for pain control. Home medications were re-introduced after the
NG tube was discontinued, and the patient started on sips. He
experienced a transient low grade temperature on [**2119-12-25**], and he
was again cultured, but then defervesced. WBC did remain in the
24-30 range after splenectomy, but the WBC was stable. Diet was
advanced to low sodium/heart healthy regular diet by [**12-26**]. TPN
was discontinued on [**12-23**]. Foley was discontinued the morning of
[**12-24**]; the patient was subsequently able to void without problem.
[**Name (NI) **] had been removed, and steri-strips applied. Incision
remained clean and intact. By discharge, the aspiration
pneumonia was treated, and there was four days remaining of
treatment for C.diff.
.
During this hospitalization, the patient ambulated early and
frequently, was adherent with respiratory toilet and incentive
spirrometry, and actively participated in the plan of care.
Physcial and Occupational Therapy were consulted. The patient
received subcutaneous heparin and venodyne boots were used
during this stay. The patient's blood sugar was monitored
regularly throughout the stay; sliding scale insulin was
administered when indicated. He received glucose monitoring and
insulin administration teaching. Labwork was routinely followed;
electrolytes were repleted when indicated.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating his diet,
ambulating with assistance, voiding without assistance, and pain
was well controlled. He was discharged to an extended care
facility for rehabilitation and nursing care. The patient
received discharge teaching and follow-up instructions with
understanding verbalized and agreement with the discharge plan.
Medications on Admission:
1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**3-5**]
hours as needed for fever or pain.
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
4. Flonase 50 mcg/Actuation Spray, Suspension Sig: [**12-2**] sprays in
each nostril Nasal once a day as needed for allergy symptoms.
5. Zocor 20 mg Tablet Sig: One (1) Tablet PO once a day.
6. Buspirone 5 mg Tablet Sig: 1.5 Tablets PO QAM and 1 tablet PO
(by mouth) QPM.
7. Reglan 5 mg Tablet Sig: One (1) Tablet PO BID
8. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
9. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO once a day.
10. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
11. Singulair 10 mg Tablet Sig: One (1) Tablet PO once a day.
12. ProAir HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: [**12-2**]
puffs Inhalation four times a day as needed for shortness of
breath or wheezing.
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. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**3-5**]
hours as needed for fever or pain.
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*11*
4. Flonase 50 mcg/Actuation Spray, Suspension Sig: [**12-2**] sprays in
each nostril Nasal once a day as needed for allergy symptoms.
5. Zocor 20 mg Tablet Sig: One (1) Tablet PO once a day.
6. Buspirone 5 mg Tablet Sig: 1.5 Tablets PO QAM and 1 tablet PO
(by mouth) QPM.
7. Reglan 10 mg Tablet Sig: One (1) Tablet PO QID with meals and
at bedtime.
Disp:*120 Tablet(s)* Refills:*0*
8. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
9. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO once a day.
10. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
11. Singulair 10 mg Tablet Sig: One (1) Tablet PO once a day.
12. ProAir HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: [**12-2**]
puffs Inhalation four times a day as needed for shortness of
breath or wheezing.
13. One Touch Ultra Test Strip Sig: One (1) strips In [**Last Name (un) 5153**]
four times a day.
Disp:*100 strips* Refills:*2*
14. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
15. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
16. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
17. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation: Hold for loose stools.
18. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
19. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
20. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO Q6H
(every 6 hours).
21. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
22. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO BID (2 times
a day): give 30 minutes before breakfast and dinner .
23. Insulin Regular Human 100 unit/mL Solution Sig: 4-12 units
Injection As directed per Regular Insulin Sliding Scale.
24. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 4 days: Completion date: [**2120-1-1**].
25. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:
Five Hundred (500) mg Intravenous every eight (8) hours for 4
days: Completion Date: [**2120-1-1**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital 745**] Health Care Center
Discharge Diagnosis:
1. Neuroendocrine cystic tumor of the tail of pancreas.
2. Cystic lesion of the left kidney.
3. Intraoperative hemorrhage.
4. Acute on chronic renal failure
5. Atrial fibrillation
6. Bilateral aspiration pneumonia
7. CLOSTRIDIUM DIFFICILE
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**4-8**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have [**Month/Year (2) 14073**], they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2832**], MD Phone:[**Telephone/Fax (1) 1231**]
Date/Time:[**2120-1-26**] 9:45. Location: [**Hospital Ward Name 23**] 3, [**Hospital Ward Name 516**].
.
Please call ([**Telephone/Fax (1) 83583**] to arrange a follow-up appointment
with Dr. [**Last Name (STitle) **] (PCP) in [**1-3**] weeks.
Completed by:[**2119-12-27**]
ICD9 Codes: 5849, 5070, 486, 9971, 2767, 2724, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3474
} | Medical Text: Admission Date: [**2129-3-7**] Discharge Date: [**2129-3-18**]
Date of Birth: [**2055-9-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Shellfish
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
cardiac catheterization
EGD
colonoscopy
GI capsule study
History of Present Illness:
Mr. [**Known lastname **] is a 73 year old male with severe 3-vessel coronary
disease s/p complex PCI with 5 RCA bare metal stents placed in
[**2127**] (pt declined CABG), CHF with EF 40%, PVD, and seizure
disorder who is transferred from [**Hospital3 4107**] for management
of NSTEMI and anemia.
Mr. [**Known lastname **] presented to his PCP [**Last Name (NamePattern4) **] [**3-4**] with complaints of
exertional dyspnea and chest/epigastric discomfort for the past
2 weeks. At baseline he can walk 2 miles and climb 1 flt of
stairs w/o chest pain or dyspnea, but over the past 2 weeks
these symptoms are brought on with only 50ft of walking and last
about 1 hour with improvement with rest. He denies orthopnea,
PND, LE edema, LH or palpitations. At his PCP he was found to
have Hct of 22.9 and was sent to [**Hospital3 4107**]. On
presentation to [**Hospital1 **] his EKG showed sinus tachycardia with
rate 100, IVCD, horizontal ST depression V2-V6. He was treated
conservatively with BB, ACE, aspirin, plavix, and blood
transfusion (3U). His chest pain completely resolved and he was
pain free during his admission. He ruled in with a NQWMI, trop I
peak of 23.7, CK peak 670.
With regards to his anemia, he first notes that he was found to
be anemic a few months ago (after complaining of exertional
dyspnea). He was trasfused 2U pRBCs with improvement in symptoms
and as workup had an upper GI series with barium swallow, but no
endoscopy or C-scope. He denies any abdominal pain (other than
with angina), early satiety, constipation, + loose stool. He
notes 1 episode of melena a few months ago, but none since. He
notes no other blood loss. Denies alcohol consumption or FH of
GI malignancy. His OSH labs did show a ferritin of 5.7 and MCV
79.
Past Medical History:
recent NSTEMI - no intervention at osh [**3-5**] ?cabg.
ischemic CM (per report)
CHF (EF 15-20%)
?DM (pt denies)
COPD (dx ~6 mo ago)
HTN (50+ yrs)
seizure disorder ([**3-5**] head trauma)
Social History:
Lives with wife in [**Name2 (NI) **]. Smoked 20 years 4 ppd, quit ~10
years ago, denies alcohol presently, was drinking ~1 case / day
x 10 years, quit ~20 years ago, denies IVDU. Used to work with
heavy machinery.
Family History:
no premature CAD or SCD, mother "big heart", died in 80s, father
died of leukemia.
Physical Exam:
VS - HR 79 BP 114/60 RR 18 96% on RA
Gen: WDWN middle elderly male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with non-elevated JVP.
CV: PMI difficult to palpate given barrel chest. Heart sounds
distant, but RR normal S1, S2. No m/r/g. No thrills, lifts. No
S3 or S4.
Chest: Notable for barrel chest, no scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Decrease breath-sounds
throughout, CTAB, no crackles, wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: No c/c/e. No femoral bruits, diminished pulses.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
- guaiac negative
Pertinent Results:
[**2129-3-18**] 07:00AM BLOOD WBC-7.9 RBC-3.43* Hgb-9.3* Hct-28.7*
MCV-84 MCH-27.0 MCHC-32.3 RDW-16.1* Plt Ct-213
[**2129-3-14**] 12:16PM BLOOD PT-12.6 PTT-36.6* INR(PT)-1.1
[**2129-3-18**] 07:00AM BLOOD Glucose-99 UreaN-22* Creat-1.4* Na-139
K-4.1 Cl-107 HCO3-23 AnGap-13
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2129-3-15**] 5:06 PM
CHEST (PORTABLE AP)
Reason: ? ptx s/p ct removal
[**Hospital 93**] MEDICAL CONDITION:
73 year old man with s/p cabg
REASON FOR THIS EXAMINATION:
? ptx s/p ct removal
INDICATION: 73-year-old man with status post CABG and chest tube
removal, evaluate for pneumothorax.
COMPARISON: [**2129-3-15**], 8:32 a.m. (9 hours prior to this
study).
SINGLE VIEW, CHEST: Interval removal of the chest tube and the
mediastinal drain. No evidence of pneumothorax. Small bilateral
pleural effusions, [**Year (4 digits) 1506**]. No new consolidations or
infiltrates are noted. Mild engorgement of the mediastinal
vasculature suggesting volume overload. Pleural calcifications
appear [**Year (4 digits) 1506**]. Endotracheal tube and nasogastric tube in
standard locations. Median sternotomy wires are evident without
evidence of sternal dehiscence. Swan catheter in standard
location.
IMPRESSION: No pneumothorax. Small bilateral pleural effusions
and mild volume overload [**Year (4 digits) 1506**].
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Name (STitle) 35563**]
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**]
Approved: [**Doctor First Name **] [**2129-3-17**] 10:46 AM
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 69089**] (Complete)
Done [**2129-3-14**] at 9:50:17 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
Division of Cardiothoracic [**Doctor First Name **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2055-9-9**]
Age (years): 73 M Hgt (in): 69
BP (mm Hg): 126/ Wgt (lb): 145
HR (bpm): 53 BSA (m2): 1.80 m2
Indication: Intra-op TEE for CABG, ? MVR
ICD-9 Codes: 440.0, 441.2, 414.8, 424.0
Test Information
Date/Time: [**2129-3-14**] at 09:50 Interpret MD: [**Name6 (MD) 928**]
[**Name8 (MD) 929**], MD, MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 929**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW209-9:4 Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.5 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 3.9 cm <= 5.2 cm
Left Ventricle - Septal Wall Thickness: 0.9 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 0.9 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.9 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 4.2 cm
Left Ventricle - Fractional Shortening: *0.14 >= 0.29
Left Ventricle - Ejection Fraction: 30% to 35% >= 55%
Left Ventricle - Stroke Volume: 93 ml/beat
Left Ventricle - Cardiac Output: 4.94 L/min
Left Ventricle - Cardiac Index: 2.75 >= 2.0 L/min/M2
Aorta - Sinus Level: 3.6 cm <= 3.6 cm
Aorta - Sinotubular Ridge: *3.2 cm <= 3.0 cm
Aorta - Ascending: 3.2 cm <= 3.4 cm
Aorta - Arch: 2.7 cm <= 3.0 cm
Aorta - Descending Thoracic: *2.7 cm <= 2.5 cm
Aortic Valve - LVOT VTI: 19
Aortic Valve - LVOT diam: 2.5 cm
Findings
LEFT ATRIUM: Mild LA enlargement. No spontaneous echo contrast
in the body of the LA. No spontaneous echo contrast is seen in
the LAA. Good (>20 cm/s) LAA ejection velocity.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Dynamic interatrial septum. No
ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Moderate regional LV systolic dysfunction. Moderately depressed
LVEF.
RIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic
function.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Normal ascending aorta diameter.
Normal aortic arch diameter. Simple atheroma in aortic arch.
Mildly dilated descending aorta. Simple atheroma in descending
aorta.
AORTIC VALVE: Three aortic valve leaflets. No AS. Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. No MS. Mild to moderate ([**2-2**]+) MR.
TRICUSPID VALVE: Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
Dilated main PA. Dilated branch PA.
PERICARDIUM: Trivial/physiologic 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. See Conclusions for post-bypass data
The post-bypass study was performed while the patient was
receiving vasoactive infusions (see Conclusions for listing of
medications).
Conclusions
PRE-BYPASS:
1. The left atrium is mildly dilated. No spontaneous echo
contrast is seen in the body of the left atrium. No spontaneous
echo contrast is seen in the left atrial appendage. No atrial
septal defect is seen by 2D or color Doppler.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. There is moderate regional
left ventricular systolic dysfunction with apical, inferior,
septal and anterior wall hypokinesis. Overall left ventricular
systolic function is moderately depressed (LVEF= 30 %).
Spontaneous echo contrast in noted in the LV, that resolved with
systemic heparinization.
3. The right ventricular cavity is mildly dilated with normal
free wall contractility.
4. There are simple atheroma in the aortic arch. The descending
thoracic aorta is mildly dilated. There are simple atheroma in
the descending thoracic aorta.
5. There are three aortic valve leaflets. There is no aortic
valve stenosis. Trace aortic regurgitation is seen.
6. The mitral valve leaflets are mildly thickened. Mild to
moderate ([**2-2**]+) mitral regurgitation is seen. Provocative
maneuvers were used, pt in trendelenburg, and BP 170/80,
Eccentric anterior jet seen, billowing of the posterior leaflet
and mild restriction of the anterior leaflet.
7. The main pulmonary artery is dilated. The branch pulmonary
arteries are dilated.
8. There is a trivial/physiologic pericardial effusion.
Dr. [**Last Name (STitle) **] was notified in person of the results on the MR at
0830hrs.
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including Epinephrine and
phenylephrine, Pt is in Sinus tachycardia.
1. LV function is slightly improved. RV function is [**Last Name (STitle) 1506**]
2. MR [**First Name (Titles) **] [**Last Name (Titles) 1506**]
3. Aorta is intact post decannulation
4. Other findings are [**Last Name (Titles) 1506**]
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 928**] [**Name8 (MD) 929**], MD, MD,
Interpreting physician [**Last Name (NamePattern4) **] [**2129-3-14**] 11:49
Brief Hospital Course:
The pt. was admitted on [**2129-3-8**] with severe exertional dyspnea
and epigastric distention for the past 2 weeks. He had an
MSTEMI and had a Hct of 22.9 at the outside hospital. He had an
echo which revealed a 30-35% LVEF with global hypokinesis and
1+MR. [**Name13 (STitle) **] underwent EGD on [**3-9**] which revealed erythema,
congestion and superifical erosions of the mucosa in the antrum.
He had mild gastritis and the rest of his mucosa was normal.
He was followed by cardiac surgery throughout this time. He
then had a colonoscoy which was negative. A capsule study
showed 2 areas fof bleeding in the samll intestine but his Hct
remained stable and he had a cardiac catth on [**3-11**] which revealed
no obstructive disease in the LMCA, a focally calcified mid LAD
lesion, 80% mid LCX lesions, and an 80% RCA stenosis.
ON [**2129-3-14**] he underwent a CABGx4(LIMA->LAD, SVG->[**Last Name (LF) **], [**First Name3 (LF) **], and
PDA). He tolerated the procedure well and was transferred to
the CVICU on Epi, Neo, and Propofol in stable condition. He was
extubated on POD#1. The Epi was d/c'd on POD#1 and his chest
tubes were d/c'd on POD#2. He was transferred to the floor on
POD#2 and his epicardial pacing wires were d/c'd on POD#3. He
continued to progress with physical therapy and was discharged
to home in stable condition on POD#4.
He will undergo a small bowel enteroscopy with Dr. [**First Name (STitle) 908**] in 1
month.
Medications on Admission:
Toprol xL 25mg dailiy
Lisinopril 20mg daily
Lasix 40mg po daily
Zocor 20mg daily
Plavix 75mg daily
Aspirin 325mg daily
dilantin 300mg daily
Phenobarbital 64.8mg po bid
Omeprazole 20mg po daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Phenobarbital 15 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
Disp:*180 Tablet(s)* Refills:*2*
4. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
Disp:*90 Capsule(s)* Refills:*2*
5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
8. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily).
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
CAD
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.
Call our office for sternal drainage, temp>101.5
Do not use creams, lotions, or powders on wounds.
Followup Instructions:
Make an appointment with Dr. [**First Name (STitle) **] for 1-2 weeks.
Make an appointment with Dr. [**Last Name (STitle) 10543**] for 2-3 weeks.
Make an appointment with Dr. [**Last Name (STitle) **] for 4 weeks.Provider: [**Name10 (NameIs) **]
WEST,ROOM THREE GI ROOMS Date/Time:[**2129-4-14**] 9:00
Provider: [**Name10 (NameIs) **] PROCEDURES FELLOW Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2129-4-14**] 9:00
Completed by:[**2129-3-18**]
ICD9 Codes: 4280, 5789, 5849, 496, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3475
} | Medical Text: Admission Date: [**2180-5-15**] Discharge Date: [**2180-5-31**]
Date of Birth: [**2121-5-11**] Sex: M
Service: MEDICINE
Allergies:
Percocet / Tylenol / Warfarin / fentanyl
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
agitation, AFib with RVR, multifocal PNA
Reason for MICU transfer: increased nursing requirement
Major Surgical or Invasive Procedure:
None
History of Present Illness:
59yoM with h/o AFib, asthma, BOOP, DM2, spinal stenosis and
chronic back pain and high narcotic requirement at baseline, now
s/p L1-2 total laminectomy, fusion of L1-3, reomval of previous
instrumentation L3-5 and autograft on [**2180-5-15**].
His post op course has been complicated by HAP, ? aspiration,
delirium, and AFib with RVR. Pain management has been following
her given high narcotic requirement and difficulty managing post
op pain, and post-op he was on a Ketamine gtt.
He was having delirium with hallucinations and periods of
unresponsiveness, and his chronic pain meds were decreased and
started on PRN Zyprexa. He spiked a fever [**5-17**] and CXR showed
multifocal PNA, so started on Vancomycin and Ceftazadime for
HCAP, went to SICU. BP's have been variable between 200/100 on
arrival to TSICU and then noted to be hypotensive to 80/50 which
responded well to IVF's and albumin. EKG has been noted to have
some ST depressions V3-5 but negative Trops. Hct noted to
decrease from 28 on admission to 23 through course, stable
thereafter. AFib with RVR has been addressed with uptitration of
PO Diltiazem and apparently also with Metoprolol (? -- not noted
on transfer from floor).
Pt was transferred from TSICU to Medicine floor late pm of [**5-22**]
and was switched from Vanc/Ceftaz to Vanc/Zosyn. He triggered on
the floor for AFib with RVR, agitation, delirium. Noted to be in
pain, turning from left to right, temp noted 100.6 and RVR to
150 but other vitals stable. Dilt ER changed to 60 qid, given 10
mg IV Dilt, given Zyprexa 5mg PO.
ROS: On arrival to MICU pt sleeping comfortably, awoken and
conversant, and denied any symtpoms, no SOB, CP, abd pain, n/v.
Knew where he was and was calm.
Past Medical History:
HTN
CHF ?, pt unsure
Hyperlipidemia
NIDDM
Paroxysmal AFib -- on Dabigatran and ASA 81 daily
Sarcoidosis
BOOP
Asthma
Chronic back pain since a fall in [**2150**] s/p L1-L2, L3-L4 fusion
and severe spinal stenosis above this; then in [**4-/2180**] s/p L1-2
total laminectomy, fusion of L1-3, reomval of previous
instrumentation L3-5 and autograft
C-spine fx in [**8-4**] s/p C2-C3 diskectomy
Carpal tunnel surgery [**2170**].
Left hip replacement [**2178**].
Social History:
Denies tobacco use, rare Etoh. No illicts. On disability. Lives
with son (who has a narcotic problem). Ambulates with walker at
baseline.
Family History:
Father with CAD. Mom with parkinson's and breast ca.
Physical Exam:
PHYSICAL EXAM ON ADMISSION
101.4 102 131/63 17
Large gentleman, sleeping, awoken with voice and calm,
conversant, no distress.
EOMI, no scleral icterus
Difficult to assess JVD
CTAB anteriorly, no w/c/r/r, good air movement
Irregularly irregular, without gross m/g
Obese NT ND, soft abdomen, benign
No BLE edema, extrems are warm
CN 2-12 grossly intact, no focal neuro deficits noted. Oriented
to [**Hospital1 18**], not oriented to date but doesn't answer corrently.
Answers some questions correctly, but gets tangential with
others, he is redirectable though
Back with well healing midline lumbar surgical scar, no
purulence or cellulitis
PHYSICAL EXAM ON DISCHARGE
97.6, 145/60s, 73, 20, 93% on RA
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement,
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT, distended, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials,
DPs), 2+ pitting edema bilaterally
SKIN - no rashes or lesions
WOUND - nonerythematous induration over anterior aspects of the
incision line, mildly tender, rest of incision line clean,
intact, morderately tender on palpation over distal portions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**2-29**] in quards and knee on the right, [**3-30**] throughout otherwise,
sensation grossly intact throughout, DTRs 2+ and symmetric
Pertinent Results:
ADMISSION LABS
[**2180-5-16**] 04:00AM BLOOD WBC-6.8# RBC-3.19* Hgb-9.7* Hct-28.5*
MCV-89 MCH-30.3 MCHC-34.0 RDW-14.0 Plt Ct-115*
[**2180-5-23**] 08:32AM BLOOD Neuts-75.7* Lymphs-12.8* Monos-5.7
Eos-5.2* Baso-0.8
[**2180-5-18**] 02:05AM BLOOD Neuts-82.5* Bands-0 Lymphs-11.1*
Monos-6.0 Eos-0.2 Baso-0.1
[**2180-5-17**] 10:55AM BLOOD PT-15.1* PTT-27.0 INR(PT)-1.3*
[**2180-5-16**] 04:00AM BLOOD Glucose-159* UreaN-17 Creat-0.7 Na-140
K-3.7 Cl-108 HCO3-25 AnGap-11
[**2180-5-19**] 12:30PM BLOOD ALT-71* AST-89* AlkPhos-74 TotBili-0.6
[**2180-5-23**] 09:11PM BLOOD ALT-82* AST-39 LD(LDH)-263* AlkPhos-169*
TotBili-0.6
[**2180-5-22**] 01:42AM BLOOD CK-MB-2 cTropnT-<0.01
[**2180-5-22**] 02:01PM BLOOD CK-MB-2 cTropnT-<0.01
[**2180-5-23**] 09:11PM BLOOD CK-MB-3 cTropnT-<0.01
[**2180-5-17**] 10:55AM BLOOD Calcium-7.6* Phos-1.8* Mg-1.9
[**2180-5-24**] 05:38AM BLOOD calTIBC-164* VitB12-747 Folate-14.9
Ferritn-289 TRF-126*
[**2180-5-19**] 06:19AM BLOOD Vanco-7.4*
[**2180-5-24**] 05:38AM BLOOD Vanco-25.3*
[**2180-5-15**] 05:06PM BLOOD Type-ART pO2-166* pCO2-42 pH-7.43
calTCO2-29 Base XS-3
DISCHARGE LABS:
[**2180-5-31**] 05:14AM BLOOD WBC-3.1* RBC-2.55* Hgb-7.6* Hct-22.9*
MCV-90 MCH-29.9 MCHC-33.3 RDW-15.4 Plt Ct-146*
[**2180-5-31**] 05:14AM BLOOD Glucose-115* UreaN-22* Creat-0.8 Na-138
K-3.6 Cl-103 HCO3-29 AnGap-10
[**2180-5-23**] 09:11PM BLOOD ALT-82* AST-39 LD(LDH)-263* AlkPhos-169*
TotBili-0.6
[**2180-5-31**] 05:14AM BLOOD Calcium-8.3* Phos-4.3 Mg-2.2
PERTINENT STUDIES:
# L-spine ([**5-15**])
Single cross-table lateral demonstrates posterior fusion with
rods and pedicle screws as well as retractors. Please refer to
operative note for full details.
# portable CXR ([**5-18**])
FINDINGS: In comparison with the study of [**5-17**], there is little
overall
change. There is persistent enlargement of the cardiac
silhouette with low
lung volumes and evidence of increased pulmonary venous
pressure. There may be minimal blunting of the costophrenic
angles bilaterally.
# portable CXR ([**5-19**])
IMPRESSION: AP chest compared to [**5-17**] and 23:
Large scale multifocal consolidation, although accompanied by
pulmonary
vascular congestion, is quite likely multilobar pneumonia.
Moderate right
pleural effusion has increased. Heart size is normal.
Mediastinum is not
widened. Right subclavian line ends in the SVC. No pneumothorax.
Dr. [**Last Name (STitle) 27362**]
was paged at the time of dictation.
# CHEST (PORTABLE AP) Study Date of [**2180-5-23**] 7:16 AM
Consolidation at the lung bases, left greater than right,
worsened
substantially at least on the right side between [**5-18**] and
[**5-19**]. Some of that interval change was due to concurrent
pulmonary edema which persists, but bibasilar consolidation is
improving. At least a small volume of right pleural fluid is
present, some still in the major fissure. Heart is top normal
size, pulmonary and mediastinal vascular engorgement persists.
Right subclavian line ends in the mid SVC. No pneumothorax.
# ECHO [**2180-5-24**]
The left atrium is elongated. The right atrium is moderately
dilated. The left ventricular cavity size is normal. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is normal (LVEF>55%). Tissue Doppler imaging suggests a
normal left ventricular filling pressure (PCWP<12mmHg). The
right ventricular cavity is mildly dilated with normal free wall
contractility. The ascending aorta is mildly dilated. The aortic
valve leaflets (?#) appear structurally normal with good leaflet
excursion. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. No mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Suboptimal image quality. Normal global
biventricular systolic function. Mild right ventricular
dilation. Technically suboptimal to exclude focal wall motion
abnormality. Mild aortic dilation. Biatrial dilation.
# Droppler studies ([**5-28**])
FINDINGS: Doppler son[**Name (NI) 1417**] of the bilateral subclavian veins
and the right internal jugular, right axillary, right brachial,
right basilic and cephalic veins were performed. There is normal
compressibility and flow in the subclavian and axillary veins.
There are three brachial veins, one of which contains occlusive
echogenic thrombus. Nearly occlusive echogenic thrombus is also
seen in the distal cephalic vein with minimal flow.
IMPRESSION:
Deep venous thrombus in a right brachial vein, and superficial
thrombosis of a cephalic vein.
Brief Hospital Course:
Mr. [**Known lastname 27363**] is 59 yo M with a history of A-fib, CHF, DM, spinal
stenosis secondary to MVA on chronic narcotics for pain, came in
for elective laminectomy for L1-L2 and fusion for L1-L3, and had
a complicated post-op course, requring SICU/MICU admission for
A-fib with RVR, delirium, hypotension and multifocal peumonia.
ACTIVE ISSUES
# Orthopedic surgery & routine post-op issues
Pt underwent uncomplicated total laminectomy of L1 and L2,
fusion L1 to L3, instrumentation L1-L3, removal of previous
instrumentation from 3 to 5 and autograft. Patient is mild soft
tissue swelling at distal incision site without sign of
infection; Dr [**Last Name (STitle) 363**] aware of seroma at time of discharge.
OUTPATIENT ISSUES:
-- Continue to monitor site
-- Ortho follow-up on [**6-5**]
-- Continue to wear stabilizing brace with ambulation
.
# Delirium
Patient noted to have display considerable delirum in ICU as
well as the floor in the post-operative period. Etiology likely
secondary to acute infectious process. Mental status slowly
improved with treatment of PNA as well as improved pain control.
At time of discharge patient was alert and oriented x3.
.
# A-fib RVR
Patient developed A-fib with RVR post-op. Etiology thought
secondary to catocholamine surge post-op, under controlled pain
as well as infection. With treatment of pain and infection as
well as rate controlled with uptitration of diltazam rates
controlled. Prior to discharge patient had converted back to
sinus rhythm with rates well controlled on Dilt XR.
OUTPATIENT ISSUES:
1. Rate control. Continue with dilt XR
2. Anticoagulation. Patient had previously been on pradexa
however due to concern for bleed in the ICU (low HCT) pradexa
held. Patient started on Lovenox for treatment of provoked DVT.
Will continue Lovenox x1 month (end date [**6-28**]) with plan to
transition back to pradexa thereafter for rate control,
.
# Multifocal pneumonia
On post-op day #2, patient developed fever, hypertension and
tachycardia. On the subsequently portable CXR, multiple focal
consolidations were found, concerning for hospital acquired
pneumonia vs aspiration pneumonia. Patient finished a total
course of 5 days of vancomycin / ceftriaxone and 3 days of
vancomycin / zosyn for complete treatment of HAP. His
respiratory status remained stable. Patient continued to spike
intermittent low grade fever till he finished his antibiotics
course. Prior to discharge patient with stable respiratory rate.
.
# DVT
Patient noted to have upper extremity swelling on [**5-28**]. Upper
extremity ultrasound demonstrated deep venous thrombus in a
right brachial vein, and superficial thrombosis of a cephalic
vein. Patient was started on Lovenox for planned 1month course
in treatment of provoked DVT as patient had previously had line
in place.
OUTPATIENT ISSUES:
-- Continue anticoagulation with Lovenox until [**6-29**] for 1month
treatment of provoked DVT
.
# Chronic Pain.
Patient with history of chronic pain. Post-operatively the pain
team was consulted for assistance in management. At time of
discharge patients pain adequately controlled MS [**Last Name (Titles) **] 75mg
[**Hospital1 **] with Morphine IR 15-30 Q4hrs for breakthru.
.
# Lower extremity edema
Patient with 1+ lower extremity edema to mid-shins bilaterally.
[**5-24**] TTE demonstrated normal global biventricular systolic
function, mild right ventricular dilation without appreciable
valvular abnl. Though overall study technically suboptimal to
exclude focal wall motion abnormality. Patient continued on
lasix 40mg PO, diuresising ~1L daily.
OUTPATIENT ISSUES:
-- Monitor weights, I/O, contact physician/discuss increasing
diuretic in advent of weight gain.
.
# Hypotension. Patient with intermittent episodes of hypotension
the ICU. Hypotension likely secondary to infection as well as
Afib with RVR. Patient bolused with IV fluid. Infection treated
and patient rate controlled. SBPs returned to baseline prior to
discharge and patient tolerating all home PO medications.
.
# Hypertension.
Anti-hypertensives held during hypotensive episodes. Restarted
on gradually in house. Patient tolerating Imdur, Dilt.
amlodipine and benzopril prior to discharge with SBPs 130-150
.
# Diabetes.
Patient maintained on insulin sliding scale in house. Metformin
restarted prior to discharge.
.
# OSA
Patient require CPAP during sleep.
.
# Dispo: Rehab
.
# Code: Full
Medications on Admission:
ALBUTEROL SULFATE [PROAIR HFA] - (Prescribed by Other Provider)
- Dosage uncertain
AMLODIPINE-BENAZEPRIL [LOTREL] - (Prescribed by Other Provider)
- 10 mg-40 mg Capsule - 1 (One) Capsule(s) by mouth once a day
CARBAMAZEPINE [TEGRETOL] - (Prescribed by Other Provider) - 100
mg Tablet, Chewable - 1 (One) Tablet(s) by mouth twice a day
CLONIDINE - (Prescribed by Other Provider) - 0.1 mg Tablet - 1
to 2 Tablet(s) by mouth once a day
DABIGATRAN ETEXILATE [PRADAXA] - (Prescribed by Other Provider)
- 150 mg Capsule - 1 Capsule(s) by mouth twice a day
DIAZEPAM [VALIUM] - (Prescribed by Other Provider) - 10 mg
Tablet - 1 (One) Tablet(s) by mouth four times a day
DILTIAZEM HCL - (Prescribed by Other Provider) - Dosage
uncertain
EZETIMIBE-SIMVASTATIN [VYTORIN 10-40] - (Prescribed by Other
Provider) - 10 mg-40 mg Tablet - 1 (One) Tablet(s) by mouth at
bedtime
FUROSEMIDE [LASIX] - (Prescribed by Other Provider) - 40 mg
Tablet - 1 (One) Tablet(s) by mouth once a day
ISOSORBIDE MONONITRATE [IMDUR] - (Prescribed by Other Provider)
- 30 mg Tablet Extended Release 24 hr - 1 (One) Tablet(s) by
mouth once a day
METFORMIN - (Prescribed by Other Provider) - 500 mg Tablet - 2
(Two) Tablet(s) by mouth in the morning and 1 and [**11-28**] at bedtime
OXYMORPHONE [OPANA ER] - (Prescribed by Other Provider) - 40 mg
Tablet Extended Release 12 hr - 2 (Two) Tablet(s) by mouth twice
a day
RANITIDINE HCL - (Prescribed by Other Provider) - 150 mg Tablet
- 1 (One) Tablet(s) by mouth at bedtime
SUCRALFATE [CARAFATE] - (Prescribed by Other Provider) - 1 gram
Tablet - 1 (One) Tablet(s) by mouth at bedtime
TERAZOSIN - (Prescribed by Other Provider) - 10 mg Capsule - 1
(One) Capsule(s) by mouth at bedtime
TOPIRAMATE - (Prescribed by Other Provider) - 25 mg Capsule,
Sprinkle - 2 (Two) Capsule(s) by mouth once a day
Medications - OTC
ASPIRIN - (OTC) - 81 mg Tablet, Chewable - 1 (One) Tablet(s) by
mouth once a day
DOCUSATE SODIUM [STOOL SOFTENER] - (Prescribed by Other
Provider; OTC) - Dosage uncertain
IRON - (Dose adjustment - no new Rx) - 325 mg (65 mg iron)
Tablet - 1 (One) Tablet(s) by mouth once a day
POTASSIUM - (OTC) - Dosage uncertain
Discharge Medications:
1. albuterol sulfate Inhalation
2. Lotrel 10-40 mg Capsule Sig: One (1) Capsule PO once a day.
3. clonidine 0.1 mg Tablet Sig: 1-2 Tablets PO DAILY (Daily).
4. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. enoxaparin 120 mg/0.8 mL Syringe Sig: One (1) shot
Subcutaneous Q12H (every 12 hours).
Disp:*14 * Refills:*0*
6. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. sucralfate 1 gram Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. terazosin 5 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
9. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
13. Vytorin 10-40 10-40 mg Tablet Sig: One (1) Tablet PO at
bedtime.
14. potassium Oral
15. diltiazem HCl 360 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO once a day.
16. topiramate 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
17. Orphenadrine Compound Oral
18. metformin 500 mg Tablet Sig: Two (2) Tablet PO qAM.
19. metformin 500 mg Tablet Sig: 1.5 Tablets PO at bedtime.
20. morphine 15 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
21. morphine 15 mg Tablet Extended Release Sig: Five (5) Tablet
Extended Release PO Q12H (every 12 hours).
22. diazepam 10 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day) as needed for agitation.
23. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day).
24. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily) as needed for constipation.
25. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
26. Advair Diskus 100-50 mcg/dose Disk with Device Sig: One (1)
puff Inhalation twice a day.
Discharge Disposition:
Extended Care
Facility:
Commons Residence At Orchard - [**Location (un) 2624**] (a.k.a. [**Location (un) 5481**])
Discharge Diagnosis:
Primary diagnosis
Secondary diagnosis
Atrial fibrillation
Pneumonia
Delirium
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 27363**],
You came to our hospital for surgery of your spine. The surgery
went smoothly, however you did develop some complications
post-op that required treatment in an intensive care unit.
Briefly, you developed pneumonia, which was treated with
antibiotics. Your atrial fibrillation also recurred, which has
been successfully controlled by medication. Since your
condition has improvement significantly, we think it will be at
your best interest to continue your recovery at a rehabilitation
facility.
Please note that the following of your medications has been
changed:
-- Please stop taking Carbamazepine
-- Please stop taking oxymorphone
-- Please stop taking Dabigatran (Pradaxa). You doctor may
advise you to restart this medication after finishing 4 weeks of
lovenox.
-- Please start taking topiramate (Topamax)at 50 mg twice a day
(instead of daily)
-- Please take Enoxaparin (Lovenox) 110 mg twice a day for 4
weeks
-- Please take Morphine SR (MSContin) 75 mg twice a day
-- Please take Morphine IR 15-30 mg as needed for pain up to
every 4 hours
It has been a privilege to take care of you while you are here.
We all wish you a speedy recovery.
Followup Instructions:
Name: [**Last Name (LF) 363**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital1 **]
Address: [**Location (un) **], [**Hospital Ward Name **] 2, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 3573**]
Appointment: Monday [**6-5**] at 12PM
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
Completed by:[**2180-5-31**]
ICD9 Codes: 486, 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3476
} | Medical Text: Admission Date: [**2139-12-22**] Discharge Date: [**2140-1-6**]
Date of Birth: [**2077-7-8**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Zestril / Heparin Agents / Heparin,Beef / Diovan /
Prevacid / Amiodarone
Attending:[**First Name3 (LF) 1828**]
Chief Complaint:
Hip pain, bruising
Major Surgical or Invasive Procedure:
none
History of Present Illness:
62 yo Man with MMP including severe COPD on chronic high dose
steroids, difficult to control AF, and AS s/p prosthetic valve
replacement, presented with RLE pain. Pt had been in USOH when
10d prior to admission he was arising from a chair, felt a
tugging sensation in his R hip, which over the next day
developed into progressive pain. The pain decreased over two
days, but then he noticed extensive ecchymoses on his RLE. No
fall, no other trauma. No change in medications. Pt stated he
always bruises easily and only takes baby ASA 81 mg twice a week
because of increased bruising if he takes it more often. Pt also
reported increased dyspnea at rest over the past 3 days. Denies
f/c, changed cough, CP, n/v, or other sxs. He did have a chronic
cough productive of thick, often bloody secretions.
.
In [**Name (NI) **] pt had an episode of rapid AF with HR to 130s, associated
with diaphoresis and SOB, which resolved eventually after nebs
and disopyramide were given.
.
Past Medical History:
1) Aortic stenosis -> [**Name (NI) 1291**] [**1-5**] [**Company **] porcine valve, post op
course c/b delerium, ARF, afib, shock liver, repiratory failure,
trach and PEG, Pneumonia (Staph, tx with Vanco)
2) PAF: initially noted during [**Company 1291**] and treated with Procainamide
due to transaminitis and then discharged on Amiodarone and
Digoxin. Digoxin was d/c'd in [**2-6**]. Amio d/c'd 3 mos later
secondary to rash. Now controlled with
rate control with digoxin and diltiazem and with rhythm control
with norpace.
3) HTN
4) Severe COPD ([**3-11**] FEV1 14% FVC 39%) on 4L NC: Recently
admitted [**1-7**] for COPD exacerbation. Followed previously by Dr.
[**Doctor Last Name 496**] and now Dr. [**Last Name (STitle) **] from pulmonary. Has been through
pulmonary rehab. Has considered and decided against, both lung
transplant and lung reduction surgery. No evidence of alpha-1
antitrypsin deficiency.
5)H/o Trachomalacia - s/p flex bronch [**12-7**] - 50% collapse
indistal trachea and left mainstem, 80% right bronchus
intermedius - no surgical intervention
6) Heparin induced thrombocytopenia
7) GIB secondary to ulcer [**2-6**] (Hct 21), duodenitis, UGIB
8) L hip osteomyelitis, s/p hip replacement
9) L wrist septic arthritis
Social History:
Married, retired fire fighter. Tob [**2-3**] ppd x 30-40 years and
quit in [**8-5**]
ETOH: socially drinks beer on weekends
Family History:
+ CAD
Physical Exam:
VS: T 97.9, BP 141/95, P 105, RR 22, 96% 3L
GEN: Resting, somewhat stiff appearing. Speech with pauses to
resume pursed lip breathing x few breaths before able to finish
sentences
HEENT: mmm, anicteric
Neck: Supple, no masses
CV: Irreg irreg, III/VI early SEM at LSB
PULM: Decreased bs bilat, scant wheezing only
ABD: NABS S ND NT
EXTR: R hip and thigh extensive ecchymosis
NEURO: AAO x 3, moves all extremities equally
Pertinent Results:
[**2139-12-22**] 03:00PM WBC-34.3* RBC-6.30*# HGB-12.4*# HCT-46.1#
MCV-73* MCH-19.7*# MCHC-26.9* RDW-18.6*
[**2139-12-22**] 03:00PM NEUTS-89* BANDS-4 LYMPHS-5* MONOS-1* EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-1*
[**2139-12-22**] 03:00PM PLT SMR-VERY HIGH PLT COUNT-732*
[**2139-12-22**] 03:00PM PT-14.0* PTT-30.2 INR(PT)-1.2*
[**2139-12-22**] 03:00PM GLUCOSE-125* UREA N-22* CREAT-0.9 SODIUM-141
POTASSIUM-5.2* CHLORIDE-95* TOTAL CO2-39* ANION GAP-12
[**2139-12-22**] 08:41PM CK(CPK)-26*
[**2139-12-22**] 08:41PM cTropnT-0.06*
[**2139-12-22**] 09:21PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
.
Hip plain film: No evidence of fracture.
.
CT hip: No acute fracture involving the right hip. Mild
degenerative
disease of the right hip. Large right intramuscular hematoma
just posterior to the greater trochanter.
.
Brief Hospital Course:
ON admission, the assessment was that of a 62 yo Man w/ numerous
medical problems including AS s/p valve replacement, AF, and
severe COPD on high dose steroids now presenting with R hip pain
and dyspnea.
# Hip hematoma/ pain: Pt was thought to be more predisposed to
injury [**3-6**] chronic high dose steroids. A question was raised
whether he had muscular injury/tear or possible AVN of hip also,
but this was ruled out.
# COPD: On admit he appeared to be having flare, with increased
sputum production and increased dyspnea. He was started on
Prednisone 60mg daily and Azithromycin. Additionally he was
given Albuterol, atrovent nebs, [**Month/Day (2) 8895**] and advair. The
patient began having significant respiratory distress on [**12-25**].
An ABG showed pH 7.26, PCO2 89 and PaO2 73. He was transfered to
the ICU and placed on CPAP. He was placed on IV methylprednisone
and continued on Azithromycin as well as nebs. He improved
quickly in the ICU and was transitioned back to nasal canula
within hours. A CXR on day of admission to the ICU, showed a
unilateral opacification of unclear significance -possibly
artifact- and the radiology read noted only bilateral
interstitial opacities but no focal pneumonia. Repeat CXR did
not show unilateral opacification. He was transferred to the
floor on [**1-2**] but continued to have severe dyspnea with almost
any activity. This was improved somewhat by ensuring good
cardiac rate control. On [**1-5**] pulmonary recommended adding
BIPAP while on the floor - this was begun and the patient
reported this provided some relief.
# Chest discomfort: In [**Name (NI) **] pt had chest tightness and T Wave
inversions on repeat ECG, at similar heart rate to prior ECG.
An acute coronary syndrome was ruled out with enzymes.
.
# AF/MAT: Chronic, managed with diltiazem, dysopyrimide,
digoxin. Periodically he went into Afib or MAT with RVR. Given
his COPD and allergy to amiodarone, neither lopressor nor
amiodarone were attempted, but he responded in the ICU to 250cc
fluid bolus, and on the floor he responded to an increase in
digoxin dosing. His digoxin and diltiazem dosing was adjusted
so as to be optimized.
# Leukocytosis: Persistently high, also with thrombocytosis.
Presumed to be [**3-6**] steroids, and has been at this level since
[**3-/2139**] so no further workup was persued
.
# H/o HIT: Avoided all heparin products
Medications on Admission:
ASA 81 mg twice weekly
Celexa 20 mg daily
Digoxin 125 mcg daily
Diltiazem 240 mg SR daily
Disopyramide 150 mg SR [**Hospital1 **]
Guaifenesin 600 mg [**Hospital1 **]
Advair 500/50 [**Hospital1 **]
[**Hospital1 **] 10 mg hs
Pantoprazole 40 mg daily
Tiotropium 2 puffs qam
Bactrim 400/80 mg daily
Discharge Medications:
1. Methylprednisolone Sodium Succ 125 mg/2 mL Recon Soln Sig:
One (1) Recon Soln Injection Q8H (every 8 hours).
2. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Insulin Lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED).
4. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: Two (2)
Capsule, Sustained Release PO DAILY (Daily).
5. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed.
6. Levalbuterol HCl 0.63 mg/3 mL Solution Sig: One (1)
Inhalation q6H ().
7. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation q12hours ().
8. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
11. Disopyramide 150 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO Q12H (every 12 hours).
12. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
15. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
COPD
paroxysmal atrial tachycardia
Diastolic heart failure
cataracts
Hypertension
Discharge Condition:
requires aggressive management of pulmonary status
Discharge Instructions:
Weights every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Recheck a doigoxin level on [**1-8**]
Followup Instructions:
He needs to schedule a follow-up appointment with Dr. [**Last Name (STitle) **] in
ophthalmol. [**Telephone/Fax (1) 253**] following discharge
Pulmonary follow-up with Dr. [**Last Name (STitle) **], Pulmonary Medicine [**Hospital1 18**]:
[**Telephone/Fax (1) 612**].
ICD9 Codes: 4280, 2762, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3477
} | Medical Text: Admission Date: [**2107-5-26**] Discharge Date: [**2107-6-3**]
Date of Birth: [**2078-11-9**] Sex: F
Service: NEPHROLOGY
HISTORY OF PRESENT ILLNESS: The patient is a 29-year-old
female with a history of renal transplant in [**2097**], who had
worsening renal failure for the past several months. Her
chief complaints were hypotension and seizure.
months prior to admission and had been more hypertensive
recently, requiring blood pressure medications. She was
noted to have worsening renal function secondary to recent
preeclampsia and her blood pressure control was thought
to be secondary to renal failure. A renal biopsy showed
severe nephron loss and scarring, although no rejection. The
patient had since been followed by Dr. [**Last Name (STitle) **] in the renal
At approximately 1 AM on the morning of admission, the
patient experienced a severe headache accompanied by nausea
and vomiting. Her temperature was normal and her blood
pressure at home was 220/130 at that time. The patient
deferred coming to the emergency room, but at 5 AM her
husband awoke to find her with her teeth and fists clenched
close to her sides for approximately five minutes in
duration. There was no incontinence of stool or urine. The
EMS was called and the patient was noted to have a systolic
blood pressure of 220.
The patient was sent to an outside hospital and at 6 AM was
started on a Nipride drip. At 6:15 AM, she had her second
seizure that was a generalized tonic-clonic seizure. She was
given 3 mg of Ativan intravenous and Lasix intravenous. At 7
AM, she was given another 1 mg intravenous. After her first
event, she was postictal for 15 minutes and then was
responsive. She was transferred to [**Hospital1 190**] at 7:30 AM and continued on the Nipride drip.
She was also given hydrocortisone and thiosulfate.
PAST MEDICAL HISTORY:
1. Renal transplant from her sister with 6/6 HLA match in
[**2097**] for congenital abnormality and focal segmental
glomerular sclerosis.
2. History of preeclampsia.
3. Hypertension.
MEDICATIONS ON ADMISSION:
1. Atenolol 50 mg p.o. q.d.
2. Lasix 80 mg p.o. b.i.d.
3. Hytrin 1 mg p.o. h.s.
4. Nifedipine 90 mg p.o. q.d.
5. Lipitor 10 mg p.o. h.s.
6. Medrol 12 mg p.o. q.d.
7. Rapamycin 4 mg p.o. q.d.
SOCIAL HISTORY: The patient was married with a one year old
child
FAMILY HISTORY: The patient's mother had celiac sprue.
ALLERGIES: There were no known drug allergies.
LABORATORY DATA ON ADMISSION: The patient had a white blood
cell count of 10,500, hematocrit of 28.6 and platelet count
of 133,000. There was a sodium of 143, potassium of 4.6,
chloride of 104, bicarbonate of 17, BUN of 85, creatinine of
6.7 and glucose of 96. The urinalysis showed one white blood
cell and greater than 300 protein.
ELECTROCARDIOGRAM: The electrocardiogram showed normal sinus
rhythm with no acute changes.
RADIOLOGY: A head CT scan was performed and was negative.
HOSPITAL COURSE:
1. RENAL: The patient had a tunnel catheter placed on
[**2107-5-26**] and was begun on hemodialysis on [**2107-5-27**]. She was
continued on Nephrocaps and TUMS. Electrolytes were followed
and remained normal. The patient is to continue on
hemodialysis from this point on. Her family is being
re-screened for possible repeat renal transplant. The
patient's immunosuppression regimen was tailored down, given
her failed transplant. She was continued on rapamycin 2 mg
p.o. q.d. and her rapamycin level was within normal limits at
the time of her admission. Her seizure was not felt to be
due to overdose. The patient was continued on Medrol 12 mg
p.o. q.d. CellCept was discontinued.
2. NEUROLOGY: The patient had a negative lumbar puncture
performed as well as a negative head CT scan. All viral and
bacterial cultures were negative. She had an
electroencephalogram that showed a question of a temporal
lobe abnormality with a possible focus for seizure. She was
continued on Dilantin at discharge. She had no further
episodes of seizure.
3. CARDIOVASCULAR: The patient had very poorly controlled
hypertension. She had increasing doses of antihypertensives
added on. Her blood pressure was well controlled on the
discharge regimen including Hytrin, labetalol, Procardia and
Lasix. Her blood pressure at the time of discharge was under
150 systolic.
4. INFECTIOUS DISEASE: The patient was noted to have a
urinary tract infection. She was started on amoxicillin, to
be continued after discharge.
5. HEME: The patient had a hematocrit that was stable, but
she was started on Epogen during dialysis. This was
restarted after her hypertension was more controlled.
DISPOSITION: The patient was discharged to home in stable
condition.
DISCHARGE MEDICATIONS:
1. Labetalol 300 mg p.o. t.i.d.
2. Procardia XL 90 mg p.o. b.i.d.
3. Captopril 50 mg p.o. t.i.d.
4. Dilantin 300 mg p.o. h.s.
5. Ativan 1 to 2 mg p.o. every six hours p.r.n. for anxiety.
6. Amoxicillin 500 mg p.o. q.d. on hemodialysis days.
7. Rapamycin 2 mg p.o. q.d.
8. Medrol 12 mg p.o. q.d.
9. TUMS 500 mg p.o. t.i.d.
10. Nephrocaps one tablet p.o. q.d.
11. Lipitor 10 mg p.o. h.s.
12. Tylenol 650 mg p.o. every four to six hours p.r.n.
FOLLOW UP: The patient is to follow up at the dialysis unit
on Monday, [**2107-6-6**], at noon for her next hemodialysis
treatment. She is also to follow up in the neurology center
with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 15462**] on [**2107-8-23**] at 2:30 PM, or the next
available cancellation appointment. She was also instructed
to call Dr. [**Last Name (STitle) **] with any questions and to report to the
emergency room or call 911 if she had further seizures. She
is going to need her Dilantin level followed up as an
outpatient.
DISCHARGE DIAGNOSES:
1. End stage renal disease with failed renal transplant, on
hemodialysis.
2. Hypertensive emergency under control.
3. Seizure disorder.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15463**], M.D. [**MD Number(1) 15464**]
Dictated By:[**Last Name (NamePattern1) 9422**]
MEDQUIST36
D: [**2107-6-16**] 12:28
T: [**2107-6-17**] 08:36
JOB#: [**Job Number 15465**]
ICD9 Codes: 5849, 5990, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3478
} | Medical Text: Admission Date: [**2171-3-7**] Discharge Date: [**2171-3-11**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3151**]
Chief Complaint:
hematemesis
Major Surgical or Invasive Procedure:
endoscopy, blood transfusion
EGD
History of Present Illness:
[**Age over 90 **] M with HTN including hypertensive urgency, extremely hard of
hearing, PR prolongation, RBBB, [**Age over 90 4448**], hiatal hernia, TIA,
and previous UGIB in [**2166**] presents with multiple episodes of
hematemesis x 1 day. Patient says the first time he vomited
brought up food, the second, clots, and subsequent episodes
brought up bright red blood. Denied any accompanying symptoms:
no CP, SOB, abd pain.
.
In the ED patient patient was given 2 L NS and 1 dose of IV
lasix. He was NG lavaged but did not clear after 1 L. Per
report, he was guiac negative.
Past Medical History:
PR prolongation, RBBB s/p pacer [**7-14**]
Hypertension
Benign prostatic hypertrophy
Chronic diarrhea
Hiatal hernia
Upper GI bleed [**10-12**]
Bladder cancer s/p focal radiation/ablation
Nasal polyps s/p R maxillary antrectomy
DJD
TIA
Social History:
Currently lives at home alone, has help of an aide (24 hours per
day). Widowed. Denies any ETOH, drug use. Remote tobacco use,
quit '[**19**]. Former pathologist. Son is a surgeon.
Family History:
non-contributory
Physical Exam:
afebrile BP: 157/58 P: 71 R: 16 SaO2: 99%
GEN: lying in bed, sleepy, NAD
HEENT: AT, NC, OP clear, MM dry
CV: RRR, soft [**1-15**] sys murmur
PULM: CTAB on anterior exam, no w/r/r
ABD: soft, NT, ND, + BS, guiac negative
EXT: warm, dry, no c/c/e BL, +1 distal pulses BL
NEURO: sleepy but able to answer simple questions
Pertinent Results:
[**2171-3-7**] 08:48PM PT-14.1* PTT-29.2 INR(PT)-1.2*
[**2171-3-7**] 08:48PM PLT COUNT-234
[**2171-3-7**] 08:48PM NEUTS-86.3* BANDS-0 LYMPHS-9.1* MONOS-3.0
EOS-1.3 BASOS-0.3
[**2171-3-7**] 08:48PM WBC-12.3*# RBC-4.42* HGB-13.5* HCT-39.7*
MCV-90 MCH-30.5 MCHC-34.0 RDW-14.5
[**2171-3-7**] 08:48PM GLUCOSE-130* UREA N-23* CREAT-1.1 SODIUM-138
POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-28 ANION GAP-13
[**2171-3-7**] 08:58PM HGB-13.4* calcHCT-40
[**2171-3-8**] EGD
Small hiatal hernia
Propable visible vessel in the cardia close to the GE junction
seen on retroflexion. multile injections with total of 6 CC
1;10,00 epinephrine and then thermocoagulation applied
Schatzki's ring
Prominent ampulla of Vater
(injection)
Stomach had a large blood clot
Otherwise normal EGD to second part of the duodenum
Brief Hospital Course:
[**Age over 90 **] M with HTN with past medical history of hypertension, TIA,
extremely hard of hearing, and [**Age over 90 4448**] was admitted with
hematemesis x 1 day which has now resolved with electrocautery
during EGD.
.
1. GI Bleed:
Patient admitted with upper GI bleed most likely secondary to
his initial vomiting. EGD demonstrated visible vessel seen on
EGD which resolved with epi injection and electrocautery.
Patient's hematocrit now stable and pt was started on PO PPI
[**Hospital1 **]. Patient's aspirin and plavix were also discontinued for two
weeks and was recommended to follow-up with his primary care
physician.
.
2. Coronary Artery Disease:
Patient denies any chest or abdominal pain. He was continued on
him home metoprolol. Patient was also recommended to hold
aspirin and plavix for two weeks and follow-up with his primary
care physician.
.
3. Acute Renal Failure
Patient with mildly elevated creatinine, consistent with
pre-renal etiology in the setting of bleed. Patient's creatinine
trending down upon discharge.
.
4. Hypothyroidisim
Patient maintained on levothyroxine.
.
5. Hypertension:
Patient with elevated BP during stay in the MICU. Pt with a
history of orthostatic hypotension with aggressive BP control so
patient was continued on home regimen of hydrochlorothiazide
from 12.5mg and metoprolol 25mg [**Hospital1 **]
.
6. History of TIA: hold aspirin and plavix for two weeks.
.
7. BPH: cont Tamsulosin
Medications on Admission:
1. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS
2. Clopidogrel 75 mg Tablet 1 Tablet PO DAILY
3. Hydrochlorothiazide 25 mg Tablet 0.5 Tablet PO DAILY
4. Levothyroxine 50 mcg Tablet (1) Tablet PO DAILY
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.)
(1) Tablet, Delayed Release (E.C.) PO Q24H
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
7. Aspirin 81 mg Tablet O DAILY
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
5. Hydrochlorothiazide 25 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
1. Upper GI bleed
.
SECONDARY DIAGNOSIS:
PR prolongation, RBBB s/p pacer [**7-14**]
Hypertension
Benign prostatic hypertrophy
Chronic diarrhea
Hiatal hernia
Upper GI bleed [**10-12**]
Bladder cancer s/p focal radiation/ablation
Nasal polyps s/p R maxillary antrectomy
DJD
TIA
Discharge Condition:
Stable - Patient is tolerating oral intake, ambulating, and has
returned to his baseline condition.
Discharge Instructions:
- While you were here, you were diagnosed with an upper
gastrointestinal bleed due to a bleeding vessel in your stomach.
You underwent an endoscopy where the vessel was visualized and
cauterized to stop the bleeding. Since your procedure, your
blood counts have remained stable.
- Please take all your medications as prescribed.
- If you have any further symptoms of nausea, vomiting with
blood, feeling light-headedness, dizziness, chest pain,
shortness of breath, fevers, chills, or night sweats, please
seek medical attention.
Followup Instructions:
- Please follow-up with your primary care physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **]
[**Name (STitle) 665**] on Tuesday [**3-19**] at 10:20am. His phone number is
[**Telephone/Fax (1) 250**].
- Please also go to your previously scheduled appointments at
the Device Clinic on [**2171-6-3**] 11:00. If you need to reschedule,
please call their office at [**Telephone/Fax (1) 59**].
- Please also go to your previously scheduled appointments with
[**Name6 (MD) 251**] [**Last Name (NamePattern4) 1114**], M.D. on [**2171-8-13**] 11:40. If you need to
reschedule, please call their office at [**Telephone/Fax (1) 250**].
ICD9 Codes: 5789, 5849, 2449, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3479
} | Medical Text: Admission Date: [**2201-6-18**] Discharge Date: [**2201-6-24**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
DOE
Major Surgical or Invasive Procedure:
AVR(21mm CE) [**2201-6-18**]
History of Present Illness:
80 y/o male with 2 yr h/o SOB. Had Echo that revealed AS. Has
had serial Echo's since, with the last done on [**4-28**] which showed
worsening AS.
Past Medical History:
Aortic stenosis
Hypertension
Hypercholesterolemia
Diabetes Mellitus Type 2
Left Eye Glaucoma
Severe LE Varicosities
h/o Bilat. Renal Calculi
s/p bilat. cataract surgery
s/p appendectomy
s/p tonsillectomy
s/p lithotripsy
Social History:
Lives with wife, retired. Quit smoking 20yrs ago (40-50 pk yrs).
ETOH: 1 glass wine/day.
Family History:
Sister with RHF/valve [**Doctor First Name **].
Physical Exam:
VS: 76 14 154/78 5'[**06**]" 165#
General: Well-appearing, well-nourished elderly man
Skin: Unremarkable, -lesions
HEENT: PERRLA, EOMI, NC/AT
Neck: Supple, FROM, -JVD, Murmur radiating to carotids
Chest: CTAB, -w/r/r
Heart: RRR, +S1S2, 2/6 SEM
Abd: Soft, NT/ND +BS
Ext: Warm, well-perfused, -c/c/e, +severe bilat varicosities
(L>R) 2+ pulses bilat. Fem, PT, and L DP. No pulse on R DP.
Neuro: CN 2-12 intact, non-focal, MAE [**4-28**] strengths
Pertinent Results:
[**2201-6-18**] 10:16AM BLOOD WBC-15.2*# RBC-2.89*# Hgb-9.6*#
Hct-26.3*# MCV-91 MCH-33.3* MCHC-36.5* RDW-13.8 Plt Ct-175
[**2201-6-23**] 06:25AM BLOOD WBC-8.5 RBC-3.44* Hgb-11.0* Hct-31.5*
MCV-92 MCH-32.0 MCHC-34.9 RDW-14.2 Plt Ct-228
[**2201-6-18**] 10:16AM BLOOD PT-16.1* PTT-40.3* INR(PT)-1.7
[**2201-6-22**] 02:40AM BLOOD PT-13.3 PTT-26.3 INR(PT)-1.2
[**2201-6-18**] 11:25AM BLOOD UreaN-15 Creat-0.8 Cl-105 HCO3-27
[**2201-6-18**] 07:55PM BLOOD Glucose-111* K-3.3
[**2201-6-23**] 06:25AM BLOOD Glucose-167* UreaN-34* Creat-0.9 Na-140
K-3.4 Cl-101 HCO3-28 AnGap-14
[**2201-6-24**] 06:25AM BLOOD K-3.9
Brief Hospital Course:
As stated in the HPI, he is a 80 y/o male with a h/o AS who was
initially seen as an outpt. He was a same day admit and brought
to the operating room, where he underwent an aortic valve
replacement. Please see op note for full surgical details. He
tolerated the procedure well with a total bypass time of 71
minutes and cross clamp time of 58 minutes. He was transferred
to CSRU in stable condition with a MAP of 60, CVP 7, PAD 13, [**Doctor First Name 1052**]
18, HR 87 NSR and being titrated on Neo, Propofol, and Insulin.
Pt was weaned from propofol and mechanical ventilation and was
extubated later on op day. He was awake, alert, MAE, and
following commands. On POD #1 he was recovering well. Swan Ganz
catheter was removed. Diuretics and B-blockers were started per
protocol. His chest x-ray showed bibasilar atelectasis and small
r. pleural effusion which was matched with bibasilar rales and
dimished bs on exam. POD #2 his chest tubes were removed, but
cont. to have decreased breath sounds with CXR showing cont.
atelectasis and effusion. He was cont. to be aggressively
diuresed along with aggressive cpt w/ postural drainage. Also
received flovent and combivent and Levaquin was started for
poss. pneumonia. POD #3 his epicaridal pacing wires and foley
were removed. He remained in the CSRU and repeat cxr showed
cont. r. effusion and atelectasis w/ poss. superimposed
pnuemonia. POD #4 he appeared to be improved, but had cont.
decreased bs right base. He was transferred to telemetry floor.
CXR showed decreased atelectasis. By POD #5 he appeared to be
doing quite well. Cont. to ambulate and get OOB. O2 sats
remained alittle low depsite O2 via NC. Exam unremarkable. He
was d/c'd on POD #6. Exam was unremarkable, incisions stable,
breath sounds clear. Labs were stable and he would follow-up as
directed.
Medications on Admission:
1. HCTZ 50mg qd
2. Atenolol 50mg qd
3. Glucophage 500mg qd
4. KCL ER 600mg qd
5. Gemfibrozil 600mg qd
6. Omeprazole 20mg qd
7. Vit. E qd
8. Omega 5 Oils
9. Allphagan [**First Name9 (NamePattern2) **] [**Male First Name (un) **]
10. B-Complex
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Brimonidine Tartrate 0.15 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
Disp:*1 bottle* Refills:*2*
5. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 inhaler* Refills:*2*
6. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-25**]
Puffs Inhalation Q4H (every 4 hours).
Disp:*1 inhaler* Refills:*2*
7. Metformin HCl 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
9. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
Disp:*1 bottle* Refills:*2*
10. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO DAILY (Daily) for 7 days.
Disp:*14 Capsule, Sustained Release(s)* Refills:*0*
11. Lopressor 50 mg Tablet Sig: 1.5 Tablets PO three times a
day.
Disp:*135 Tablet(s)* Refills:*2*
12. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days.
Disp:*14 Tablet(s)* Refills:*0*
13. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
14. Zocor 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 8300**] VNA NH
Discharge Diagnosis:
Aortic stenosis s/p Aortic Valve Replacement
Hypertension
Hypercholesterolemia
Diabetes Mellitus Type 2
Left Eye Glaucoma
Severe LE Varicosities
h/o Bilat. Renal Calculi
Discharge Condition:
Good
Discharge Instructions:
Follow medications on discharge instructions.
You may not drive for 4 weeks.
You may not lift more than 10 lbs. for 3 months.
You should shower, let water flow over wounds, pat dry with a
towel
Do not put lotions or creams on incisions.
Followup Instructions:
Make an appointment with Dr. [**Last Name (STitle) **] for 1-2 weeks.
Make an appointment with Dr. [**Last Name (STitle) 5017**] for 2-3 weeks.
Make an appointment with Dr. [**Last Name (STitle) **] for 4 weeks.
Completed by:[**2201-6-25**]
ICD9 Codes: 4241, 486, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3480
} | Medical Text: Admission Date: [**2111-4-9**] Discharge Date: [**2111-4-12**]
Date of Birth: [**2057-12-17**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Adhesive Tape
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
subglottic stenosis
Major Surgical or Invasive Procedure:
Microsuspension laryngoscopy dilatation of subglottis, flexible
bronchoscopy, chest tube placement
History of Present Illness:
53 F s/p baloon dilation and jet ventillation for subglottic
stenosis today, complicated by desaturations, s/p left
pneumothorax, s/p chest tube placed by general surgery
emergently
in the OR. The sequence of events is as follows: she was
saturating well on a face mask, then she was intubated with a 4
Fr ETT, then extubated, then dilated from 4-5 mm to 6-7 mm just
below the vocal cords. She desaturated during this dilation.
She was then jet ventillated using the laryngoscope and then a
cook catheter was placed and she was further jet ventillated for
about 5- 10 minutes. The cook catheter was then removed and she
was further dilated to about 8-9 mm. She continued to
desaturate
to the 40's. She was then re-intubated with a 4 Fr ETT and she
continuted to desaturate. Importantly, per her ENT surgeon, her
airway looked fine and there was no bleeding or evidence of
injury. At this time, she had absent breath sounds on the left.
Bilateral needle thoracosomy was attempted, but due to her
obesity and body habitus they were unable to get any return of
air. At that point, general surgery was called and a chest tube
was placed without any return of air or blood. Her saturations
improved and she was successfully extubated.
She is s/p multiple dilations, CO2 laser lysis, and sterios
injections by Dr. [**First Name (STitle) **] (ENT) since [**2102**]. She has had SOB for 5
years, initally thought to be caused by asthma, but did not
respond to appropriate therapy.
Past Medical History:
HTN, polychondritis, Nissen fundoplication, transient
tracheotomy
with an anterior cricoid split with rib cartilage graft, iron
deficiency anemia
Social History:
n/c
Family History:
n/c
Physical Exam:
NAD, AxOx3
RRR, S1S2
CTA b/l
obese, soft, NT/ND
Pertinent Results:
[**2111-4-9**] 10:16AM BLOOD WBC-10.3 RBC-4.17* Hgb-12.8 Hct-37.5
MCV-90 MCH-30.7 MCHC-34.1 RDW-14.7 Plt Ct-368
[**2111-4-11**] 07:45AM BLOOD WBC-7.7 RBC-3.87* Hgb-11.8* Hct-33.6*
MCV-87 MCH-30.4 MCHC-35.0 RDW-14.9 Plt Ct-309
[**2111-4-9**] 10:16AM BLOOD PT-12.3 PTT-30.0 INR(PT)-1.0
[**2111-4-9**] 10:16AM BLOOD Glucose-140* UreaN-13 Creat-0.7 Na-139
K-4.0 Cl-102 HCO3-28 AnGap-13
[**2111-4-11**] 07:45AM BLOOD Glucose-89 UreaN-11 Creat-0.6 Na-142
K-3.8 Cl-102 HCO3-28 AnGap-16
Brief Hospital Course:
The patient was admitted [**2111-4-19**] for a scheduled microsuspension
laryngoscopy dilatation of subglottis. During the operation she
desaturated and had a left chest tube placed, as described in
the HPI. She was transferred to the ICU. Bronchoscopy was
performed at the bedside. Please see operative note for
details. A small, healing tracheal tear was found. Antibiotics
(Zosyn and Fluconazole) were started prophylactially. She was
perfectly stable on an oxygen face mask and did not require
intubation. A barium swallow was performed to look for
esophageal injury. This was negative. On HD 2, she was
transferred from the ICU to the floor. She was stable on an
oxygen face mask. Repeat bronchoscopy was performed and was
stable. On HD 4, her chest tube was removed. Repeat CXR looked
ok. She was weaned off oxygen and sent home.
Medications on Admission:
[**Doctor First Name **] 180', Fe, MVI, lisinopril/HCTZ 20/25', methotrexate 10 q
Fri, Nexium 40', Singulair 10', Astelin ", Nasocort', Mucinex"
Discharge Medications:
1. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO BID (2 times a day).
3. Fexofenadine 60 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
4. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
5. Methotrexate Sodium 2.5 mg Tablet Sig: Four (4) Tablet PO
1X/WEEK (SA).
6. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
8. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
9. Amoxicillin-Pot Clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
subglotic stenosis, tracheal injury
Discharge Condition:
good
Discharge Instructions:
Please call or come to the ED with any fevers > 101, cough,
shortness of breath, wheezing, abdominal pain, or any other
worrisome issues.
Please continue your antibiotics as directed.
Please continue on all of your home medications
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 14465**], MD Phone:[**Telephone/Fax (1) 2226**]
Date/Time:[**2111-4-28**] 8:45
Please follow up with Dr. [**First Name (STitle) 34209**] please call his office
Please follow-up with Dr. [**Last Name (STitle) 3450**] of GI to proceed with GERD
work-up
Completed by:[**2111-4-12**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3481
} | Medical Text: Admission Date: [**2168-3-13**] Discharge Date: [**2168-3-19**]
Date of Birth: [**2096-6-10**] Sex: M
Service: TRAUMA/SURGERY
HISTORY OF PRESENT ILLNESS: The patient is a 71 year old
male, status post motor vehicle crash driver, high speed
crash approximately 70 mph, no loss of consciousness,
however, ETOH involved, whose chest impacted the steering
wheel. The patient presented to the Trauma Bay, was found on
examination to be hemodynamically stable.
Trauma workup revealed a grade III liver laceration of a
complex nature, close to but not involving the hilum and
portal venous structures. The patient's workup also revealed
some elevated liver enzymes consistent with this injury and
some T wave inversions on his electrocardiogram in leads I,
II and V6.
HOSPITAL COURSE: For this, he was admitted to the Surgical
Intensive Care Unit where he underwent volume resuscitation
and he was ruled out for myocardial infarction. Over the
next couple days, the patient's hematocrit was serially
followed and he was found to have a slowly decreasing
hematocrit although the changes were slowing and the patient
remained hemodynamically stable. The patient's hematocrit
continued to be serially followed and were found to level out
at approximately 29.0.
After several days, the patient was transferred to the floor
where he remained afebrile with stable vital signs. However,
he developed a significant ileus requiring placement of a
nasogastric tube. Nasogastric decompression for three days
resulted in resolution of the patient's nausea and vomiting.
He began passing stool and flatus. Nasogastric tube was
removed and diet was slowly advanced. On the day of
discharge, he was tolerating regular diet, passing stool and
flatus, and will be discharged home.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To home.
MEDICATIONS ON DISCHARGE:
1. Metoprolol 25 mg p.o. b.i.d. which the patient was on
prior to admission.
2. Captopril 100 mg p.o. t.i.d., however, he did not require
this during this admission and has been instructed not to
continue this as a home medication and he should follow-up
with his primary care physician regarding this.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**], M.D. [**MD Number(1) 521**]
Dictated By:[**Last Name (NamePattern1) 22409**]
MEDQUIST36
D: [**2168-3-18**] 21:36
T: [**2168-3-22**] 20:34
JOB#: [**Job Number **]
ICD9 Codes: 496, 4439, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3482
} | Medical Text: Admission Date: [**2197-12-6**] Discharge Date: [**2197-12-13**]
Service: CARDIOTHORACIC
Allergies:
Shellfish Derived
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
Cardiac catherization [**12-6**]
Aortic valve replacement, 23-mm Mosaic tissue heart valve,
Mitral valve repair with a triangular resection of the posterior
leaflet and a 28-mm annuloplasty with a Future CG [**Company 1543**]
ring, Coronary artery bypass grafting x3: Left internal mammary
artery graft to left anterior descending, reverse saphenous vein
graft to the marginal branch onto the diagonal branch [**12-8**]
Bronchoscopy [**12-8**]
History of Present Illness:
84 year old male with known aortic stenosis, progressively
worsening over last six months. Has had increased fatigue and
syncopal episode while driving, and presents for cardiac
catherization.
Past Medical History:
Hypertension
[**Month/Year (2) 982**] [**Month/Year (2) **] type 2
Mitral Regurgitation
Aortic stenosis
Hyperlipidemia
Social History:
Retired truck driver
Lives with spouse
quit smoking > 30 years ago (cigars)
ETOH denies
Family History:
father deceased 70's myocardial infarction
mother deceased 70' myocardial infarction
Physical Exam:
General HR 52, RR 18, B/P 148/49 weight 153 pounds, no acute
distress
Skin unremarkable
HEENT unremarkable
Neck supple full range of motion, right carotid bruit
Chest clear to ausculatation bilateral
Heart regular, systolic ejection murmur [**2-23**]
Abdomen soft nondistended non tender + bowel sounds
Extremeties warm well perfused, pulses palpable
Varicosites none
Neuro grossly intact
discharge exam
VS: 98.9, 134/76, 70SR, 20, 94%RA
Gen: NAD, elderly male
HEENT: unremarkable
Chest: lungs CTAB
CV: RRR, no murmur or rub
Abd: NABS, soft, non-tender, non-distended
Ext: 1+edema b/l
Incisions: sternum- c/d/i no erythema or drainage, LEVH- c/d/i,
distal stab incision with serosanguinous drainage
Pertinent Results:
[**2197-12-12**] 03:35AM BLOOD WBC-5.5 RBC-2.96* Hgb-9.2* Hct-26.0*
MCV-88 MCH-31.1 MCHC-35.5* RDW-15.2 Plt Ct-85*
[**2197-12-12**] 03:35AM BLOOD Glucose-100 UreaN-31* Creat-1.4* Na-142
K-4.3 Cl-101 HCO3-36* AnGap-9
[**2197-12-12**] 03:35AM BLOOD Mg-2.1
Brief Hospital Course:
Presented for cardiac catherization, was admitted post procedure
for preoperative workup. On [**12-8**] he was brought to the
operating room and underwent coronary artery bypass graft,
mitral valve repair, and aortic valve replacement. Please see
operative report for further details. Received vancomycin for
periop antibiotics due to being in hospital preoperatively. He
was transferred to the intensive care unit for hemodynamic
monitoring. Post operative chest radiograph revealed RLL
collapse and he was bronched for small amount of clots, but no
secretions. In the first twenty four hours he was weaned from
sedation, awoke neurologically intact, and was extubated without
complications. He was started on betablockers and lasix for
gentle diuresis. On postoperative day 2 he had atrial
fibrillation treated with beta blockers and amiodarone, which he
converted back to normal sinus rhythm. Physical therapy worked
with him on strength and mobility. He was transferred to the
floor post operative day three. The patient remained in sinus
rhythm and was maintained on amiodarone. He made good progress
with physical therapy. The patient was found stable for
discharge on POD 5.
Medications on Admission:
Aspirin 81 mg daily
atenolol 25 mg daily
fosinopril 40 mg daily
glipizide 5 mg daily
metformin 1000 mg in am and 500 mg in pm
multivitamin daily
proscar 5 mg daily
vitamin E 400 IU daily
Zetia 10 mg daily
Zocor 80 mg daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
2. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours) as needed.
Disp:*qs * Refills:*0*
3. Glipizide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Metformin 500 mg Tablet Sustained Release 24 hr Sig: Two (2)
Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*60 Tablet Sustained Release 24 hr(s)* Refills:*0*
5. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400mg 2x/day x 2 weeks, then 200mg 2x/day for 2 weeks,
then 200mg daily.
Disp:*120 Tablet(s)* Refills:*0*
6. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
9. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day
for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO BID (2 times a
day) for 2 weeks.
Disp:*28 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
12. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*135 Tablet(s)* Refills:*0*
13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**3-26**]
hours.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
interim
Discharge Diagnosis:
Coronary artery disease s/p CABG
Aortic Stenosis s/p AVR
Mitral regurgitation s/p MR
[**First Name (Titles) 982**] [**Last Name (Titles) **] type 2
Hypertension
Hyperlipidemia
Discharge Condition:
Good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
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 all appointments:
Dr [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment
Dr [**Last Name (STitle) **] in 1 week ([**Telephone/Fax (1) 41901**]) please call for appointment
Dr [**Last Name (STitle) 5017**] in [**1-22**] weeks - please call for appointment
Wound check appointment [**Hospital Ward Name 121**] 6 as instructed by nurse
([**Telephone/Fax (1) 3071**])
Completed by:[**2197-12-13**]
ICD9 Codes: 4241, 5180, 4240, 2724, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3483
} | Medical Text: Admission Date: [**2135-11-18**] Discharge Date: [**2135-11-30**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3853**]
Chief Complaint:
"Anemia."
Major Surgical or Invasive Procedure:
EGD: no source of bleeding found
Flexible sigmoidoscopy: radiation proctatitis with friable
mucosa which was cauterized (APC)
History of Present Illness:
88 y/o woman with MMP including AFib (off coumadin), dCHF, CVA,
multifactorial chronic anemia and chronic LGIB [**1-12**] radiation
proctitis after tx for vulvar cancer, single gastric fundic AVM
and gastritis, with numerous past admissions for GI bleed and
low HCT in past, admitted from nursing home yesterday after
having dark colored vomiting, dark red stool and low Hct.
Pt reports GI upset for several days, and has been producing
dark colored vomitus, possibly blood. Also reports dark stools
for several days (although has them chronically from iron
tablets). Hct was noted to be 19 with hgb of 6.1 in the nursing
home. She presented to the ED for transfusion and possible GI
bleed. Some fatigue and lightheadedness. No chest pain. Minimal
SOB.
Ms. [**Known lastname 47136**] has a long standing history of chronic anemia
requiring multiple admissions. She was most recently admitted in
[**Month (only) **] for anemia where an upper endoscopy demonstated no
significant lesions. Her hematocrit was stable and bleeding was
felt to be due to AVMs in the rectum which have been coagulated
in the past and were last coagulated in 12/[**2133**]. More recently
she was seen in the ED for anemia, her hct was stable without
evidence of obvious bleed so she was discharged back to her
nursing facility.
In the ED inital vitals were, T 100.0 HR 104 BP 102/66 RR 16
Satting 91% on RA. An initial hct was 20.8 (baseline 24-28) and
creatinine 0.7. An NG lavage demonstrated BRB with clots that
eventually cleared. She was started on IVF slowly given
diastolic heart failure and 2 units of pRBC were ordered and
hung prior to transfer. She was started on IV protonix gtt. SBPs
dipped into the high 80s but responded to fluids and blood
transfusion. GI was consulted who recommended transfer to [**Hospital Unit Name 153**]
and upper endoscopy on arrival. Vitals on transfer were HR 120
BP 90/60 RR 20.
On arrival to the ICU, initial vitals were 99.8 37.7 134 97% on
RA 21. She was mentating normally and able to participate with
history and exam. She confirmed DNR/I status. In the [**Hospital Unit Name 153**], GI
performed EGD which didnt show any UGI source of bleeding. There
was no blood in the stomach.
Past Medical History:
- Recurrent LGIBs due to radiation proctitis from Tx of vulvar
cancer ([**3-/2135**], [**8-/2134**], [**1-/2134**], [**10/2132**], [**1-/2132**] x 2, [**11/2130**],
[**4-/2129**])
- Symptomatic anemia due to chronic blood loss (admitted [**2-/2135**],
[**1-/2135**] x 2)
- Atrial fibrillation, dx [**2115**] on and off anticoagulation given
rectal bleeding
- Chronic diastolic CHF
- Wide open TR with systolic murmur
- Cognitive impairment, no HS education
- Hypertension
- Hypercholesterolemia
- h/o stroke in [**2118**] with residual numbness of left face
- Irritable Bowel Syndrome
- Spinal stenosis
- Vulvar Ca s/p XRT [**Date range (1) 47137**]
- Basal cell carcinoma
- Dementia
Social History:
Patient lives with husband in nursing home ([**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] Nursing
Home - [**Location (un) **]). She currently has VNA services.
Patient uses a walker to ambulate.
- Tobacco: quit in [**2093**]
- Alcohol: no
- Illicits: no
Family History:
No known family history of cancer.
Physical Exam:
Admission Exam:
Vitals: 99.8 37.7 134 97% on RA 21
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
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis or
edema
.
VS: Tm: 98 Tc:96.9 BP:112/58 HR:90 RR:20 O2 Sats 96% on RA
.
Discharge exam
pain: none
GEN: AAOX3 in NAD, somewhat difficult to understand
HEENT: CN 2-12 grossly intact, MMM, mild edema in left cheek and
below eye lids
NECK: no lad
CV: 4/6 systolic murmur
RESP: CTAB, no wrr
ABD: abdomen flat, non tender, no HSM, active BS
EXTR: extremities somewhat cool and mottled, 5/5 strength,
sensation, pulses intact and equal, mild edema in BUE
-patient has symetric 2+ pitting edema in BLE
DERM: no obvious rashes
NEURO: CN intact, strength, sensation wnl
PSYCH: mood and affect wnl
Pertinent Results:
Admission Labs:
[**2135-11-17**] 10:00PM BLOOD WBC-5.8# RBC-2.02* Hgb-6.2* Hct-20.8*
MCV-103* MCH-30.7 MCHC-29.7* RDW-18.8* Plt Ct-191
[**2135-11-17**] 10:00PM BLOOD Neuts-71.0* Lymphs-22.1 Monos-5.0 Eos-1.2
Baso-0.6
[**2135-11-17**] 10:00PM BLOOD PT-13.8* PTT-31.7 INR(PT)-1.3*
[**2135-11-17**] 10:00PM BLOOD Glucose-100 UreaN-56* Creat-0.7 Na-143
K-4.1 Cl-99 HCO3-39* AnGap-9
[**2135-11-17**] 10:00PM BLOOD CK(CPK)-151
[**2135-11-17**] 10:00PM BLOOD CK-MB-3 cTropnT-0.03*
[**2135-11-18**] 06:04AM BLOOD CK-MB-3 cTropnT-0.03*
[**2135-11-18**] 11:40AM BLOOD CK-MB-3 cTropnT-0.04*
[**2135-11-18**] 06:04AM BLOOD Albumin-2.7* Calcium-7.9* Phos-3.5 Mg-2.0
EGD [**2135-11-18**]:
Impression: Esophagitis
Normal mucosa in the stomach
Normal mucosa in the whole duodenum
Otherwise normal EGD to third part of the duodenum
Sigmoidoscopy [**2135-11-24**]
Radiaiton proctitis (thermal therapy)
Grade 1 internal hemorrhoids
.
[**2135-11-23**] EGD
Erythema and congestion in the whole stomach compatible with
mild gastritis
Otherwise normal EGD to third part of the duodenum
.
AXR [**2135-11-29**]
IMPRESSION: No ileus or obstruction.
.
CXR [**2135-11-29**]
IMPRESSION: Stable cardiomegaly with small bilateral pleural
effusions with
associated atelectasis. Slightly worse pulmonary edema.
Brief Hospital Course:
HOSPITAL COURSE
88 yo woman with MMP including AFib (off coumadin), dCHF, CVA,
dementia, multifactorial chronic anemia and chronic LGIB [**1-12**]
radiation proctitis after tx for vulvar cancer, single gastric
fundic AVM and gastritis, with numerous past admissions for GI
bleed and low HCT in past, admitted from nursing home after
having dark colored vomiting, dark red stool and low Hct with
positive NG tube lavage concerning for upper GI bleed.
.
ACTIVE ISSUES
# UGIB: Patient had BRB in NG lavage indicating UGI source. Most
likely ddx on admission included PUD vs gastric erosion vs
severe gastritis vs bleeding gastric AVM, a more rare cause is a
dieulafoy lesion. However, EGD did not show any source of
bleeding in the esophagus, stomach or proximal duodenum.
Patient received a total of 2 pRBC transfusions and hct
stabilized at her baseline in the high 20s (28). She had melena
and BRBPR again on [**11-23**], and EGD repeated and again was
negative for a source. Hct remained stable. Flexible
sigmoidoscopy was performed and showed radiation proctitis with
a friable mucosa and areas of edema at the distal and
mid-rectum. An Argon-Plasma Coagulator was applied for
hemostasis
successfully. The patient had some blood streaking in her BM's,
it was unclear if this was a vaginal source or GI source but her
hemoglobin was stable.
.
# Anemia: Pt has a long standing history of chronic anemia
requiring multiple admissions and is multifactorial [**1-12**] chronic
LGIB d/t radiation proctitis after tx for vulvar cancer, single
gastric fundic AVM and gastritis, with numerous past admissions
for GI bleed and low HCT in past. Baseline Hct 24-28. UGIB
treated as above. Ferrous sulfate increased to TID with vitamin
C.
.
# Vulvar pain with a history of vulvar cancer s/p XRT in [**2130**]
Patient c/o persistent vulvar pain. Physical exam not
consistent with atrophic vaginitis. Gyn consult placed and they
advised placing the patient on lidocaine jelly, warm water [**Last Name (un) **]
baths, leave vulva open to air, and to avoid other topical
applications/irritants. They also arranged for the patient to
follow up with Gyn. The paient will be given oxycodone and
tramadol for breakthrough pain related to vulvar or perineal
pain.
.
# Perioribital Edema: Patient developed worsening dependent
edema in the periorbital area a well as in her arms. Patient
does not complain of SOB or wheezing. No new medications.
Could be [**1-12**] fluid overload after lasix held in the setting of
GIB. Treated with solumedrol 40mg q8H x3. She was also treated
with IV lasix 10mg and 20mg. Her peri-orbital edema improved
mildly. Her husband reported this was baseline for her,
therefore angioedema felt to be less likely diagnosis.
.
# Atrial fibrillation (tachy/brady) s/p pacemaker placement:
Patient was diagnosed w/ afib in [**2115**] and is s/p pacemaker
placement in 9/[**2134**]. The pacemaker was implanted secondary to
atrial fib with a slow ventricular response, tachybrady
syndrome, high-grade AV block, and severe tricuspid
regurgitation. Patient tachycardic when metoprolol held for
GIB. Restarted metoprolol home dose 50mg TID once BP stable.
Patient off coumadin for multiple episodes of LGIB from
radiation proctitis and chronic anemia. Ultimately the patients
dose of metoprolol was decreased to 50 [**Hospital1 **] because it was
frequently being held for hypotension.
.
# Diastolic heart failure: TTE in [**3-21**] revealed significantly
enlarged [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 47138**] chronic dCHF. Held lasix initially for
GIB and was restarted prior to discharge after vitals remained
stable.
# HTN: Held home lasix 10mg daily given GI bleeding, relative
hypotension (80s), poor po intake and pre-renal azotemia
transiently in the hospital, requiring fluid resuscutation.
Metoprolol was continued however given her atrial fibrillation
with occasional RVR.
# Depression: continued home paroxetine 30mg daily.
#Transitional issues:
-follow up with palliative care, Gyn, PCP
[**Name10 (NameIs) **] up labs (CBC and BMP in 1 week)
-adjust lasix dose and attempt to wean off oxygen if able
Medications on Admission:
1. furosemide 20 mg Tablet Sig: 0.5 Tablet PO once a day.
2. loperamide 2 mg Capsule Sig: [**12-12**] Capsules PO four times a day
as needed for diarrhea.
3. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO three
times a day.
4. paroxetine HCl 30 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. oxybutynin chloride 5 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
7. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. Keflex 500 mg Capsule Sig: One (1) Capsule PO twice a day for
5 days.
Disp:*qs Capsule(s)* Refills:*0*
9. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
10. sucralfate 1 gram Tablet Sig: One (1) Tablet PO twice a day
as needed for heartburn.
11. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) as needed for pain.
12. nystatin-triamcinolone 100,000-0.1 unit/g-% Cream Sig: One
(1) Topical twice a day as needed for rash.
13. senna 8.6 mg Capsule Sig: [**12-12**] Capsules PO once a day as
needed for constipation.
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day): Appl TP [**Hospital1 **] cutaneous candidiasis
to involved areas or groin and intertrigenous areas [**Hospital1 **]
.
3. sucralfate 1 gram Tablet Sig: One (1) Tablet PO BID (2 times
a day).
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. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
6. paroxetine HCl 30 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every six
(6) hours as needed for pain.
8. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**12-12**]
Drops Ophthalmic PRN (as needed) as needed for dryness.
9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
11. oxybutynin chloride 5 mg Tablet Sig: Two (2) Tablet PO twice
a day.
12. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO TID (3 times a day).
13. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
14. ipratropium bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours) as needed for SOB.
15. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
16. polyethylene glycol 3350 17 gram/dose Powder Sig: Seventeen
(17) grams PO DAILY (Daily) as needed for constipation.
17. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for pain.
18. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)
as needed for pain.
Disp:*15 Tablet(s)* Refills:*0*
19. lidocaine HCl 5 % Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day) as needed for vulvar pain.
20. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: 1 -2
Drops Ophthalmic [**Hospital1 **] (2 times a day).
21. Outpatient Lab Work
Please check a CBC and basic metabolic panel in 1 week to follow
up hemoglobin and electrolytes
Discharge Disposition:
Extended Care
Facility:
[**Male First Name (un) **] [**Hospital **] Nursing Home - [**Location (un) **]
Discharge Diagnosis:
Upper GI bleeding
Chronic heart failure with preserved ejection fraction
AF with RVR
vulvodynia
Discharge Condition:
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Level of Consciousness: Alert and interactive.
Mental Status: Confused - always.
Discharge Instructions:
You were admitted to the hospital with coffee ground emesis and
bloody bowel movements which were thought to come from your
upper GI tract. A endoscopy of your esophagus and stomach were
negative for a bleeding source.
A flexible sigmoidoscopy revealed radiation procitis and
hemorrhoids which were treated with thermal therapy. Your
hospital course was also complicated by vulvar pain. You were
seen by Gynecology and they recomended lidocaine jelly/ointment
and keep the area dry and clean. You were also started on
oxygen in house. Attempts to wean this off were unsuccessful.
You have been requiring 1-3 L NC here. You will be discharged
to rehabilitation and your oxygen requirement may decrease after
you increase your activity level.
You may apply lidocaine jelly to your perineum and use [**Last Name (un) **]
baths for irritation of your vulvar region adn use either
tramadol or oxycodone as needed.
Medication changes:
decreased dose of metoprolol from 50 TID to 50 [**Hospital1 **]
stop loperamide
Followup Instructions:
2) gastroenterology - Dr. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 679**]. Call for appointment at:
([**Telephone/Fax (1) 16940**]
3) follow up with Gyn Dr. [**Last Name (STitle) 2028**] booked for [**2135-12-28**]
ICD9 Codes: 2851, 5180, 5849, 4280, 4019, 4241, 2720, 4589, 2767, 4168, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3484
} | Medical Text: Admission Date: [**2120-4-23**] Discharge Date: [**2120-4-26**]
Date of Birth: [**2054-8-19**] Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Crestor
Attending:[**First Name3 (LF) 158**]
Chief Complaint:
transferred for hypotension; Afib
Major Surgical or Invasive Procedure:
none
History of Present Illness:
65yo F with history of pituitary adenoma s/p transphenoidal
resection [**3-/2119**] and hyperplastic polyposis s/p lap total
colectomy w/ iliorectal anastomosis [**3-/2120**] presents from [**Hospital1 9487**] with hypotension. She reports increased liquid
stools, nausea, vomiting, and poor po intake over the past
several days. Yesterday she felt very tired and noted
blurry/darkening of her vision. She presented to the OSH and was
found to be in afib with HR >130s and SBP 50s-60s. She was given
fluids and diltiazem. She converted to NSR but was started on
levophed to support her BP. She had low UOP and was given a dose
of lasix. Her Cr was found to elevated on admission as well. She
was pancultured due to elevated WBC of 16 on admission. She was
given stress dose steroids. She was then transferred to [**Hospital1 18**] at
her request for further management. She denies fever, chills,
and no current nausea or vomiting. She
denies hematemesis, hematochezia, melena, abdominal pain, chest
pain, and SOB.
Past Medical History:
- HTN, HLD
- acromegaly:
-- "high normal" [**Hospital1 **] 30 yrs ago per patient
-- elevated [**Hospital1 **], IGF-1 found [**2118-12-21**]
-- 1.4 cm pit adenoma on MRI brain [**2118-12-30**]
-- confirmed by failure of [**Hospital1 **] suppression with OGTT [**1-/2119**]
-- excision [**2119-4-13**]
- silent MI dx [**2119**]
- multiple colonic polyps visualized [**2120-1-31**]
- carpal tunnel syndrome dx [**9-/2119**]
- DM2, diet-controlled
.
PSH:
- Pituitary adenoma s/p transhpenoidal resection [**2119-4-13**]
- carpel tunnel surgery [**10/2119**]
Social History:
- Tobacco: quit 1 month ago
- Alcohol: rare
- Illicits: none
Family History:
noncontributory
Physical Exam:
ON ADMISSION:
Vitals: T:98.0 BP:118/58 P: R: 18 O2: 98%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. laparotomy
scars well healed
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, trace edema of
lower extremities
Discharge Physical Exam:
Gen: A&O, NAD
CV: RRR no M/R/G
Pulm: CTAB
Abd: S/NT/ND
Ext: w/d
Pertinent Results:
CXR [**2120-4-23**]
IMPRESSION: Bilateral low lung volumes with increased opacity in
the
bilateral lung bases which may either reflect atelectasis, but
given the
clinical setting possibility of pneumonia cannot be ruled out.
Additional
lateral views may help for further evaluation.
KUB ([**2120-4-24**]): Findings consistent with early small-bowel
obstruction or ileus, similar in appearance to radiographs of
[**2120-3-30**]. No free air
CT Abd/Pel ([**2120-4-24**]):
1. Slight small bowel dilatation up to 4.2 cm without distal
decompression or other evidence of obstruction.
2. Small bilateral pleural effusions.
3. Left adrenal adenoma
4. Mild distal esophageal thickening may correlate with
esophagitis
[**2120-4-23**] 07:06PM BLOOD WBC-17.7*# RBC-3.64* Hgb-11.6*# Hct-35.1*
MCV-97 MCH-32.0 MCHC-33.1 RDW-14.9 Plt Ct-423#
[**2120-4-24**] 03:16AM BLOOD WBC-17.2* RBC-3.56* Hgb-11.0* Hct-33.7*
MCV-95 MCH-31.0 MCHC-32.7 RDW-14.4 Plt Ct-421
[**2120-4-24**] 12:26PM BLOOD WBC-13.3* RBC-3.44* Hgb-10.8* Hct-32.4*
MCV-94 MCH-31.4 MCHC-33.4 RDW-14.8 Plt Ct-421
[**2120-4-25**] 04:45AM BLOOD WBC-10.5 RBC-3.60* Hgb-10.8* Hct-34.2*
MCV-95 MCH-30.0 MCHC-31.5 RDW-14.4 Plt Ct-478*
[**2120-4-23**] 08:03PM BLOOD PT-11.6 PTT-23.0* INR(PT)-1.1
[**2120-4-24**] 12:26PM BLOOD Ret Aut-1.4
[**2120-4-23**] 07:06PM BLOOD Glucose-248* UreaN-38* Creat-1.8*# Na-133
K-3.7 Cl-101 HCO3-14* AnGap-22*
[**2120-4-24**] 03:16AM BLOOD Glucose-171* UreaN-37* Creat-1.6* Na-134
K-3.6 Cl-104 HCO3-18* AnGap-16
[**2120-4-25**] 04:45AM BLOOD Glucose-128* UreaN-22* Creat-0.6 Na-135
K-3.6 Cl-106 HCO3-20* AnGap-13
[**2120-4-23**] 07:06PM BLOOD AST-18 LD(LDH)-141 CK(CPK)-17* AlkPhos-78
TotBili-0.4
[**2120-4-25**] 04:45AM BLOOD Calcium-7.7* Phos-2.0* Mg-1.8
[**2120-4-24**] 03:16AM BLOOD calTIBC-146* Ferritn-569* TRF-112*
[**2120-4-24**] 03:44AM BLOOD Type-[**Last Name (un) **] pO2-64* pCO2-33* pH-7.37
calTCO2-20* Base XS--4
[**2120-4-24**] 03:44AM BLOOD Lactate-0.9
[**2120-4-23**] 09:46PM BLOOD Lactate-0.7
Brief Hospital Course:
REASON FOR ICU ADMISSION:
65 y/o F history of pituitary adenoma s/p resection [**3-31**], with
recent colectomy for polyps [**2120-3-26**] presents with to OSH in new
Afib with RVR, hypotensive requiring pressors.
The patient was transferred to the ICU while on Levophed. Her
SBP were in the 120's. She was aggressively hydrated and the
pressors were weaned off overnight. Her home
lisinopril was held due to rise in the creatiine to 1.8 on
admission. The bicarb level was low at 14 and this improved to
20 after hydration with lactated ringers.
Neuro: The patient remained alert and oriented throughout the
hospitalization. She did not require any pain medication.
CV: The patient was transferred to the ICU on Levophed. She was
aggressively hydrated and the levophed was weaned off overnight
HD #1. The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored. Her home lisinopril was
held due to elevated creatinie to 1.8 on admission.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored. Good pulmonary toilet,
early ambulation and incentive spirometry were encouraged
throughout this hospitalization.
GI/GU/FEN:
In the ICU a KUB was obtained demonstrating air-fluid levels in
small bowel consistent with SBO/ileus which was similar from
prior exam on [**3-30**]. She continued to pass flatus and have bowel
movements.
The patient was maintained on a clear diet and advanced as
tolerated.
The patient's intake and output were closely monitored, and IVF
were adjusted when necessary. The patient's electrolytes were
routinely followed during this hospitalization, and repleted
when necessary. Her creatinine normalized to 0.6 on HD 3 after
hydration. A CT scan of the abdomen was obtained HD2 which
demonstrated slight small bowel dilation without distal
decompression or evidence of obstruction. She continued to have
frequent loose stools. A C.diff assay was negative, stool
cultures are pending. She was started on Rifaximin for possible
bacterial overgrowth.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. Her WBC trended down and
she remained afebrile. Urine culture was negative. Blood
cultures showed no growth at time of discharge. She did not
require antibiotics during the hospitalization
Endocrine: The patient's blood sugar was monitored throughout
this stay; insulin dosing was adjusted accordingly.
Hematology: The patient's complete blood count was examined
routinely; no transfusions were required during this stay.
Prophylaxis: The patient received subcutaneous heparin and PPI
during this stay, and was encouraged to get up and ambulate as
early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. She will follow up in the colorectal clinic for
post-operative checkup. She will follow up with her PCP for
[**Name9 (PRE) 41081**] check up and to have CBC and chemistries
drawn.
Medications on Admission:
lisinopril 20, carvedilol 6.25, HCTZ 12.5, ASA 325, cilostazol
100'', ergocalciferol, lactolotion''
Discharge Medications:
1. rifaximin 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) for 1.5 days: Please complete this prescription. .
Disp:*5 Tablet(s)* Refills:*0*
2. lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
3. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO once a day.
4. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
5. cilostazol 100 mg Tablet Sig: One (1) Tablet PO twice a day.
6. ergocalciferol (vitamin D2) Oral
7. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily): please talk to you pcp about tapering
dose.
8. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
once a day.
9. Outpatient Lab Work
Thursday [**2120-5-2**] CBC and Chem 10
Discharge Disposition:
Home
Discharge Diagnosis:
Acute renal failure related to dehydration, possible GI
bacterial overgrowth
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 for dehydration whicih caused
acute renal failure and an ICU admision related to your recent
surgery to remove your colon. You had an xray of your abdomen
which showed dilated small bowel, a ct scan was done to be sure
that the area of the surgery was intact and there was no
infection in your abdomen. These were all negative. It is
thought that you were passing so much loose stool that you
because dehydrated. It is critical that you eat small frequent
meals with protien and you drink water and an electrolyte drink
like gatorade or vitamin water. If you notice your stool output
increasing, take in more electrolyte drink. Please monitor
yourself for signs and symptoms of dehydration including:
dizziness (especially upon standing), weakness, dry mouth,
headache, or fatigue. If you notice these symptoms please call
the office or return to the emergency room for evaluation if
these symptoms are severe. You are going to finish a treatment
for bacterial overgrowth in your gut which may be causing some
of your symptoms such as gassiness. Please finish this course of
Rifamixin. You should also continue your omeprazole. Please call
us with any questions ore concerns. You must have your labs
check next week as described below. Please call the office if
you are having more than 4 bowel movements daily and we can
assist you further.
Followup Instructions:
Please have your CBC and Electrolytes checked at your primary
care physicians office next week too be sure you are keeping
yourself well hydrated. Thursday [**2120-5-2**] at 2pm at Dr.[**Name (NI) 37762**]
office (your PCP).
Please keep your appointment with Dr. [**Last Name (STitle) **] as listed below.
Please call our office with any questions or concerns related to
dehydration or your colorectal surgery [**Telephone/Fax (1) 160**].
Department: MEDICAL SPECIALTIES
When: MONDAY [**2120-4-29**] at 1 PM
With: DR. [**Last Name (STitle) **] & ZHIHENG [**Telephone/Fax (1) 1803**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: SURGICAL SPECIALTIES
When: THURSDAY [**2120-5-16**] at 11:00 AM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 11714**], MD [**Telephone/Fax (1) 274**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2120-4-26**]
ICD9 Codes: 5849, 2762, 2761, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3485
} | Medical Text: Admission Date: [**2160-11-3**] Discharge Date: [**2160-11-14**]
Date of Birth: [**2086-9-11**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
presenting for elective cardiac catheterization
Major Surgical or Invasive Procedure:
cardiac catheterization
History of Present Illness:
74M CAD s/p CABG in [**2147**], CHF, dm2, admitted to CCU for
hypotension, heamturia during elective cath procedure. He
presented for a relook
cardiac catheterization and possible ICD placement since stress
testing has revealed new fixed defects and recent Holter
monitoring has demonstrated an increase in ventricular ectopy.
At the end of the procedure, the pt was noted to have sbp in 70s
with HR 50s and was treated with atropine 0.5 mg IV x3 to treat
presumed vagal reaction. He required dopamine drip briefly as
well.
With regard to symptoms, the patient reports that in [**Month (only) 216**] he
had several episodes of classic angina with exertion, responding
to SL nitroglycerin. Currently he describes intermittent chest
heaviness, often occurring in the evening when climbing the
stairs to go to bed. These episodes resolve with rest. He has
also had some episodes that have woken him from sleep.
.
ROS: Denies claudication, LE edema, orthopnea, PND,
lightheadedness
Patient reports being diagnosed with neuropathy and complains of
burning of the soles of his feet when lying down.
Past Medical History:
[**2144**] MI x 2 (One of his MI's was treated with thrombolysis)
- [**2147**] CABG: LIMA to LAD, SVG to RCA, SVG to diagonal
- [**2157-4-12**] cath for + ETT: LVEF 40%. LAD occluded at its origin.
Cx
with mild disease. RCA with sequential tight lesions. LIMA to
LAD
widely patent. SVG to diagonal widely patent. SVG to RCA totally
occluded at its origin. Patient underwent successful
PTCA/stenting of the proximal, mid and distal RCA with three Bx
Velocity stents.
- [**1-14**] EPS: inducible AVNRT, s/p ablation. No inducible
ventricular arrhythmias.
- [**2160-9-30**] Holter: Predominant rhythm was sinus. Low grade
atrial
ectopy noted. Very frequent isolated VPB's noted including
episodes of ventricular bigeminy, trigeminy and quadrageminy.
Frequent couplets and twelve 3 beat runs of NSVT. Ventricular
ectopy has increased since Holter study dated [**2159-12-13**].
- [**2160-9-30**] echo: Moderately dilated LV cavity with an LVEF
20-25%. Anterior and inferior walls near akinetic with severe
hypokinesis of the remaining segments. Moderately thickened
aortic valve leaflets. Peak gradient 32 mmHG, mean gradient 16
mmHG, [**Location (un) 109**] 0.8cm2. 1+ AI, 2+ MR, 1+ TR, moderate systolic
pulmonary hypertension. Compared with prior study dated [**11-11**],
the severity of the aortic stenosis, MR and pulmonary artery
pressure have all increased. LV systolic function is slightly
worse.
- [**2160-9-30**] ABI's: Right: 1.03 left 0.97. Impression: bilateral
tibial disease with predominant involvement of the anterior
tibial and dorsalis pedis arteries.
- [**2160-10-13**] ETT: 6.5 minutes modified [**Doctor First Name **] protocol, 84% max PHR,
stopping due to 3mm ST depression in the inferolateral leads. No
anginal symptoms. Rhythm was sinus with frequent isolated
polymorphic VPB's at rest and low level exercise. Imaging: new
moderate to severe fixed anteroseptal and moderate fixed apical
defects. Stable mild to moderate fixed inferolateral defect.
Global hypokinesis calculated LVEF 21%. LV cavity size
significantly enlarged, worsened from the prior study.
[**2158**]: RCA stenting
Ischemic cardiomyopathy
Paroxysmal atrial fibrillation
SVT, s/p ablation
Adult onset diabetes
Hyperlipidemia
Seasonal allergies
Social History:
Patient was born in Poland, immigrated to the US
in [**2102**]. He is remarried.
His wife [**Name (NI) 553**] and his son [**Name (NI) **] accompanied him to the
hospital.
Family History:
Father with an MI at age 73. Mother with
diabetes.
Physical Exam:
Upon arrival in the CCU:
Pertinent Results:
[**2160-11-3**] 04:20PM WBC-6.5 RBC-3.92* HGB-11.9* HCT-34.6* MCV-88
MCH-30.4 MCHC-34.4 RDW-14.0
[**2160-11-3**] 04:20PM PLT COUNT-167
[**2160-11-3**] 04:37PM GLUCOSE-177* K+-4.0
.
[**2160-11-3**]: Cardiac catheterization: (see full report for details)
1. Native three vessel coronary artery disease.
2. Severe aortic stenosis with Dobutamine.
3. Occluded SVG-RCA, SVG-D1.
4. Patent LIMA-LAD.
5. Severe instent restenosis of the RCA.
6. Successful PTCA and stenting of the proximal and mid RCA with
drug
eluting stents.
.
ICD placement: [**Company 1543**] Virtuoso dual cahmber via left
cephalic. Not tested b/c mild AS and recent stents
RA: P=4.1, Imp=475 , <0.1 @ 0.5
RV:R=8.8, Imp=525, 0.5 @ 0.5
Brief Hospital Course:
This 74-year old male with CAD history, s/p CABG ([**2147**]), AS,
CHF, dm2, was admitted to CCU for hypotension, heamturia during
elective cath procedure.
.
1. Cardiovascular: Patient presented for elective cardiac
catheterization for new fixed defects in the anteroseptal and
apical regions, which resulted in two overlapping 2.5 mm and 3.0
mm Cypher stents. The patient was continued on his aspirin and
statin, and treated with plavix. He remained chest pain free
for the duration of his admission.
.
b. pump: During his catheterization, patient had a brief
hypotensive episode which was thought likely secondary to a
vagal reaction. He briefly required dopamine, with resolution
of his SBPs to baseline. From his past history, patient was
known to have severe ischemic cardiomyopathy with a recent EF
~20-25% and noted to have a mildly elevated wedge pressure. He
remained on his home diuretic regimen and after his blood
pressures normalized, he was resumed on his home dose of ACEi.
Following his ICD placement he was started with beta-blockade
with metoprolol 12.5 qid.
.
c. Valves:
Patient, with known AS with [**Location (un) 109**] 0.8 mean gradient 16 by echo,
had a dobutamine challenge during catheterization to measure the
degree of stenosis, which showed significant aortic stenosis
with a low cardiac index.
.
d. Vasculature: PCP concern for tibial vascular disease,
recommending that bed be kept in a reverse trendelenburg
position at all times.
.
2. GENITOURINARY: Upon placement of a Foley catheter s/p
cardiac catheterization for feeling of bladder fullness, patient
had bright red blood, which prompted urology evaluation and
subsequent placement of a large bore catheter and chronic foley
flushes, to be discontinued 48 hours after passage of blood
clots. Urology recommended initiation of flomax, with
recommendation to continue for 30 days and to send for urine
cytology when urine is clear yellow, which could not be done as
an inpatient since bloody urine was not completely resolved.
Follow up with Dr. [**Last Name (STitle) 261**] ([**Telephone/Fax (1) 277**]) in urology was arranged
to address above as well as to check PSA (if pt has [**9-21**] yr
life expectancy), upper tract imaging (CT urogram), cystosopy,
and to assess LUTS (lower urinary tract symptoms) to see if he
should continue flomax.
.
3. DM2: Upon admission, patient PO medications, metformin and
glipizide, were initially held and patient was covered
successfully with an ISS.
.
Medications on Admission:
Glipizide 10mg three times a day
Lipitor 40mg daily every evening
Enalapril 2.5mg daily every morning
Digitek 0.125mg, 2 tablets on Sunday, one and a half tablets all
other days
Metformin 500mg, two tablets every morning, one tablet every
evening
Plavix 75mg daily every evening
Aspirin 325mg daily every evening
B complex
MVI
Senekot
Lasix 20mg daily on Monday's and Friday's
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. B-Complex with Vitamin C Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
Disp:*60 Capsule, Sust. Release 24HR(s)* Refills:*2*
7. Enalapril Maleate 5 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
8. Metformin 500 mg Tablet Sig: Two (2) Tablet PO QAM (once a
day (in the morning)).
9. Metformin 500 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
10. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 11 days: Please take this medication for as
long as you have the Foley catheter plus an additional 2 days. .
Disp:*11 Tablet(s)* Refills:*0*
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed.
12. Digoxin 125 mcg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
Disp:*45 Tablet(s)* Refills:*2*
13. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO once a day.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
14. Glipizide 10 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*90 Tablet(s)* Refills:*2*
15. Lasix 20 mg Tablet Sig: One (1) Tablet PO qMonday.
16. Lasix 20 mg Tablet Sig: One (1) Tablet PO qFriday.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary:
1. Coronary Artery Disease
2. Stable Angina
3. Aortic Stenosis
4. CHF - systolic
5. Non-sustained Ventricular Tachycardia
6. Hematuria
Secondary:
7. Diabetes mellitus type 2 - controlled
Discharge Condition:
Patient discharged in stable condition, with stable vital signs,
oxygenating well on room air, ambulating unassisted.
Discharge Instructions:
You have been evaluated and treated for your coronary disease,
your irregular heart beat, and your aortic stenosis. The testing
resulted in a new stent being placed in one of your coronary
arteries, a pacemaker/ICD being placed, more evidence of your
heart muscle's response to the aortic stenosis.
.
You did develop blood in the urine during this hospitalization.
You will need to keep the foley catheter in your bladder until
you see the urologists in clinic. A visiting nurse will come to
your house to flush the catheter once a day.
.
Please make sure that you discuss with your primary care
physician the metformin. In the setting of heart failure, many
physicians prefer to use other agents for blood sugars. As we
have discussed, there are some risks associated with metformin
use in heart failure.
Followup Instructions:
1. Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**]
Date/Time:[**2160-11-13**] 1:00
2. Provider: [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 276**], M.D. Phone:[**Telephone/Fax (1) 277**]
Date/Time:[**2160-11-19**] 8:40
3. Provider: [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 276**], M.D. Phone:[**Telephone/Fax (1) 277**]
Date/Time:[**2160-11-19**] 10:00
4. Please call Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] to set up an appointment
within 2-3 weeks to address these medical issues.
ICD9 Codes: 4271, 2724, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3486
} | Medical Text: Admission Date: [**2171-5-3**] Discharge Date: [**2171-5-5**]
Date of Birth: Sex: M
Service: Neurology
REASON FOR ADMISSION: Intracerebral hemorrhage.
HISTORY OF PRESENT ILLNESS: This is a 58-year-old gentleman
with a history of borderline hypertension who was coming home
from the symphony and became somewhat disoriented. His left
side was felt to be weak, and he pulled over to the side of
the road. Once out of the car he vomited and Emergency Medical
Service
was called. The patient was intubated in the field due to
the patient's posturing and poor airway protection. His
blood pressure was noted to be 160/90.
The patient was brought to [**Hospital1 188**] where a computed tomography scan showed a large right
frontoparietal temporal hemorrhage with subfalcine and uncal
herniation.
In the Emergency Department he received Ativan, Dilantin, and
Decadron.
PAST MEDICAL HISTORY: Hypertension.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Occasionally took Ritalin to stay awake.
2. Aspirin 81 mg by mouth once per day.
3. Herbal medicines which were unknown by his wife at this
time.
SOCIAL HISTORY: He is a psychiatrist and is married with
children. There was no history of tobacco, alcohol, or
drugs.
FAMILY HISTORY: There is no history of aneurysm of cancer.
There was a positive family history of coronary artery
disease and myocardial infarction.
PHYSICAL EXAMINATION ON PRESENTATION: He was afebrile with a
blood pressure of 146/84. Generally, he was intubated and
not responsive to his environment. The lungs were clear to
auscultation bilaterally. His cardiovascular examination
revealed a regular rhythm with tachycardia. There were no
murmurs audible. His abdomen was soft. The extremities
showed no edema or cyanosis. Neurologically, he was
intubated without sedation. He did not follow commands or
open his eyes to verbal stimulation or sternal rub. On
cranial nerve testing, his right pupil was dilated to 7 mm
and his left pupil was 5 mm and nonreactive. No
oculocephalic reflex was present. There were corneas present
bilaterally. There was no gag reflex. On motor examination,
he was observed to have brief myoclonic jerks (left greater
than right) and had decorticate posturing bilaterally to
pain. There were no other spontaneous movements. Deep
tendon reflexes were very brisk bilaterally throughout with
upgoing toes bilaterally as well. Sensation testing revealed
the patient was posturing in a decorticate pattern to painful
stimulus bilaterally.
SUMMARY OF HOSPITAL COURSE: This was a 58-year-old gentleman
with hypertension who was admitted to the Neurology Intensive
Care Unit for an intracerebral hemorrhage with the likely
etiology of hypertension.
It was explained to the family; although there was no way to
entirely know for sure what was the underlying cause of the
hemorrhage, including aneurysm or neoplasm. The diagnosis of
this unfortunately would not alter the management and the
prognosis of such a large hemorrhage.
Family meetings were held throughout the hospital course, and
the family (including his wife and children) understood the
poor prognosis. The patient was made do not resuscitate and
do not intubate, and the [**Location (un) 511**] Organ Bank was called in
to discuss with the family options for organ donation.
It should also be noted that Neurosurgery was also consulted,
and they did not offer any invasive management due to the
poor prognosis of the large hemorrhage.
On the morning of [**2171-5-4**] the patient's family came to
a decision regarding withdrawal of care, and this was done so
later in the afternoon of [**2171-5-4**]. The patient
appeared comfortable throughout his hospital stay and became
apneic and asystolic on [**5-5**] at 7:30 in the morning.
He was pronounced dead, and the [**Location (un) 511**] Organ Bank was
notified for donation options.
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**], M.D. [**MD Number(1) 4269**]
Dictated By:[**Name8 (MD) 4064**]
MEDQUIST36
D: [**2171-5-28**] 17:21
T: [**2171-5-29**] 08:00
JOB#: [**Job Number 54740**]
ICD9 Codes: 431, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3487
} | Medical Text: Admission Date: [**2179-5-25**] Discharge Date: [**2179-6-3**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1148**]
Chief Complaint:
Cholangitis, Afib w/ RVR (transfer from [**Hospital Unit Name 153**])
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
87M h/o CVA on coumadin, PAF, porcine AVR initally presented to
OSH with 5 days of fever (Tmax 104) and chills where he was
found to have cholangitis. He was hypotensive at presentation
with elevated LFTS (Tbili 4.7, D bili 3.9, AP 641, AST 117) and
WBC 22K. RUQ U/S revealed a distended gallbladder with multiple
stones and common duct measuring 1.5 cm associated with dilated
and intra and extrahepatic ducts. Blood cultures 1/2 bottles
grew gram negative rods and he was treated with ampicillin,
levofloxacin, and flagyl. The patient was transferred to [**Hospital1 18**]
[**Hospital Unit Name 153**] for ERCP notable for pus and underwent removal of a stone
and placement of CBD stent. While in the [**Hospital Unit Name 153**], he developed
unstable Afib with RVR and was started on amiodarone gtt and
then given digoxin 0.125mg x2 with improvement in his rate. He
was transferred to the medicine floor. On presentation, he has
no complaints. ROS was negative for abdominal pain, fevers,
chills, palpitations, LH, chest pain.
Past Medical History:
-HTN
-Aortic Valve Replacement for aortic stenosis (porcine graft) 22
years ago. Rheumatic valve disease. Last ECHO [**1-15**] bioprosthetic
valve functioning normally. Has normal EF per that report.
-HTN
-LBBB
-CVA, TIA
-Left Sided Hemiparesis
-Hx of elevated PSA-BPH
-PAF
-GERD
-CHF
Social History:
married , 2 children , was a [**Doctor Last Name 9808**] operator, no alcohol, no drug
use. quit smoking 40 years prior (only 1 year of limited use).
Family History:
brother died of cancer, mother was alcoholic
Physical Exam:
T 95.4 HR 120 BP 97/63 RR 18 SaO2 93-94% on RA Weight 62.2kg
General: NAD, breathing comfortably
HEENT: PERRL, EOMi, anicteric, conjunctivae pink
Neck: supple, trachea midline, no thyromegaly or masses, no LAD
Cardiac: [**Last Name (un) **] [**Last Name (un) 3526**], tachy, s1s2 normal, JVP ~12cm, no carotid
bruits
Pulmonary: Bibasilar crackles, no wheeze
Abdomen: +BS, soft, nontender, nondistended, no HSM
Extremities: warm, no edema
Neuro: A&Ox3, CN II-XII intact, 5/5 strength throughout. No
sensory deficits to light touch appreciated. No pass-pointing on
finger to nose. 2+DTR's-patellar and biceps
Skin: Pink, warm, no jaundice, multiple stuck-on lesions on back
Pertinent Results:
[**2179-5-25**] 02:06PM BLOOD WBC-25.9* RBC-3.43* Hgb-12.3* Hct-36.0*
MCV-105* MCH-36.0* MCHC-34.2 RDW-13.1 Plt Ct-130*
[**2179-6-3**] 06:50AM BLOOD WBC-13.9* RBC-3.04* Hgb-10.5* Hct-31.5*
MCV-104* MCH-34.6* MCHC-33.3 RDW-15.1 Plt Ct-242
[**2179-5-25**] 02:06PM BLOOD Neuts-68.0 Bands-27.0* Lymphs-2.0*
Monos-3.0 Eos-0 Baso-0
[**2179-6-2**] 11:10AM BLOOD Neuts-83.8* Lymphs-11.1* Monos-3.7
Eos-1.1 Baso-0.2
[**2179-5-25**] 02:06PM BLOOD PT-29.5* PTT-41.9* INR(PT)-3.1*
[**2179-6-3**] 06:50AM BLOOD PT-23.2* PTT-31.2 INR(PT)-2.3*
[**2179-5-25**] 02:06PM BLOOD Glucose-98 UreaN-28* Creat-1.0 Na-146*
K-4.3 Cl-111* HCO3-24 AnGap-15
[**2179-6-1**] 06:40AM BLOOD Glucose-124* UreaN-17 Creat-0.8 Na-140
K-3.9 Cl-101 HCO3-31 AnGap-12
[**2179-6-3**] 06:50AM BLOOD UreaN-20 Creat-0.8 Na-136 K-4.0
[**2179-5-25**] 02:06PM BLOOD ALT-132* AST-123* LD(LDH)-252*
AlkPhos-461* Amylase-473* TotBili-5.1*
[**2179-5-27**] 12:56AM BLOOD ALT-114* AST-111* LD(LDH)-279*
CK(CPK)-304* AlkPhos-446* Amylase-110* TotBili-2.6*
[**2179-6-2**] 06:25AM BLOOD ALT-24 AST-23 AlkPhos-229* TotBili-1.3
[**2179-5-25**] 02:06PM BLOOD Lipase-341*
[**2179-5-30**] 10:06PM BLOOD Lipase-120*
[**2179-5-27**] 12:56AM BLOOD CK-MB-12* MB Indx-3.9 cTropnT-0.08*
proBNP-[**Numeric Identifier 73202**]*
[**2179-5-27**] 07:53AM BLOOD CK-MB-11* MB Indx-5.3 cTropnT-0.07*
[**2179-5-27**] 04:37PM BLOOD CK-MB-9 cTropnT-0.05*
[**2179-5-28**] 06:06AM BLOOD CK-MB-6 cTropnT-0.05*
[**2179-5-25**] 02:06PM BLOOD Albumin-3.0* Calcium-8.1* Phos-2.2*
Mg-2.1
[**2179-5-27**] 04:37PM BLOOD TSH-3.8
[**2179-5-25**] 03:10PM BLOOD Cortsol-26.6*
[**2179-5-25**] 03:58PM BLOOD Cortsol-23.0*
[**2179-5-29**] 04:00AM BLOOD Digoxin-0.4*
[**2179-6-1**] 06:40AM BLOOD Digoxin-0.5*
[**2179-5-26**] 08:09AM BLOOD Lactate-2.7*
[**2179-5-26**] 11:26PM BLOOD Lactate-1.8
[**2179-5-27**] 01:09AM BLOOD Lactate-1.7
.
Blood cultures [**2179-5-25**]: negative
.
EKG: afib, LBBB
.
CXR [**2179-5-29**]: Diffuse cardiogenic edema. More confluent opacity
in the right suprahilar region is likely due to confluent edema
although an underlying pneumonia cannot be entirely excluded.
Repeat radiography following appropriate diuresis recommended to
assess for underlying infection.
.
CXR [**2179-6-2**]: No evidence for pneumonia. Probable residual mild
interstitial edema.
.
TTE [**2179-5-27**]: EF 20%. The left atrium is mildly dilated. There is
mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. There is an echodense region
at the apex consistent with probable mural clot. Overall left
ventricular systolic function is severely depressed with
anteroseptal and apical akinesis/dyskinesis and hypokinesis
elsewhere. Right ventricular chamber size and free wall motion
are normal. The ascending aorta is moderately dilated. A
bioprosthetic aortic valve prosthesis is present. The
transaortic gradient is normal for this prosthesis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Moderate (2+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
.
ERCP [**2179-5-25**] -
.
Findings:
Esophagus: Limited exam of the esophagus was normal
Stomach: Limited exam of the stomach was normal
Duodenum: Limited exam of the duodenum was normal
Major Papilla: There was purulent discharge seen at the major
papilla.
.
Cannulation: Cannulation of the biliary duct was successful and
deep with a sphincterotome using a free-hand technique. Contrast
medium was injected resulting in partial opacification. High
pressure injection was not performed.
.
Procedures: A 10cm by 10Fr Cotton-[**Doctor Last Name **] biliary stent was placed
successfully. radiologic interpretation: Fluoro time: 2.1 min.
The CBD measured approx. 13 - 15mm. Multiple filling defects in
the CBD were noted.
.
Impression: There was purulent discharge seen at the major
papilla.
Selective cannulation of the biliary duct was successful and
deep with a sphincterotome using a free-hand technique. Contrast
medium was injected resulting in partial opacification. High
pressure injection was not performed. The CBD measured approx.
13 - 15mm. Multiple filling defects consistent with calculi in
the CBD were noted. A 10cm by 10Fr Cotton-[**Doctor Last Name **] biliary stent
was placed successfully with brisk drainage of purulent bile.
.
Recommendations: Repeat ERCP with the patient off Coumadin in 10
weeks' time, for sphincterotomy and CBD clearance. Continue
antibiotics.
.
U/S @ OSH: as above
Brief Hospital Course:
87M h/o CVA, PAF on coumadin, porcine AVR presented with
cholangitis s/p ERCP stone removal and CBD stent and developed
atrial fibrillation with a rapid ventricular response.
.
# Cholangitis: The patient presented with hypotension, fever,
chills compatible with septic shock. Interestingly, he never
experienced abdominal pain. At the OSH, blood cultures were
positive for Klebsiella pneumoniae only resistent to ampicillin.
The hypotension resolved with intravenous fluids and he was
treated for the infection with levofloxacin and flagyl initially
for a 7 day course, which was then extended to 14 days given
persistence of leukocytosis despite being afebrile. The patient
was transferred to [**Hospital1 18**] for ERCP where he underwent common bile
duct stone removal and stenting. Repeat blood cultures were
negative. The patient's LFTs, which were initially elevated,
normalized by the time of discharge. He will require a repeat
ERCP in 10 weeks (off coumadin for the procedure) for
sphincterotomy and CBD clearance. The patient was tolerating POs
prior to discharge.
.
#Atrial fibrillation, paroxysmal: In the setting of the
underlying infection, the patient developed unstable atrial
fibrillation with a rapid ventricular response and was started
on an amiodarone gtt which was then discontinued and the patient
was loaded with digoxin. He was not cardioverted. He also
received lopressor with good response. His heart rate was
difficult to control but improved with these measures (HR 90s,
SBPs 90-100 at discharge) and he remained hemodynamically stable
and asymptomatic. His digoxin dose was increased to 0.125mg
daily for a level of 0.5 and will need to be rechecked as an
outpatient. He was continued on coumadin with goal INR [**2-13**].
.
# CHF: EF 20% on recent echo, although this may represent an
underestimation as the patient was in atrial fibrillation at the
time. His EF was preserved in [**2177**] after porcine AVR
replacement. The patient was diuresed and now appears euvolemic.
Continue BB. His ACEi was held due to borderline low BPs. Lasix
was restarted. 2gm Na+ diet, daily weights.
.
# HTN: Continued beta-blocker.
.
# h/o CVA and TIAs: Continued coumadin at home dose. INR 2.3 at
discharge.
.
# GERD: Continued PPI.
.
# Mental Status changes: The patient had transient delerium
while in the ICU related to his underlying infection. His mental
status improved with antibiotic treatment. He was alert and
oriented x3 at discharge.
Medications on Admission:
Lasix PO 40 qd
Coumadin
KCl po
Zocor 20 qd
Losartan 25 mg qd
NTG sl PRN
Tylenol PRN
MVI
Ranitidine 150 [**Hospital1 **]
Discharge Medications:
1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Zocor 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*2*
5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 5 days.
Disp:*15 Tablet(s)* Refills:*0*
8. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
9. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company **]
Discharge Diagnosis:
Primary:
Cholangitis
Paroxysmal atrial fibrillation with rapid ventricular response
Decompensated systolic congestive heart failure
.
Secondary:
s/p porcine aortic valve replacement for aortic stenosis
Hypertension
h/o CVA, TIA with residual mild left Sided Hemiparesis
BPH with h/o elevated PSA
PAF
GERD
Discharge Condition:
Good. Afebrile. Off supplemental O2. HR 90s.
Discharge Instructions:
You presented with septic shock from an infection in your
liver/gallbladder (cholangitis) and improved with antibiotics.
Due to the infection you developed atrial fibrillation with a
rapid heart rate that was somewhat difficult to control
initially but improved with treatment of the infection. You also
had heart failure due to the fluids that you received to treat
your low blood pressures that was treated with diuretics to
remove the excess fluid.
.
Please take all medications as prescribed.
New medications: levofloxacin, flagyl, digoxin, toprol XL
Changed medications: lasix
Discontinued medications: losartan
.
Call your doctor or return to the ED immediately if you
experience worsening chest pain, shortness of breath, nausea,
vomiting, abdominal pain, sweating, fevers, chills, bleeding, or
other concerning symptoms.
Followup Instructions:
You are scheduled for the following appointments. Please contact
the [**Name2 (NI) 11686**] provider with any questions or if you need to
reschedule.
.
PCP: [**Last Name (NamePattern4) **]. [**First Name (STitle) 3535**] Phone: [**Telephone/Fax (1) 8572**] Date/Time: Wednesday [**2179-6-9**]
at 10:45am. Please have your blood sample tested (INR, WBC
count, Creatinine, electrolytes). You will also need to have a
repeat ERCP off coumadin in 10 weeks for sphincterotomy and CBD
clearance (your procedure was performed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at
[**Hospital1 18**], phone [**Telephone/Fax (1) 1983**]).
ICD9 Codes: 4280, 4240, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3488
} | Medical Text: Admission Date: [**2118-6-20**] Discharge Date: [**2118-7-2**]
Date of Birth: [**2071-7-1**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2118-6-20**] Emergent Five Vessel Coronary Artery Bypass Grafting(left
internal mammary artery to left anterior descending, vein grafts
to diagonal, first obtuse marginal, second obtuse marginal and
posterior descending artery)
History of Present Illness:
Mr. [**Known lastname **] is a 46 year old male with ESRD and known CAD. In
[**2116-12-16**] he underwent placement of drug eluding stent to
the circumfex. RCA was totally occluded at that time. Since
[**2117-8-15**], he had self discontinued taking Aspirin, Plavix,
Lipitor and Lopressor secondary to AV fisutla bleeding
complications.
On the day of admission, he presented to OSH with progressive
worsening chest pain for several weeks duration. He was started
on intravenous therapy and transferred to the [**Hospital1 18**] for further
evaluation and treatment. He did rule in for a myocardial
infarction with positive cardiac enzymes.
Past Medical History:
-Coronary Artery Disease, s/p PCI/Stenting(see above)
-End Stage Renal Disease, s/p Renal Transplantation 27 years
ago(failure since [**2109**]), on Hemodialysis, Left AV Fistula
-Hypertension
-Congestive Heart Failure
-Obstructive Sleep Apnea
-Hyperphosphotemia
Social History:
Married, lives with wife.
Family History:
Denies premature coronary artery disease
Physical Exam:
vitals: bp 96/60, hr83, rr 30, sat 96% on 3l
general: no acute distress, nontoxic
heent: oropharynx benign, moist mucous membranes
neck: supple, no jvd
lungs: tachypneic, crackles noted anteriorly
heart: regular rate and rhythm, normal s1s2
abdomen: benign
extremeties: warm, no edema, left AV fistula with good thrill
pulses: 1+ distally
neuro: alert and oriented x 3, no focal deficits noted
Pertinent Results:
[**2118-6-20**] 04:45PM BLOOD WBC-11.5* RBC-3.85* Hgb-12.7* Hct-37.7*
MCV-98 MCH-33.1* MCHC-33.8 RDW-13.9 Plt Ct-326
[**2118-6-20**] 04:45PM BLOOD Neuts-73.2* Lymphs-20.3 Monos-2.4 Eos-3.2
Baso-0.9
[**2118-6-20**] 04:45PM BLOOD PT-12.1 PTT-30.6 INR(PT)-1.0
[**2118-6-20**] 04:45PM BLOOD Glucose-122* UreaN-50* Creat-13.8* Na-135
K-7.1* Cl-91* HCO3-26 AnGap-25*
[**2118-6-20**] 04:45PM BLOOD ALT-16 AST-23 AlkPhos-101 TotBili-0.7
[**2118-6-20**] 04:45PM BLOOD Albumin-3.9
[**2118-6-20**] 04:45PM BLOOD %HbA1c-5.7
[**2118-6-20**] Cardiac Cath:
1. Coronary angiography of this right dominant system revealed
severe 3
vessel disease. The LMCA was angiographically normal. The
proximal LAD
had a 90% stenosis after D1, followed by 80% mid stenosis. D1
had 99%
proximal stenosis. The LCx was 100% occluded proximally at the
site of
prior stent placement in [**2116**]. The RCA was 100% occluded
proximally
with distal filling via left to right collaterals.
2. Resting hemodynamics revealed severely elevated right sided
filling
pressures with RVEDP of 30 mmHg. There was severe pulmonary
arterial
systolic hypertension with PASP of 72 mmHg. Pulmonary capillary
wedge
pressure was severely elevated (a/v/m=44/50/40 mmHg). There was
systemic arterial systolic hypotension with aortic systolic
pressure of
96 mmHg. Cardiac output was compromised at 2.10 l/min/m2.
3. Left ventriculograpy was not performed.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted and underwent cardiac catheterization
which showed critically severe three vessel coronary artery
disease(see result section). He was therefore taken urgently to
the operating room where coronary artery bypass grafting was
performed by Dr. [**First Name (STitle) **]. For surgical details, please see
seperate dictated operative note. Following the operation, he
was brought to the CSRU for invasive monitoring. Given his end
stage renal disease, CVVHD was initiated for fluid management
with gradual transition to hemodialysis. He has an isolated
episode of SVT which was successfully treated with Adenosine
with conversion back to a normal sinus rhythm. He initially
remained critically ill and was kept intubated and sedated for
several days. Tube feedings were eventually initiated for
nutritional support. He required placement of a left chest tube
for hemothorax on postoperative day four. On postoperative day
five, fevers were noted along with a leukocytosis. Pan cultures
were obtained, and empiric antibiotics were initiated. Chest
x-ray was suscipious for pneumonia. Given persistent agitation,
the psychiatry service was consulted which attributed it to
postoperative delirium. He intermittenly required Haldol and
Ativan for behavioral control. He was eventually extubated
without incident and gradually weaned from inotropic support.
His chest tubes and pacing wires were DC'd without incidence,
After his CSRU stay. Pt did quite well. He was transfered to the
floor. On the floor he made steady progress. He worked with PT.
He progressed to a point were he no longer needed rehab.
He also recieved hemodialysis while on the floor in his regualr
scheduled cirriculum. M / W / F.
Pt [**Name (NI) 1788**] in stable condition
Medications on Admission:
Transfer Meds: Intravenous Heparin, Plavix 300mg(single dose),
Protonix, Aspirin 325 qd, Lopressor
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
4. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
5. Loratadine 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
7. Sensipar 60 mg Tablet Sig: One (1) Tablet PO twice a day.
8. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Coronary Artery Disease - s/p Emergent CABG
Postop Delirium
Postop Hemothorax
End Stage Renal Disease - prior Renal Transplantation(failure
[**2109**])
Hypertension
Congestive Heart Failure
Obstructive Sleep Apnea
Discharge Condition:
Good
Discharge Instructions:
1)Please shower daily, no baths.
2)Avoid creams, lotions, ointments to surgical incisions.
3)Please call cardiac surgeon if start to experience sternal
drainage, or signs of wound infection.
4)No driving for at least one month.
5)No lifting more than 10 lbs for at least 10 weeks.
Followup Instructions:
Dr. [**First Name (STitle) **] in [**2-17**] weeks, call for appt
Dr. [**Last Name (STitle) 1295**] or Dr. [**Last Name (STitle) 656**] in [**12-18**] weeks, call for appt
Dr. [**Last Name (STitle) **] in [**12-18**] weeks, call for appt
Dr. [**Last Name (STitle) 11427**] in [**12-18**] weeks, call for appt
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2118-7-2**]
ICD9 Codes: 4280, 4254, 5856, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3489
} | Medical Text: Admission Date: [**2134-10-9**] Discharge Date: [**2134-11-19**]
Date of Birth: [**2071-4-28**] Sex: F
Service: MEDICINE
Allergies:
Bactrim / Dicloxacillin / Levofloxacin
Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
Subclavian CVL
History of Present Illness:
Mrs. [**Known lastname 52**] is a 63-year-old woman with a history of recurrent
Burkitt's lymphoma D +15 of [**Hospital1 **], who was recently discharged
from [**Hospital1 18**] after her first treatment for recurrence (see PMH).
She had been doing well at home until the morning of [**2134-10-9**].
She had awoken early to come to her outpatient appointment at 7
[**Hospital 1826**] clinic, and on standing from bed, felt very
lightheaded. She does not recall much after that point. Her son
found her in the kitchen, lying against the cabinets in a pool
of feces. They called 911, and on transport to [**Hospital3 **], her BP was found to be 58/38. She was given IVF on
transport and in the ED at [**Hospital3 **].
.
She was afebrile, and her blood pressure responded to fluid
resuscitation to 90s/40s on transfer. She has been mentating the
entire time. At the OSH a chest X-Ray and Head CT were done.
Both of which were negative for any acute process. She was given
a dose of vancomycin and cefepime at the outside hospital out of
concern for infection given her neutropenia (WBC 0.2 at the OSH)
and hypotension.
.
On arrival to the floor, her vitals were T 99.4, BP 105/50, HR
99, RR 18 and O2 sat 100% on RA. She is mentating well and is
currently asymptomatic. She denies any fever or chills, cough,
chest pain, shortness of breath, dysuria, frequency, urgency,
myalgias, or abdominal pain. She admits to diarrhea this am,
lightheadedness, feeling "dry," and pain in her mouth.
Past Medical History:
Interval History:
Burkitt's Lymphoma: She was admitted [**2134-9-20**] with 6 weeks of
persistent, progressive shoulder pain. On admission, there was a
palpable mass on her right chest wall and axilla. A CT scan
showed a large axillary mass that was cocerning for recurrence
of disease. She had an IR guided biopsy [**9-22**] which was
inconclusive, and was then taken to the OR for surgical
excisional biopsy [**9-23**] that showed recurrence of disease. On
[**2134-9-25**] she had an echocardiogram and began treatment with
[**Hospital1 **]. She had an LP done on [**10-1**], which was positive for
disease. At that time she recieved intrathecal methotrexate and
hydrocort. On [**2134-10-5**] her LP was repeated and she recieved
intrathecal cytarabine. She was discharged with neupogen for
one week with close follow-up.
.
1. Burkitt's lymphoma
- Diagnosed in [**2133-11-27**], s/p multiple chemo regimens.
- Most recent cycle (IVAC) was on [**2134-4-29**] with complications of
admission for profound neutropenia, fever, parainfluenza
infection, and bacteremia.
2. Hypothyroidism.
3. Hyperlipidemia.
4. Hx of Pseudomonas bacteremia.
5. Hx of Coag-neg staph bacteremia.
6. Hx of Enterobacter bacteremia.
7. Hx of Parainfluenza and pneumonia
Social History:
(from OMR, confirmed with patient)
Her husband has COPD and has required frequent hospitalizations.
One of her sons and daughter-in-law live downstairs with their
three children. She worked as a system analysis at NHIC, but is
currently retired. Denies tobacco or alcohol use.
Family History:
(from OMR, confirmed with patient)
There is no family history of lymphoma or other malignancies
within the family. Her sister has a history of cirrhosis. Her
brother has diabetes and anterograde amnesia.
Physical Exam:
Vitals: T: 99.4 BP: 105/50 HR: 99 RR: 18 O2 sat 100% on RA
Gen: Well appearing woman
HEENT: PERRL, EOMI, Dry MM, no JVP, no LAD, multiple areas of
mucositis in her mouth
CV: Tahcycardic, regular rhythm, no m/r/g normal s1 and s2
Chest: old ecchymosis on right breast
Lungs: CTAB, no wheezes rales or rhonchi
Back: 3x5 cm contusion on her left midback, inferior to the
scapula, no associated tenderness surrounding the lesion, also a
3x1.5 cm contusion along the top of the left scapula
Abdomen: Soft, non-tender, mildly distended, NABS, palpable
liver tip
Ext: No edema, cyanosis, clubbing. 2+ radial and DP pulses
bilaterally
Skin: No abnormalities other than contusions noted above, warm,
dry
Neuro: CNII-XII grossly intact, AAOx3, strength 5/5 in upper and
lower extremities
Pertinent Results:
Admission Labs:
[**2134-10-9**] 03:45PM BLOOD WBC-0.3*# RBC-2.20* Hgb-7.7* Hct-21.3*
MCV-97 MCH-35.0* MCHC-36.2* RDW-14.5 Plt Ct-14*#
[**2134-10-9**] 03:45PM BLOOD Neuts-11* Bands-22* Lymphs-7* Monos-0*
Eos-1 Baso-1 Atyps-0 Metas-1* Myelos-1* Other-56*
[**2134-10-9**] 03:45PM BLOOD PT-15.3* PTT-28.0 INR(PT)-1.3*
[**2134-10-9**] 03:45PM BLOOD Plt Smr-RARE Plt Ct-14*#
[**2134-10-9**] 03:45PM BLOOD Glucose-125* UreaN-24* Creat-0.6 Na-136
K-3.5 Cl-104 HCO3-24 AnGap-12
[**2134-10-9**] 03:45PM BLOOD ALT-98* AST-39 LD(LDH)-169 AlkPhos-134*
TotBili-1.7*
[**2134-10-9**] 03:45PM BLOOD Albumin-3.2* Calcium-8.8 Phos-3.5 Mg-2.0
UricAcd-2.9
[**2134-10-9**] 06:45PM BLOOD Lactate-1.0
Discharge labs:
[**2134-11-19**] 12:00AM BLOOD WBC-2.1* RBC-2.92* Hgb-8.7* Hct-24.7*
MCV-84 MCH-29.9 MCHC-35.5* RDW-13.4 Plt Ct-85*
[**2134-11-19**] 12:00AM BLOOD Neuts-67 Bands-0 Lymphs-14* Monos-17*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-2* NRBC-1*
[**2134-11-19**] 12:00AM BLOOD Gran Ct-1449*
[**2134-11-19**] 12:00AM BLOOD Glucose-143* UreaN-15 Creat-0.4 Na-132*
K-3.9 Cl-99 HCO3-25 AnGap-12
[**2134-11-19**] 12:00AM BLOOD ALT-75* AST-54* LD(LDH)-377* AlkPhos-135*
TotBili-0.4
[**2134-11-19**] 12:00AM BLOOD Calcium-8.9 Phos-2.2* Mg-2.0 UricAcd-1.7*
Micro:
[**2134-10-24**] 4:56 am BLOOD CULTURE Source: Line-TLCL.
**FINAL REPORT [**2134-10-30**]**
Blood Culture, Routine (Final [**2134-10-30**]):
PSEUDOMONAS AERUGINOSA. OF TWO COLONIAL MORPHOLOGIES.
FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- 16 S
TOBRAMYCIN------------ <=1 S
Aerobic Bottle Gram Stain (Final [**2134-10-24**]):
GRAM NEGATIVE ROD(S).
[**10-14**] LP (#1) - no malignant cells
[**11-4**] LP (#2) - no malignant cells
[**11-11**] LP (#3) - no malignant cells
[**11-18**] LP (#4) - no malignant cells
Studies:
[**10-10**] CT ABD/PELVIS- 1. No infectious source identified in the
chest, abdomen or pelvis. 2. Interval decrease in size of
confluent right axillary adenopathy compared to [**2134-9-21**]. 3. Single stable left paraaortic lymph node. 4. Sigmoid
diverticulosis, without diverticulitis. 5. Distention of the
stomach, without evidence for mechanical obstruction. Correlate
clinically.
[**11-6**] CT Chest: IMPRESSION:
1. No acute pulmonary embolism or aortic pathology.
2. Similar appearance of 1-cm ground-glass nodular opacity in
the right upper lobe. Recommend continued followup.
3. Sub-4mm pulmonary nodules, with questionable interval
increase in size,
could be re-evaluated when followup for the ground-glass
opacity.
4. Slightly interval decrease in size of the right axillary
lymph node
conglomerate.
[**11-8**] ECHO: IMPRESSION: Mild global hypokinesis. Mild mitral
regurgitation. No evidence of endocarditis seen. If clinically
suggested, the absence of a vegetation by 2D echocardiography
does not exclude endocarditis. Compared with the prior study
(images reviewed) of [**2134-10-29**], the findings are similar.
Abnormal septal motion was seen on the prior study also.
[**11-14**] MRI shoulder: The lymphomatous mass in the right axilla,
encasing the right brachial plexus has increased in size
compared to prior imaging.
[**11-17**] U/S: No evidence of DVT in the right upper extremity.
[**11-18**] CT torso: read pending at time of discharge, will be
followed up at outpatient appt on Monday [**11-22**]
Brief Hospital Course:
Assessment and Plan: Mrs. [**Known lastname 52**] is a 63-year-old woman with
recurrent Burkitt's lymphoma who is D+15 of [**Hospital1 **] admitted from
an OSH with hypotension and neutropenia after a syncopal episode
at home.
.
# Hypotension/Syncope: She was found to be hypotensive to 58/38
by EMS, which responded to fluids. She was fluid resuscitated to
SBP of 70s by EMS and SBP of 90's by OSH ED prior to transfer.
Blood cultures were drawn and she was given cefepime and vanco
and transferred to 7 [**Hospital Ward Name 1826**]. On arrival she was given 2L of
fluid, 1 unit of blood, and cefepime, vancomycin, and flagyl.
Her pressures responded. OSH cultures came back as VRE 1:4
bottles, sensitive to ampicillin, daptomycin, levofloxacin, and
linezolid. She was switched to ampicillin on [**10-12**] and her PICC
was pulled. She was switched to daptomycin on Monday [**2134-10-18**]
because she had begun receiving hyper CVAD part B and amp
interferes with clearance of methotrexate. She had a TTE and
TEE which showed no vegetations. As she was being treated for
the bacteremia, Ms. [**Known lastname 52**] again became hypotensive and
febrile, requiring transfer to the [**Hospital Unit Name 153**] where she required
pressors. Blood cultures were sent and ultimately returned
positive with pseudomonas, believed to be associated with her
central line. Her line was pulled and her broad spectrum
antibiotic coverage (started given her sepsis in the setting of
neutropenia) was narrowed to cefepime, gentamicin, and
linezolid. Gentamicin was d/c-ed a few days after transfer to
the floor and linezolid was transitioned to ampicillin as the
patient was believed to have leukosuppression secondary to the
linezolid. She completed a 10 day course of antibiotics (amp and
cefepime) from the time her ANC was greater than 1000 per ID
recommendations and remained afebrile and hemodynamically stable
for the remainder of her hospital course.
.
# Burkitt's Lymphoma: She was admitted on day +15 of [**Hospital1 **]. An
LP with intrathecal chemotherapy was performed on [**2134-10-14**]. A
subclavian line was placed on [**10-15**] and treatment with hyper
CVAD part B was started on [**10-16**]. She tolerated her chemotherapy
well, complicated by mild mucositis and the bacteremia discussed
above. She had one more round of intrathecal chemotherapy with
cytarabine on [**11-4**]. LPs on [**11-18**], and [**11-11**] were negative
for malignant cells. Patient had significant right shoulder and
arm pain as well as right hand weakness, believed secondary to
brachial plexus involvement of her lymphoma. She underwent MRI
of her R shoulder which confirmed this finding and had 4
sessions of XRT as a palliative therapy. She had 4 LP's which
were negative for malignant cells. Had IT cytarabine on [**11-18**]
prior to discharge which she tolerated well. Pt had CT of torso
to evaluate for progression of disease, read at the time of
discharge was pending but will be followed up at follow-up
appointment Monday following discharge when pt will return for
chemotherapy gemcitabine and vinorelbine. Acyclovir and
fluconazole were held given elevated LFTs, will trend LFTs as
outpatient and do liver ultrasound if necessary. Pt was given
pentamidine prior to discharge for PCP [**Name Initial (PRE) 1102**].
.
# Cardiomyopathy: Patient became tachycardic at the time of her
second episode of sepsis. This continued intermittently through
her [**Hospital Unit Name 153**] stay and subsequently on the floor. Tachycardia was
sinus in nature, up into the 140s with movement, and was
attributed to an underlying cardiomyopathy (EF 45-50% on echo,
last on [**10-29**]). Cardiology was consulted for management and she
was started on metoprolol 12.5mg [**Hospital1 **] which she tolerated well.
.
# DVT: Found to have right upper extremity DVT last admission
and was on lovenox for that until she had a drop in platelets
(treatment related). She was thrombocytopenic during her
admission and her lovenox was held. An ultrasound of the arm was
repeated and was negative for clot.
.
# Hypothyroidism: Stable. Continued Levothyroxine 100mcg PO
daily
.
# Depression: Patient was frequently tearful and endorsed
saddened mood and symptoms of depression. Was started on
citalopram 10 mg daily.
Medications on Admission:
1. acyclovir 400 mg PO Q8 hours
2. clonazepam 0.5 mg PO TID PRN for anxiety.
3. levothyroxine 100 mcg PO DAILY
4. pyridoxine 50 mg PO DAILY
5. docusate sodium 100 mg PO BID
6. nystatin 100,000 unit/mL Suspension 5 ML PO QID
7. senna 8.6 mg PO QHS PRN constipation
8. gabapentin 600 mg PO TID
9. polyethylene glycol 17 gram/dose Powder PO Daily PRN
constipation
10. MS contin 60 mg PO Q8H
11. hydromorphone 2-4 mg PO Q4h prn pain
12. saliva substitution 30ML QID
13. enoxaparin 60 mg/0.6 mL Subcutaneous Q12H
14. filgrastim 300 mcg/mL SC Inj Q24H for 5 days.
15. dexamethasone 2 mg PO DAILY
Discharge Medications:
1. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed for insomnia.
2. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
5. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
7. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours).
8. oxycodone 30 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
Disp:*60 Tablet Sustained Release 12 hr(s)* Refills:*0*
9. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
10. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
11. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
12. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Burkitt's lymphoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 52**],
You were admitted to the hospital with an infection in your
blood. You had a short stay in the ICU and were treated with
antibiotics and recovered. During your hospitalization you
received chemotherapy and radiation therapy for your Burkitt's
lymphoma.
You will be returning on Monday for outpatient chemotherapy.
Please call if you have any symptoms or concerns before then.
We have made the following changes to your medications:
Take metoprolol 12.5mg twice a day for blood pressure
Take celexa 10mg daily for depression
Take dexamethasone 4mg daily
Take OxyContin 30mg twice a day for long-acting pain control
You can continue your home dilaudid 2-4mg every 6hrs as needed
for breakthrough pain
Please do not take acyclovir or fluconazole until you follow-up
as an outpatient because these medications can elevate liver
labs
It was a pleasure taking care of you. We wish you a speedy
recovery.
Followup Instructions:
The following appointment has been scheduled for you:
Department: [**Known lastname 3242**]/ONCOLOGY UNIT
When: MONDAY [**2134-11-22**] at 9:30 AM [**Telephone/Fax (1) 447**]
Building: Fd [**Hospital Ward Name 1826**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3971**]
Campus: EAST Best Parking: Main Garage
Completed by:[**2134-11-19**]
ICD9 Codes: 2449, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3490
} | Medical Text: Admission Date: [**2190-3-20**] Discharge Date: [**2190-3-27**]
Date of Birth: [**2112-1-2**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Increased work of breathing
Major Surgical or Invasive Procedure:
PICC Placement
History of Present Illness:
78 yo male with multiple medical problems including [**Name2 (NI) 3696**],
Chronic aspiration, CVA, CAD, DM, Afib on coumadin presented
from rehab after routine vitals on the morning of admission
noted an oxygen saturation of 69% on RA. He was suctioned twice
with thick white secretions. He appeared to demonstrate
increased work of breathing at that time. Oxygen saturation
improved to 96% on 4L.
In the ED, initial vitals were 100.7, 104/54, 124, 35, 99 NRB.
On exam, he was noted to be minimally responsive. He was noted
to have coarse breath sounds, and appeared to have evidence of
volume overload on exam. EKG showed afib. He was given lasix 40
mg IVx1. Initial VBG showed 7.35 / 39 / 43 / 22. Bipap was
initiated and ABG showed 7.19/59/217/24. Based on worsening ABG,
patient was intubated and started on fentanyl/versed for
sedation. He received Vancomycin 1g IVx1, and Zosyn 4.5 g x1, as
well as tylenol 650 mg pr x1. On transfer, VS were 117/59, 102,
ac 100 FiO2, 600 cc, 20, Peep 5 on fent 25 mcg.
In the ICU, patient appeared comfortable but was unresponsive to
sternal rub.
Of note, patient was admitted [**3-10**] though [**2190-3-19**] at [**Hospital1 18**] with
pneumonia. He was initially intubated and briefly on pressors,
and later extubated on [**3-11**]. Course was also complicated by
NSTEMI that was felt to be demand, and anemia requiring 4 U
PRBC. Antibiotics included Vanco/Cefepime/Flagyl for planned
course through [**3-21**] for total 12 day course. On [**3-17**], patient
was retransferred to the MICU for respiratory distress that
improved with bipap and diuresis. He was transferred to the
floor and back to [**Last Name (un) 2299**] house the same day. Multiple family
meetings were help regarding code status, but HCP and son [**Name (NI) **]
[**Name (NI) 42086**], and decision was made to keep patient FULL CODE at that
time until the family could come to a complete consensus.
Past Medical History:
#. Ogilvies Syndrome- Has frequent admissions for abdominal
distention, with dilated colon on imaging, which resolves with
rectal tube decompression.
#. Chronic aspiration (Per PCP)
#. CVA complicated by expressive aphagia, dysphagia
#. Coronary artery disease, s/p CABG in [**2154**], mild systolic
regional hypokinesis with EF 55%
#. HTN
#. Hyperlipidemia
#. GERD
#. History of pancreatitis
#. Type 2 diabetes c/b gastroparesis
#. Anemia h/o intermittent heme+ stools
#. Atrial fibrillation on coumadin
Social History:
Living at [**Hospital3 1186**] nursing home since stroke in [**2183**], wife
passed away 5 years ago, no tobacco or ETOH use.
Family History:
NC
Physical Exam:
Vitals: T: 99.8 BP: 105/65 P: R: 21 18 O2: FiO2 40 AC 500 x 15
PEEP 5
General: Sedated, intubated, minimal grimace to sternal rub
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not assessible, no LAD
Lungs: rhonchorous, good airmovement
CV: RRR. Nl S1 and S2.
Abdomen: soft, ABS. slightly distended from edema. nontender.
tube in place.
GU: foley in place. brown urine in foley bag.
Ext: 2+ LE edema to knees
Pertinent Results:
[**2190-3-20**] 10:41PM TYPE-ART PO2-155* PCO2-31* PH-7.41 TOTAL
CO2-20* BASE XS--3
[**2190-3-20**] 10:15PM SODIUM-149* CHLORIDE-120* TOTAL CO2-20*
[**2190-3-20**] 10:15PM HCT-24.3*
[**2190-3-20**] 08:56PM TYPE-ART PO2-61* PCO2-28* PH-7.40 TOTAL
CO2-18* BASE XS--5
[**2190-3-20**] 05:30PM GLUCOSE-135* UREA N-60* CREAT-1.4*
SODIUM-150* POTASSIUM-3.7 CHLORIDE-121* TOTAL CO2-20* ANION
GAP-13
[**2190-3-20**] 05:30PM CK(CPK)-184
[**2190-3-20**] 05:30PM CK-MB-22* MB INDX-12.0* cTropnT-1.38*
[**2190-3-20**] 05:30PM CALCIUM-7.9* PHOSPHATE-3.2 MAGNESIUM-2.1
[**2190-3-20**] 05:30PM HCT-26.1*
[**2190-3-20**] 02:28PM TYPE-ART PO2-336* PCO2-29* PH-7.47* TOTAL
CO2-22 BASE XS-0
[**2190-3-20**] 11:48AM TYPE-ART PO2-217* PCO2-59* PH-7.19* TOTAL
CO2-24 BASE XS--6
[**2190-3-20**] 11:48AM LACTATE-1.7
[**2190-3-20**] 11:14AM PO2-43* PCO2-39 PH-7.35 TOTAL CO2-22 BASE
XS--3
[**2190-3-20**] 11:14AM LACTATE-2.1*
[**2190-3-20**] 11:00AM LACTATE-2.3*
[**2190-3-20**] 10:55AM GLUCOSE-180* UREA N-63* CREAT-1.3*
SODIUM-148* POTASSIUM-4.1 CHLORIDE-118* TOTAL CO2-19* ANION
GAP-15
[**2190-3-20**] 10:55AM ALT(SGPT)-25 AST(SGOT)-38 CK(CPK)-195 ALK
PHOS-85 TOT BILI-0.5
[**2190-3-20**] 10:55AM LIPASE-31
[**2190-3-20**] 10:55AM CK-MB-23* MB INDX-11.8* cTropnT-1.24*
proBNP->[**Numeric Identifier **]
[**2190-3-20**] 10:55AM ALBUMIN-2.5* CALCIUM-8.3* PHOSPHATE-3.5
MAGNESIUM-2.4
[**2190-3-20**] 10:55AM WBC-20.3*# RBC-3.38* HGB-10.1* HCT-31.9*
MCV-95 MCH-30.0 MCHC-31.8 RDW-17.4*
[**2190-3-20**] 10:55AM NEUTS-93.0* LYMPHS-2.8* MONOS-3.2 EOS-0.7
BASOS-0.3
[**2190-3-20**] 10:55AM PLT COUNT-358#
[**2190-3-20**] 10:55AM PT-25.0* PTT-39.6* INR(PT)-2.4*
[**2190-3-20**] 10:55AM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.017
[**2190-3-20**] 10:55AM URINE BLOOD-LG NITRITE-NEG PROTEIN-150
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2190-3-20**] 10:55AM URINE AMORPH-FEW
[**2190-3-19**] 12:02PM GLUCOSE-61* UREA N-60* CREAT-1.3* SODIUM-147*
POTASSIUM-4.2 CHLORIDE-116* TOTAL CO2-15* ANION GAP-20
[**2190-3-19**] 12:02PM CK(CPK)-208
[**2190-3-19**] 12:02PM WBC-13.3* RBC-3.18* HGB-9.8* HCT-30.4* MCV-95
MCH-30.8 MCHC-32.3 RDW-17.2*
[**2190-3-19**] 12:02PM PLT COUNT-227#
[**2190-3-19**] 12:02PM PT-26.5* PTT-44.3* INR(PT)-2.6*
CXR [**2190-3-20**]
SINGLE FRONTAL CHEST RADIOGRAPH: Compared to the study on [**3-19**], there is interval increase of pulmonary markings in the
right lung, compatible with interval increase of pulmonary
edema. Small bilateral pleural effusions are present. Bibasilar
atelectasis persists. There is no pneumothorax. The
cardiomediastinal silhouette is grossly normal and unchanged.
Multiple median sternotomy wires are unchanged. The right
shoulder arthroplasty is unchanged. Moderate degenerative
disease is noted in the left shoulder. Abdominal drains are
partially imaged.
IMPRESSION: Mild-to-moderate pulmonary edema, worse in the
interval, with
small bilateral pleural effusions and bibasilar atelectasis.
CT Abd/Pelvis [**2190-3-21**]:
FINDINGS: There are large bilateral pleural effusions, similar
when compared
to prior exam. There is no pericardial effusion. Calcifications
of the
aortic valve are noted. NG tube is identified terminating within
the stomach.
GJ-tube is also identified terminating within the proximal
jejunum. Within
the limitation of a non-contrast exam, the spleen, liver,
adrenal glands,
pancreas, and kidneys are unremarkable. Calcifications of the
splenic artery,
descending aorta and its branches are noted. Small bowel loops
are normal in
caliber and without focal wall thickening. There is no free
fluid or free
air. There is no mesenteric or retroperitoneal lymphadenopathy.
There is no
evidence of large retroperitoneal bleed identified.
CT OF THE PELVIS: Extensive streak artifact from bilateral hip
prosthesis
limits evaluation of the pelvis. The bladder contains a Foley
catheter, with
small foci of air, likely due to recent catheterization. Large
amount of air
and fluid within the sigmoid colon and rectum are noted. The
fluid appears
hyperdense and distends the lumen of the colon. Correlation with
Hemoccult
test is recommended. There is no definite pelvic or inguinal
lymphadenopathy.
There is diffuse anasarca.
BONE WINDOWS: There are no suspicious lytic or sclerotic lesions
identified.
Multilevel degenerative changes are unchanged.
IMPRESSION:
1. No evidence of retroperitoneal bleeding.
2. Hyperdense fluid within the sigmoid colon. Correlation with
Hemoccult is
recommended to exclude blood within the colon. Alternately, this
may
represent oral contrast. Correlation with clinical history is
recommended.
3. Large bilateral pleural effusions, similar when compared to
prior exam.
4. Vascular calcifications.
5. Diffuse anasarca.
CXR [**2190-3-24**]:
INDICATION: 78-year-old male with pneumonia.
COMPARISON: [**2190-3-23**].
CHEST, AP: Mild interstitial edema, cardiomegaly, and moderate
bilateral
layering effusions are unchanged. The mediastinal and hilar
contours are
normal. Again seen is an endotracheal tube 3 cm from the carina,
median
sternotomy wires, gastrojejunostomy tube, and right humeral
prosthesis.
IMPRESSION: Mild volume overload.
Brief Hospital Course:
# Acute hypercarbic respiratory failure:
Initial CXR without significant change or improvement on BiPAP.
Pt was intubated and showed improved ventilation on ABG. BNP was
greater than assay and was consistent with CHF. The patient made
good urine in the ED to Lasix. Patient was initially
anticoagulated, so PE seemed less likely. The patient had
worsening of leukocytosis and persistent fever that was
concerning for possible resistant organism.
The patient was started on Meropenem, vancomycin, and flagyl for
likely hospital acquired pneumonia. The patient was maintained
on a vent, suctioned as needed, and daily CXRs were obtained.
The patient was initially diuresed as tolerated including
briefly being on a lasix drip, however, he no longer responded
to diuretics and became oliguric. The patient was total body
volume overloaded with anasarca.
After family discussions regarding goals of care, the patient
was initially made DNR. When family could gather together and
have further discussion on [**2190-3-26**], the patient was made comfort
measures only. He had tolerated an SBT well and was extubated.
The patient had done well for the next 24 hours and arrangements
were made to transfer back to the patient's long term care
facility, the [**Hospital3 1186**].
# Hypotension:
Patient initially required vasopressors (levophed) for
hypotension. On HD #3 the patient was weaned from pressors and
remained normotensive with occasional SBPs in the 90s for the
remainder of his admission.
# Pneumonia:
Initially the patient was on vanc/pip-tazo for HCAP on recent
admission on [**3-11**]. Piperacillin-tazobactam was changed to
cefepime on [**3-13**]. Metronidazole was added on [**3-13**] due to
persistent fevers.
Vancomycin troughs were obtained and vancomycin was dosed
accordingly. Blood cultures, urine cultures, sputum cultures
from admission did not show any growth nor any microorganisms.
The patient was planned for an additional 8 day course of
antibiotics to be discontinued on [**2190-3-28**]. After goals of
treatment were addressed with the patient's family, however,
antibiotics were discontinued on [**2190-3-26**].
# Fluid Overload/Anasarca:
Patient with total body overload as above.
# Hypernatremia:
Upon admission, patient was initially hypernatremic to 150. It
was postulated that this could have been due to poor po intake,
but patient was total body overloaded.
He was started on free water flushes through tube 250cc x Q6h
and this was slowly titrated down with resolution of
hypernatremia. His hypernatremia resolved, and labs were no
longer checked after patient was made CMO.
# NSTEMI:
Troponin was elevated but flat CK, could be consistent with
resolving infarct on last admission. EKGs were performed with
signs of demand in lateral leads.
The patient's troponin peaked at 1.39 and then remained elevated
around 1.28 when labs were no longer being checked.
Until the patient was made CMO, he was maintained on [**Date Range **] 325mg
and high dose statin. Beta [**Date Range 7005**] was held for hypotension.
# Atrial fibrillation:
Was previously in atrial fibrillation in ED. Pt had been on
anticoagulation for afib but hematocrit was slowly trending
down. Anticoagulation was held and a CT was performed to
evaulated for RP bleed. CT did not demonstrate any
retroperitoneal blood or other source of bleeding.
# Anemia:
The patient's hematocrit slowly trended down to a nadir of 24.3.
Due to his demand ischemia and likely evolving NSTEMI, the
patient received a transfusion of 1 unit of pRBCs. Since that
time his HCT appeared stable and was 30.2 when labs were last
checked.
He was maintained with 2 peripheral IVs, PICC line, and an
active type and screen until he was made comfort measures only.
# Diabetes mellitus:
The patient was maintained on an ISS with satisfactory control
of his blood sugar.
# Dementia:
The patient was continued on his home dose of mirtazapine.
Medications on Admission:
# Aspirin 81 mg daily
# Lisinopril 20 mg daily
# Lansoprazole 30 mg [**Hospital1 **]
# Furosemide 20 mg daily
# Metoprolol Tartrate 25 mg [**Hospital1 **]
# Isosorbide Dinitrate 10 mg TID
# Mirtazapine 30 mg QHS
# Coumadin 1 mg Tablet daily
# Simvastatin 80 mg daily
# Multivitamin daily
# Vitamin D 400 daily
# Prednisolone Acetate 1 % Drops, Suspension [**Hospital1 **]: 1-2 drops
Ophthalmic twice a day: right eye.
# Bacitracin 500 unit/g Ointment [**Hospital1 **]: One (1) application
Ophthalmic twice a day.
# Nitroglycerin 0.3 mg prn
# Metronidazole 500 mg po Q8H
# Vancomycin 750 mg Recon Soln [**Hospital1 **]: Seven [**Age over 90 1230**]y (750)
mg Intravenous every twelve (12) hours: last day [**3-21**].
# Cefepime 2 gram Recon Soln [**Month/Year (2) **]: Two (2) gm Intravenous every
twenty-four(24) hours: last day [**3-21**].
# ISS
Discharge Medications:
1. Morphine Concentrate 20 mg/mL Solution [**Month/Year (2) **]: 0.5-1 ml PO Q2H
(every 2 hours) as needed for respiratory distress.
2. Morphine Concentrate 20 mg/mL Solution [**Month/Year (2) **]: 0.25-0.5 ml PO
Q15 MIN () as needed for respiratory distress.
3. Lorazepam 1 mg Tablet [**Month/Year (2) **]: 1-2 Tablets PO Q2H (every 2 hours)
as needed for agitation.
4. Morphine 2 mg/mL Syringe [**Month/Year (2) **]: 2-4 mg Injection Q4H (every 4
hours) as needed for pain.
5. Heparin, Porcine (PF) 10 unit/mL Syringe [**Month/Year (2) **]: Ten (10) ML
Intravenous PRN (as needed) as needed for line flush.
6. Scopolamine Base 1.5 mg Patch 72 hr [**Month/Year (2) **]: One (1) Patch 72 hr
Transdermal ONCE (Once) for 1 doses.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
Primary:
(1) Respiratory Failure
(2) Oliguria
(3) Anasarca
(4) Hospital Acquired Pneumonia
(5) NSTEMI
(6) Congestive Heart Failure
(7) Anemia
(8) Atrial Fibrillation
Secondary:
(1) Coronary Artery Disease
(2) [**Last Name (un) 3696**] Syndrome
(3) CVA
(4) HTN
(5) GERD
Discharge Condition:
Mental Status: Confused - sometimes
Level of Consciousness: Lethargic but arousable
Activity Status: Bedbound
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Please return to the [**Hospital3 **] and contact us with any
further questions or concerns.
Followup Instructions:
No follow up recommended at this time.
ICD9 Codes: 0389, 5070, 2760, 4280, 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3491
} | Medical Text: Admission Date: [**2173-1-31**] [**Year (4 digits) **] Date: [**2173-2-12**]
Service: CCU
HISTORY OF PRESENT ILLNESS: The patient is an 81-year-old
female with a history of atrial fibrillation on Coumadin and
hypertension who was transferred from [**Hospital3 **] with
left temporoparietal hemorrhage with intraventricular
extension. The patient had an INR of 3.6 at an outside
hospital. She was in her usual state of health until this
past week when she had some slight word-finding difficulties
and began forgetting more things than usual.
On the morning of admission she woke up with a severe
headache associated with nausea. At 1 p.m., the patient's
daughter called her, and she was very confused and did not
recognize her daughter. At that point, Emergency Medical
Service was called, and she was taken to an outside hospital;
at which time she presented with an initial blood pressure of
186/91, and a pulse in the 150s. There was no demonstrated
focal weakness or numbness. The patient did complain of a
right visual field looking "not normal," and reported that
she could not see the left of people. She still complained
of a headache; although, it had somewhat improved, as well as
persistent nausea.
The patient received 2 units of fresh frozen plasma at the
outside hospital as well as a Cardizem drip for rate control
and was transferred to [**Hospital1 69**].
PAST MEDICAL HISTORY:
1. Atrial fibrillation, on Coumadin for one year.
2. Hypertension for 15 years.
3. Colon cancer, status post resection five years ago.
4. Left below-knee amputation for cancer of unknown type
in [**2145**].
5. No history of stroke, transient ischemic attacks, or deep
venous thromboses.
6. Recurrent urinary tract infections.
7. Hysterectomy.
MEDICATIONS ON ADMISSION:
1. Coumadin 5/2.5 mg p.o. q.o.d.
2. Betapace 120 mg p.o. b.i.d.
3. Pravachol 20 mg p.o. q.d.
4. Toprol-XL 50 mg p.o. q.d.
5. Zestoretic (lisinopril/hydrochlorothiazide) 20/12.5 1
tablet p.o. q.d.
ALLERGIES: The patient has no known drug allergies.
FAMILY HISTORY: The patient's died of a stroke at the age
of 83. There was no history of bleeding disorders in the
family.
SOCIAL HISTORY: The patient lives by herself and was widowed
two years ago. She is independent and able to do her own
activities of daily living. The patient denies any smoking
or alcohol use, and she walks with a cane and prosthesis.
PHYSICAL EXAMINATION ON PRESENTATION: In general, in no
acute distress. Cardiovascular revealed first heart sound
and second heart sound were normal. No murmurs, rubs or
gallops. Lungs were clear to auscultation bilaterally.
Abdomen was soft, protuberant, and nontender. Extremities
revealed left below-knee amputation and no edema.
Neurologically, awake, alert, conversant, oriented to self,
oriented to month/date but not the year. Followed simple
commands. No dysarthria, but frequent word substitutions.
Paraphasic errors. Fluent sentences with repetition 4 on
first attempt then intact, failed all naming with use of word
substitution. Motor revealed normal tone, [**4-18**] bilaterally in
the upper extremity and bilateral lower extremity (note left
below-knee amputation). Reflexes were 0 at knees, right
ankle, right toe was downgoing. Sensation was intact to
light touch throughout.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories at
the time of admission revealed a white blood cell count
of 8.8, hematocrit of 36.7, platelets of 298. Sodium of 144,
potassium of 3.1, chloride of 102, bicarbonate of 28, blood
urea nitrogen of 13, creatinine of 0.8, glucose of 109.
Calcium of 9.2, phosphorous of 3.6, magnesium of 1.7. ALT
of 13, AST of 16, alkaline phosphatase of 117, total
bilirubin of 0.6.
RADIOLOGY/IMAGING: Electrocardiogram at the outside hospital
revealed a normal sinus rhythm at 75 beats per minute, and no
acute ST-T wave changes.
Head CT revealed approximately 3-cm X 3-cm X 5-cm
heterogenous hemorrhage in the left temporoparietal region
with extension into the left lateral ventricle with
questionable surrounding edema and minimal midline shift.
HOSPITAL COURSE: The patient is an 81-year-old female with a
history of hypertension and atrial fibrillation (on
Coumadin), with new onset of mild cognitive and word-finding
changes who was transferred from an outside hospital with
left temporoparietal hemorrhage in the setting of an INR
of 3.6, demonstrating signs of conduction aphasia and
cognitive changes with questionable right visual field cut.
The patient was treated with fresh frozen plasma to correct
her elevated INR as well as administration of vitamin K. An
attempt was made to maintain the patient's systolic blood
pressure at 150 with Nipride in order to maintain cerebral
perfusion. Lasix was provided following fresh frozen plasma
administration, and the patient was admitted to the Neurology
Surgical Intensive Care Unit for close observation and q.1h.
neurologic checks.
In addition, the patient was given intravenous Dilantin load
of 1 g and then started on 100 mg intravenously t.i.d. for
prophylaxis against seizures.
Over the next few hospital days, the patient was monitored
closely in the neurologic Intensive Care Unit and then
transferred to the floor for further monitoring. She was
only treated conservatively with management of her elevated
INR as well as provided with a Dilantin load and maintenance
therapy.
The patient was slowly restarted back on her beta blocker and
diuretic medications. An effort was made to maintain her
blood pressure at less than 150. A magnetic resonance
imaging was obtained on [**2-1**] which demonstrated no
significant changes.
In addition, given the patient's history of atrial
fibrillation and the questionable use of sotalol in the past,
the patient was started on sotalol 120 mg p.o. b.i.d.
beginning on [**2-2**].
Over the next few hospital days, the patient's neurologic
status slowly improved, and she began to have less difficulty
with word-finding and less difficulty with expressive
aphasia; although, her progress was very slow. The patient's
persistent nausea was treated successfully with Zofran, and
her diet was advanced as tolerated. The patient remained
confused and had a significant short-term memory loss.
The patient was being screened for rehabilitation when she
was noted to develop episodes of severe bradycardia as well
as o'clock episodes of nonsustained ventricular tachycardia.
A Cardiology consultation was obtained, who suggested that
treatment of atrial fibrillation with sotalol as well as a
beta blocker was resulting in prolongation of the Q-T
interval with subsequent development of torsades and runs of
polymorphic ventricular tachycardia, associated with
occasional episodes of bradycardia.
Therefore, the patient was transferred to the Coronary
Intensive Care Unit for isoproterenol infusion to maintain an
elevated heart rate while her sotalol was metabolized and
cleared. Upon admission to the Coronary Care Unit, the
patient had no complaints; however, she continued to be
relatively confused with significant short-term memory
deficits. At the time of admission, the patient had a heart
rate in the 40s and was maintaining a blood pressure in the
140s/60s. The patient was started on isoproterenol at 1 mcg
per minute which was titrated up to 3.5 mcg per minute in
order to maintain her heart rate in the 80s. Sotalol and
beta blockers were discontinued, and [**Hospital1 1516**] pads were placed on
the patient should quick defibrillation be required. In
addition, the patient's electrolytes were checked on a b.i.d.
basis and repleted very carefully.
Over the next few hospital days as the sotalol was
metabolized and cleared, the patient required less
isoproterenol until it was actually turned off on hospital
day three. The patient's antihypertensive medications were
slowly titrated back as tolerated. Her neurologic status
continued to improve slowly, and the patient was continued on
Dilantin for prophylaxis.
An electrophysiology consultation was obtained in order to
evaluate for initiation of amiodarone therapy and pacemaker
placement. Electrophysiology consultation suggested that the
patient was suffering a tachy-brady syndrome with long Q-T
and torsades in the setting of sotalol administration. It
was felt that the patient could not be anticoagulated
secondary to her intracranial hemorrhage; and therefore
should be kept in sinus rhythm to avoid potential side
effects of thromboembolic disease. Therefore, placement of a
pacemaker and initiation of amiodarone therapy was planned.
The patient had an DDD pacemaker placed on [**2-9**]
without complications. However, the patient continued to be
in atrial fibrillation and subsequently received DC
cardioversion on the following day with successful conversion
to normal sinus rhythm after one shock. Following this, the
patient was started on amiodarone with plans to load her
orally and then switch to a chronic dose.
At the time of this [**Month (only) **] Summary, the patient's blood
pressure had been stable and within normal limits, and her
blood pressure medications were titrated back slowly as
tolerated. She was to follow up in the Electrophysiology
Clinic on [**2-17**] for interrogation and further management of
her DDD pacemaker. The patient was also to continue
amiodarone oral load as dictated per Electrophysiology
consultation.
In addition, the patient's neurologic status continued to
improve and it was explained to the family that she would
likely need a prolonged period of time for improvement in her
short-term memory and expressive aphasia. However, at the
time of [**Month (only) **] the patient was hemodynamically stable and
ready for rehabilitation.
[**Month (only) 894**] STATUS: The patient was discharged to
rehabilitation.
CONDITION AT [**Month (only) 894**]: In stable condition.
[**Month (only) 894**] FOLLOWUP: She was to follow up in the
Electrophysiology Clinic on [**2173-2-17**], at 2 p.m. She
was to follow up with her primary care doctor [**First Name (Titles) **]
[**Last Name (Titles) **] from acute rehabilitation in order to establish an
appointment with a primary cardiologist.
MEDICATIONS ON [**Last Name (Titles) 894**]:
1. Lisinopril 10 mg p.o. q.d.
2. Hydrochlorothiazide 12.5 mg p.o. q.d.
3. Dilantin 100 mg p.o. b.i.d.
4. Amiodarone 400 mg p.o. t.i.d. times one week; then 400 mg
p.o. b.i.d. times one week; then 400 mg p.o. q.d. times three
weeks; then 200 mg p.o. q.d.
5. Compazine 10 mg p.o. q.6h. p.r.n. for nausea.
6. Zantac 150 mg p.o. b.i.d.
7. Pravachol 20 mg p.o. q.d.
8. Tylenol 650 mg p.o. q.4h. p.r.n.
NOTE: The patient is to avoid aspirin, heparin, and all
blood thinners.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 8227**]
Dictated By:[**Name8 (MD) 8860**]
MEDQUIST36
D: [**2173-2-11**] 15:41
T: [**2173-2-11**] 15:59
JOB#: [**Job Number **]
ICD9 Codes: 431, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3492
} | Medical Text: Admission Date: [**2199-8-3**] Discharge Date: [**2199-8-15**]
Date of Birth: [**2142-12-14**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3256**]
Chief Complaint:
BRBPR, LLQ pain
Major Surgical or Invasive Procedure:
Sigmoidoscopy, Colonoscopy, Esophagoduodenoscopy
History of Present Illness:
56M w/ hx of mitral valve repair, diverticulitis, multiple
episodes of lower and upper GIB presenting with 2 days of LLQ
pain and BRBPR, presenting to OSH with INR of 14 on morning of
admission. 2 days ago began having LLQ pain, sharp as knife,
constant, progressive. Last normal stool 2-3 days ago and have
been getting darker and darker until morning of admission when
LLQ pain was [**7-7**] and noticed bright red blood in stool, then
second stool then greenish, diarrhea, foul smelling and "coffee
groundish." Denied having any dizziness when standing up. Called
EMS when pain was [**9-6**]. Had one episode of small vomitus at
[**Hospital1 **] who which was gastroocult positive. Guiaic positive. At
OSH got 2u ffp + vit k 10 iv. ivf. 1g ceftriaxone, Protonix 80
bolus, 8/h. no recent abx use or change in coumadin dose, no
recent changes in diet. No headache, no shortness of breath or
chest pain.
In the ED, Initial Vitals/Trigger: 18:40 6 116 151/79 16 95%
Getting cont IVF, 1 more units FFP (got 2U FFP and vit k iv 1o
at [**Hospital1 **]),1mg IV dilaudid for llq pain (morphine not
working)40meq K PO, 40meq K IV, 4mg zofran, 1mg lorazepam. CT
abdomen and pelvis was done.
Past Medical History:
Mitral valve repair-mechanical valve [**2167**]
Hypertension
s/p appendectomy
lower and upper GI bleeds
diverticulitis
Social History:
Lives with and takes care of his mother. [**Name (NI) 1403**] at [**Company 44081**]in the parking/transportation department, works
nights. No tobacco, occ social EtOH, no illicit drug use.
Family History:
noncontributory
Physical Exam:
Admission Physical Exam:
General: Alert, oriented, uncomfortable appearing
HEENT: Sclera anicteric, bloodshot, MMM, oropharynx clear, EOMI,
PERRL 1-2mm
Neck: supple, JVP not elevated, no LAD
CV: tachycaric, regular, S1 + S2, MV mechanical click audible
without stethoscope, heard throughout chest and abdomen,
holosystolic murmur heard at LSB
Lungs: few right basilar crackles, left lung clear to
auscultation, no wheezes, rales, ronchi
Abdomen: tense, distended, tenderness to percussion at LLQ,
tenderness to light palpation at LLQ, bowel sounds present,
unable to appreciate organomegaly due to distension, no rebound
appreciated, no guarding
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, grossly normal sensation, gait deferred,
Discharge Physical Exam:
Vs: Afebrile, stable
GEN: Alert. Cooperative. No acute distress.
HEENT/NECK: PERRLA. EOMI. Mucous membranes pink/moist.
LUNGS: Clear to auscultation B/L. No wheezes or crackles
CV: S1, S2 with mechanical click audible throughout. Pulses
equal throughout.
ABDOMEN: BS present. Soft. Tender to palpation over LLQ. No
rigidity, rebound, or guarding.
EXTREMITIES: No pitting edema, No gross deformities, clubbing,
or cyanosis.
Pertinent Results:
ADMISSION:
[**2199-8-3**] 07:00PM BLOOD WBC-10.3 RBC-3.69* Hgb-12.6* Hct-33.9*
MCV-92 MCH-34.3* MCHC-37.2* RDW-14.4 Plt Ct-183
[**2199-8-3**] 07:00PM BLOOD PT-32.1* PTT-47.0* INR(PT)-3.1*
[**2199-8-4**] 01:49AM BLOOD PT-20.0* INR(PT)-1.9*
[**2199-8-3**] 07:00PM BLOOD Glucose-131* UreaN-14 Creat-1.2 Na-137
K-2.8* Cl-93* HCO3-29 AnGap-18
[**2199-8-3**] 07:00PM BLOOD ALT-30 AST-49* AlkPhos-81 TotBili-0.6
[**2199-8-3**] 07:00PM BLOOD Albumin-3.8 Calcium-8.5 Phos-2.1* Mg-1.4*
[**2199-8-3**] 07:15PM BLOOD Lactate-4.5*
[**2199-8-3**] 07:00PM BLOOD Lipase-42
.
IMAGING/STUDIES:
CT-Angio Abdomen/Pelvis [**2199-8-3**]:
IMPRESSION:
1. No evidence of active gastrointestinal bleeding.
2. Numerous colonic diverticula without associated inflammatory
changes.
3. Small hiatal hernia.
4. Mural fatty replacement of the ascending colon, suggestive
of sequela of a prior inflammatory process.
5. Status post mitral valve replacement.
.
Chest X-Ray [**2199-8-7**]: Cardiac size is top normal. Bibasilar
opacities, larger on the left side, could be due to atelectasis
but superimposed infection cannot be excluded. If any, there is
a small right pleural effusion. There is elevation of the right
hemidiaphragm. There is mild vascular congestion. Sternal
wires are aligned. Patient is status post MVR.
.
CT-Abdomen/Pelvis [**2199-8-7**]:
IMPRESSION: Interval development of small right greater than
left pleural effusions with bibasilar subsegmental atelectasis.
No acute intra-abdominal pathology identified
.
MICRO:
Blood Culture, Routine (Final [**2199-8-9**]): NO GROWTH.
MRSA SCREEN (Final [**2199-8-6**]): No MRSA isolated.
FECAL CULTURE (Final [**2199-8-6**]): NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final [**2199-8-6**]): NO CAMPYLOBACTER
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final [**2199-8-5**]): NO E.COLI
0157:H7 FOUND.
Blood Culture, Routine (Final [**2199-8-13**]): NO GROWTH.
C. difficile DNA amplification assay (Final [**2199-8-9**]):
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
.
PRE-DISCHARGE:
[**2199-8-8**] 08:17AM BLOOD Lactate-1.0
[**2199-8-11**] 05:25AM BLOOD WBC-6.1 RBC-3.32* Hgb-10.9* Hct-32.0*
MCV-96 MCH-32.6* MCHC-33.9 RDW-15.1 Plt Ct-218
[**2199-8-11**] 05:25AM BLOOD Calcium-8.7 Phos-2.6* Mg-1.9
[**2199-8-12**] 07:00AM BLOOD UreaN-9 Creat-1.1 Na-136 K-4.2 Cl-101
HCO3-24 AnGap-15
[**2199-8-15**] 06:55AM BLOOD PT-14.3* PTT-76.9* INR(PT)-1.3*
Brief Hospital Course:
56 yo M with PMH MVR on coumadin, hypertension, LBIG and UGIB,
and recurrent diverticulitis presenting with persistent left
lower quadrant pain and bright red blood per rectum.
Active Issues:
# Lower GIB: Unclear precipitant. Patient was supratherapeutic
on warfarin (INR 14), which was held initially. Lactate was
initially elevated, but trended downward. Flex sigmoidoscopy was
unrevealing. CTA and CT-abdomen/pelvis were unrevealing. GI
performed EGD and colonoscopy and found diverticuli but no
definitive sources of bleeding. The patient reported no signs of
bleeding or melenic stools since the evening of [**8-4**] and
thereafter, his HCT was stable and had been trending upward. The
patient was treated with IVF and proton pump inhibitors and his
bleeding remained stable for the rest of the admission.
# LLQ pain, presumed diverticulitis: However AVM vs ischemic
colitis vs diverticular disease vs hemorrhoidal causes were all
considered. Lactate was initially elevated but was normal by
time of discharge. Pain was treated with Dilaudid, first IV,
then PO. The patient had a single recorded fever during his
stay, and he was started on ciprofloxacin and metronidazole for
empiric treatment of a GI infection. However, C. Diff and stool
cultures were negative. His pain gradually improved and was at a
bearable level by time of discharge. He remained afebrile the
rest of his admission.
# Mechanical mitral valve replacment on warfarin with goal INR
2.5-3.5. Given INR of 14 on admission, warfarin was held.
Unclear etiology for admission INR of 14 given no history of
antibiotic use or changes in diet. [**Month (only) 116**] be related to poor PO
intake since LLQ pain began. Heparin drip started when INR
decreased below 2, while Coumadin was still being held. Once the
patient's GI workup was complete (as above) with no further
bleeding, warfarin was restarted. The INR responded slowly so
heparin drip bridging was switched to enoxaparin bridging on
discharge.
Chronic Issues:
# HTN: The patient's home metoprolol was initially held, but was
restarted on [**2199-8-5**]. The patient remained clinically stable
thereafter
# Anxiety: The patient's home diazepam was initially held and he
remained clinically stable on lorazepam prn.
Transitional Issues:
1) The patient will need follow-up of his INR to therapeutic
range of 2.5-3.5 before discontinuing his enoxaparin bridging.
Medications on Admission:
warfarin 5 mg Tab Oral 1 Tablet(s) M,W,F,[**Doctor First Name **]
warfarin 7.5 mg Tab Oral 1 Tablet(s) Tu,Th,Sa
amlodipine 5 mg Tab Oral
metoprolol tartrate 50 mg Tab Oral 1 Tablet(s) Twice Daily
diazepam 5 mg Tab Oral 1 Tablet(s) Once Daily, at bedtime for
sleep
Discharge Medications:
1. Enoxaparin Sodium 100 mg SC Q12H Duration: 14 Days
RX *enoxaparin 100 mg/mL 1 injection every twelve (12) hours
Disp #*28 Syringe Refills:*0
2. Amlodipine 5 mg PO BID
3. Metoprolol Tartrate 50 mg PO BID
4. Warfarin 7.5 mg PO 3X/WEEK (TU,TH,SA)
5. Warfarin 5 mg PO 4X/WEEK ([**Doctor First Name **],MO,WE,FR)
6. Ciprofloxacin HCl 500 mg PO Q12H Duration: 3 Days
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*7 Tablet Refills:*0
7. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H Duration: 3 Days
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*10 Tablet Refills:*0
8. Diazepam 5 mg PO QHS
9. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*3
10. Acetaminophen 1000 mg PO TID
RX *Acetaminophen Pain Relief 500 mg [**1-28**] tablet(s) by mouth
q8h:PRN Disp #*100 Tablet Refills:*0
11. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
12. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
hold for RR<12 or somnolence
RX *oxycodone 5 mg [**1-28**] tablet(s) by mouth q4h:PRN Disp #*60
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Gastrointestinal Bleeding, Abdominal Pain
Secondary: Diverticulosis, Mechanical Valve,
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure to care for you at [**Hospital1 827**]. You were transferred here because you were
bleeding in your digestive tract and had abdominal pain, as well
as an INR of 14. We treated you with blood products, IV fluids,
pain medications, and agents to lower your INR. We also stopped
your warfarin(coumadin) and started you on a heparin drip for
your mechanical valve. Your bleeding stopped during your
admission.
.
To assess your bleeding and pain, we performed CT-scans of your
abdomen and the GI team performed several endoscopies.
Unfortunately, we could not find a definitive source of your
symptoms. Most likely, the symptoms are related to your chronic
diverticular disease (small outpouchings of your colon. It is
likely these have become inflamed (diverticulitis) and bled. We
are treating you for possible diverticulitis with antibiotics.
We recommend that you eat a low-residue or low-fiber diet to
help avoid future episodes of diverticulitis.
.
We restarted your warfarin (Coumadin)and put you on heparin drip
as we waited for your INR to return to its normal range. On your
day of discharge, your INR was 1.3 and we switched you to an
injectable blood thinner, called Enoxaparin. It is important you
take this injection every 12 hours until your INR is back within
range.
.
Please note the following changes to your medications:
You should START taking Ciprofloxacin (Cipro) and Metronidazole
(Flagyl) antibiotics until you finish the full course.
You should START enoxaparin (Lovenox) every 12 hours until your
INR is between 2.5-3.5.
You may continue the rest of your medications as previously
prescribed.
Followup Instructions:
Please followup with your PCP to check/adjust your INR and
warfarin dosing:
.
Department: Primary Care
Name: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Monday: [**2199-8-19**] at 2:45 PM
Location: COMMUNITY PHYSICIANS ASSOCIATES, INC.
Address: [**Street Address(2) 4472**] [**Apartment Address(1) 19251**], [**Hospital1 **],[**Numeric Identifier 9331**]
Phone: [**Telephone/Fax (1) 61899**]
Completed by:[**2199-8-24**]
ICD9 Codes: 2851, 2875, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3493
} | Medical Text: Admission Date: [**2111-5-29**] Discharge Date: [**2111-6-1**]
Date of Birth: [**2048-5-19**] Sex: M
Service: MEDICINE
Allergies:
Tetanus Diphtheria
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: 63M COPD/asthma and OSA with continued tobacco use presents
with SOB x 1 1/2 weeks. 3 weeks PTA, pt was treated with abx
(levofloxacin 500 mg PO QD x 10 days) for a sinus infection
(mostly had sinus pressure/nasal congestion/discharge). These sx
essentially resolved, but patient subsequently developed
productive cough (yellow sputum) with SOB/wheezing x 1 [**2-1**]
weeks. He felt he was having post nasal gtt, which was building
up in his chest, and eliciting his sx. When these sx began, he
called his pulmonologist, who prescribed a prednisone taper. His
sx improved after completing the taper, but again returned. He
was started on a second taper, and was two days into the second
course but was breathing so poorly he could not move and was on
continuous home nebulizers, but no home O2. He currently feels
better after solumedrol and continuous nebs. He denies any
fevers, or chills, but wife noted he felt warm over last week.
He denies any other chest pain, pleuritic pain, abd pain,
nausea/vomiting or diarrhea, except constipation. No urinary sx.
In ED so received continuous nebs, solumedrol, ceftriaxone and
azithromax. Admitted to MICU where treatment was continued with
improvement in respiratory status overnight. Now transferred to
Medicine for further care.
Past Medical History:
Past Medical History:
1. COPD FEV1/FVC= 40%, FEV1 = 41% of predicted (moderately
severe COPD)
2. Anemia - ?GI bleed with negative w/u-[**2107**]-- improved on iron
--->Had upper/lower endoscopy; did not f/u for capsule endoscopy
3. Vocal cords squamous dysplasia
4. Hypertension
5. Obstructive sleep apnea-- not using CPAP
6. Negative Mibi [**5-/2106**], EF 60% and no defects
7. Lower extremity venous stripping (age 28)
8. C7 neuroma
9. History of esophageal obstruction
10. S/p knee surgery
[**17**]. up to date on flu and pneumovax shot, per patient
Social History:
+ETOH, drinks a few alcoholic drinks a day ([**7-8**] drinks of
scotch/whiskey over past 5-6 months), no hx of withdrawals. He
smokes one/half pack cigarettes per day-- former 80 pack yr hx.
The patient is married and lives with wife, no pets.
Family History:
Mother had a blood clot, diabetes mellitus. Sister had question
of blood clots. Father died of myocardial infarction at age 35.
History of respiratory problems.
MEDICATIONS ON ADMISSION
prednisone taper- took 40mg on AM of admission
asa 81mg qd
servent 2puffs [**Hospital1 **]
flovent 4puffs [**Hospital1 **]
atrovent 4puffs qid
albuterol nebs q2-4hrs prn
verapamil 240mg qd
mavik 4mg qd
aciphex qd
MEDICATIONS ON TRANSFER
1. MED Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral
IV - Inspect site every shift [**5-30**] @ 1355
2. MED Acetaminophen 325-650 mg PO Q4-6H:PRN pain, fever [**5-30**]
@ 1355
3. MED Pantoprazole 40 mg PO Q24H [**5-30**] @ 1355
4. MED Heparin 5000 UNIT SC TID [**5-30**] @ 1355
5. MED Azithromycin 250 mg PO Q24H Duration: 4 Days Start: In am
[**5-30**] @ 1355
6. MED Trandolapril 4 mg PO DAILY Hold for SBP<100 [**5-30**] @ 1355
7. MED Verapamil SR 240 mg PO Q24H Hold for SBP<100, HR<60
[**5-30**] @ 1355
8. MED Aspirin 81 mg PO DAILY [**5-30**] @ 1355
9. MED Folic Acid 1 mg PO DAILY [**5-30**] @ 1355
10. MED Thiamine HCl 100 mg PO DAILY [**5-30**] @ 1355
11. MED Multivitamins 1 CAP PO DAILY [**5-30**] @ 1355
12. MED Lorazepam 0.5-1 mg PO/IV Q1H:PRN CIWA>10 [**5-30**] @ 1355
13. MED Nicotine Patch 21 mg TD DAILY [**5-30**] @ 1355
14. MED Zolpidem Tartrate 5-10 mg PO HS:PRN [**5-30**] @ 1355
15. MED Insulin SC (per Insulin Flowsheet) Sliding Scale 04/30
@ 1355
16. MED Ipratropium Bromide Neb 1 NEB IH Q4H [**5-30**] @ 1355
17. MED Albuterol 0.083% Neb Soln 1 NEB IH Q4H [**5-30**] @ 1355
18. MED Prednisone 60 mg PO DAILY [**5-30**] @ 1355
19. MED Sodium Chloride Nasal [**2-1**] SPRY NU QID:PRN [**5-30**] @ [**2053**]
20. IV IV access: Peripheral, 1 ports, Date inserted: [**2111-5-29**]
[**5-30**] @ 1355
Physical Exam:
Physical Exam:
VS: AF, VSS, 94% 2L
General: NAD
HEENT: PERRL, MMM, clear OP, no tenderness to palpation of
sinuses
CV: nml S1, S2, no m/r/g, distant heart sounds
CHEST: scattered wheezes, good air movement
Abdomen: Obese; distended but soft, NT/ND
Extremities: 2+ DP blaterally without edema
SKIN: no rash
NEURO: not anxious
Pertinent Results:
Hematology
[**2111-6-1**] 06:55AM BLOOD WBC-8.3 RBC-4.06* Hgb-13.1* Hct-38.4*
MCV-94 MCH-32.3* MCHC-34.2 RDW-13.3 Plt Ct-263
[**2111-5-31**] 07:30AM BLOOD WBC-14.7* RBC-4.29* Hgb-13.7* Hct-41.3
MCV-96 MCH-31.9 MCHC-33.2 RDW-13.5 Plt Ct-301
[**2111-5-30**] 03:45AM BLOOD WBC-9.8 RBC-4.00* Hgb-12.3* Hct-37.7*
MCV-94 MCH-30.9 MCHC-32.8 RDW-13.6 Plt Ct-276
[**2111-5-29**] 11:45AM BLOOD WBC-7.5 RBC-4.43* Hgb-14.0 Hct-41.9
MCV-95 MCH-31.5 MCHC-33.4 RDW-13.9 Plt Ct-332
[**2111-5-29**] 11:45AM BLOOD Neuts-90.7* Lymphs-6.8* Monos-1.9*
Eos-0.1 Baso-0.4
[**2111-6-1**] 06:55AM BLOOD Plt Ct-263
[**2111-5-31**] 07:30AM BLOOD Plt Ct-301
[**2111-5-30**] 03:45AM BLOOD Plt Ct-276
[**2111-5-29**] 11:45AM BLOOD Plt Ct-332
Chemistry
[**2111-6-1**] 06:55AM BLOOD Glucose-88 UreaN-35* Creat-0.8 Na-137
K-4.6 Cl-105 HCO3-26 AnGap-11
[**2111-5-31**] 07:30AM BLOOD Glucose-158* UreaN-34* Creat-0.8 Na-134
K-4.5 Cl-99 HCO3-24 AnGap-16
[**2111-5-30**] 03:45AM BLOOD Glucose-113* UreaN-28* Creat-0.6 Na-136
K-4.2 Cl-98 HCO3-25 AnGap-17
[**2111-5-29**] 06:15PM BLOOD K-4.7
[**2111-5-29**] 11:45AM BLOOD Glucose-154* UreaN-24* Creat-0.8 Na-136
K-5.1 Cl-98 HCO3-26 AnGap-17
[**2111-5-30**] 12:00AM BLOOD CK(CPK)-567*
[**2111-5-29**] 06:15PM BLOOD CK(CPK)-370*
[**2111-5-29**] 11:45AM BLOOD CK(CPK)-168
[**2111-5-30**] 12:00AM BLOOD CK-MB-24* MB Indx-4.2 cTropnT-<0.01
[**2111-5-29**] 06:15PM BLOOD cTropnT-<0.01
[**2111-5-29**] 06:15PM BLOOD CK-MB-17* MB Indx-4.6
[**2111-5-29**] 11:45AM BLOOD CK-MB-10 MB Indx-6.0 cTropnT-<0.01
[**2111-6-1**] 06:55AM BLOOD Calcium-8.5 Phos-3.3 Mg-2.3
[**2111-5-31**] 07:30AM BLOOD Calcium-9.4 Phos-4.4 Mg-2.3
[**2111-5-30**] 03:45AM BLOOD Mg-2.1
[**2111-5-29**] 11:45AM BLOOD Calcium-9.4 Phos-4.0 Mg-2.0
[**2111-5-29**] 11:53AM BLOOD Lactate-2.5*
Microbiology: BlCx's x 2 NGTD as of [**2111-6-1**]
Brief Hospital Course:
A/P: 63M COPD presents with cough, worsening SOB with failed
outpatient treatment, admitted with COPD exacerbation.
1. COPD-Sx c/w COPD exacerbation, ? [**3-4**] recent sinusitis
[**5-29**]: solumedrol 125 mg IV Q8h, start azithro, continuous nebs
until status improves, monitor O2 sats and maintain >92%
4/30: tapered nebs to q3-4 hours as tolerated and encouraged
smoking cessation; Up to date on pneumovax; change IV to PO
steroids (60mg prednisone PO Qday)
[**5-31**]: subjectively feels better but RA sat was 88% with
ambulation today, so continuing steroids at this dose as well as
q4h nebs
[**5-2**]: RA sat improved and pt feels subjectively better, so
sending home with home O2 and pulmonary + PCP follow up in the
next week
2. OSA-Not using CPAP at home; with patient's COPD/OSA, likely
with significant component of pulmonary HTN
3. ETOH abuse-Patient with significant ETOH use at home;
starting MVI, thiamine, folate, CIWA scale ativan
[**6-1**]: no ativan given for withdrawl per CIWA scale
4. GERD-Continue PPI (Rabeprazole at home, will use pantoprazole
here)
5. Anemia-On FeSO4 as per home regimen (patient did not have
this with him, ask him the dose)
[**6-1**]: mild anemia of 38 on hct, to be followed up as outpatient
6. HTN-Continue home meds including Mavik/Verapamil; continue
asa
7. FEN-Cardiac diet; monitor K in setting of albuterol use as
causes hypokalemia
8. Proph-PPI (on steroids and on this at home); SC heparin;
bowel regimen
9. Code: FULL
Medications on Admission:
prednisone taper- took 40mg on AM of admission
asa 81mg qd
servent 2puffs [**Hospital1 **]
flovent 4puffs [**Hospital1 **]
atrovent 4puffs qid
albuterol nebs q2-4hrs prn
verapamil 240mg qd
mavik 4mg qd
aciphex qd
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain, fever.
2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO Q24H
(every 24 hours) for 1 days.
Disp:*1 Capsule(s)* Refills:*0*
4. Trandolapril 4 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Verapamil HCl 120 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO Q24H (every 24 hours).
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q4H (every 4 hours).
8. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q4H (every 4 hours).
9. Prednisone 10 mg Tablet Sig: prednisone taper Tablet PO once
a day for 14 days: 6 tablets every day for 2 days, then 5
tablets every day for 2 days, then 4 tablets every day for 2
days, then 3 tablets every day for 2 days, then 2 tablets every
day for 2 days, then 1 tablet every day for 2 days, then [**2-1**]
tablet every day for 2 days.
Disp:*43 Tablet(s)* Refills:*0*
10. Oxygen-Air Delivery Systems Device Sig: One (1) device
Miscell. once a day: start at 2L home O2 for goal O2 sat > 92%;
pt desatted to 88% on RA with ambulation.
Disp:*1 device* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1. COPD exacerbation
2. OSA
3. hypertension
4. mild anemia
Discharge Condition:
fair
Discharge Instructions:
1. please take medications as directed
2. please quit smoking
3. please follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 2204**] in one week, and
with the pulmonary division at [**Hospital1 18**] tomorrow
4. VNA services for Home O2
Followup Instructions:
1. Provider: [**Name10 (NameIs) 1571**] BREATHING TEST Where: [**Hospital6 29**]
PULMONARY FUNCTION LAB Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2111-6-2**]
9:00
2. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 5265**], M.D. Where: [**Hospital6 29**]
REHAB SERVICES (DYSPNEA) Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2111-6-2**]
9:15
Completed by:[**2111-6-1**]
ICD9 Codes: 4168, 4019, 3051, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3494
} | Medical Text: Admission Date: [**2162-7-25**] Discharge Date: [**2162-7-31**]
Date of Birth: [**2100-8-20**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 4917**]
Chief Complaint:
abdominal pain
cecal carcinoma metastatic to liver
Major Surgical or Invasive Procedure:
diagnostic and therepeutic paracentesis
History of Present Illness:
Mr. [**Known lastname 112071**] is a 61M with cecal cancer metastatic to the liver
undergoing chemotherapy and radiation (last chemo 1.5wks ago)
who presented to an OSH with SOB, lethargy and abdominal pain.
Per EMS reports, pt was hypotensive with BP as low as 91/46,
breathing between 22-24 satting 97-99% on 4L.
In OSH [**Name (NI) **] pt. was tachycardic to the 150s, breathing 38 with a
BP of 86/30, satting 98% on nonrebreather. CT abdomen showed
ascites and free air. Pt. received Levaquin and Zosyn as well
as 1.6L NS prior to transfer to [**Hospital1 18**].
In the ED, initial VS were: T 98.8 BP 99/68, P 129, 99% 3LNC. Pt
was bolused 3L NS in the ED and BP improved to low 100s/60s.
On arrival to the MICU, patient's VS: T 98.2, BP 133/97, P 130,
RR 25 96% 2LNC.
Past Medical History:
Cecal cancer metastatic to liver, diagnosed in [**2162-5-25**]
Social History:
Pt. lives at home with wife, [**Name (NI) **] who is HCP [**Name (NI) **]:
[**Telephone/Fax (1) 112072**]).
Family History:
None
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: 97.7, 109/68, 120, 24, 96% on 4L
GENERAL: Ill-appearing but comfortable, NAD
HEENT: PERRL, sclera are icteric
NECK: Supple, no JVD
LUNGS: CTAB on anterior exam
HEART: Tachycardic but regular, no murmurs
ABDOMEN: Obese, distended but soft, NT, NABS
EXTREMITIES: WWP, no edema, pedal pulses intact
NEUROLOGIC: Sleepy but arousable, A&Ox3, CNs grossly intact,
strength and sensation grossly intact
Pertinent Results:
ADMISSION LABS
[**2162-7-25**] 06:00PM ASCITES TOT PROT-2.1 GLUCOSE-2 LD(LDH)-293
ALBUMIN-1.3
[**2162-7-25**] 06:00PM ASCITES WBC-1675* RBC-1300* POLYS-92*
LYMPHS-1* MONOS-7*
[**2162-7-25**] 02:15PM URINE HOURS-RANDOM CREAT-85 SODIUM-11
POTASSIUM-95 CHLORIDE-15 TOT PROT-128 PROT/CREA-1.5* albumin-3.5
alb/CREA-41.2*
[**2162-7-25**] 02:15PM URINE OSMOLAL-471
[**2162-7-25**] 02:15PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.031
[**2162-7-25**] 02:15PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-MOD UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2162-7-25**] 02:15PM URINE RBC-17* WBC-2 BACTERIA-NONE YEAST-NONE
EPI-5
[**2162-7-25**] 02:15PM URINE AMORPH-FEW
[**2162-7-25**] 02:02PM LD(LDH)-202
[**2162-7-25**] 04:53AM GLUCOSE-73 UREA N-47* CREAT-1.6* SODIUM-136
POTASSIUM-5.1 CHLORIDE-102 TOTAL CO2-21* ANION GAP-18
[**2162-7-25**] 04:53AM CALCIUM-7.8* PHOSPHATE-4.4 MAGNESIUM-2.1
[**2162-7-25**] 04:53AM WBC-0.7* RBC-3.36* HGB-9.8* HCT-30.1* MCV-90
MCH-29.1 MCHC-32.5 RDW-20.5*
[**2162-7-25**] 04:53AM PLT COUNT-106*
[**2162-7-25**] 12:03AM LACTATE-6.9*
[**2162-7-24**] 11:50PM GLUCOSE-79 UREA N-48* CREAT-1.5* SODIUM-135
POTASSIUM-5.0 CHLORIDE-98 TOTAL CO2-20* ANION GAP-22*
[**2162-7-24**] 11:50PM estGFR-Using this
[**2162-7-24**] 11:50PM ALT(SGPT)-43* AST(SGOT)-53* ALK PHOS-419* TOT
BILI-10.5*
[**2162-7-24**] 11:50PM LIPASE-8
[**2162-7-24**] 11:50PM proBNP-1103*
[**2162-7-24**] 11:50PM ALBUMIN-2.2*
[**2162-7-24**] 11:50PM WBC-.7* RBC-3.48* HGB-10.1* HCT-31.3* MCV-90
MCH-28.9 MCHC-32.1 RDW-20.6*
[**2162-7-24**] 11:50PM NEUTS-51 BANDS-7* LYMPHS-16* MONOS-20* EOS-0
BASOS-0 ATYPS-3* METAS-2* MYELOS-0 PROMYELO-1* NUC RBCS-1*
[**2162-7-24**] 11:50PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-1+ POLYCHROM-1+ OVALOCYT-1+ TEARDROP-1+
[**2162-7-24**] 11:50PM PLT SMR-LOW PLT COUNT-130*
[**2162-7-24**] 11:50PM PT-22.8* PTT-33.2 INR(PT)-2.2*
MICROBIOLOGY
[**2162-7-25**] 6:00 pm PERITONEAL FLUID
**FINAL REPORT [**2162-7-31**]**
GRAM STAIN (Final [**2162-7-25**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
FLUID CULTURE (Final [**2162-7-31**]):
GRAM NEGATIVE ROD(S). GROWING IN BROTH ONLY.
UNABLE TO ISOLATE ORGANISM TO IDENTIFY FURTHER.
ENTEROCOCCUS SP..
Isolated from broth media only, INDICATING VERY LOW
NUMBERS OF
ORGANISMS.
ANAEROBIC CULTURE (Final [**2162-7-31**]):
CLOSTRIDIUM SPECIES NOT C. PERFRINGENS OR C. SEPTICUM.
RARE GROWTH.
IMAGING
CT Abd and Pelvis w/o contrast [**7-25**]:
1. Limited study without IV contrast. Small intraperitoneal
air and large ascites. Hemoperitoneum cannot be excluded given
the slightly increased density of fluid in the cul de sac. The
etiology of the free air is not
identified on this study. Per discussion with Dr. [**Last Name (STitle) **], the
patient does not have a history of recent paracentesis.
2. Abnormal cecum consistent with known malignancy with liver
mestases,
peritoneal carcinomatosis and mesenteric and retroperitoneal
lymphadenopathy.
Correlate with prior imaging for interval change (not available
in our
system).
3. Bone metastases with impression on the thecal sac,
particularly at L5.
Consider MRI if there is no recent MRI already performed.
Consider radiation oncology consult.
Brief Hospital Course:
61M with cecal carcinoma metastatic to the liver, s/p 2 weeks of
radiation and chemotherapy who presented with increased
shortness of breath, fatigue and abdominal pain who was found to
have bowel perforation with bacterial peritonitis.
The patient was admitted to the [**Hospital Unit Name 153**] with abdominal pain and was
found to have ascites and free air w/ sepsis. Diagnostic and
therepeutic paracentesis was preformed, results showed high
polys and gram negative rods, it was felt that he had a small
perforation in his GI tract leading to bacterial peritonitis. He
was not a surgical candidate. Goals of care were discussed with
the patient, and he became DNR, DNI. Discussions were initiated
with palliative care. He was given broad vanc/zosyn and fluid
resuscitated, including albumin. Once his BP was stablized he
was transferred to the floors. Palliative care was consulted and
recommended increasing morphine for pain control. He has
worsening liver and kidney failure and his mental status
declined. After conversations with his family, outpatient
providers, and the palliative care service, he was made comfort
measures only and passed away.
# Bowel perforation: Pt was found to have had a perforated bowel
and was initially started on broad spectrum abx. He was seen by
surgery, and due to his condition he was deemed to not be a
surgical candidate given his neutropenia and coagulopathy. Pt
was found to have gram negative rods growing in his peritonial
fluid.
# Sepsis: He was initially hypotensive in the setting of
presumed infection but his BP stablilized after fluid
resuscitation.
# Metastatic colon ca/pancytopenia- The patient is s/p 2 weeks
of radiation and chemotherapy for metastatic colon cancer.
Recent chemotherapy is likely the cause of his pancytopenia as
it did improve somewhat after treatment for sepsis.
# Liver Failure/ [**Name (NI) 112073**] Pt had severe jaundice
secondary to hyperbilirubimemia which is likely related to his
liver mets and biliary cholestasis which was previously
diagnosed.
# Coagulopathy- Secondary to hepatic mets. INR was elevated. No
evidence of bleeding was present.
# [**Last Name (un) 13160**] Pt had poor renal function which was intially thought to
be seondary to his hypotension and pre-renal etiology. However
after adequate volume resuscitation, his kidney function
continued to progressively decline.
#Death: Pt died on [**2162-7-31**]. Cause of death
Primary Diagnosis: Bowel Perforation
Secondary Diagnosis: Metastatic Cecal Carcinoma
PCP and outpatient oncologist were notified of his death.
Medications on Admission:
1. Betoptios ophthalmic solution 0.25% 1 gtt [**Hospital1 **] in each eye
2. Ciprofloxacin 500 mg PO BID
3. Oxycodone 5 mg PO q4hrs prn pain
4. Oxycontin 20 mg PO BID
5. Denavir topical prn
6. Compazine 10 mg PO QID prn nausea/vomiting
Discharge Medications:
Deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary Diagnosis: Bowel Perforation
Secondary Diagnosis: Metastatic Cecal Carcinoma
Discharge Condition:
Deceased
Discharge Instructions:
None
Followup Instructions:
None
ICD9 Codes: 0389, 5845, 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3495
} | Medical Text: Admission Date: [**2185-11-29**] Discharge Date: [**2185-12-2**]
Date of Birth: [**2151-1-15**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 7299**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
34M with hx of IDDM complicated by gastroparesis/retinopathy,
chronic kidney disease stage III, HTN, 2 recent admissions last
two months for DKA presents with nausea/vomiting and abdominal
pain and found to have an Anion Gap Acidosis.
.
Patient was in his usual state of health until this afternoon
when he developed nausea, vomiting, mild diffuse abdominal pain.
He feels this is consistent with his normal gastroparesis flair.
He does note that emesis was darker in color and reminded him of
coffee. He noted no obvious blood. He states he hasn't otherwise
been unwell recently. No fevers, chills, diarrhea, sick
contacts, travel. [**Name2 (NI) **] exotic foods. Denies chest pain, productive
cough. No urinary frequency, burning with urination. No new
sexual contact.
.
In the ED initial vitals 97.6 123 161/115 14 100%. Physical exam
was unrevealing. Lab data revealed Hyperglycemia and Anion Gap
19. EKG with sinus tachycardia. Patient was given four liters of
fluid. Insulin Bolus 10 units regular and gtt. 8mg IV zofran.
4mg IV morphine. 1mg IV dilaudid. 1 mg IV ativan. Two peripheral
IVs in place. Vitals prior to transfer: 113 156/93, 18, 98% RA.
.
In the ICU the patient appears somewhat sedated though is able
to communicate clearly. He notes feeling much better and hoped
to try to drink some water.
Past Medical History:
-DM1 x 15 years; Complicated by gastroparesis, retinopathy,
chronic renal disease stage III
-HTN
-HLD
-Asthma as a child
-[**Doctor Last Name 9376**] Syndrome
Social History:
Lives [**Location 6409**] with his girlfriend and 2 children - ages 3
and 14. No sexual exposures. No tobacco or ETOH. No drugs. Pt is
currently unemployed.
Family History:
Father with CAD/MI. Mother Thyroid [**Name (NI) 3730**]
Physical Exam:
Admission exam:
VS: Temp: AFebrile BP:167/96 HR: 111 RR:16 O2sat: 100%
GEN: pleasant, comfortable, NAD
HEENT: PERRL, EOMI, anicteric, Dry Mucous Membranes, 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. 5/5 strength throughout. No
sensory deficits to light touch appreciated. No pass-pointing on
finger to nose. 2+DTR's-patellar and biceps
NG Lavage: Tea colored fluid and specs of clotted blood,
Gastrocult positive, Cleared after 500cc.
Pertinent Results:
Admission Results:
[**2185-11-29**] 01:25AM BLOOD WBC-8.9 RBC-3.94*# Hgb-11.6*# Hct-33.8*#
MCV-86 MCH-29.3 MCHC-34.2 RDW-14.1 Plt Ct-233
[**2185-11-30**] 03:01AM BLOOD WBC-7.9 RBC-3.23* Hgb-9.2* Hct-27.4*
MCV-85 MCH-28.5 MCHC-33.6 RDW-14.1 Plt Ct-182
[**2185-11-29**] 01:25AM BLOOD Glucose-417* UreaN-37* Creat-3.3* Na-139
K-4.2 Cl-101 HCO3-19* AnGap-23*
[**2185-11-30**] 04:41PM BLOOD Glucose-95 UreaN-20 Creat-2.5* Na-137
K-4.2 Cl-107 HCO3-24 AnGap-10
Imaging:
CXR [**2185-11-29**]:
FINDINGS: As compared to the previous radiograph, there is no
relevant
change. No evidence of mediastinal air. No pneumothorax. Normal
size of the cardiac silhouette. No pleural effusions, no focal
parenchymal opacities.
ECG [**2185-11-29**]:
Sinus tachycardia, rate 117. Moderate baseline artifact.
Non-diagnostic
Q waves in leads II, III, aVF and V3-V6. Compared to the
previous tracing
of [**2185-11-8**] the rate has increased from 75 to 117. The J point
elevation seems
somewhat more prominent. No other diagnostic interval change.
Read by: [**Last Name (LF) **],[**First Name3 (LF) 125**] M.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
117 128 76 354/453 64 66 73
Discharge Results:
[**2185-12-2**] 06:40AM BLOOD WBC-5.6 RBC-3.41* Hgb-9.8* Hct-29.0*
MCV-85 MCH-28.9 MCHC-34.0 RDW-14.2 Plt Ct-179
[**2185-11-29**] 01:25AM BLOOD Neuts-86.6* Lymphs-10.9* Monos-1.5*
Eos-0.2 Baso-0.8
[**2185-12-2**] 06:40AM BLOOD Plt Ct-179
[**2185-12-2**] 06:40AM BLOOD
[**2185-12-2**] 06:40AM BLOOD Glucose-153* UreaN-20 Creat-2.9* Na-140
K-4.1 Cl-105 HCO3-26 AnGap-13
[**2185-11-29**] 06:56AM BLOOD CK(CPK)-38*
[**2185-12-2**] 06:40AM BLOOD Calcium-8.5 Phos-4.6* Mg-1.8
.
Microbiology
[**2185-11-30**] 7:33 pm URINE Source: CVS.
URINE CULTURE (Preliminary):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. >100,000
ORGANISMS/ML..
SENSITIVITIES REQUESTED PER DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ON
[**2185-12-2**] AT
12:56PM.
.
[**2185-12-1**] 5:59 pm URINE Source: CVS.
Chlamydia trachomatis, Nucleic Acid Probe, with Amplification
(Pending):
NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH
AMPLIFICATION
(Pending):
Brief Hospital Course:
34M with hx of IDDM complicated by gastroparesis/retinopathy,
chronic kidney disease stage III, HTN, 2 recent admissions last
two months for DKA presents with nausea/vomiting and abdominal
pain and found to be in DKA.
.
1. Diabetic Ketoacidosis: Presentation similar in character to
prior episodes of DKA. Likely related to flair in gastroparesis
N/V/Abdominal Pain. No clear source of infection and cardiac
biomarkers were cycled and were negative. Pt was initially on an
insulin gtt for 24 hrs and his anion gap resolved. Once the pt
was able to tolerate PO's the pt was started on his home lantus
dose.
.
2. Nausea/Vomiting/Abdominal Pain: Severe gastroparesis on
recent gastric emptying study which is the most likely
contributor. LFTS, Lipase are not elevated. EKG without evidence
of ischemia/infarct. Of note, the pt's metoclopramide was
recently discontinued due to concerns that it might be worsening
gastroparesis symptoms. The pt was not able to take PO's
initially, but after the first 24 hours of the hospitalization
he was able to tolerate clears. He was continued on
anti-emetics, erythromycin, and metoclopramide. He was able to
tolerate POs prior to discharge.
.
3. Coffee Ground Emesis: Initial HCT elevated compared to recent
baseline though undoubtedly hemoconcentrated. NG lavage without
evidence of active bleed and cleared with only 500cc fluid.
There was no further evidence of GIB, and CXR did not show any
signs of mediastinal air to suggest [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear, and pt
was restarted on home antihypertensive meds.
.
4. Acute on Chronic Kidney Injury: Creatinine 3.3 which is up
from baseline of approx 2.5. Chronic kidney disease secondary to
diabetes. Acute kidney injury likely secondary to dehydration in
the setting of DKA. Creatinine returned to baseline of 2.5 with
IV fluids. He had a mild elevation of his creatinine to 2.9 and
was given 1L of IVF's prior to discharge.
.
5. Hypertension: The patient's medications were held on
admission because of acute kidney injury. After fluid repletion,
he was hypertensive, so a clonidine patch was placed and his
home lisinopril dose was restarted. He remained hypertensive, so
nifedipine 10mg PO TID was started. His pressures became
normotensive, and his nifedipine dose was changed to 10 mg Q12H.
He was discharged home with instructions to measure his blood
pressure at home and if his SBP was > than 170 or his DBP > 100,
he should take nifedipine and recheck is blood pressure later in
the day. Pt was scheduled for close follow up with his PCP and
nephrologist.
.
6. UTI: The patient had coag negative staph in his urine on
admission. He has been asymptomatic, and was not treated as a
repeat UA was entirely normal. He was also given instructions to
call Urology to get evaluated for any potential anatomical
abnormalities predisposing him to UTIs.
.
7. Social: PCP was concerned about patients compliance and
reliability to follow with providers. SW was consulted and pt
was educated about the importance of keeping in contact with his
PCP to help prevent progression of DM related damage.
Medications on Admission:
1. Lantus 10 Units once daily
2. Lantus 7 Units at bedtime
3. Humalog Sliding Scale
4. Lisinopril 10 mg Daily
5. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID
6. Erythromycin 250 mg Tablet TID
7. Omeprazole 40mg Daily
8. Cholecalciferol (vitamin D3) 400 unit one tablet daily
9. Procrit 10,000 unit/mL one injection weekly
Discharge Medications:
1. erythromycin 250 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO TID W/MEALS (3 TIMES A DAY
WITH MEALS).
2. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QTHUR (every Thursday).
Disp:*30 Patch Weekly(s)* Refills:*0*
4. metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
Disp:*40 Tablet(s)* Refills:*2*
5. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 4 days.
Disp:*3 Tablet(s)* Refills:*0*
6. Lantus 100 unit/mL Solution Sig: One (1) units Subcutaneous
qAM, qPM: Please take 10 units at breakfast.
Please take 7 units at bedtime.
Disp:*3 100 units* Refills:*5*
7. Humalog 100 unit/mL Cartridge Sig: One (1) units Subcutaneous
four times a day: Please take Humalog based upon your insulin
sliding scale.
8. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO three times a
day: Please take if you can not fill your prescription for the
clonidine patch.
Disp:*90 Tablet(s)* Refills:*2*
9. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
10. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO once a day.
11. Procrit 10,000 unit/mL Solution Sig: One (1) Injection once
a week.
12. lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for nausea, anxiety.
Disp:*28 Tablet(s)* Refills:*0*
13. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*2*
14. prochlorperazine maleate 5 mg Tablet Sig: Two (2) Tablet PO
Q6H (every 6 hours) as needed for nausea.
Disp:*40 Tablet(s)* Refills:*2*
15. nifedipine 10 mg Capsule Sig: One (1) Capsule PO Q 12H
(Every 12 Hours): Please measure your blood pressure at home.
If your blood pressure is greater than 170. Please take one
pill and recheck in 5 hours.
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
Diabetic ketoacidosis
Secondary Diagnosis
gastroparesis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure treating you at [**Hospital1 18**] during your
hospitalization.
You were admitted for nausea, vomiting, and worsening abdominal
pain. When you arrived, you were found to be hyperglycemic and
to be in diabetic ketoacidosis. You were admitted to the MICU
and started on a continuous insulin drip. Your DKA resolved
within two days, and you were restarted on your home insulin
dose.
Your nausea, vomiting, and abdominal pain were thought to be
related to a flare of your gastroparesis. You were treated with
erythromycin and antiemetics. Your symptoms improved over the
next few days and you were able to eat on [**12-1**].
When you were admitted, you were found to have acute kidney
injury over your underlying chronic kidney disease. This
resolved with IV fluids. You were also hypertensive. We added
nifedipine to your antihypertensive medications and were able to
get better control of your blood pressure.
We made the following changes to your medications:
# ADD nifedepine 10 mg SR. Please take your blood pressure
prior to taking this medication. If your systolic blood
pressure (the top number) is greater than 170 or your diastolic
blood pressure (the bottom number) is greater than 100, please
take one pill. Please recheck your blood pressure several hours
afterwards. If you blood pressure is still high, then you may
take another pill at the regularly scheuled interval.
Please continue to take the rest of your medications as
prescribed.
The following medications were added to your regiment:
Reglan, thiamine, zofran, compazine, loarazepam, nifedipine
Please attend the follow-up appointments listed below.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **]
Location: [**Hospital1 641**]
Address: [**Street Address(2) 642**], [**Location (un) **],[**Numeric Identifier 643**]
Phone: [**Telephone/Fax (1) 644**]
When: Tuesday, [**12-6**], 10AM
Name: [**Last Name (LF) 85321**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2296**]
*Someone from Dr. [**Last Name (STitle) 85321**] office will call you to schedule an
appointment. If you dont hear back in 2 business days, call the
number above.
Name: [**Last Name (LF) 76274**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2296**]
When: Tuesday, [**12-13**], 9:10AM
Name: ZANDI-NEJAD,[**Name8 (MD) 40716**] MD
Location: [**Location (un) 2274**] [**Location (un) 2277**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2263**]
When: Tuesday, [**12-27**], 9:30
Completed by:[**2185-12-2**]
ICD9 Codes: 5849, 5789, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3496
} | Medical Text: Admission Date: [**2178-3-12**] Discharge Date: [**2178-3-12**]
Date of Birth: [**2109-1-27**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
neck, throat swelling
Major Surgical or Invasive Procedure:
none
History of Present Illness:
69 year-old man with a h/o DM2, CAD, CHF, GERD, chronic
sinusitis, asthma, s/p esophageal dilatation who presents with
uvular swelling. Pt reports that he was walking to the bathroom
at midnight when he noted the onset of a swelling sensation in
his throat with difficulty and mild pain on swallowing. He also
notes mild lip swelling. No urticaria, flushing, pruritis, or
lightheadedness. No fevers, cough, swollen lymph nodes, sore
throat, or purulent sputum. He has stable rhinorrhea worst at
night from chronic sinusitis. He denies any difficulty handling
his secretions or dysphagia; these sx are dissimilar from those
leading to his esophageal dilatation several years ago. The
patient does recall one similar prior episode a few years ago
after eating a [**Location (un) 6002**]. At an OSH ED, he was given some
medications and the swelling resolved after several hours; this
was attributed to mayonnaise. He has tolerated this fine since
and denies mayonnaise or other new foods recently. He reports
being on lisinopril for 2-3 years; he believes he was taking it
at the time of this previous episode. His only new medication is
ferrous sulfate, started yesterday AM. He has not taken ASA or
NSAIDs in at least 4 months due to his renal failure. No insect
stings or chemical exposures. No chronic abdominal pain or
family history of angioedema.
.
In the ED, initial vs were: T 98, P 82, BP 161/66, RR 22, O2sat
100. Pt was without stridor or wheezing with minimal tongue and
lip swelling but +uvular hydrops. He was given diphenhydramine
50mg IV, famotidine 20mg IV, and methylprednisolone 125mg IV. Pt
stable but given absence of improvement, he is being admitted to
the ICU. VS on transfer: T 98.0, P 83, BP 151/79, RR 14, O2sat
100% 2L.
.
On the floor, pt currently reports slight improvement in his
swelling. No difficulty handling secretions.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, stably fluctuating
weights due to CHF. Denies headache. Chronic sinus tenderness,
rhinorrhea, and congestion. Denies cough, shortness of breath,
or wheezing. Denies chest pain, chest pressure, palpitations,
or weakness. Denies nausea, vomiting, abdominal pain. 1 episode
of diarrhea yesterday; none since. Denies dysuria, frequency,
or urgency. Denies arthralgias or myalgias. Denies rashes or
skin changes.
Past Medical History:
Diabetes mellitus 2
Hypertension
Hyperlipidemia
CAD with "mild MI" in the past per patient
CHF (EF 51% on [**2178-2-19**] stress MIBI)
ESRD undergoing work-up for PD and transplant
Chronic sinusitis
H/o asthma (last exacerbation in [**2152**])
GERD
Prostate cancer (new dx on [**2-19**] prostatic bx - [**Doctor Last Name **] score 6
(3+3), small focus involving less than 5% of the core tissue)
S/p esophageal dilatation several years ago
S/p removal of benign cyst under tongue at age 15
Social History:
Lives with wife and daughters and granddaughters. Retired, used
to work for a cleaning company.
- Tobacco: Quit tobacco 20 yrs ago
- Alcohol: Denies
- Illicits: Denies
Family History:
Strong family history of DM and CAD
Physical Exam:
T 96.9, P 90, BP 165/73, RR 14, O2sat 100% 2L
General: Alert, oriented, no acute distress, stridor, or
wheezing
HEENT: Sclera anicteric, MMM, lips and tongue not noticeably
swollen, uvular hydrops without exudates, no erythema, no
parotitis
Neck: Supple, JVP not elevated, no LAD, nontender
Lungs: Minimal crackles at bilateral bases, otherwise clear
without wheezes.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Soft, non-tender, obese but 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
Skin: No flushing or rash
Neuro: AAO x 3, nonfocal
Pertinent Results:
[**2178-3-11**] 10:36AM BLOOD WBC-6.8 RBC-3.92* Hgb-11.0* Hct-33.3*
MCV-85 MCH-28.0 MCHC-32.9 RDW-13.5 Plt Ct-405
[**2178-3-11**] 10:36AM BLOOD UreaN-58* Creat-5.9* Na-140 K-4.7 Cl-100
HCO3-27 AnGap-18
[**2178-3-11**] 10:36AM BLOOD Calcium-7.9* Phos-4.5
[**2178-3-11**] 10:36AM BLOOD PTH-527*
[**2178-3-12**] 12:35PM BLOOD C4-39
Brief Hospital Course:
69 yo man with DM, CAD, GERD, chronic sinusitis, asthma, s/p
esophageal dilatation p/w angioedema.
.
# Angioedema: C/w angioedema. Most commonly associated with
ACE-I. Does have a history of similar episode; acquired C1
inhibitor deficiency possible - familial less likely given age
and absence of family hx. Did just start iron supplement and
allergy to a component is possible, but time course not as
consistent and more likely kinin-mediated rather than mast cell
given absence of urticaria, prurutis. No inhalant abuse; not
taking ASA or NSAIDS due to renal failure. Pharyngitis can cause
uvular swelling but no fever, exudates, or sore throat to
suggest acute infectious etiology. Lisinopril was held on
admission and the patient was instructed not to resume this
medication. Complement levels were checked. His angioedema
resolved completely by the end of the day and he was discharged.
.
# HTN: He was restarted on home blood pressure medications
except for lisinopril. Blood pressure was controlled and he was
discharged with instructions to f/u with his PCP.
.
# DM: He reports episodes of hypoglycemia at home in the 50s and
Lantus was recently lowered. His Glyburide was stopped on
admission due to his end stage renal disease. He will continue
to monitor his blood sugars regularly at home.
.
# ESRD: In work-up for PD and transplant. Sevelamer and
calcitriol continued.
.
# CAD: Stable: Simvastatin and b-blocker continued.
.
# CHF: Euvolemic: Home lasix dose continued.
.
.
# Prostate cancer: New dx, [**Doctor Last Name **] score 6
- Outpt f/u with Dr. [**Last Name (STitle) 770**] on [**2178-3-19**]
Medications on Admission:
ALBUTEROL SULFATE (not taking)
CALCITRIOL 0.25 mcg daily
FUROSEMIDE 80 mg [**Hospital1 **]
GLYBURIDE 5 mg daily
INSULIN GLARGINE [LANTUS] 8 units daily
LISINOPRIL 40 mg [**Hospital1 **]
METOPROLOL TARTRATE 25 mg [**Hospital1 **]
NIFEDIPINE SR 90 mg daily
SEVELAMER CARBONATE [RENVELA] 1600 mg tid w/ meals
SIMVASTATIN 80 mg daily
IRON 325 mg daily
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
3. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
4. Insulin Glargine 100 unit/mL Solution Sig: Eight (8) units
Subcutaneous once a day.
5. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a
day.
6. Sevelamer HCl 800 mg Tablet Sig: Two (2) Tablet PO three
times a day.
7. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
1. Angioedema
Secondary Diagnosis:
2. Diabetes Mellitus
3. End-Stage Renal Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with a reaction called
angioedema. We think that this was due to your Lisinopril
dosing. It may have been related to your iron as well. You
should not take Lisinipril ever or this may cause a
life-threatening reaction.
The following changes were made to your medications:
STOP Lisinopril
STOP glyburide
You should follow-up with your PCP [**Last Name (NamePattern4) **] 2 weeks.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
You should monitor your blood pressure at home and call your
primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] values over 160 systolic.
You should check your blood sugars regularly and call your
primary care doctor for values over 200 or less than 70.
Followup Instructions:
Scheduled Appointments:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2178-3-16**]
3:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4653**], MD Phone:[**Telephone/Fax (1) 5727**]
Date/Time:[**2178-3-19**] 4:00
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2178-3-26**]
8:30
Please see your primary care doctor within 2 weeks of discharge.
ICD9 Codes: 5856, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3497
} | Medical Text: Admission Date: [**2130-12-23**] Discharge Date: [**2130-12-30**]
Date of Birth: [**2075-4-19**] Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: This is a 55-year-old man
admitted to the Coronary Care Unit after four left anterior
descending artery stents were placed for an acute
anterolateral ST-elevation myocardial infarction.
The patient has a history of hypertension and a family
history of coronary artery disease. No known history of
personal coronary artery disease, hypercholesterolemia, or
diabetes mellitus.
He was washing his bus today when he noted the onset of
severe left-sided chest pain (like "knives"), diaphoresis,
and nausea. He was taken by Emergency Medical Service to
[**Hospital3 417**] Hospital in [**Location (un) **] where an acute
anterolateral myocardial infarction was noted on the
electrocardiogram. He received aspirin, nitroglycerin,
heparin, and was transferred to [**Hospital1 188**] for percutaneous coronary intervention.
In the Catheterization Laboratory, the patient had an
Angio-Jet of a complete mid left anterior descending artery
lesion and four stents placed. He was briefly hypotensive
during the procedure and was given dopamine until an
intra-aortic balloon pump was placed. He was transferred to
the Coronary Care Unit stable off of dopamine.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Multiple sclerosis (Symptoms include dysarthria and left
leg weakness worse with exertion. The patient has just
completed a 6-month regimen of chemotherapy and steroids;
alternating months).
3. Possible nephrotic syndrome (lower extremity edema,
protein in urine).
MEDICATIONS ON ADMISSION: Medications at home included
lisinopril b.i.d., tizanidine, Lasix 20 mg p.o. b.i.d.,
albuterol, and famotidine.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: He lives in [**Location **] with his wife and four
children. He drives a [**Hospital1 **] bus. He has no history of
smoking or alcohol use.
FAMILY HISTORY: Family history positive for coronary artery
disease; his sister was deceased at the age of 58, status
post coronary artery bypass graft times three. His mother
had coronary artery disease.
PHYSICAL EXAMINATION ON PRESENTATION: Examination upon
admission revealed vital signs were stable and unremarkable.
He had no carotid bruits. His lungs were clear to
auscultation bilaterally. His heart was regular in rate and
rhythm with soft heart sounds. His abdomen was benign. His
right groin catheter site was soft and without hematomas or
bruits. He had dorsalis pedis pulses present bilaterally.
His neurologic examination revealed alert and mentating well
with dysarthria.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories on
admission revealed white blood cell count was 14.6,
hematocrit was 37, platelets were 263. INR was 1.3, PTT was
98.2. Sodium was 139, potassium was 4, chloride was 103,
bicarbonate was 22, blood urea nitrogen was 25, creatinine
was 0.8, and blood glucose was 133. Calcium was 9.6. His
first creatine kinase was 300. His blood gas was
7.41/38/302.
RADIOLOGY/IMAGING: Electrocardiogram prior to
catheterization demonstrated a sinus rhythm at the rate of
88, normal axis and normal intervals. ST elevations in I,
aVL, V2 through V5. ST depressions in III and aVF.
Catheterization results with pressures which revealed right
atrial pressure mean of 9 mmHg, pulmonary artery was 42/21,
right ventricular was 50/5. Arteries revealed left anterior
descending artery with diffuse 30% proximal lesion, 100% mid
lesion, 90% origin first diagonal lesion. The left
circumflex with diffuse 30% ostial/proximal 40% mid, 70% left
posterior descending artery. The right coronary artery with
mild luminal irregularities.
HOSPITAL COURSE BY SYSTEM:
1. CARDIOVASCULAR SYSTEM: (a) Coronaries: As above, the
patient had 2-vessel coronary artery disease and had four
stents placed in his left anterior descending artery. He was
enrolled in the Cool-MI trial.
The patient was treated with aspirin, Plavix, Lipitor,
captopril, and metoprolol status post myocardial infarction.
His peak creatine kinase was 7436 with a MB fraction of 830.
The creatine kinases after this trended downward. After his
intervention, the patient did not have any evidence of
ischemia by symptoms or by electrocardiogram.
(b) Pump: The patient was maintained on an intra-aortic
balloon pump for one day following his percutaneous coronary
intervention. The balloon pump was weaned without event.
He had an echocardiogram on day three status post myocardial
infarction which revealed an left ventricular ejection
fraction of 25% to 30%, with severe regional left ventricular
systolic dysfunction; comprising septal, anterior, and apical
akinesis. The patient was placed on heparin for this
akinesis; which was converted to warfarin prior to discharge.
(c) Rhythm: The patient had multiple runs of nonsustained
ventricular tachycardia after his myocardial infarction. The
longest run consisted of 15 beats to 20 beats and occurred
within 48 hours of his infarction. He had several shorter
runs of 5 beats to 10 beats occurring more than two days
status post myocardial infarction.
The Electrophysiology Service was consulted regarding
implantable cardioverter-defibrillator placement. They
elected to see the patient in one month when his course of
Plavix was completed and he was at less of a risk of
bleeding. He was to have a T wave alternans study at this
time and follow up with Dr. [**Last Name (STitle) 284**] of the
Electrophysiology Service.
2. PULMONARY SYSTEM: The patient oxygenated well throughout
his admission and did not have pulmonary problems.
3. RENAL SYSTEM: The patient's creatinine remained stable
at a level under 1 throughout his admission.
4. HEMATOLOGY: The patient had a drop in his hematocrit
from 37 to 31.4 after his catheterization. His hematocrit
remained stable around 30 to 31 after that initial drop, and
he did not receive any blood transfusions.
5. ENDOCRINE SYSTEM: The patient was noted to have multiple
fasting blood sugars of greater than 126 during this
admission. He had a hemoglobin A1c that was in the upper
limits of normal range. He was to follow up with his primary
care physician for further diagnosis and management of
possible type 2 diabetes mellitus.
DISCHARGE DIAGNOSES:
1. Acute ST-elevation myocardial infarction.
2. Status post left anterior descending artery stents.
CONDITION AT DISCHARGE: Condition on discharge was fair.
MEDICATIONS ON DISCHARGE:
1. Coumadin 5 mg p.o. q.h.s.
2. Lisinopril 10 mg p.o. q.d.
3. Metoprolol-XL 150 mg p.o. q.d.
4. Aspirin 325 mg p.o. q.d.
5. Lipitor 10 mg p.o. q.d.
6. Plavix 75 mg p.o. q.d. (times one month).
7. Protonix 40 mg p.o. q.d.
8. Lasix 40 mg p.o. b.i.d.
DISCHARGE STATUS: Discharge status was to home.
DISCHARGE FOLLOWUP:
1. The patient was to follow up with the Cardiology Clinic
at [**Hospital1 69**] in one to two weeks.
2. The patient was to follow up with Electrophysiology in
three to four weeks.
3. The patient was to follow up with primary care physician
in one to two weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15176**], M.D. [**MD Number(1) 15177**]
Dictated By:[**Last Name (NamePattern1) 5596**]
MEDQUIST36
D: [**2131-1-4**] 09:00
T: [**2131-1-5**] 11:42
JOB#: [**Job Number 28155**]
ICD9 Codes: 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3498
} | Medical Text: Admission Date: [**2198-1-26**] Discharge Date: [**2198-3-5**]
Date of Birth: [**2138-11-8**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 4377**]
Chief Complaint:
Neutropenic fever, diffuse large B-cell lymphoma.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname **] is a 59 year-old man with a history of diffuse large
B-cell lymphoma s/p IVAC D11 who presents with fever, nausea and
vomiting of 1 day duration. He was feeling overall well until
this morning when he developed a fever of 102. He vomited twice
(bilious, non-bloody). Denies abdominal pain or diarrhea. Denies
cough, sore throat, rhinorrhea or headache. Denies sick contacts
though was concerned his milk was old. Denies shortness of
breath or chest pain. Denies rashes. Does report increased
urinary frequency but no dysuria. Yesterday he went to his
outpatient oncology appointment, received 1 unit platelets with
no complications and felt well enough to walk home.
.
In the ED, initial vitals were T 100.3, BP 112/89, HR 94, RR 18,
100% NRB. During ED course Tmax 102.7. He was noted to be in
AFib at a rate of 135-160 which improved without intervention.
O2 sat 98-100% 2L. BP dropped to 76 and he was given 5L NS and
started on levophed. He received vancomycin and cefepime before
being transferred to the ICU. On arrival to the ICU patient was
actively rigoring.
.
Patient recently admitted [**Date range (3) 21959**] and treated with IVAC
chemotherapy x 5 days which was complicated by neutropenia,
thrombocytopenia, dizziness and diarrhea. Hospital stay was also
complicated by Atrial Fibrillation treated with metoprolol and
digoxin. Patient also has history of pulmonary embolism ([**10-15**]
admission) felt to be secondary to right atrial
catheter-associated thrombus complicated by likely TIA/amaurosis
fugax. Patient was treated with fondaparinux but this was then
stopped last admission due to thrombocytopenia.
.
ROS: The patient denies melena, hematochezia, chest pain,
shortness of breath, orthopnea, PND, lower extremity edema,
cough, lightheadedness, gait unsteadiness, focal weakness,
vision changes, headache, rash or skin changes.
Past Medical History:
ONCOLOGIC HISTORY:
Mr. [**Known lastname **] initially presented in early [**6-/2197**] with fever, weight
loss, and muscle and joint aches. He was diagnosed with PMR and
started on prednisone with improvement in his symptoms. During
the preceding six months, he reported a history of the
generalized body pain as well as fatigue, weakness, and poor
appetite. He also reported periodic fevers, drenching night
sweats, and a 25-pound weight loss also over the same six
months. Marked improvement of both his musculoskeletal and
constitutional symptoms after prednisone treatment. He then
presented to the emergency room on [**2197-7-17**] with palpitations
and dizziness and was found to be in atrial fibrillation. He has
had a history of PAF in the past. He was febrile to 101.6 with a
heart rate of 126. CT scan of the chest, abdomen, and pelvis on
showed multiple low-attenuation lesions within the liver,
spleen, and kidneys with characteristics felt atypical for
lymphoma. A follow-up MRI of the abdomen showed hypovascular
masses in both kidneys and spleen of various sizes consistent
with lymphoma. Mr. [**Known lastname **] then underwent bone marrow aspirate and
biopsy on [**2197-7-26**], which showed extensive necrosis with focal
involvement by a high-grade B-cell lymphoma, diffuse large
B-cell type. FISH translocation was notable for c-Myc and Bcl-2
indicating a "double hit" lymphoma characterized by a
Burkitt's-like lymphoma.
.
Mr. [**Known lastname **] has overall tolerated his chemotherapy relatively well.
He has continued on his Fondaparinux daily when on [**2197-11-16**],
he noted sudden onset sudden of a dark cover in the lower half
of the visual field in his right eye, which lasted [**10-20**]
minutes, then self-resolved. He presented to the emergency room
for evaluation. TEE revealed thrombus at the tip of his right
atrial catheter, with no PFO. Ophthalmology work up was negative
and the episode was attributed to TIA with recommendation to
continue fondaparinux. He was discharged on [**2197-11-18**] with no
further episodes.
.
TREATMENT HISTORY:
1. Initiated treatment with [**Hospital1 **] chemotherapy on [**2197-7-29**]
with two doses of Rituxan on [**2197-8-2**] and [**2197-8-3**]. Follow
up CT imaging on [**2197-8-5**] showed stable lymphomatous lesions
in the kidney, spleen, and abdominal nodes.
2. Rituxan 500 mg given on [**2197-8-10**] with a fever that evening
and admission for neutropenia. During admission, noted for
atrial fibrillation with RVR and was started on digoxin at 0.125
mg daily along with metoprolol 200 mg daily.
3. Readmitted on [**2197-8-18**] for his second cycle of [**Hospital1 **]
chemotherapy, which was delayed for two days due to hypotension
and cough. A CT of the chest showed bilateral lower lobe
opacities, right greater than left, concerning for infection and
he was treated with a course of Levaquin.
4. On [**2197-8-30**], received Rituxan at 375 mg/m2.
5. Follow up PET scan on [**2194-9-6**] showed no evidence for
lymphoma but was notable for multiple peripheral base pulmonary
opacities with rims of soft tissue density and relative central
lucencies most of which were new. He underwent CT of the chest
for further evaluation, which showed multiple filling defects
within the segmental and subsegmental branches of the right
lower lobe arteries compatible with pulmonary emboli.
6. Admitted on [**2197-9-7**] for initiation of anticoagulation with
fondaparinux and began third cycle of treatment with [**Hospital1 **] on
[**2197-9-8**](dose level 2)
7. Received Rituxan 375 mg/m2 on [**2197-9-25**].
8. Admitted on [**2197-9-29**] for fourth cycle of treatment with
[**Hospital1 **](dose level 3).
9. Received Rituxan 375 mg/m2 on [**2197-10-17**].
10. Admitted on [**2197-10-20**] for fifth cycle of treatment with
[**Hospital1 **](dose level 3 with Adriamycin at dose level 2. Received
Rituxan on [**2197-11-7**].
11. Admitted on [**2197-11-23**] for high-dose cyclophosphamide.
12. Admitted on [**2198-1-15**] for IVAC (originally admitted for
high-dose MTX, but PET scan showed progressive disease).
.
OTHER MEDICAL HISTORY:
1. Diffuse large B-cell lymphoma, Burkitt's like with c-Myc and
Bcl-2 positivity s/p [**Hospital1 **] x 5 cycles and multiple rituxan
infusions. He has had recurrent disease within 2 - 3 months of
his last treatment. Patient recently admitted [**Date range (3) 21959**]
for CNS prophylaxis with high-dose MTX for his aggressive
lymphoma. However, PET scan prior to admission was concerning
for rapidly progressive disease and CT torso on admission agreed
with these findings and his LDH continued to rise. He was
therefore started on IVAC chemotherapy x5 days and discharged on
neupogen.
2. PAF diagnosed in [**2180**] with now chronic atrial fibrillation in
the past several months. He had no history of treatment with
anti-arrhythmia or anticoagulation prior to his admission in
[**8-/2197**], currently receiving treatment with metoprolol and
digoxin.
3. Pulmonary embolism, currently receiving treatment with
fondaparinux.
4. Polymyalgia rheumatica diagnosed in [**2197**] and managed by Dr.
[**Last Name (STitle) **], although further treatment on hold while getting
treatment for lymphoma and unclear if his symptoms were related
to lymphoma and not PMR.
5. Remote history of syphilis, gonorrhea, and genital herpes in
[**2160**].
6. Tonsillectomy and adenoidectomy in the [**2137**].
7. Myopia.
8. Recent probable TIA with from thrombus on right atrial
catheter tip
Social History:
Mr. [**Known lastname **] is married and lives in [**Location **]. He previously worked
as a software engineer, but now works without pay from home
contributing to open source software projects. He gas two adult
children but has minimal contact with them. He is a nonsmoker,
drinks alcohol on occasion, and denies any history of illicit
drugs.
Family History:
Father had an MI in his 70s and his paternal grandfather had an
MI in his 40s. His mother is status post aortic valve
replacement. His younger brother had probable schizophrenia and
died from suicide at age 18. There is no family history of
cancer.
Physical Exam:
ADMISSION EXAM:
Vitals: T: 98.8 BP: 100/53 HR: 64 RR: 18 O2Sat: 94% 2L
GEN: Pale, thin, no acute distress.
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, OP Clear, pale conjunctiva
NECK: No JVD,
COR: Irregular rate, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, ND, +BS, mild tenderness on LLQ and RUQ but described
as "tightness" and not overt abdominal pain, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. Moves all 4
extremities.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
.
DISCHARGE EXAM:
GEN: Cachectic, NAD
CV: RRR, nl s1 and s2, no m/r/g
Chest: CTAB
ABD: Soft, NTND, +BS
Pertinent Results:
ADMISSION LABS:
[**2198-1-25**] 12:20PM BLOOD WBC-<0.1* RBC-3.32* Hgb-10.0* Hct-29.0*
MCV-87 MCH-30.2 MCHC-34.5 RDW-14.8 Plt Ct-13*#
[**2198-1-26**] 01:30PM BLOOD WBC-0.1* RBC-3.17* Hgb-9.5* Hct-26.4*
MCV-83 MCH-29.8 MCHC-35.8* RDW-14.9 Plt Ct-21*
[**2198-1-25**] 12:20PM BLOOD Neuts-53 Bands-0 Lymphs-40 Monos-0 Eos-7*
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2198-1-26**] 01:30PM BLOOD Neuts-0* Bands-0 Lymphs-100* Monos-0
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2198-1-26**] 01:30PM BLOOD PT-14.5* PTT-29.5 INR(PT)-1.3*
[**2198-1-26**] 01:30PM BLOOD Glucose-134* UreaN-19 Creat-1.0 Na-134
K-3.6 Cl-104 HCO3-20* AnGap-14
[**2198-1-25**] 12:20PM BLOOD Albumin-4.2 Calcium-8.9
[**2198-1-25**] 12:20PM BLOOD ALT-15 AST-19 LD(LDH)-161 AlkPhos-94
TotBili-0.5
[**2198-1-26**] 01:30PM BLOOD Digoxin-0.7*
[**2198-1-26**] 01:38PM BLOOD Lactate-1.9
.
PERTINENT LABS:
[**2198-2-9**], [**2198-1-29**] Aspergillus Galactommanan Ag: negative
[**2198-2-9**], [**2198-1-28**] B-Glucan: negative
.
DISCHARGE LABS:
[**2198-3-5**] 05:47AM BLOOD WBC-6.1 RBC-3.01* Hgb-8.4* Hct-25.9*
MCV-86 MCH-27.9 MCHC-32.5 RDW-17.8* Plt Ct-201
[**2198-3-5**] 05:47AM BLOOD Neuts-61.1 Lymphs-28.4 Monos-9.4 Eos-0.8
Baso-0.2
[**2198-3-5**] 05:47AM BLOOD PT-15.0* PTT-40.3* INR(PT)-1.3*
[**2198-3-5**] 05:47AM BLOOD Glucose-99 UreaN-21* Creat-1.1 Na-141
K-4.2 Cl-107 HCO3-27 AnGap-11
[**2198-3-5**] 05:47AM BLOOD ALT-55* AST-49* LD(LDH)-209 AlkPhos-81
TotBili-0.2
[**2198-3-5**] 05:47AM BLOOD Albumin-3.3* Calcium-8.6 Phos-3.2 Mg-2.0
................................................................
MICROBIOLOGY:
[**2198-2-12**] BAL: no growth
[**2198-2-12**] Lung tissue: no bacterial, fungal, AFB, or
mycobacterial growth
**All blood, urine, and stool cultures were negative**
................................................................
PATHOLOGY:
[**2198-2-12**] Right 6th rib biopsy: Unremarkable bone, cartilage and
soft tissue
.
[**2198-2-12**] Right lower lobe biopsy: Acute and organizing pneumonia
with abscess formation. No fungal organisms identified on GMS
and PAS stains.
.
[**2198-2-12**] Lymph node biopsy right, level 12: No carcinoma
identified in three examined lymph nodes.
................................................................
IMAGING:
[**2197-1-27**] CXR: As compared to the previous radiograph, there is a
newly appeared right basal and perihilar opacity with subtle air
bronchograms, in continuation with the inferior hilar
structures. In the setting of neutropenia and fever, a newly
appeared pneumonia must be suspected.
.
[**2198-1-29**] CT Chest w/ con:
1. Right lower lobe pneumonia.
2. Small-to-moderate bilateral pleural effusions.
3. Mesenteric edema and ascites may reflect third spacing.
.
[**2198-2-3**] CXR:
AP chest compared to chest radiograph since [**1-28**], and a
chest CT scan [**1-29**]. Sequence of radiographic findings to
suggest pneumonia present on [**1-28**] worsened in the right
lower lobe on [**1-29**] and then the patient subsequently
developed pulmonary edema. Since [**1-31**] nearly all of
these abnormalities have resolved. Small bilateral pleural
effusions remain.
.
[**2198-2-8**] CT Chest/Abd/Pelvis w/ con:
Large area of consolidation within the right lower lobe now has
a new area of cavitation. This could represent progression of
known pneumonic consolidation or be representative of fungal
disease. Clinical correlation recommended. No lymphomatous
involvement noted.
.
[**2198-2-13**]: CXR:
Moderate right pneumothorax has changed in distribution, with a
change in posture from supine to erect, now visible in the upper
hemithorax. Two right pleural tubes are also in place. There is
substantial atelectasis at the base of the postoperative right
lung and perihilar consolidation which could be atelectasis.
Obviously follow up will be careful for possibility of
postoperative pneumonia. Left lung is clear. Heart size is
normal. A right subclavian infusion port ends in the right
atrium.
Brief Hospital Course:
59M with Burkitt's-like DLBCL s/p R-[**Hospital1 **], high-dose cytoxan,
and recent IVAC for progressive disease, initially admitted to
the ICU for febrile neutropenia, found to have pneumonia.
.
# Neutropenic Fever: The patient presented on [**1-26**] with
neutropenic fever to 102 and nausea/vomiting. He became hypoxic
requiring oxygen, and hypotensive requiring Levophed, and was
admitted to the [**Hospital Unit Name 153**]. He had diarrhea, so the source was thought
to be GI. He was empirically treated with vanc/cefepime/flagyl.
Urine and stool cultures (including multiple C.diff's), and
urine Legionella antigen were negative. CXR and CT showed
RML/RLL pneumonia (management of pneumonia is discussed below)
and micafungin was added. He was eventually weaned off pressors
and had improved oxygenation. The micafungin was d/c'd and he
was transferred to the floor on [**1-31**]. All blood cultures were
negative. G-CSF was continued post-chemo and his counts improved
markedly, so it was stopped on [**2-1**].
.
# Pneumonia: Patient was found to have a RML/RLL pneumonia on
CXR, confirmed by CT chest. He was initially treated broadly
with vanc/cefepime/flagyl/micafungin, which was later tapered to
vanc/cefepime. He improved clinically, though continued to have
intermittent low-grade fevers and productive cough. There was
concern for aspiration so he underwent a video-assisted
swallowing study which did not reveal any aspiration, though he
was switched to thin liquids and soft solids with aspiration
precautions. A repeat CT chest on [**2-8**] showed new cavitary lesion
within the pneumonia. Pulmonary was consulted but felt that they
would be unable to reach the area via bronchoscopy. Antibiotics
were switched to vanc/zosyn for better anaerobic coverage out of
concern for aspiration pneumonia. At this point the patient was
due for another round of chemotherapy, which could not be
initiated in the setting of active pneumonia. Therefore, CT
surgery was consulted to evaluate for possible lobectomy. Dr.
[**First Name (STitle) **] took the patient to the operating room on [**2-12**] where he
underwent right thoracotomy and right lower lobectomy with
buttressing of bronchial staple line with intercostal muscle,
and bronchoscopy with BAL. The patient remained in the ICU POD
1, to monitor atrial fibrillation. He had afib with RVR POD 1,
which stopped after metoprolol 7.5mg IV was given. The anterior
chest tube was removed on [**2-14**], and he was transferred to the
floor. The last chest tube was discontinued on [**2-16**]. Post-op
course was complicated by a hydropneumothorax which required
placement of a pigtail catheter on [**2-22**] which was later removed.
.
# Increased stool output: Unclear etiology, but all of his stool
studies negative, including numerous C. diff toxins. Symptomatic
control with Imodium QID PRN. The diarrhea eventually resolved.
.
# DLBCL: Burkitt's-type lymphoma, previously on R-[**Hospital1 **],
high-dose cytoxan, and IVAC with continued anemia and
thrombocytopenia s/p chemo. He was transfused with goal Plt>10,
Hct>24. He was continued on acyclovir and Bactrim for viral and
PCP [**Name Initial (PRE) 1102**]. Rituxan was given on [**2198-2-11**], but complicated by
a reaction [**2-8**] of the way through the dose, and the dose was not
restarted. He was given another dose of Rituxan on [**2198-3-4**]. He
is scheduled for a follow-up PET scan on [**2198-3-12**].
.
# Atrial fibrillation: His HR was poorly controlled despite
uptitrating the digoxin and metoprolol. Cardiology was consulted
and a TEE with cardioversion was performed on [**2198-2-28**]. Digoxin
was stopped. He was started on amiodarone 40mg TID for 1 week,
then 400mg [**Hospital1 **] for 1 week, then 400mg daily. He was continued on
anticoagulation with Fondaparinux. His metroprolol succinate
was decreased to 100 mg daily from 200 mg daily. He will
follow-up with Dr. [**Last Name (STitle) **] from cardiology.
Medications on Admission:
1. G-CSF (Neupogen) 300mcg SC daily
2. Levofloxacin 500mg PO daily
3. Acyclovir 400mg PO Q8H
4. Sulfamethoxazole-trimethoprim 800-160mg PO MWF
5. Digoxin 125mcg PO DAILY
6. Metoprolol succinate 100mg PO HS
7. Fondaparinux 7.5mg/0.6mL Syringe SC daily, on hold since
[**2198-1-25**]
8. Oxycodone 5-10mg PO Q4H prn pain
9. Calcium carbonate 200 mg (500 mg) PO TID
10. Cholecalciferol (vitamin D3) 400 unit PO DAILY
11. Famotidine 20mg PO Q12H
12. MVI one Tablet PO DAILY
13. Ondansetron 4mg PO TID prn
Discharge Medications:
1. acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8
hours).
2. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO MWF ([**Month/Day/Year 766**]-Wednesday-Friday).
3. famotidine 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
5. multivitamin Tablet Sig: One (1) Tablet PO once a day.
6. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO see below:
take 400 mg three times per day until [**2198-3-6**], then two times per
day until [**2198-3-13**], then once per day after that.
Disp:*60 Tablet(s)* Refills:*2*
7. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. Calcium 500 500 mg (1,250 mg) Tablet Sig: One (1) Tablet PO
three times a day.
9. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO at bedtime.
10. Guaifenesin-DM NR 10-100 mg/5 mL Liquid Sig: Five (5) mL PO
twice a day as needed for cough for 5 days.
Disp:*1 bottle* Refills:*0*
11. fondaparinux 7.5 mg/0.6 mL Syringe Sig: One (1) injection
Subcutaneous once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
- Pneumonia
- Atrial fibrillation
.
Secondary diagnosis:
- Diffuse large B-cell lymphoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure taking part in your care at the [**Hospital1 771**]. You were initially admitted to the
intensive care unit after becoming quite ill after your recent
chemotherapy treatment. You were found to have a pneumonia which
was treated with antibiotics and the surgeons then removed part
of your infected right lung. We also converted your heart back
to a normal rhythm and started medication for this.
.
The following changes were made to your medications:
-STOP digoxin.
-DECREASE metoprolol succinate.
-START amiodarone.
.
For your incisions: Call Dr. [**First Name (STitle) **] at [**Telephone/Fax (1) 2348**] if these
become red, swollen, or drain. Keep chest tube sites covered
with gauze and bandages, changing daily, until healed.
.
You may shower but do not tub bath for 6 weeks.
Followup Instructions:
Department: Radiology - PET scan
When: [**Telephone/Fax (1) 766**] [**2198-3-12**] at 1:45 p.m.
Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 249**]
When: [**Hospital3 **] [**2198-3-26**] at 11:20 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15675**], MD [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) 895**]
Campus: EAST
Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: CARDIAC SERVICES
When: WEDNESDAY [**2198-4-4**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], 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: 5070, 5849, 2930 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3499
} | Medical Text: Admission Date: [**2178-10-28**] Discharge Date: [**2178-11-5**]
Date of Birth: [**2107-2-13**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
1-2 weeks of malaise, SVTs, and palpitations
Major Surgical or Invasive Procedure:
left atrial myxoma resection
History of Present Illness:
71 yo female with recent history of SVT bursts, palpitations and
malaise. Transferred in from OSH for evaluation after workup
there revealed a left atrial mass by CT scan and echo.CXR also
showed bilat. pleural effusions and right apical pneumothorax.
CT scan showed a 5.4cm X 1.4 cm left atrial mass and pulmonary
consolidation. There were also multiple calcified pulm.
granulomas on repeat scan. Echo showed the mass to be arising
from the interatrial septum, and moving through the mitral valve
in diastole.Aortic stenosis was also present with [**Location (un) 109**] 1.0 cm2,
1+ MR, 1+ TR, and moderate to severe pulm. HTN. Referred to Dr.
[**Last Name (STitle) **] for resection in the near future.
Past Medical History:
Osteoporosis, Autoimmune hepatitis, HTN, hyperlipidemia,
anxiety, "inflammation of stomach" w/neg EGD. (-) ETT 1.5-2
years ago (done for palpitations).
Negative colonoscopy "4-5months ago," neg mammogram [**10-1**]
Social History:
Married, lives with husband. Smokes [**11-30**] ppd x many years,
minimal EtOH. No IVDU.
Family History:
NC
Physical Exam:
T 98.4 HR 89 106/56 RR 22 96% sat
NAD, non cachectic
PERRL, EOMI
neck supple, no carotid bruits appreciated
RRR, no m/r/g
lungs CTAB
abd soft, NT, ND, no HSM
extrems no c/c/e
63" 97 #
Pertinent Results:
[**2178-11-4**] 06:55AM BLOOD WBC-6.9 RBC-3.42* Hgb-10.1* Hct-28.5*
MCV-83 MCH-29.4 MCHC-35.3* RDW-15.7* Plt Ct-367
[**2178-11-4**] 06:55AM BLOOD Plt Ct-367
[**2178-11-5**] 07:00AM BLOOD Glucose-89 UreaN-11 Creat-0.8 Na-132*
K-5.0 Cl-96 HCO3-30 AnGap-11
[**2178-11-2**] 09:20AM BLOOD ALT-11 AST-17 AlkPhos-246* Amylase-49
TotBili-0.5
[**2178-11-2**] 09:20AM BLOOD Lipase-30
Brief Hospital Course:
Admitted on [**10-28**] and underwent elective resection of a left
atrial tumor with Dr. [**Last Name (STitle) **]. Transferred to the CSRU in stable
condition on phenylephrine and propofol drips.Extubated later
that evening in sinus rhythm.She was awake and alert on POD #1
and gentle diuresis was begun. On POD #2, she complained of some
upper abdominal pain and was examined by Dr. [**Last Name (STitle) **] with no
peritoneal signs. She was transfused one unit of PRBCs for a Hct
of 24.3. Beta blockade was stopped for a HR of 52 and she
remained in the unit an extra day for monitoring. Transferred to
the floor on POD #4 in SR. Her BP remained labile and an ACE
inhibitor was titrated with intermittent hydralazine over the
next several days. She was ambulating on the floor on POD #4.
On POD #5, she c/o pain at her left lower ribs toward the front
of her chest. She denied any abd. pain and had not had a BM
since surgery despite a good appetite. MOM was given. Magnesium
was repleted. Epicardial wires remained in place for
intermittent pacing. BP meds continued to be adjusted and she
was intermittently A- paced. Lopressor was stopped and wires
were removed on POD #7 in SR at 60. Had BM on [**11-4**] with no abd
discomfort.
On POD #8, SR 64 121/50 RR 18 93%RA sat. T 98.7 50 kg
(pre-op 44kg), sternum stable with staples intact, lungs CTAB,
RRR S1 S2. Staples to be removed by VNA in one week and
discharged to home with services on [**2178-11-5**].
Medications on Admission:
fosamax 70 mg q week
lorazepam 0.5 mg [**Hospital1 **] prn
ASA 81 mg daily
colace
heparin sc tid
lopressor 50 mg [**Hospital1 **]
oxycodone
senna
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
10 days.
Disp:*10 Tablet(s)* Refills:*0*
2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO once a day for 10 days.
Disp:*20 Capsule, Sustained Release(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 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every six (6) hours as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
6. Captopril 25 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*180 Tablet(s)* Refills:*2*
7. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. FOSAMAX 70 mg Tablet Sig: One (1) Tablet PO once a week.
9. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day as
needed.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
s/p left atrial myxoma resection
PMH:Autoimmune hepatitis,HTN,^chol,anxiety
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:
Dr [**Last Name (STitle) **] in 4 weeks
Dr [**Last Name (STitle) 22552**] in [**1-1**] weeks
Completed by:[**2178-11-26**]
ICD9 Codes: 4241, 2761, 5119, 4019, 2720 |
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