meta
dict | text
stringlengths 0
55.8k
|
|---|---|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3500
} | Medical Text: Admission Date: [**2175-5-30**] Discharge Date: [**2175-6-15**]
Date of Birth: Sex: F
Service:
ADMISSION DIAGNOSIS: End stage renal disease, admitted for
transplant surgery.
HISTORY OF PRESENT ILLNESS: The patient is a 65 year-old
woman with end stage renal disease, secondary to malignant
hypertension. She was started on dialysis in [**2174-2-7**]. She currently was on peritoneal dialysis and appears
to be doing well. She has a history of gastric angiectasia
which she requires endoscopy. She was admitted on [**2175-5-30**] for
a scheduled living donor kidney transplant by her son, who is
the donor. She does have a donor specific antibody (B-51)
and will have a final T & B cell class match prior to
transplantation.
PAST MEDICAL HISTORY: End stage renal disease, secondary to
malignant hypertension on dialysis. History of anemia
following gastric angiectasia. She has no known history for
coronary artery disease for diabetes.
ALLERGIES: No known drug allergies.
MEDICATIONS: Unknown.
SOCIAL HISTORY: Married, lives with her husband. She has a
history of a half pack of cigarettes per day for 20 years.
Occasional alcohol.
PHYSICAL EXAMINATION: The patient was afebrile. Vital signs
were stable. Blood pressure was 124/58; heart rate 76; weight
160 pounds. Abdomen soft and nontender. She has a peritoneal
dialysis catheter in the right lower quadrant. She has good
femoral pulses bilaterally. Mild pedal edema.
HOSPITAL COURSE: On [**2175-5-30**], the patient went to the
operating room for living donor kidney transplant, performed
by Dr. [**Last Name (STitle) **] and assisting by Dr. [**Last Name (STitle) **]. Please see details
of this surgery in operating room note. Also during her
operating room time, the patient also had a right iliac
artery thrombosis. It was noted that at the end of the
completion of the procedure, that she had an ischemic
appearing right foot and absence of a right femoral pulse. In
the operation, there was some difficulty with arterial
anastomosis, renal artery to the left iliac artery and Dr.
[**Last Name (STitle) **] came to assist Dr. [**Last Name (STitle) **]. Again, please see
details of that operation in the operative report.
Postoperatively, the patient went to the Intensive Care Unit.
The patient had an A line, a central line, Foley. She was
placed on a heparin drip to keep PTT between 45 and 50. The
patient's dressing was clean, dry and intact. The patient had
2 [**First Name8 (NamePattern2) 1661**] [**Last Name (NamePattern1) 1662**] drains in place. Good femoral pulse and good
dorsalis pedis pulse. These pulses were palpable. The
patient was making good urine output postoperatively. Renal
was consulted and made recommendations. Postoperatively, the
patient had a renal ultrasound demonstrating an unremarkable
renal transplant ultrasound with normal size and appearance
of the transplanted kidney and normal arterial wave forms and
resistive disease, ranging from 0.63 to 0.75 throughout.
On postoperative day number one, the patient had another
ultrasound secondary to her hematocrit decreasing and they
wanted to rule out hematoma. The ultrasound demonstrated that
there was no hematoma seen adjacent to the transplanted
kidney. The transplanted kidney is minimally changed from
yesterday which was on [**2175-5-30**] with a small amount of pelvic
ectasis. Relatively unchanged resistive indices. The
patient did get multiple transfusions for her low hematocrit.
Her heparin was discontinued on [**2175-6-1**]. The patient received
1/2 cc per cc of replacement and on [**6-1**], Tacrolimus was
started. On [**2175-6-2**], the patient had some complaint of right
foot numbness. Lower extremity ultrasound was obtained to
rule out deep venous thrombosis and this showed no evidence
of right lower extremity deep venous thrombosis. On [**2175-6-2**],
WBC was 2.9, hematocrit of 35.2. Also on [**6-2**], PT was 13.5,
PTT was 36.7, INR of 1.2. Sodium that day was 129 and 4.4,
100 BUN, creatinine of 69 and 6.2 with a glucose of 96.
Vascular surgery continued to see the patient. It was
decided that hematocrit was stable, that heparin could be
continued. The patient was restarted on heparin. The patient
still complained of right foot numbness but it was about the
same and not worse. She was continued on all of her
immunosuppressive medications, including Tacrolimus, Valcyte,
Cellcept, Bactrim, Solu-Medrol. The patient was transitioned
from heparin to Coumadin. The patient was transferred to the
floor, continued to make excellent urine output. The patient
had another ultrasound on [**2175-6-6**] because there was blood in
her [**First Name8 (NamePattern2) 1661**] [**Last Name (NamePattern1) 1662**] drain and with the decreasing hematocrit.
Ultrasound demonstrated normal arterial and venous color,
blood flow and wave form with normal residual indices. 7.6
by 3.5 cm fluid collection, likely simply fluid, anterior to
the contrast. Focal area of heterogeneity within the lateral
aspect of the mid pole, probably which demonstrates normal
blood flow and may represent artifact; however, attention to
this area on a follow up scan is recommended to document
interval change or resolution.
On [**2175-6-9**], the patient's right lower extremity was swollen.
The patient complained of right hip and thigh pain, pitting
edema of right lower extremity greater than left lower
extremity so an ultrasound was performed which included the
right iliac artery. This demonstrated acute deep venous
thrombosis within the right common femoral and superficial
femoral veins which had developed since [**2175-6-2**]. There
is a right groin hematoma which was unchanged. The patient
continued to be anticoagulated for DVT. One drain was
eventually removed, continued on [**2175-6-12**] with drain output of
170, afebrile, vital signs stable. She went home with
services on the following medications: Valcyte 450 mg q.
day, Bactrim SS 1 tab q. day, Protonix 40 mg q. day, Nystatin
5 ml suspension, 5 ml four times a day, Colace 100 mg twice a
day, Movlapine 10 mg q. day, Percocet 22 tabs q. day,
Lopressor 100 mg twice a day, MMF 500 mg q.o.d. Coumadin 2 mg
q. day. This should be monitored to keep the INR between 2
and 3. Reglan 10 mg four times a day before meals and at
bedtime. Tacrolimus 10 mg p.o. twice a day. Potassium sodium
phosphate, one packet q. day and Compazine 10 mg q. 6 hours
prn. The patient has a follow up appointment with Dr.
[**Last Name (STitle) **], please call [**Telephone/Fax (1) 673**] for an appointment. The
patient needs to change dressings on her wound twice a day
located on her groin, place a dry gauze between the wound and
her skin. No heavy lifting of greater than 10 pounds for the
first 6 weeks after surgery.
DIAGNOSES: End stage renal disease, status post renal
transplant.
Arterial thrombosis.
Deep venous thrombosis.
Resolving hypertension.
[**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 55494**]
Dictated By:[**Last Name (NamePattern1) 4835**]
MEDQUIST36
D: [**2175-9-15**] 16:39:51
T: [**2175-9-15**] 17:14:46
Job#: [**Job Number 55495**]
ICD9 Codes: 2767, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3501
} | Medical Text: Admission Date: [**2167-1-30**] Discharge Date: [**2167-2-3**]
Date of Birth: [**2095-1-29**] Sex: F
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
Esophageal Stent Migration and airway obstruction
Major Surgical or Invasive Procedure:
EGD with stent removal
History of Present Illness:
72 yo woman with PMH sig for metastatic esophageal cancer who
presented for an outpt procedure to have an esophageal stent
removed after it had migrated to her stomach. A plastic stent
was placed in the distal esophagus at the site of the stricture
prior to removal of the original stent. The procedure became
complicated when the stent became lodged on a vertebral
osteophyte blocking its extraction at the level of the high
cervical spine. Obvious bleeding was noted and concern for her
airway prompted intubation. This was complicated by her
underlying anatomy as well as the stent's position but
ultimately was successful. Interventional pulmonology and ENT
were immediately consulted. The trachea appeared clear of any
stent debris. The stent was able to be removed endoscopically
without any major trauma to the esophagus the could be seen
grossly. The pt had approximately 300-400 cc of blood suctioned
while in the GI suite and an NG tube was passed under direct
visualization. The pt was then admitted to the [**Hospital Unit Name 153**] for further
observation and mgt after getting a CT of the neck. Upon
arrival to the [**Hospital Unit Name 153**], vital signs were stable and there was no
sign of further bleeding.
Past Medical History:
1. Esophageal CA with liver mets s/p chemotx with Taxotere, 5-FU
and leucovorin with minimal residual disease
2. Irritable bowel syndrome
3. GERD
4. h/o diverticulitis
5. Colon polyps
6. Degenerative joint disease
7. Laryngeal polyps
8. Systemic lupus
9. Fibromyalgia
10. CAD s/p Anterior MI [**8-/2152**]
11. Osteoporosis
12. Macular Degeneration
13. Left patellar chondromalacia
Past Surgical Hx:
1. s/p cervical decompression [**1-/2153**]
2. h/o ruptured Gallbladder repair [**8-/2157**]
3. Right medial meniscus repair [**7-/2161**]
Social History:
No ETOH or smoking. Married
Family History:
Positive for colon CA and Crohn's dz
Physical Exam:
T: 95.2 HR: 55 BP: 136/96 100% on FiO2 0.40
Gen: sedated but arousable, intubated
HEENT: anicteric, blood noted in ET tube, NGT draining dark
green fluid
Neck: crepitus noted above sternum
CV: bradycardic, S1S2 no murmur
Chest: coarse rhonchi at bases b/l, pirt noted on left upper
chest
Abd: +BS soft, NT
Ext: no C/C/E
Pertinent Results:
72 year old woman with hx stent placement for esophageal cancer
REASON FOR THIS EXAMINATION:
chest fluoroscopic assistance for esophageal stent placement and
retrieval
INDICATION: Chest fluoroscopic assistance for endoscopic removal
of esophageal stent and placement of a new esophageal stent.
[**2167-1-30**] 01:00PM WBC-3.7*# RBC-2.87*# HGB-8.5*# HCT-31.1*#
MCV-109*# MCH-29.5 MCHC-27.2*# RDW-15.0
[**2167-1-30**] 01:00PM PT-13.1 PTT-32.0 INR(PT)-1.1
[**2167-1-30**] 01:00PM HCV Ab-NEGATIVE
[**2167-1-30**] 01:00PM HBsAg-NEGATIVE HBs Ab-NEGATIVE HBc
Ab-NEGATIVE HAV Ab-POSITIVE
[**2167-1-30**] 01:00PM UREA N-11 CREAT-0.6 SODIUM-116*
POTASSIUM-2.1* CHLORIDE-92* TOTAL CO2-18* ANION GAP-8
Brief Hospital Course:
1. s/p upper airway obstruction: Pt was admitted to ICU for
observation. She was maintained on intubation and ventilation
for 48 hours for airway protection. On initial check for trach
leak, she had some stridor, and was started empirically on
steroids. The following day she was extubated without
complications and streroids discontinued.
2. GI bleed: Hematocrits were stable throughout the
hospitalization and the patient did not have to be transfused.
Her outpatient HTN meds, as well as aspirin and coumadin were
held. She was normotensive and stable, BP meds were slowly
restarted as tolerated.
3. Possible esophageal perf: She was started on zosyn
empirically for the possibility of esophageal perf. None was
seen on CXR or CT, and she was changed over to PO antibiotics
for empiric 7 days of amox/clav.
4. Afib: Off of her beta-blocker and diltiazem, she had several
runs of rapid Afib (HR 150s), which ultimately required that she
be placed on diltiazem drip. Upon extubation, she was restarted
on her outpatient diltiazem and atenolol. As above, coumadin and
ASA were held in lue of GI bleed.
5. ASA allergy: patient was desensitized to ASA in [**2152**]'s and
has had periods of time off ASA (up to 10 days) and has
restarted in past without incident. On some occassions, patient
was started on steroids concommitantly to avoid reactions. In
this situation, our allergist, Dr. [**Last Name (STitle) 2603**], recommended
consideration for repeat desensitization if off ASA for > 5
days. Patient will consult with her outpatient allergist, Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], prior to restarting her ASA after 7 day period.
6. Malpositioned port-a-cath. On 2 subsequent CXRs the patient's
L subclavian port-a-cath was noted to be malpositioned cephalad
in the L brachiocephalic vein. This issue is likely ongoing and
patient was referred to our "IV access" team, specifically [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 23793**] for likely replacement. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] was also
notified of this issue.
Medications on Admission:
Cardizem CD 300mg QD
Imdur 30mg QHS
Restasis 1 gtt OU QD
Nexium 20mg [**Hospital1 **]
KCl 20mEq M/W/F
Ativan 1mg QHS PRN
Moduretic (Amiloride/HCTZ) [**5-/2112**] 1 tab M/W/F
Lipitor 40mg QD
MVI
Coumadin 1mg QD
Amitriptyline 25mg QHS
Atenolol 25mg QHS
ECASA 81mg QD
Reglan 10mg QID PRN
Mag Glycinate 200mg QD
Discharge Medications:
1. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Diltiazem HCl 300 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
4. Amitriptyline HCl 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
5. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO twice a
day for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1) Metastatic Esophageal Cancer
2) s/p stent removal and replacement
3) Possible mediastinitis - though no evidence on CT scan or
with fever, completing [**10-23**] day course of broad spectrum
antibiotics empirically.
4) Ischemic heart Disease
5) Lupus
6) Fibromyalgia
7) Hypokalemia
Discharge Condition:
Good
Discharge Instructions:
Call Dr. [**Last Name (STitle) 1940**] if you develop a temperature of 100.5 degrees
or higher, feel chills, chest pain, trouble breathing or
otherwise unwell.
Follow-up with Dr. [**Last Name (STitle) 1940**] in 7 days for a repeat CBC.
Follow-up with your Cardiologist in early [**Month (only) 956**] as planned.
You should remain off anticoagulation for AT LEAST seven days,
or as long as possible according to Dr. [**Last Name (STitle) **].
Do not take an aspirin or coumadin or any other blood thinning
medication until further directed.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) 1940**] in 7 days for a repeat CBC.
Follow-up with your Cardiologist in early [**Month (only) 956**] as planned.
You should remain off anticoagulation for AT LEAST seven days,
or as long as possible according to Dr. [**Last Name (STitle) **].
Do not restart aspirin until you see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for
discussion of possible steroids prior to re-starting this
medication. Please see Dr. [**Last Name (STitle) **] in next 5-7 days.
Provider: [**First Name11 (Name Pattern1) 396**] [**Last Name (NamePattern4) 397**], MD Where: [**Hospital6 29**]
HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2167-3-20**] 1:15
Provider: [**Name10 (NameIs) **] SCAN Where: [**Hospital6 29**] RADIOLOGY
Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2167-3-16**] 1:15
Completed by:[**2167-2-3**]
ICD9 Codes: 2768 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3502
} | Medical Text: Admission Date: [**2139-3-23**] Discharge Date: [**2139-5-12**]
Date of Birth: [**2139-3-23**] Sex: F
Service: Neonatology
Baby will be transferred to the [**Hospital 1474**] Hospital today.
HISTORY: This is a 28-2/7 week twin baby girl #1 [**Name2 (NI) **] at 1135
grams to a 25-year-old G3 P1-3. Mother is Portuguese. Her
prenatal screens are blood type O positive, antibody
negative, RPR nonreactive, hepatitis B surface antigen
negative, group B Strep unknown.
Pregnancy was complicated by cervical shortening at 24 weeks.
She was transferred from [**Hospital 1474**] Hospital to the [**Hospital1 346**] at that time. She received
betamethasone also at that time. Her pregnancy was also
complicated by gestational diabetes, which was controlled
with diet. She developed preterm labor, which was managed
with magnesium sulfate, however, labor continued in spite of
tocolysis. Spontaneous rupture of membranes occurred in this
twin 30 minutes prior to delivery. A C section was performed
secondary to breech-breech presentation of the twins.
Twin #1 was [**Hospital1 **] and had mild respiratory distress in the
delivery room. She was given facial CPAP and stimulation.
She had Apgars of 7 and 8 at one and five minutes. She was
shown to her mother and transferred to the Neonatal ICU with
facial CPAP. Birth weight was 1135 grams, which is the 50th
percentile at 28-2/7 weeks. Length was 35 cm, which was the
25th percentile and head circumference was 27 cm, the 50th
percentile.
INITIAL EXAMINATION: Temperature was 96.4, which warmed to
98.5 with neutral thermal environment. Pulse 135,
respiratory rate 60, blood pressure was 41/27 with a mean of
33. On exam, she was a premature female, who was pink, but
with retractions. She was orally intubated. Her anterior
fontanel was open, soft, and flat. She was nondysmorphic.
She had an intact palate. Normal red reflexes were noted
bilaterally. Her chest was symmetric, but had mild
retractions and she had good aeration pre-Surfactant.
Cardiovascular: There was no murmur, regular, rate, and
rhythm, normal pulses. Abdomen was soft with three-vessel
cord. No hepatosplenomegaly. Genitalia was premature
female. Anus was patent. Spine was smooth without sacral
dimples. Extremities noted to have no hip clicks, 10 digits
on the hands and feet. Neurologic: She was active,
responsive, and had normal tone for her age.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS:
Respiratory: Due to surfactant deficiency, this twin was
treated with Surfactant replacement x1. She was placed on
SIMV with maximum settings of 25/5 with a rate of 25 in room
air. She was loaded with caffeine on day of life one and
weaned quickly to CPAP 6 cm in room air by 24 hours of age.
She remained on room air CPAP of 6 until day of life 10. She
was placed briefly on nasal cannula for three days and then
returned to CPAP of 6, and then reduced to CPAP of 5 on room
air, where she remained until day of life 40. She was placed
in room air at that time, and has remained so without apnea
of prematurity. Her caffeine was discontinued on day of life
44. She occasionally has bradycardic events noted with
feeds.
Cardiovascular: This twin received a normal saline bolus x2
for initial hypotension. She remained on dopamine for under
24 hours. She has continued to be cardiovascularly stable
since that time with normal blood pressures most recently
ranging 62/30 with a mean of 48.
She had a murmur noted on day of life two at which time she
had an echocardiogram to rule out a PDA. The echocardiogram
showed an intermittent closing PDA. It was repeated on the
following day, [**3-27**]. Echocardiogram at that time revealed a
PFO with a small 1 mm duct. She has remained
cardiovascularly stable. Has an intermittent murmur on exam.
Fluids, electrolytes, and nutrition: Initial IV fluids were
administered through an umbilical arterial catheter and
peripheral IV. She had a PICC line placed for PN and lipids,
which remained in place for six days, which was removed
without incident.
Enteral feeds were started on day of life six with breast
milk and advanced to full enteral feedings by day of life 14
without incident. Feeds were well tolerated, and calories
were increased to a maximum of breast milk 30 with HMF and
ProMod. Electrolytes and nutrition laboratories are all
within the normal range.
She maintained growth along the 25th percentile recently
increasing back to the 50th percentile and calories were
reduced at 24 calories/ounce on day of life 42, currently
receiving breast milk with HMF to 24 calories or premature
Enfamil 24 with iron. Weight at time of transfer is 2420
grams in the 50th percentile for gestational age, corrected
now at 35-3/7 weeks. Head circumference is 31.5 cm, in the
25th-50th percentile, and length currently is 44 cm at the
25th percentile.
Gastrointestinal: Max bilirubin was noted to be 6.1/0.3 on
day of life one. Phototherapy was in place through day of
life eight. This issue has been resolved. On physical exam,
this baby has had a full, but soft abdomen. She has a
moderate umbilical hernia, which is easily reduced. She has
demonstrated a normal stooling pattern.
Hematologic: Initial CBC revealed a white blood cell count
of 8.7 with 41 neutrophils and 10 bands. Hematocrit of 42
and a platelet count of 239,000. She was started on iron and
vitamin E on day of life 14. Her last hematocrit on [**4-27**]
was 25.8 with a reticulocyte count of 11%. She received no
blood products during her NICU stay.
Infectious disease: She received the ampicillin and
gentamicin for 48 hours. Her blood cultures remained
negative. There have been no further ID issues.
Neurologic: Head ultrasounds were performed on [**3-30**] and
repeated on [**4-24**] at a month of age, and were normal.
Sensory: Hearing screening passed.
Ophthalmology: An initial eye exam was performed on [**4-27**],
which revealed immature retinas in Zone II. A repeat eye
exam by Dr. [**Last Name (STitle) **] was performed on [**5-11**], which revealed
immature retinas Zone II in the anterior zone. Recommended
eye exam would be repeated in two weeks.
Psychosocial: Parents are Portuguese and have had limited
transportation. Had family meetings facilitated by a
Portuguese interpreter. Social worker at [**Hospital1 346**] has been [**First Name8 (NamePattern2) 5036**] [**Last Name (NamePattern1) 4467**]. She may be
contact[**Name (NI) **] for further information. Parents had selected [**First Name5 (NamePattern1) **]
[**Last Name (NamePattern1) 54735**] as a Portuguese speaking liaison to facilitate
communication with the family.
CONDITION AT DISCHARGE: Good.
DISCHARGE DISPOSITION: To transfer to [**Hospital 1474**] Hospital for
continued care.
PRIMARY PEDIATRICIAN: Has not yet been selected.
CARE RECOMMENDATIONS: Corrected gestational age is 35-3/7
weeks. Feedings are with breast milk 24 calories with human
milk fortifier or premature Enfamil 24 with iron at 150
cc/kg/day. PG feeds are running over one hour. PO feedings
are being offered upon infants feeding cues and are slowly
improving.
MEDICATIONS:
1. Ferrous sulfate 0.2 mL by mouth each day 25 mg/mL.
2. Vitamin E 5 IU by mouth each day.
CAR SEAT SCREEN: Car seat screening has not yet been
performed.
NEWBORN SCREENING STATUS: This twin has had newborn screens
sent on [**3-25**], and on [**5-5**] with the last one at a
weight of 2.045 kg.
IMMUNIZATIONS RECEIVED: The initial hepatitis B vaccine was
administered on [**4-24**]. She has not yet received two month
immunizations. She is day of life 50 at the time of
transfer.
IMMUNIZATIONS ALSO RECOMMENDED:
1. Synagis RSV prophylaxis should be considered from
[**Month (only) 359**] through [**Month (only) 547**] for infants who meet any of the
following three criteria: 1) [**Month (only) **] at less than 32 weeks, 2)
[**Month (only) **] between 32 and 35 weeks with two of three 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.
2. Influenza immunization is recommended annually in the fall
for all infants once they reach six months of age. Before
this age and for the first 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out-of-home caregivers.
FOLLOW-UP APPOINTMENTS: Continued screening for retinopathy
and primary pediatric care.
DISCHARGE DIAGNOSES:
1. Surfactant deficiency, RDS.
2. Sepsis suspect.
3. Apnea of prematurity.
4. Anemia of prematurity.
5. Immature feeding skills.
6. Immature retinas.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 37233**], M.D. [**MD Number(1) 36463**]
Dictated By:[**Name8 (MD) 52370**]
MEDQUIST36
D: [**2139-5-12**] 00:33
T: [**2139-5-12**] 04:49
JOB#: [**Job Number 54736**]
ICD9 Codes: 769, 7742 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3503
} | Medical Text: Admission Date: [**2181-8-17**] Discharge Date: [**2181-9-7**]
Date of Birth: [**2120-10-31**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Imuran / Cephalosporins / Sulfa (Sulfonamide
Antibiotics) / Reglan / Latex / Ampicillin / Lactose / Soy,
Lentals, Beans
Attending:[**First Name3 (LF) 5037**]
Chief Complaint:
dyspnea, shortness of breath
.
Reason for MICU transfer: Dyspnea, Respiratory Distress
Major Surgical or Invasive Procedure:
[**2181-8-23**] - Cardiac catheterization
History of Present Illness:
This is a pleasant 60-year old Indian female with a complicated
past medical history significant for type 1 IDDM (s/p revision
renal and pancraes transplants, [**2160**] and [**2174**]), diastolic CHF
(Echo 35-40%, [**7-/2181**]), sleep-disordered breathing (on 2L home
oxygen at night) who presented on [**2181-8-17**] with dyspnea and
evidence of bilateral pleural effusions.
.
Of note, the patient was most recently admitted ([**Date range (1) 17771**]) with
complaints of weakness and dyspnea. She was found to be
inurosepsis and was treated empirically with Meropenem and
Vancomycin (she has a history of prior urosepsis in [**6-/2180**],
speciating MDR E.coli). She was again found to have E.coli in
her urine as a source, and was treated with Meropenem IV and
switched to Ertapenem on discharge. She also had an NSTEMI with
positive tropoinin of 0.36 on admission (MB 10.6) which peaked
at 1.11 on HD#3, thought to be related to demand ischemia. Her
prior EKG had evidence of LBBB. ETT was obtained, showing a
likely distal LAD lesion, not cardiomyopathy, distal septal
akinesis, 3+ MR which may have been associated with volume. She
was aggressively diuresed with a Lasix gtt given her acute CHF
exacerbation and transitioned to Lasix 60 mg IV BID, likely
triggered by urosepsis. She was also treated with empirically
for C.diff with PO Vancomycin to end on [**2181-8-21**].
.
In the ED, VS BP 102-125 systolic, MAPs mid 50-60s, HR 63, RR
27, 98% 2L; the patient was hypoxic to the 90s on 2L. Bedside
ultrasound showed bilateral pleural effusions. IP was consulted
for possible thoracentesis, and diuresis was recommended. She
was given 60 mg IV Lasix. Her troponin was 0.38. BNP 24,918.
Levofloxacin 750 mg IV and Vancomycin 1g IV x 1 were given;
Lactate 0.6. She has a RUE PICC line.
.
She was admitted to MICU due to low MAPs to the 50s-60s in the
ED and oxygen saturations in the low 90s on 2 liters. In the
MICU, she was started on a Lasix gtt and metolazone was added.
She is LOS: -3.2 Liters. VS prior to transfer: 95.6 141/67 91 14
98% on 2L NC. Notably had visual hallucinations and started on
seroquel.
.
On the floor, she appears fatigued, but is in no acute distress.
She denies chest pain or trouble breathing. She denies
palpitations, lightheadedness, and feels only mildly dizzy when
standing. She denies headaches or vision changes. She has no
nausea or vomiting and has been tolerating diet.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea.
She does have some edema in her right leg; but she denies
palpitations, syncope.
Past Medical History:
PAST MEDICAL & SURGICAL HISTORY:
1. diastolic CHF (preserved EF 35-40%, moderate regional
systolic dysfunction, [**7-/2181**])
2. s/p renal transplant ([**2157**], complicated by chronic rejection,
second transplant [**2160**])
3. s/p pancreas transplant (with allograft pancreatectomy
[**5-/2174**], redo transplant [**6-/2175**], acute rejection [**7-/2180**] which
resolved with increased immunosuppresion)
4. diabetes mellitus type I (complicated by neuropathy,
retinopathy, dysautonomia, no longer requires regular insulin
after pancreas transplant)
5. autonomic neuropathy
6. sleep-disordered breathing (on 2L NC nighttime, unable to
tolerate CPAP)
7. osteoporosis
8. hypothyroidism
9. pernicious anemia
10. cataracts
11. glaucoma
12. anemia from chronic kidney disease (on Aranesp previously)
13. Right foot fracture, complicated by RLE DVT
14. chronic LLE edema
15. Reucrrent MDR E.coli pyelonephritis
16. s/p anal polypectomy ([**5-/2176**])
17. s/p bilateral trigger finger surgery ([**8-/2178**])
18. s/p left [**Year (4 digits) 6024**] ([**8-/2179**])
Social History:
Child psychiatrist, on disability. Lives alone in [**Hospital1 8**], MA.
Has a PCA 8 hours/day. Ambulatory with a prosthesis for left
leg. Was at [**Hospital3 **] prior to this admission. Denies
tobacco use or alcohol use; no recreational substance use.
Family History:
Father with MI at 57 year old; denies family history of
arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise
non-contributory.
Physical Exam:
ON ADMISSION (to floor):
VITALS: 97.3/97.3 122 98/52 20 98% 2L NC
GENERAL: Appears in no acute distress, but is fatigued. Alert
and interactive.
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear.
Mucous membranes appear dry. No xanthalesma.
NECK: supple without lymphadenopathy. JVD 6-7 cm.
CVS: irregularly irregular, [**1-28**] harsh, systolic murmur at base
and holosystolic murmur at apex, normal S1-S2. No S3 or S4.
RESP: Respirations unlabored, no accessory muscle use. Decreased
breath sounds at bases with bilateral inspiratory crackles to
mid-lung fields. No wheezing, rhonchi. Stable inspiratory
effort.
ABD: soft, non-tender, non-distended, with normoactive bowel
sounds. No palpable masses or peritoneal signs. Abdominal aorta
not enlarged to palpation, no bruit.
EXTR: no cyanosis, clubbing or edema, 2+ peripheral pulses RLE;
LLE [**Month/Day (4) 6024**] well-healed
DERM: No stasis dermatitis, ulcers, scars, or xanthomas.
NEURO: CN II-XII intact throughout. Alert and oriented x 3. DTRs
2+ throughout, strength 5/5 bilaterally (limited effort),
sensation grossly intact. Gait deferred.
PULSE EXAM:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
ON DISCHARGE:
Vitals: 98.6, 123/71 69 20 98% on 2L
General: chronically ill appearing, alert and oriented
Heart: RRR no m/r/g
Lungs: decreased at the bases R>L
Abdomen: soft, NT, ND, +BS
Extremities: 2+ edema, left [**Month/Day (4) 6024**]
Pertinent Results:
Admission Labs
[**2181-8-17**] 12:10PM BLOOD WBC-3.3* RBC-3.31* Hgb-9.6* Hct-29.6*
MCV-90 MCH-29.0 MCHC-32.5 RDW-15.4 Plt Ct-179
[**2181-8-17**] 12:10PM BLOOD Neuts-65.9 Lymphs-21.2 Monos-6.0 Eos-5.9*
Baso-1.0
[**2181-8-17**] 12:10PM BLOOD Glucose-88 UreaN-96* Creat-2.1* Na-130*
K-5.8* Cl-98 HCO3-23 AnGap-15
[**2181-8-17**] 12:10PM BLOOD ALT-12 AST-34 AlkPhos-96 TotBili-0.2
[**2181-8-17**] 12:10PM BLOOD proBNP-[**Numeric Identifier **]*
[**2181-8-17**] 12:10PM BLOOD cTropnT-0.38*
[**2181-8-17**] 12:57PM BLOOD pO2-92 pCO2-47* pH-7.27* calTCO2-23 Base
XS--5
[**2181-8-17**] 12:24PM BLOOD Lactate-0.6
.
EKG ([**2181-8-17**]): Sinus rhythm. Left atrial abnormality. A-V
conduction delay. Left bundle-branch block. No significant
change compared to the tracing of [**2181-8-1**].
.
2D-ECHOCARDGIOGRAM ([**2181-8-1**]): The left atrium is mildly dilated.
The left atrium is elongated. Left ventricular wall thicknesses
are normal. The left ventricular cavity is mildly dilated. There
is moderate regional left ventricular systolic dysfunction with
akinesis of the apex and hypokinesis of the distal segments of
the LV. The remaining segments contract normally (LVEF = 35-40
%). Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). Right ventricular
chamber size and free wall motion are normal. The diameters of
aorta at the sinus, ascending and arch levels are normal. 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. Moderate to severe
(3+) mitral regurgitation is seen. The tricuspid regurgitation
jet is eccentric and may be underestimated. There is moderate
pulmonary artery systolic hypertension. There is a trivial
physiologic pericardial effusion. There are no echocardiographic
signs of tamponade.
.
[**2181-8-17**] CXR - Interval enlargement of bilateral pleural
effusions. The adjacent bibasilar opacity is likely in part due
to the effusion and atelectasis; however, early developing
infiltrate in either or both areas is not excluded. Mild
interstitial prominence may indicate edema.
.
[**2181-6-22**] STRESS/P-MIBI - Mild to moderate reversible defect of the
distal anteroseptal and apical walls. Severe left ventricular
enlargement with mild systolic dysfunction. LVEF of 41%. The
patient was administered 0.142 mg/kg/[**Month/Day/Year **] of Persantine over four
minutes. No chest, neck, back, or arm discomforts were reported
by the patient throughout the study. Palpitations were reported
in the setting of PSVT. Post-infusion, ~0.5 mm of horizontal ST
segment depression was noted in leads V5-6, resolving by minute
12 post infusion. The rhythm was sinus with 2 runs of 7 and 11
beat PSVT (~130 bpm) and one apb throughout the study.
Appropriate hemodynamic response to the infusion. (0-4 minutes
0.142MG/ KG/[**Month/Day/Year **] vitals 73 126/60 RPP 9198 - total exercise
time 4 [**Month/Day/Year **], % max HR achieved: 46%)
.
[**2181-8-23**] CARDIAC CATH: Selective coronary angiography in this
right dominant system demonstrated three vessel disease. The
LMCA had no angiographically apparent disease. The LAD had a
proximal 90% stenosis, 90% D! and a long 40% mid LAD and diffuse
mild disease. The LCx had a mid 60% stenosis and 80% stenosis
small OM1. The RCA had a proximal 70% stenosis, mid 50% and 70%
distal. Resting hemodynamics revealed elevated right and left
sided filling pressures with RVEDP of 15 mmHg and PCW 32 mmHg.
There was moderate pulmonary artery systolic hypertension with
PASP of 60 mmHg. The cardiac index was preserved at 3.9
L/[**Month/Day/Year **]/m2. There was normal systemic arterial systolic and
diastolic central pressures at the aortic level. Left
ventriculography was deffered due to elevated filling pressures.
.
[**2181-8-24**] BLADDER U/S - No evidence of mobile debris in bladder to
suggest fungus ball as questioned. Thickened posterior bladder
wall, which could relate to known history of cystitis. As other
etiologies for bladder wall thickening cannot be entirely
excluded, suggest correlation with urine cytology.
.
[**2181-8-25**] CT HEAD NON-CONTRAST - No acute intracranial process.
.
[**2181-8-26**] EEG - This is an abnormal EEG because of diffuse
background
slowing and bursts of generalized delta slowing. These findings
are
indicative of a mild to moderate diffuse encephalopathy which is
etiologically non-specific. No epileptiform features were seen.
.
[**2181-8-27**] CXR PA & LATERAL - There are bilateral pleural effusions.
There is pulmonary vascular re-distribution. There is volume
loss at both bases. An underlying infectious infiltrate cannot
be excluded in these regions. Compared to the prior study the
pulmonary edema is worse and the PICC line position has changed
[**2181-8-30**] MRI HEAD - Suboptimal MRI study secondary to patient
motion. Within these limitations, unremarkable MRI of the head.
[**2181-9-3**] RUE U/S -
1. Non-occlusive thrombus in the right axillary and subclavian
veins.
2. Right-sided PICC line terminating in the right axillary vein
with thrombus in the basilic vein around the line.
DISCHARGE LABS
[**2181-9-7**] 04:40AM BLOOD WBC-2.1* RBC-3.30* Hgb-9.6* Hct-29.6*
MCV-90 MCH-29.1 MCHC-32.4 RDW-15.1 Plt Ct-149*
[**2181-9-7**] 04:40AM BLOOD PT-22.9* PTT-99.0* INR(PT)-2.1*
[**2181-9-7**] 04:40AM BLOOD Glucose-135* UreaN-91* Creat-2.3* Na-137
K-4.0 Cl-95* HCO3-31 AnGap-15
[**2181-9-7**] 04:40AM BLOOD Amylase-96
[**2181-9-7**] 04:40AM BLOOD Lipase-29
[**2181-9-7**] 04:40AM BLOOD Calcium-8.8 Phos-2.8 Mg-1.7
[**2181-9-5**] 04:20AM BLOOD rapmycn-7.0
[**2181-9-5**] 04:20AM BLOOD tacroFK-7.2
Brief Hospital Course:
60F with PMH significant for type 1 IDDM (s/p revision renal and
pancraes transplants, [**2160**] and [**2174**]), systolic CHF (Echo 35-40%,
[**7-/2181**]), sleep-disordered breathing (on 2L home oxygen at night)
who presented on [**2181-8-17**] with dyspnea and evidence of bilateral
pleural effusions consistent with acute CHF exacerbation.
.
# CHF - The patint has known systolic CHF with a 2D-echo showing
mild LV cavity dilatation, moderate LV dysfunction with akinesis
of the apex and hypokinesis of the distal segment; LVEF 35-40% -
admitted with dyspnea and fatigue attributed to volume overload
in the setting of acute CHF exacerbation, likely due to
inadequate diuresis. Put on a lasix drip while in the MICU, then
transferred to cardiology. The patient continued to demonstrate
evidence of CHF exacerbatio with 1+ pitting edema of the right
LE, B/L faint inspiratory crackles on exam, and CXR consistent
with pleural effusions. She was diuresed with IV lasix up to
80mg IV BID, and then transitioned to torsemide 80mg PO daily.
Continued to be net negative about 1L daily. Her torsemide was
decreased to 40mg daily on discharge. ACE-I was avoided given
her acute kidney injury. Medically optimized with beta-blocker
and diuretics.
# ACUTE ON CHRONIC RENAL INSUFFICIENCY - The patient had renal
insufficiency in the setting of known renal transplant (with
redo) and remained on chronic immune suppresion with Prednisone,
Tacrolimus and Sirolimus. She had acute kidney injury that was
assumed to be prerenal vs. contrast induced nephropathy. Her Cr
peaked at 3.1 post-cardiac cath before slowly downtrending to
2.3 even with continued diuresis. Baseline is about 1.5 to 1.9.
Her hyperphosphatemia was managed with calcium acetate with
meals TID which was discontinued after electrolyte
normalization. Prednisone continued was continued at 5mg daily.
Her tacrolimus was decreased to 1.5mg q12 and sirolimus was
decreased to 1mg qAM given her [**Last Name (un) **] on admission. These doses
were continued as an outpatient as her levels were around 7.
# RUE DVT - On [**9-3**], she was found to have swelling in her right
upper extremity. A ultrasound noted clot in the axillary and
subclavian, as well as clot surrounding the midline in the
basilic vein. She was started on a heparin drip to bridge her
coumadin. She was started on 5mg of warfarin on [**9-3**], and became
therapeutic at INR of 2.1 on [**9-7**]. She was given 7.5mg of
coumadin on [**7-6**], but this was unlikely to be responsible for
her therapeutic INR, so she was reduced to 5mg and discharged.
Heparin drip was stopped and midline PICC was removed prior to
discharge. She will need to complete a 3 mth course of
anticoagulation.
# s/p pancreatic transplant: continued on home
immunosuppressants although dose of tacrolimus and sirolimus
were downtitrated due to [**Last Name (un) **]. On day of discharge, fasting
blood glucose was mildly elevated to 135 although amylase/
lipase within normal limits. Labs will need to be followed
closely as an outpatient to ensure that there is no evidence of
rejection
# ATRIAL FIBRILLATION - The patient was admitted and transferred
from MICU with a stable rhythm that was normal sinus, but on
MICU trasnfer was noted to have new onset A.fib with no prior
history. On HOD#3 she had some evidence of rapid ventricular
reponse with a rate in the 110s (130 maximum), which responded
to diuresis. This was attributed to atrial stretch from volume
overload, and once diuresis ensued, her rhythm spontaneously
converted to sinus. The patient had no symptoms of palpitations
or chest pain, she only noted mild fatigue and dizziness which
eventually resolved. She was anticoagulated with a heparin gtt
given her paroxysmal A.fib, and maintained with a PTT goal of
50-80. We monitored her closely with telemetry and optimized her
electrolytes, and her rhythm remained sinus following these
issues. We initiated Metoprolol 25 mg PO twice daily for rate
control and given her CAD. Her telemetry showed no further
concerns regarding her rhythm and she remained sinus. Of note,
coumadin was started due to RUE DVT and she will not need to
continue anticoagulation for provoked episode of afib unless
further evidence of arrhythmia arises.
.
# CAD - The patient has documented ischemic cardiomyopathy with
evidence of a mild to moderate reverisble defect of the distal
anteroseptal and apical walls on P-MIBI from [**6-/2181**] with an LVEF
41%. She had a 2D-Echo with an of EF 35-40% as well. She
developed non-specific ST depression and PVST during the study.
On a prior admission she had an NSTEMI with troponin peak of
1.11 which was treated conservatively. This admission her
troponin was 0.38 -> 0.26 which was thought to be residual from
her prior NSTEMI (given evidence of [**Last Name (un) **] and chronic renal
insufficiency). On admission she denied chest pain, nausea or
palpitations. She was therefore medically optimized with
Aspirin, Metoprolol and a statin. She was also on a heparin gtt
briefly (discontinued on [**2181-8-25**]) for A.fib concerns. Given the
history of coronary disease and the P-MIBI findings from [**Month (only) 205**]
[**2180**] in the setting of her CHF exacerbation, she was taken to
the cardiac cath lab on [**2181-8-23**] which showed extensive disease
involving three-vessels. Specifically, the LMCA had no
angiographically apparent disease. The LAD had a proximal 90%
stenosis and a long 40% mid LAD and diffuse mild disease. The
LCx had a mid 60% stenosis and 80% stenosis small OM1. The RCA
had a proximal 70% stenosis, mid 50% and 70% distal. Resting
hemodynamics revealed elevated right and left sided filling
pressures with RVEDP of 15 mmHg and PCW 32 mmHg. There was
moderate pulmonary artery systolic hypertension with PASP of 60
mmHg. The cardiac index was preserved at 3.9 L/[**Date Range **]/m2. There was
normal systemic arterial systolic and diastolic central
pressures at the aortic level. Left ventriculography was
deffered due to elevated filling pressures. The Cardiac surgery
team evaluated the patient, but given the medical problems
noted, CABG was not recommended until her other medical issues
stabilize. In the meantime, she was continued on Aspirin,
Atorvastatin, and Metoprolol. She was without chest pain
following admission.
# URINARY TRACT INFECTION - The patient was noted to have a
positive U/A which grew yeast from urine cultures on [**8-15**].
This was treated with IV Fluconazole 100 mg IV daily (started on
[**2181-8-25**]). This was continued for 5-days. She had a bladder U/S
showing no evidence of a fungal ball. She also had no WBC or
fevers, although she was immunosuppressed. Her mental status
changes were attributed to the UTI and yeast infection. She was
restarted on suppressive therapy with fosfomycin following
discharge.
.
# NORMOCYTIC ANEMIA - The patient had a hematocrit that was
trending down this admission, with no obvious source of bleeding
identified - likely her renal insufficiency was contributing to
this normocytic anemia. Stool guaiac was negative x 2. She did
have some evidence of right thigh swelling with concern for
hematoma given her recent cardiac catheterization via the right
femoral access point. She was monitored with serial HCTs and
required a single unit of packed red cells, with adequate
response. A basic hemolysis panel was obtained to rule out a
hemolytic component to her anemia, this was negative and
reassuring. She remained hemodynamically stable and required no
further transfusions.
.
# LEUKOPENIA - The patient was admitted with leukopenia in the
setting of chronic immune suppression with Tacro and Sirolmus
with chronic steroid use. Her acyclovir was held given her
immune suppression and renal insufficiency. She had blood,
mycolytic and urine cultures repeatedly drawn given some
intermittent hypotension episodes and given her mental status
changes (noted below). With the exception of yeast in her urine,
her cultures were unrevealing. She remained afebrile this
admission.
.
# HALLUCINATIONS vs. DELIRIUM - The patient was noted to have
visual hallucinations which began in the MICU on admission. She
was given Seroquel at nighttime for concerns of ICU delirium and
sleep deprivation. Her mental status issues continued despite
removal of Seroquel and on transfer to the cardiology floor. She
always remained alert and oriented but had hallucinations of
tribal warrior visitors, a plethora of feline visitors and a
Chinese family. An infectious source was suspected, given her
yeast in the urine, which was treated with Fluconazole. Her
blood cultures were negative and she was afebrile. A head CT was
negative on [**2181-8-25**]. A neurology consult was obtained, noting the
above hallucinations with mild myoclonus. Toxic metabolic
encephalopathy was suspected vs. infectious etiology. We started
low dose Trazodone, stopped her Doxepin and Seroquel given her
renal function and AMS. Her visual hallucinations resolved with
all of these measures and Neuro consult signed off on [**2181-8-29**].
MRI head performed on [**8-30**] due to continued lethargy was also
without acute pathology. Mental status slowly resolved as
azootemia and CHF exacerbation resolved. On discharge, she
remained off doxepin, seroquel and all other CNS altering meds.
.
# SLEEP DISORDERD BREATHING - The patietn was noted to utilize
2L NC supplemental oxygen in the evening given a diagnoses of
sleep-disordered brathing; she cannot tolerate non-invasives; O2
sats > 95% on this admission. She was continued on pulse
oximetry, she was maintained on 2L nasal cannula at night. She
was given ipratropium and albuterol nebs. She had no further
issues this admission.
.
# EMPIRIC C.DIFF COVERAGE - The patient was recently treated
with Meropenem IV for urosepsis with E.coli (MDR) on a prior
admission. She was treated empirically with PO Vancomycin given
some frequent stools and leukopenia noted from her immune
suppresion. This admission, the patient remained afebrile, and
completed the PO Vanc course on [**2181-8-21**] with no further issues
of frequent stooling. She is also gluten-intolerant and required
diet adjustment. A C.diff on [**2181-8-28**] was negative.
.
# GLAUCOMA - The patient was continued on her home regimen of
Cyclosporin, Dorzolamide/Timolol, Brimonodine and Latanoprost
ophthalamic drops for her known chronic glaucoma. Methazolamide
was initially held because of concerns it was contributing to
renal failure. It was restarted for glaucoma and also for her
elevated bicarb.
.
# HYPOTHYRODISM - Her previous TSH was 0.7 in [**7-/2181**] and given
her intermittent A.fib as noted above, we checked her TSH which
was stable. We continued her Levothyroxine 110-112 mcg PO daily.
TRANSITIONS OF CARE:
# CHF exacerbation:
- daily weights/ monitor ins and outs
- diuresing well with torsemide (dose reduced from 80mg to 40mg
on discharge)
- adhere to low salt diet
- medical management of CAD
# DVT: midline pulled, INR therapeutic at 2.1
- monitor PT/INR and adjust coumadin accordingly
- maintain on anticoagulation x 3 mths
# s/p renal and pancreatic transplant
- cont sirolimus/ tacrolimus
- monitor amylase/lipase, fasting glucose and renal function
twice weekly
Medications on Admission:
1. fosfomycin tromethamine 3 gram: 1 packet PO QWeek: dissolve
in [**2-23**] ounces of water. Can be taken with or without food.
2. acyclovir 400 mg Tablet: 1 Tab PO Q12H
3. doxepin 10 mg Caps: 1 Capsule PO HS
4. doxazosin 1 mg Tab: 2 Tabs PO DAILY
5. levothyroxine 100 mcg Tab: 1 Tab PO EVERY OTHER DAY
6. levothyroxine 112 mcg Tab: 1 Tab PO EVERY OTHER DAY
7. aspirin 81 mg Tab: 1 Tab PO DAILY
8. methazolamide 50 mg Tab: 1 Tab PO TID
9. prednisone 5 mg Tab: 1 Tab PO DAILY
10. atorvastatin 40 mg Tab: 2 Tabs PO DAILY
11. folic acid 1 mg Tab: 1 Tab PO DAILY
12. albuterol sulfate 0.083 Nebs: 1 INH Q6H prn
13. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
14. ipratropium bromide 0.02%: 1 INH Q6H prn
15. teriparatide 20 mcg/dose Pen Injector: 1 ML Subcutaneous
daily
16. sirolimus 1 mg Tab: 2 Tab PO DAILY administered at 6am.
17. carvedilol 12.5 mg Tab: 1 Tab PO BID
18. tacrolimus 0.5 mg Cap: 4 Caps PO Q12H
19. furosemide 20 mg Tab: 1 Tab PO BID
20. senna 8.6 mg Tab: 1 Tab PO BID
21. acetaminophen 325 mg Tab: 1-2 Tabs PO Q6H prn fever, pain.
22. gabapentin 100 mg Cap: 1 Cap PO DAILY
23. gabapentin 100 mg Cap: 2 Caps PO HS
24. lisinopril 5 mg Tab: 0.5 Tab PO HS (at bedtime)
25. cyclosporine 0.05 % Drops: 1 Drop Ophthalmic daily
26. brimonidine 0.15 % Drops: 1 Drop Ophthalmic Q8H
27. latanoprost 0.005 % Drops: 1 Drop Ophthalmic HS
28. lipase-protease-amylase 12,000-38,000 -60,000 unit Cap: 1
Cap PO TID with meals
29. dorzolamide-timolol 2-0.5 % Drops: 1 Drop Ophthalmic [**Hospital1 **]
30. oxygen 1-2L PRN SOB or sats <91%
31. Calcium 500 + D 500 mg(1,250mg) -400 unit Tab: 1 Tab PO
daily
32. Aranesp 60 mcg/mL: 1 mL Inj once a month
33. vancomycin 125 mg Cap: 1 Cap PO Q6H until [**2181-8-21**].
34. pentamidine 300 mg INH: 1 INH once a month.
.
Discharge Medications:
1. fosfomycin tromethamine 3 gram Packet Sig: One (1) packet PO
once a week.
2. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO 3X/WEEK
([**Doctor First Name **],TU,TH).
3. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO 4X/WEEK
(MO,WE,FR,SA).
4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. methazolamide 50 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
6. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) inh Inhalation Q6H (every 6 hours) as
needed for sob/wheeze.
10. ipratropium bromide 0.02 % Solution Sig: One (1) inh
Inhalation Q6H (every 6 hours) as needed for sob/wheeze.
11. teriparatide 20 mcg/dose - 600 mcg/2.4 mL Pen Injector Sig:
One (1) injection Subcutaneous once a day.
12. sirolimus 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
at 6am.
13. tacrolimus 0.5 mg Capsule Sig: Three (3) Capsule PO Q12H
(every 12 hours).
14. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
15. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
16. cyclosporine 0.05 % Dropperette Sig: One (1) drop Ophthalmic
[**Hospital1 **] (2 times a day).
17. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H
(every 8 hours).
18. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
19. lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Capsule, Delayed
Release(E.C.) PO three times a day: with meals.
20. dorzolamide-timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
21. Calcium 500 + D 500 mg(1,250mg) -400 unit Tablet Sig: One
(1) Tablet PO once a day.
22. Aranesp (polysorbate) 60 mcg/mL Solution Sig: One (1)
injection Injection once a month: most recent dose [**2181-9-7**].
23. pentamidine 300 mg Recon Soln Sig: One (1) inhalation
Inhalation once a month.
24. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
25. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
26. torsemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
27. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary Diagnoses:
1. acute CHF exacerbation
2. diastolic heart failure
3. acute on chronic renal insufficiency
Secondary Diagnoses:
1. pancreas and renal transplant patient (on immunosuppression)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms. [**Known lastname 17759**],
You were admitted to the hospital due to worsening of your
congestive heart failure. You were initially admitted to the
ICU, then the Cardiology service, and lastly the Kidney service.
We gave you diuretics to help reduce the extra fluid in your
lungs and legs.
.
CHANGES IN YOUR MEDICATION RECONCILIATION:
You should START: torsemide 40mg daily for diuresis
You should START: warfarin 5mg daily for anti-coagulation
You should START: aspirin 325mg daily for heart disease
You should START: metoprolol 25mg twice a day for blood pressure
and heart disease
* The following medications were DISCONTINUED on admission and
you should NOT resume:
DISCONTINUE: doxepin
DISCONTINUE: doxazosin
DISCONTINUE: furosemide (this has been replaced by torsemide)
DISCONTINUE: gabapentin
DISCONTINUE: carvedilol (this has been replaced by metoprolol)
DISCONTINUE: lisinopril (until your renal function has improved)
* You should continue all of your other home medications as
prescribed, unless otherwise directed above.
Followup Instructions:
Department: CARDIAC SERVICES
When: WEDNESDAY [**2181-9-12**] at 2:20 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: TRANSPLANT CENTER
When: TUESDAY [**2181-9-25**] at 9:40 AM
With: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**Name6 (MD) 2105**] [**Name8 (MD) 2106**] MD [**MD Number(2) 5038**]
ICD9 Codes: 5849, 2762, 2761, 4280, 412, 5859, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3504
} | Medical Text: Admission Date: [**2154-5-27**] Discharge Date: [**2154-6-3**]
Date of Birth: [**2085-3-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Niacin / Lopressor
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
DOE
Major Surgical or Invasive Procedure:
[**2154-5-29**] AVR (23mm CE Magna porcine)/ MVR ([**Street Address(2) 12523**]. [**Male First Name (un) 923**]
porcine valve)/ Maze procedure/ligation left atrial appendage
History of Present Illness:
69 yo male with history of RHD/Afib, found to have valvular
stenosis in [**2146**].Recently experiencing DOE and had a recent
admission for lung biopsy for BOOP. Coumadin was recently
stopped and he had a CVA in [**3-16**].Recent echo showed severe
MR/MS/AS.
Past Medical History:
rheumatic heart disease
A fib
MR/MS/AS
depresseion
CVA
interstitial lung disease
prior amiodarone toxicity
BOOP
depression
OA
elev. chol.
BPH
PNA
pneumothorax
hypothyroidism
diverticulosis
GERD
Social History:
retired
lives with wife
social ETOH
quit 30 years ago, 35 pack/yr hx
Family History:
father died at 49
Physical Exam:
98 T 104/53 HR 80 RR 18 96% RA sat
alert and oriented x3, moments of short term memory loss evident
[**Last Name (un) **], EOMI, 2+ carotids, no bruits, no JVD
4/6 SEM, no r/g
right basilar faint inspiratory wheezes
abd benign
trace pretibial edema, no c/c
5'8" 155#
Pertinent Results:
[**2154-5-31**] 06:00AM BLOOD WBC-11.9* RBC-3.14* Hgb-9.9* Hct-28.7*
MCV-91 MCH-31.6 MCHC-34.7 RDW-15.0 Plt Ct-145*
[**2154-5-31**] 06:00AM BLOOD Glucose-95 UreaN-10 Creat-0.8 Na-135
K-3.7 Cl-98 HCO3-29 AnGap-12
[**2154-5-27**] 05:29PM BLOOD %HbA1c-6.1*
PRE CPB The left atrium is moderately dilated. The left atrium
is elongated. Mild spontaneous echo contrast is seen in the body
of the left atrium. Moderate to severe spontaneous echo contrast
is present in the left atrial appendage. The left atrial
appendage emptying velocity is depressed (<0.2m/s). No
definitive thrombus is seen in the left atrial appendage. No
atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thickness, cavity size, and global systolic
function are normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. There are simple atheroma in
the aortic arch. The descending thoracic aorta is mildly
dilated. There are simple atheroma in the descending thoracic
aorta. There are three aortic valve leaflets. The aortic valve
leaflets are moderately thickened. There is moderate to severe
aortic valve stenosis (area 1.0cm2). Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened. The mitral valve shows characteristic rheumatic
deformity. There is moderate to severe valvular mitral stenosis
(area 1.0 cm2). Mild to moderate ([**1-9**]+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. There
is mild tricuspid regurgitation. There is a trivial/physiologic
pericardial effusion. Dr. [**Last Name (STitle) 914**] was notified in person of the
results in the operating room at the time of the study.
POST CPB Patient is being atrially paced. Normal biventricular
systolic function. Bioprosthesis in the mitral position is
oriented towards the left ventricular outflow tract but is well
seated. Leaflet motion is normal. There is trace valvular mitral
regurgitation. The maximum pressure gradient across the mitral
valve is 13 mm Hg with a mean pressure gradient of 4 mm Hg at a
cardiac output of 6.5 l/m. There is a bioprosthesis located in
the aortic position. It is not well seen but it does appear well
seated with normal leaflet function. There is at least trace
valvular aortic regurgitation but shadowing and poor echo
windows prevent full assessment of the regurgitation. The
maximum pressure gradient across the aortic valve is 14 mm Hg.
The left atrial appendage has been resected. The thoracic aorta
appears intact.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD, Interpreting physician
[**Last Name (NamePattern4) **] [**2154-5-29**] 14:26
Brief Hospital Course:
Admitte [**5-27**] for IV heparin bridge off coumadin. PAT w/u
completed. Underwent surgery [**5-29**] with Dr. [**Last Name (STitle) 914**]. Transferred
to the CVICU in stable condition on titrated propofol and
phenylephrine drips. Extubated that evening. Beta blockade
titrated and transferred to the floor on POD #1. Chest tubes and
pacing wires removed on POD #2. Coumadin restarted on POD #2.
CXR stable post CT removal. Pt consult / pt cleared for home.
Diuresis continued. This was carried on. On Dc INR is 1.2. Pt is
a chronic afibber. Dr [**First Name (STitle) **] will follow in the usual manner.
Coumadin has been discussed thouroughly with the patient. he
agrres with the paln.
Medications on Admission:
lasix 10 mg daily
Kcl 20 mEq daily
aldactone 25 mg daily
digoxin 0.25 mg daily
levothyroxine 75 mcg daily
verapamil 180 mg daily
celexa 20 mg [**Hospital1 **]
risperdal 0.25 mg [**Hospital1 **]
Ca++ 500 mg + D [**Hospital1 **]
coumadin 4 mg M,W,F (LD [**4-24**])
coumadin 3 mg T, [**Last Name (un) **], SAT, SUN
prednisone 5mg (LD [**5-21**])
claritin 10 mg daily
ASA 81 mg daily
MVI daily
pravachol 40 mg daily
selenium 200 mg daily
prilosec 20 mg daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. 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. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO 3X/WEEK
(MO,WE,FR).
Disp:*180 Tablet(s)* Refills:*2*
4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
5. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. 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*
7. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
9. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO 4X/WEEK
([**Doctor First Name **],TU,TH,SA).
Disp:*360 Tablet(s)* Refills:*2*
10. Citalopram 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
11. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
Disp:*30 Suppository(s)* Refills:*0*
12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain: prn.
Disp:*30 Tablet(s)* Refills:*0*
13. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO BID (2 times a
day) for 7 days.
Disp:*0 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
14. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
15. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO Q 8H
(Every 8 Hours).
Disp:*90 Tablet(s)* Refills:*2*
16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
17. Lasix 20 mg Tablet Sig: [**1-9**] tab Tablet PO once a day: start
after you complete the 40 mg daily dose.
Disp:*15 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] care
Discharge Diagnosis:
AS/MR s/p AVR/MVR/ Maze/ligation LAA
interstitial lung disease
rheumatic heart disease
A fib
CVA
BOOP/amiodarone toxicity
s/p thoracoscopic wedge resecton [**2-15**]
depression
OA
elev. chol.
BPH
PNA
pneumothorax [**1-15**]
hypothyroidism
diverticulosis
GERD
Discharge Condition:
stable
Discharge Instructions:
shower daily and pat incisions dry
no lotions, creams, or powders on any incision
no driving for one month
no lifting greater than 10 pounds for 10 weeks
call for fever greater than 100, redness or drainage
You came in on coumadin, have your INR followed in the usual
manner.
Followup Instructions:
see Dr. [**Last Name (STitle) 914**] in [**2-10**] weeks [**Telephone/Fax (1) 170**]
see Dr. [**Last Name (STitle) 55499**] in 4 weeks
INR:
See Dr. [**Last Name (STitle) 78476**] [**Name (STitle) 13434**] on DC. Your coumadin has not
changed.Keep on the same dose. Go to the lab you go to in
[**Location (un) **] and have your INR drawn NLT [**6-5**]. You are already tied
into the lab. Just in case I aven gven you a prescription for
INR draw. Take this withyou. I hav also set up VNA to draw your
INR. For some reason they cqnnot do,it is your responibiity to
have your INR drawn.
Completed by:[**2154-6-2**]
ICD9 Codes: 311, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3505
} | Medical Text: Admission Date: [**2200-3-18**] Discharge Date: [**2200-3-25**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is an 89-year-old
woman with complaints of incontinence and difficulty
ambulating and headaches. The patient reported recent falls
including [**2200-3-18**], and a month prior to admission.
The patient per EMS attempted to ambulate on the morning of
discharged from rehabilitation recovering from a fall and
admitted on [**2-1**] with head CT. On the day of admission
she complained of left-sided weakness.
PAST MEDICAL HISTORY: Coronary artery disease. Status post
coronary artery bypass grafting in [**2190**]. Congestive heart
failure with an ejection fraction of 30%. Atrial
Glaucoma. Hypertension. Tachy-brady syndrome. Status post
pacer in [**2191**].
PAST SURGICAL HISTORY: Coronary artery bypass grafting in
[**2190**]. Cataract surgery.
MEDICATIONS: Zestril 10 mg p.o. q.d., Coumadin 2.5 mg q.d.,
Lipitor 10 mg q.d., Levoxyl 15 mg q.d., Lasix 20 mg q.d.,
Glipizide 5 mg b.i.d., Atenolol 75 mg q.d., Aspirin 81 mg
p.o. q.d.
ALLERGIES: BACTRIM.
PHYSICAL EXAMINATION: General: The patient was awake and
alert, oriented to self only. Speech was clear but slow.
HEENT: She had a surgical pupils bilaterally. Extraocular
movements full. She had a decreased nasolabial fold.
Extremities: Her strength in the upper extremity was good on
the right. No antigravity strength on left. She had 2 out
of 5 leg strength, 5 out of 5 on the right, 4 out of 5 in the
left IP,. [**Last Name (un) 938**]. Sensation was grossly intact. Toes
were up on the left, down on the right. Her reflexes were 2+
at the knees, absent at the ankles.
LABORATORY DATA: Head CT showed bilateral subacute large
subdural hematomas with increased layering on the left
greater than right with no midline shift or change in
ventricle.
Her white count was 6.3, hematocrit 34.9, platelet count 237;
INR 2.6, PT 14.3, PTT 31.3.
HOSPITAL COURSE: The patient was admitted into the Surgical
Intensive Care Unit. Her INR was corrected down to less than
1.3. The patient was brought to the OR for surgical
drainage. Once her INR was corrected, she did deteriorate
neurologically becoming more somnolent prior to surgery.
On [**2200-3-20**], she underwent bilateral twist drill
drainage of the right subdural hematoma without
intraoperative complication. Postoperatively the patient was
awake and alert, and oriented times three. She continued to
have a left facial with left upper extremity weakness, but
she was 5 out of 5 in bilateral IPs. She put out 180 cc of
bloody drainage from her subdural drain postoperatively.
Repeat head CT postoperatively showed good evacuation of the
right subdural hematoma. The patient's drain was
discontinued on [**2200-3-21**], and the patient was
transferred to the regular floor. She was seen by Physical
Therapy and Occupational Therapy and found to require
rehabilitation prior to discharge to home.
DISCHARGE MEDICATIONS: Lisinopril 10 mg p.o. q.d.,
Atorvastatin 10 mg p.o. q.d., Levoxyl 15 mcg p.o. q.d., Lasix
20 mg q.d., Glipizide 5 mg p.o. b.i.d., Atenolol 75 mg p.o.
q.d., Zantac 150 mg p.o. q.d.
CONDITION ON DISCHARGE: The patient was stable at the time
of discharge.
FOLLOW-UP: She will follow-up with Dr. [**First Name (STitle) **] in [**2-3**] weeks with
repeat head CT prior to the appointment.
[**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2200-3-25**] 12:03
T: [**2200-3-25**] 12:12
JOB#: [**Job Number 22704**]
ICD9 Codes: 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3506
} | Medical Text: Admission Date: [**2152-4-11**] Discharge Date: [**2152-4-14**]
Date of Birth: [**2104-6-24**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization X 2
History of Present Illness:
47 y/o male with dyslipidemia, +tob, emergently transferred from
[**Hospital3 **] for anterior STEMI. He noted epigastric pain
(no CP/SOB/palp/n/v) 4 days ago that resolved spont. Then had
intermittent pain over the next 2 days. On day of admission
noted worse pain with 1 episode vomiting, worse with exertion.
Preseted to [**Hospital1 46**] at 11:pm. Transeferred to [**Hospital1 18**] and given
plavix/asa/lopressor/aggrastat.
Past Medical History:
hyperlipidemia
smoking
Social History:
tob [**12-12**] PPD X 20 years
Family History:
non-copntrib
Physical Exam:
97.1 80's 100's-110's/60's-80's 16 Sp02 99% RA
Gen: NAD
Neck: No JVD
Heart: RRR no mrg. PMI non-displaced
Lungs: Clear, no crackles.
Abd: Soft, nt/nd. NABS
Ext: No c/c/e
Pertinent Results:
[**2152-4-13**] 07:35AM BLOOD WBC-9.8 RBC-4.53* Hgb-14.0 Hct-39.3*
MCV-87 MCH-30.8 MCHC-35.5* RDW-13.9 Plt Ct-197
[**2152-4-13**] 07:35AM BLOOD Plt Ct-197
[**2152-4-13**] 07:35AM BLOOD PT-12.3 PTT-23.3 INR(PT)-1.0
[**2152-4-13**] 07:35AM BLOOD Glucose-87 UreaN-15 Creat-1.0 Na-142
K-4.2 Cl-108 HCO3-24 AnGap-14
[**2152-4-12**] 03:02AM BLOOD CK(CPK)-881*
[**2152-4-11**] 05:56PM BLOOD CK(CPK)-1418*
[**2152-4-11**] 03:01AM BLOOD ALT-33 AST-118* LD(LDH)-317*
CK(CPK)-1359* AlkPhos-88 TotBili-0.4
[**2152-4-12**] 03:02AM BLOOD CK-MB-54* MB Indx-6.1* cTropnT-2.86*
[**2152-4-11**] 05:56PM BLOOD CK-MB-119* MB Indx-8.4*
[**2152-4-11**] 03:01AM BLOOD CK-MB-142* MB Indx-10.4*
[**2152-4-13**] 07:35AM BLOOD Calcium-9.0 Phos-3.3 Mg-1.8
Cardiac Cath #1 ([**4-11**]):
1. Selective coronary angiography revealed a right dominant
system with
multivessel disease. The LMCA had a 50% distal lesion. The LAD
had a 99%
lesion in the mid vessel with diffuse 60% proximal and mid
disease. The
LCX had a 70% mid and 80% distal lesion. THe RCA had a 70%
mid-distal
lesion.
2. Hemodynamics post PCI showed mildly elevated right sided
filling
pressures (RA mean 11, RVEDP 14 mm Hg, PASP 30 mm Hg) and mild
to
moderately elevated left sided filling pressures (PCWP 20 mm
Hg). The
cardiac index was low normal at 2.1.
3 Successful stenting of the LAD was performed with a 2.5 x 28
mm
Cypher DES, terminating an acute anterior myocardial infarction.
4. The groin was closed with an Angioseal.
Cardiac Cath #2 ([**4-13**]):
1. Coronary angiography in this right dominant circulation
demonstrated
two vessel CAD. The LMCA had mild distal disease and the LAD
stent was
widely patent. The LCX had a focal 90% lesion at the origin of
two
medium-sized marginals. The RCA had a tubular lesion in the
mid-portion
up to 90%.
2. Successful stenting of the LCX was performed with a 2.5 x 23
mm
Cypher DES.
3. Successful stenting of the RCA was performed with
overlapping 2.5 x
23 mm and 3.0 x 33 mm Cypher DES.
ECHO ([**4-11**]): The left atrium is normal in size. Left ventricular
wall thicknesses and cavity size are normal. There is severe
regional left ventricular systolic dysfunction with hypokinesis
of the basal half of the inferior septum, inferior and
inferolateral walls and near akinesis of other segments. The
apex is mildly dyskinetic. No masses or thrombi are seen in the
left ventricle. Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets appear
structurally normal with good leaflet excursion. No aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. Mild
(1+) mitral regurgitation is seen. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
Brief Hospital Course:
A/P: 47 y/o male with dyslipidemia and smoking hx who p/w acute
anterior STEMI, found to have 3VD and LMC dz s/p mid-LAD [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) **].
1. CAD: Pt diagnosed with acute anterior STEMI at OSH and
transferred for emergent PCI. He had his prox LAD successfullky
stented terminating the STEMI. His CK peaked at 1418 and MB at
142. He was then taken to the CCU where he was monitored. He
was treated with asa/plavix/beta-blocker/ACE/statin. He was
then taken back to the cath lab where he had his LCx and RCA
successuflly stented with DES on [**2152-4-13**]. He remained chest pain
free during the hospitalization. He will be discharged with
asa/plavix/statin/beta-blocker/ace/aldactone.
2. Pump: Pt has a severe ischemic cardiomyopathy with EF ~20%.
This was prior to his second PCI, so I expect some degree of
recovery. He will require another ECHO in 30 days and if his EF
is < 30%, he will meet MADDIT II criteria and require
prophylactic ICD for primary prevention of SCD. Currently he is
not volume overloaded and requires no diuretic. Given his
normal serum K, he will not be discharged with
aldactone/epelrenone (EPHESUS). He will need his serum K
monitored.
3. Rhythm: Pt had 2 episodes of AIVR approx 12 hours after his
STEMI. Otherwise, he remained in NSR. He may require an ICD,
as per #2.
3. Smoking: Pt states he will not smoke anymore (30+ pack year
history).
Medications on Admission:
none
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily) for 300 days.
Disp:*30 Tablet(s)* Refills:*3*
3. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Toprol XL 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*
5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*0*
7. Lisinopril 5 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Acute Anterior ST Elevation MI
Discharge Condition:
Good
Discharge Instructions:
If you have these symptoms, call your doctor or go to the ER:
- shortness of breath
- chest pain
- nausea
- dizziness
- visual change
- palpitations
Followup Instructions:
PCP [**Name Initial (PRE) 176**] 2 days. You need to have your INR checked
Completed by:[**2152-4-14**]
ICD9 Codes: 4280, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3507
} | Medical Text: Admission Date: [**2184-8-23**] Discharge Date: [**2184-8-31**]
Date of Birth: [**2184-8-23**] Sex: M
Service: Neonatology
HISTORY OF PRESENT ILLNESS: Boy [**Known lastname **] was admitted for
prematurity, respiratory distress, and rule out sepsis. He
was a 785-gram male born at 23 and 6/7 weeks by spontaneous
vaginal delivery to a 38-year-old gravida 6, para 4 to 5
female.
Her pregnancy was complicated by a history of incompetent
cervix. She presented two weeks prior to his birth with
cervical funneling and had a cerclage placed. She was
admitted on [**8-22**] with preterm premature rupture of
membranes. She was treated with ampicillin and gentamicin as
well as betamethasone. Labor progressed rapidly, and boy
[**Known lastname **] was born on [**2184-8-23**]. He had spontaneous
respirations, and Neonatology team arrived at one minute of
life. He received positive pressure ventilation and was
electively intubated in the delivery room. He had Apgar
scores were 5 at one minute of age and 7 at five minutes of
age.
Prenatal screening laboratories were O positive, antibody
negative, rapid plasma reagin nonreactive, hepatitis B
surface antigen negative, and group B strep status unknown.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM:
1. RESPIRATORY ISSUES: The patient was intubated in the
delivery room. He received a total of three doses of
surfactant. He was initially on high frequency but then was
switched to synchronized intermittent mandatory ventilation
on [**8-25**]. He was weaned down to minimal ventilatory
settings until [**8-30**] when he began to have increasing
requirements and had to be switched back to high frequency
ventilation.
A chest x-ray on [**8-31**] showed right upper lobe
atelectasis versus pneumonia. The patient was taken off
ventilatory support at the parents' request for worsening
respiratory status in the setting of a poor neurological
prognosis.
2. CARDIOVASCULAR ISSUES: The infant initially had a low
mean blood pressure requiring normal saline boluses and a
dopamine drip. He was weaned off of dopamine on [**8-25**]
and subsequently maintained a stable blood pressure.
3. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: Birth weight was
785 grams. He was initially kept nothing by mouth and
started on parenteral nutrition. He was started on enteral
feeds on [**8-29**] at 10 cc/kg per day. However, oral
feedings were discontinued on [**8-30**] due to a bilious
aspirate. Initially, he was hypoglycemic with dipsticks in
the 40s requiring D-10 boluses and an increased glucose
infusion rate. However, he then became hyperglycemic with
dipsticks as high as 260. Intravenous fluids were changed,
and he received one dose of 0.1 units subcutaneously per
kilogram. He had an umbilical/arterial catheter and a double
lumen umbilical venous catheter placed on day of life one.
The umbilical arterial catheter was discontinued on [**8-28**]. A peripherally inserted central catheter line was placed
on [**8-30**]. His weight on [**8-31**] was 740 grams.
4. GASTROINTESTINAL ISSUES: Following a bilious aspirate on
[**8-30**], enteral feedings were discontinued. A bluish
abdominal hue was noted, and a KUB on [**8-31**] was concerning
for necrotizing enterocolitis.
Initially bilirubin revealed a total bilirubin of 3.1 with a
direct bilirubin of 0.2 on [**8-24**]. He was started on
single phototherapy. His bilirubin peaked on [**8-28**] with a
total bilirubin of 4.9 and a direct bilirubin of 0.4. His
bilirubin on [**8-31**] included a total bilirubin of 2.6 with
a direct bilirubin of 0.6.
5. HEMATOLOGIC ISSUES: The patient had blood type O
positive. He was transfused for a hematocrit of 32 following
consent from the parents on [**8-26**]. His last hematocrit
on [**8-30**] was 37.
6. INFECTIOUS DISEASE ISSUES: He was started on ampicillin
and gentamicin initially for rule out sepsis. The
antibiotics were discontinued following negative blood
cultures at 48 hours of life.
A chest x-ray on [**8-31**] and increasing ventilatory support
were concerning for pneumonia. A repeat complete blood count
and blood culture were drawn with plans to begin a course of
vancomycin and gentamicin.
7. NEUROLOGIC ISSUES: A head ultrasound on [**8-24**]
showed a large left intraventricular hemorrhage with
parenchymal extension as well as a right general matrix
hemorrhage. A repeat head ultrasound on [**8-25**] showed
worsening intraventricular hemorrhage on the left side with
further parenchymal extension, a worsening midline shift, and
a worsening right intraventricular hemorrhage with bleeding
into the ventricles. A repeat head ultrasound on [**8-31**]
showed rapid progression with increased bilateral
ventriculomegaly with visible clot in the ventricles.
8. PSYCHOSOCIAL ISSUES: The [**Hospital1 **] [**First Name (Titles) 7355**]
[**Last Name (Titles) **] was involved with the family. The contact social worker
is [**Name (NI) 553**] [**Name (NI) **], and she can be reached at telephone number
[**Telephone/Fax (1) 8717**]. Follow-up bereavement counseling will be
provided by the Neonatal Intensive Care Unit team.
On [**8-31**], the repeat head ultrasound results showing
worsening intraventricular hemorrhage, and a poor neurologic
prognosis, as well as the increased ventilatory requirement,
and the concern for pneumonia and necrotizing enterocolitis,
a discussion was held with the family and the decision was
made to remove ventilatory support. The infant expired soon
afterwards.
DISCHARGE DIAGNOSES:
1. Extreme Prematurity.
2. Bilateral intraventricular hemorrhage.
3. Respiratory distress syndrome.
4. Rule out sepsis.
5. Rule out necrotizing enterocolitis.
[**First Name11 (Name Pattern1) 37693**] [**Last Name (NamePattern4) 37927**], M.D. [**MD Number(1) 37928**]
Dictated By:[**Doctor Last Name 50677**]
MEDQUIST36
D: [**2184-8-31**] 18:59
T: [**2184-8-31**] 19:01
JOB#: [**Job Number 50678**]
ICD9 Codes: 769, 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3508
} | Medical Text: Admission Date: [**2165-12-30**] Discharge Date: [**2166-1-2**]
Date of Birth: [**2111-2-6**] Sex: M
Service: MEDICINE
Allergies:
Aleve
Attending:[**First Name3 (LF) 4975**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
right internal jugular central venous line placement
cardiac catheterization x 2
History of Present Illness:
54 yo M with HTN, hyperlipidema, and cervical spondylosis who
initially presented with CP and SOB x 24 hours and is now called
out of the MICU for further management on the cardiology
service.
.
The patient reports difficulty catching his breath starting on
the afternoon prior to admission. Denies orthopnea, PND, or
lower extremity edema. Also describes an episosde of left sided
[**7-19**] chest pressure starting on the afternoon prior to admission
at rest which watching TV. Denies nausea/vomiting/diaphoresis.
Denies radiation, but states his left arm felt numb. Denies loss
of consciousness. Reports voluminous water diarrhea x 3 days 6
BMs per day, non-bloody. No recent antibiotics. Chest pain was
constant until the day of admission when the patient called for
EMS and was given sublingual nitroglycerin, which he reports
completely palliated his chest pain. He was taken to OSH by EMS,
where CXR showed volume overload and BNP elevated to 1700. CK
was noted to be 404, mB 9.9 MBI 2.5, Trop-T: 0.029. He was given
ASA 324 mg x1, SL NTG x1, and lasix 20 mg IV x1. He was started
on nitro gtt and bipap for presumed CHF. Na also noted to be
114. Transferred to [**Hospital1 18**] for further cardiac evaluation.
.
In the ED, initial vital signs were T 99.4 HR 90 BP 135/61 RR 29
Sat 97% on bipap. Patient was chest pain free. However, cardiac
enzymes were noted to be positive (CK 583 MB 19, Trop-T 0.11).
The patient received Benadryl 50 mg IV x1, and combivent nebs.
Urine output noted to be 4500 cc. The patient was weaned off
bipap to 4 L NC. A right interval jugular central venous line
was also placed prior to ICU transfer. Also started on heparin
gtt for concern for ACS (guiac neg in ED).
.
The patient was admitted to the intensive care unit. There, he
denied any chest pain and stated that his shortness of breath
had improved. The patient was treated overnight with 1L NS,
metoprolol, captopril, and nitroglycerin drip. He was
transferred to the cardiology service for further management.
.
The patient underwent cardiac catheterization, which showed
heavy calcification of all coronaries, LAD 60% long proximal
stenosis, LCX occluded after OM2, RCA 80% mid calcified lesion.
An attempt was made to apply PTCA to the mid RCA, but this was
unsuccessful due to inability for full expansion of angioplasty
balloons in a heavily calcified lesion.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, 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,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS:: -Diabetes, +Dyslipidemia,
+Hypertension
2. CARDIAC HISTORY:
-CABG: n/a
-PERCUTANEOUS CORONARY INTERVENTIONS: n/a
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
Hypertension
Dyslipidemia
C4 disc herniation with myelopathy
GERD
Cervical spondylosis
Social History:
On disability. lives with a roommate in [**Location (un) 1411**].
Tobacco: Current smoker (1 ppd x30 years). Has Chantix at home,
has not yet used.
EtOH: [**5-15**] drinks per weekend day, [**1-11**] on some weekdays.
Drugs: Denies IVDU or illicits
Family History:
Extensive family history of MI (mother w/ MI in 50s, brother
with CABG in 40s, brother died sudden death in 30s, father with
MI at 76)
Physical Exam:
VS: BP 158/67, HR 68, RR 20, Sat 97% on RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with no obvious elevation of JVP, R. CVL in place.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use, diffuse expiratory
wheezing.
ABDOMEN: obese, Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+
neuro: cn2-12 intact.
Pertinent Results:
Admission labs:
[**2165-12-30**] WBC-10.6 RBC-4.43* Hgb-14.9 Hct-41.3 MCV-93 MCH-33.6*
MCHC-36.1* RDW-13.5 Plt Ct-263
[**2165-12-30**] Neuts-86.7* Lymphs-7.0* Monos-6.0 Eos-0.1 Baso-0.2
[**2165-12-30**] PT-13.9* PTT-26.5 INR(PT)-1.2*
[**2165-12-30**] Glucose-133* UreaN-9 Creat-0.9 Na-117* K-4.3 Cl-81*
HCO3-24
[**2165-12-30**] Calcium-9.4 Phos-2.2* Mg-1.7
[**2165-12-31**] ALT-26 AST-48* LD(LDH)-190 AlkPhos-61 TotBili-1.1
[**2166-1-1**] 05:50AM BLOOD %HbA1c-5.8
[**2165-12-31**] 04:36AM BLOOD Triglyc-51 HDL-47 CHOL/HD-2.1 LDLcalc-41
[**2165-12-30**] 10:34PM BLOOD Osmolal-268*
.
Discharge labs:
[**2166-1-2**] WBC-7.1 RBC-3.44* Hgb-12.3* Hct-34.5* MCV-100*
MCH-35.8* MCHC-35.7* RDW-13.5 Plt Ct-227
[**2166-1-2**] Neuts-74.6* Lymphs-17.6* Monos-6.6 Eos-0.9 Baso-0.4
[**2166-1-2**] PT-12.6 PTT-26.2 INR(PT)-1.1
[**2166-1-2**] Glucose-130* UreaN-8 Creat-0.8 Na-134 K-3.9 Cl-98
HCO3-26 [**2166-1-2**] 05:53AM BLOOD Calcium-9.0 Phos-5.0* Mg-1.9
.
Cardiac enzymes:
[**2166-1-2**] 10:40AM CK(CPK)-653* CK-MB-43* MB Indx-6.6*
cTropnT-0.46*
[**2166-1-2**] 05:53AM CK(CPK)-474* CK-MB-29* MB Indx-6.1*
[**2166-1-1**] 05:50AM CK(CPK)-210* CK-MB-4 cTropnT-0.28*
[**2165-12-31**] 11:57AM CK(CPK)-459* CK-MB-8 cTropnT-0.22*
[**2165-12-31**] 04:36AM CK(CPK)-559* CK-MB-11* MB Indx-2.0
cTropnT-0.25*
[**2165-12-30**] 10:34PM CK(CPK)-711* CK-MB-17* MB Indx-2.4
cTropnT-0.17*
[**2165-12-30**] 04:45PM CK(CPK)-583* CK-MB-19* MB Indx-3.3
cTropnT-0.11*
.
Urine:
[**2166-1-1**] URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.030
[**2166-1-1**] URINE Blood-LG Nitrite-NEG Protein-30 Glucose-NEG
Ketone-NEG Bilirub-NEG Urobiln-4* pH-7.0 Leuks-TR
[**2166-1-1**] URINE RBC-258* WBC-2 Bacteri-NONE Yeast-NONE Epi-0
[**2165-12-31**] URINE Hours-RANDOM UreaN-424 Creat-142 Na-< 10
Osmolal-293
.
Microbiology:
[**2165-12-31**] MRSA screen: No MRSA isolated.
[**2166-1-1**] urine culture: No growth
[**2166-1-1**] blood cultures x 2: pending
.
CXR PA and lateral [**2166-1-1**]: A right-sided IJ central venous
catheter terminates at the mid SVC. Cardiac and mediastinal
contours are unchanged since [**2165-12-30**]. The lungs are
hyperexpanded and clear, and there is no pneumothorax or pleural
effusion. Mild bibasilar atelectasis is unchanged. Cervical
fusion hardware is unchanged in position.
IMPRESSION: No acute intrathoracic process. Hyperexpanded lungs
denote a chronic obstructive disease such as emphysema.
.
Cardiac catheterization [**2166-1-1**]: report pending
.
Cardiac catheterization [**2165-12-31**]:
1. Coronary angiography in this right dominant system
demonstrated three vessel disease. The LMCA had minimal disease.
The LAD had a 60% long proximal stenosis. The LCX was occluded
after OM2. The RCA had a 80% mid calcified lesion.
2. Resting hemodynamics limited to central aortic pressure
revealed mild systemic arterial systolic hypertension with SBP
154 mmHg.
3. Unsuccessful PTCA of the mid RCA due to inability for full
expansion of angioplasty balloons in a heavily calcified lesion.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Unsuccessful PCI of the RCA.
.
Echocardiogram, transthoracic [**2165-12-31**]: The left atrium is
mildly dilated. There is mild symmetric left ventricular
hypertrophy with normal cavity size and global systolic function
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). Right ventricular chamber size and free wall
motion are normal. The aortic root is moderately dilated at the
sinus level. The aortic arch is mildly dilated. 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. Mild (1+) mitral regurgitation is
seen. The pulmonary artery systolic pressure could not be
determined. There is an anterior space which most likely
represents a fat pad.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with preserved global biventricular
systolic function. Elevated estimated filling pressure. Mild
mitral regurgitation.
.
EKG [**2165-12-30**]: Sinus rhythm at upper limits of normal rate with
three beats of ventricular tachycardia. There is left atrial
abnormality. P-R interval prolongation. Borderline low limb lead
voltage. No previous tracing available for comparison. Clinical
correlation is suggested.
Brief Hospital Course:
ASSESSMENT & PLAN: 54 yo M with HTN, hyperlipidemia, current
smoker presenting with chest pain and shortness of breath, found
to have NSTEMI and heavily calcified 3VD on catheterization.
.
# CORONARIES/NSTEMI: Cardiac catheterization [**2165-12-31**] showed
3-vessel disease. PTCA of the RCA was unsuccessful at that time,
and the cardiac surgery service was consulted for consideration
of CABG. CABG was recommended, but the patient elected for PCI.
On [**2166-1-1**], the patient underwent a second cardiac
catheterization, with rotablation of 80% lesion in mid RCA.
Grade B dissection was noted at the acute margin. 3 overlapping
drug-eluting stents were placed.
The day after the second catheterization, the patient's
cardiac enzymes had risen to CK 653, MB 43, MBI 6.6, Trop 0.46.
However, the patient was completely asymptomatic. In light of
the patient's lack of symptoms, the interventional team was
comfortable with discharge in spite of the rising biomarkers.
The patient was urged to return if he developed any symptoms.
A lipid panel and HbA1c were checked for secondary prevention,
and showed LDL 41 and HbA1c 5.8. The patient was urged to quit
smoking. He was discharged on
aspirin, Plavix, simvastatin, lisinopril, and metoprolol.
Omeprazole was changed to ranitidine.
The patient will follow up with his cardiologist, who will
arrange outpatient stress testing to further assess the LAD
lesion. Dr.[**Name (NI) 25977**] spoke with the patient's cardiologist
prior to discharge to coordinate follow-up.
.
# PUMP/shortness of breath/acute diastolic congestive heart
failure: The patient was hypervolemic on presentation. He
responded well to BiPAP, nitroglycerin, and Lasix.
Echocardiogram [**2165-12-31**] showed normal ejection fraction. The
patient's respiratory status improved with diuresis, and at the
time of discharge, he was satting well on room air.
On the cardiology floor, the patient's lung exam and chest
imaging were more consistent with an obstructive lung disease
than with congestive heart failure. Albuterol was prescribed.
The patient was urged to quit smoking and follow up with his
primary care physician for pulmonary function testing.
.
# RHYTHM: During the night of [**2165-12-31**] to [**2166-1-1**], the patient
had transient bradycardia to as low as the 20s during which he
was asymptomatic. During the following night, there was no
bradycardia, but there was some ventricular ectopy, including
some 5-6 beat runs of an accelerated idioventricular rhythm.
.
# Obstructive sleep apnea (likely): Given the patient's body
habitus and history of snoring, sleep apnea was deemed to be
very likely. Therefore, respiratory therapy was asked to fit the
patient for a CPAP mask that he could use as an inpatient, with
a plan for an outpatient sleep study to confirm the diagnosis.
However, the patient was asleep when the respiratory therapist
came by, and he did not want to wake up to be fitted for a mask.
The patient was urged to be evaluated for sleep apnea as an
outpatient.
.
# Bacteremia (thought to be [**Month/Day/Year 84114**]): Blood cultures from
OSH grew coagulase-negative staph in [**1-13**] bottles, pan-sensitive
(to cephazolin, clindamycin, doxycycline, erythromycin,
gentamicin, levofloxacin, oxacillin, penicillin, Bactrim, and
vancomycin). This was felt to be [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 84114**], [**First Name3 (LF) **] the patient
was not treated with antibiotics. Blood cultures from [**Hospital1 18**] were
pending at the time of discharge but had not grown any organisms
to take. These will need to be followed by the patient's
outpatient providers to be sure that they are negative.
.
# Hyponatremia: The patient's hyponatremia was thought to be due
to a combination of diarrhea and diuretics in the setting of
CHF. The patient's sodium was gradually corrected and had
reached the normal range by the time of discharge. The patient
never had any neurologic symptoms of hyponatremia.
.
# Hematuria: The patient had gross hematuria that was thought to
be secondary to Foley catheter trauma and anti-platelet therapy.
His urine was clearing at the time of discharge. He will need to
undergo urinalysis as an outpatient to ensure that his hematuria
resolves.
.
# Transient hypotension: The patient had a transient episode of
hypotension in the catheterization lab that was attributed to
increased vagal tone.
.
# Hypertension: Continued lisinopril and metoprolol.
.
# GERD: Changed omeprazole to ranitidine.
.
# Smoking cessation: Counseld patient to quit smoking.
.
# EtOH use: Urged patient to decrease EtOH consumption.
Medications on Admission:
metoprolol 75 mg [**Hospital1 **]
simvastatin 10 mg QHS
amlodipine 10 mg daily
Percocet 5/325 Q8H:PRN
ASA 325 mg PO daily
Prilosec 20 mg PO daily
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
4. Ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO twice a
day.
Disp:*60 Capsule(s)* Refills:*2*
5. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO once a day.
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*2*
6. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every six (6) hours as needed for shortness
of breath or wheezing.
Disp:*1 inhaler* Refills:*2*
7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. Hyponatremia
2. Non-ST elevation MI
3. Hypertension
4. Acute diastolic congestive heart failure
5. Smoking
.
Secondary:
1. GERD
Discharge Condition:
Alert and oriented
Chest-pain free
Hemodynamically stable
Ambulates independently
Discharge Instructions:
You came to the hospital with chest pain and difficulty
breathing. You were found a have a heart attack. You had two
cardiac catheterizations. The first catheterization showed some
blockages in the blood vessels to your heart, but no
interventions were done. During the second catheterization, you
had a stent placed in one of the blood vessels to your heart.
You talked to the cardiac surgery team about bypass surgery, but
you decided that you would prefer stenting.
.
There are still some blockages in the blood vessels to your
heart. You need to follow up with you cardiologist to evaluate
this. You cardiologist will arrange for a stress test to
evaluate these blockages and assess the need for further
intervention.
.
At the time of discharge, there were some elevation of lab tests
that indicate injury to the heart. Some elevations in these labs
is expected after the procedure that you underwent, so the
interventional cardiology team was comfortable with discharging
you with close follow-up.
.
You felt well at the time of discharge. If you develop any
symptoms of chest pain or difficulty breathing, you need to call
911 and get back to the hospital right away. You should not
exert yourself in any way today.
.
It is very likely that you have sleep apnea. You need to be
evaluated for this as soon as possible so that you can breath
well at night. If you have sleep apnea and do not treat it, you
will do damage to your heart.
.
It is very important that you take aspirin 325 mg and Plavix 75
mg every day.
.
You MUST stop smoking. Smoking damages your heart and your
lungs.
.
You were noted to be wheezing and coughing. Smoking will make
this worse. You were given an inhaler called albuterol that you
can take for wheezing.
.
You must cut back on alcohol consumption to no more than 7
drinks per week and no more than 2 drinks per occasion in order
to prevent damage to your liver and other severe health
problems.
.
You sodium was very low when you arrived. For this reason, you
were initially admitted to the intensive care unit. Your sodium
was normal at the time of discharge.
.
You had some blood in your urine. Follow up with your primary
care physician about this.
.
Some changes were made to you medications:
START aspirin 325 mg daily
START Plavix 75 mg daily
START lisinopril 5 mg daily
START albuterol inhaler as needed for shortness of breath
CHANGE metoprolol to Toprol XL 150 mg daily
START ranitidine in place of omeprazole
STOP omeprazole as this can interact with Plavix
.
Follow up as indicated below.
Followup Instructions:
Dr. [**Last Name (STitle) **] is going to talk to your cardiologist to explain
what happened and arrange for a follow-up appointment. If you do
not hear from your cardiologist's office by Monday [**2166-1-6**],
please call your cardiologist's office to make an appointment.
.
Call you primary care physician to make an appointment to see
him within the next week. Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8446**], [**Telephone/Fax (1) 17753**]
ICD9 Codes: 2761, 4280, 4019, 2724, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3509
} | Medical Text: Admission Date: [**2172-9-11**] Discharge Date: [**2172-10-9**]
Date of Birth: [**2123-11-21**] Sex: M
HISTORY OF PRESENT ILLNESS: The patient is a 48-year-old
gentleman who first noted rectal bleeding and underwent
colonoscopy and was ultimately found to have a rectosigmoid
carcinoma at approximately 12 cm. A CT angiography was
the liver including two 2-cm masses in the medial segment of
the left lobe, two small equivocal less than 5-mm lesions in
the left lateral segment, an ablation adjacent to the
falciform ligament (thought to represent focal fat), and six
lesions in the right lobe of the liver including a less than
1-cm lesion near the dome of the liver. Additionally,
demonstrated a cluster of five masses in the right
HOSPITAL COURSE: On [**2172-9-11**], the patient underwent a
right hepatic lobectomy, a cholecystectomy, a segment 4A
resection, and a Infusaid pump placement. Please see the
Operative Note per Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for details of this
component of the operation.
The patient also underwent a low anterior resection, a
splenic flexure mobilization, and an omental flap. Please
see the Operative Note per Dr. [**Last Name (STitle) 1888**] for details of this
component of the operation.
During the course of the operation, the patient received 3
units of packed red blood cells and 4 units of fresh frozen
plasma. He was ultimately transferred to the Intensive Care
Unit intubated. The patient was extubated in the Intensive
Care Unit on postoperative day two. The remainder of his
stay in the Intensive Care Unit was without any significant
events.
He was transferred to the floor on postoperative day four.
His epidural was discontinued. Additionally, on this day, it
also marked the completion of his postoperative Unasyn
prophylaxis.
On postoperative day five, an Infusaid pump study was
undertaken. He was started on sips of clear liquids which he
tolerated without difficulty. The impression from this study
was that there was a nonhomogeneous pattern of uptake in the
liver with relatively increased activity at the dome of the
liver with considerably decreased activity in the remaining
portions.
On postoperative day seven, the patient was advanced to a
full liquid diet and tolerated this without difficulty.
On postoperative day eight, his intravenous line was
hep-locked as he was taking in adequate orals.
On postoperative day nine, the patient underwent an
ultrasound of the abdomen because of increasing output from
his surgical drain. The impression from this study was that
the patency and appropriate flow was documented in the
remaining hepatic and portal veins. A repeat study was
recommended for better re-evaluation of the main portal vein.
Fluid collections were noted additionally inferior and
superior to the liver; consistent with post surgical changes.
An ultrasound on postoperative day 10 indicated that there
was excellent flow in all hepatic vessels. There were no
focal hepatic lesions, and there was only a small
postoperative fluid collection noted to the liver.
On postoperative day 11, the patient was determined to have a
seroma surrounding his Infusaid pump. The seroma was
aspirated on postoperative day 12 without incident.
On postoperative day 17, the patient reached tube feed goals
at 50 cc per hour and was tolerating this without difficulty.
On postoperative day 18, the seroma was again drained with
aspiration of approximately 150 cc of clear yellow fluid.
The procedure went without complications, and the patient
tolerated the procedure. In consultation with Nutrition,
tube feeds were advanced to 60 cc per hour which was the
patient's goal feeds.
The patient was ultimately discharged on postoperative day 28
with [**Hospital6 407**] services at home. He was
continuing to receive tube feeds as his oral intake was less
than adequate for maintaining his fluid and caloric
requirements. The patient was scheduled for close followup
with Dr. [**Last Name (STitle) **].
CONDITION AT DISCHARGE: The patient's condition on discharge
was stable.
DISCHARGE STATUS: His discharge status was to home with
nursing services.
DISCHARGE DIAGNOSES:
1. Metastatic colon cancer to the liver and rectosigmoid
cancer.
2. Status post right hepatic lobectomy.
3. Status post cholecystectomy.
4. Status post segment 4A resection.
5. Status post Infusaid pump placement.
6. Status post low anterior resection and splenic flexure
mobilization with omental flap.
MEDICATIONS ON DISCHARGE: (Discharge medications included)
1. Ursodiol 300 mg p.o. b.i.d.
2. Lansoprazole 30 mg p.o. q.d.
3. Percocet one to two tablets p.o. q.4-6h. as needed.
4. Colace 100 mg p.o. b.i.d.
5. Benadryl 50 mg p.o. q.4-6h. as needed.
6. Milk of Magnesia 30 cc p.o. q.4-6h. as needed.
7. Spironolactone 100 mg p.o. q.d.
8. Lasix 20 mg p.o. q.d.
9. Lactulose 30 cc p.o. t.i.d.
10. GoLYTELY 16 ounces p.o. b.i.d.
DISCHARGE FOLLOWUP: Plans again for close follow up with
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. The patient was instructed to call his
office for his initial appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D.,Ph.D. 02-366
Dictated By:[**Last Name (NamePattern1) 1752**]
MEDQUIST36
D: [**2172-11-25**] 18:08
T: [**2172-11-28**] 04:42
JOB#: [**Job Number **]
ICD9 Codes: 5119, 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3510
} | Medical Text: Admission Date: [**2120-11-26**] Discharge Date: [**2120-12-3**]
Date of Birth: [**2090-10-22**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
Pancreatitis, ETOH overdose, severe acidosis, ETOH hepatitis,
substance abuse, UGIB
Major Surgical or Invasive Procedure:
[**2120-11-26**]: Intubation, CVL and axillary [**Last Name (un) **] monitor placment
[**2120-12-2**]: UGI:
History of Present Illness:
30F w active EtOH abuse and alcoholic hepatitis p/w altered
mental status and report of hematemesis. Of note, HPI is per
report/documentation as pt intubated/sedated at time of
consultation. Pt has hx EtOH abuse/binge drinking w multiple
EtOH related admits/ED visits for withdraw, escalating in
frequency in recent months. Presents today in setting of
reported 2.5 day EtOH abstention with altered mental status,
nausea and vomiting. Intubated on arrival for
confusion/hematemesis and inability to protect airway. Reported
episodes of hematemesis at this time though quality/quantity of
blood in emesis unclear. Started on pressors w massive
resuscitation for hypotension/ tachycardia. Laboratories
reflected dehydration, known EtOH hepatitis and lipase 100
suggestive of acute pancreatitis. CT scan showed severe
pancreatitis and GB with edematous wall filled w sludge vs
blood.
Surgery consult obtained for pancreatitis, UGIB.
Past Medical History:
EtOH abuse with several inpatient detox stays
Social History:
The patient is originally from [**Location (un) 11177**], [**State 4565**]. She is
currently on dental student on a leave of absence. She reports a
history of binge drinking, typically [**3-26**] "strong" drinks at a
time. She reports a history of multiple inpateint detox stays
without success. She denies tobacco or IVDU
Family History:
Maternal grandfather with alcoholism
Maternal uncle with drug problem
Paternal aunt with alcoholism
Physical Exam:
At time of admission:
P/E:
Levo: 0.12, Protonix: 8; Versed: 18
VS: T: 97.0 P: 134 BP: 110/57 RR: 20 O2sat: 100
CMV 0.5; 20x500; 5
GEN: WD, WN F intubated/sedated
HEENT: NCAT, PERRLA, anicteric
CV: RRR; tachy
PULM: CTA B/L w no W/R/R, intubated
ABD: firmly distended, unable to assess tenderness [**1-24**] sedation
EXT: WWP, no CCE, 2+ B/L radial/DP/PT
NEURO: moves all 4 extremities; sedated
On Discharge:
VS:
GEN; Pleasant with NAD
CV: RRR
Lungs: Diminished breath sounds bilateraly on bases
Abd: NT/ND, soft
Extr: Warm, no c/c/e
Neuro: AAO x 3, Cranial nerves II-XII grossly intact
Pertinent Results:
Labs at time of admission:
15.7>-14.8/48.1-<393
N:86.4 L:11.2 M:1.2 E:0.7 Bas:0.5
PT: 11.0 PTT: 31.8 INR: 1.0
150 91 13
-------------< 93 AGap=58
4.7 6 2.8 ∆
ALT: 230 AP: 180 Tbili: 1.2
AST: 485 Lip: 100
Serum EtOH 255
Serum ASA, Acetmnphn, [**Last Name (LF) 2238**], [**First Name3 (LF) **], Tricyc Negative
8AM:
pH 6.93 pCO2 33 pO2 124 HCO3 8 BaseXS -26
Type:Art; Intubated; FiO2%:50; Rate:/16; TV:500;
Mode:Assist/Control
Lactate:12.0
[**12-2**]:
7.4>----<125
36.1
142 101 5 aGap=11
-------------<118
3.3 33 1.0
Ca: 9.2 Mg: 1.3 P: 2.0
ALT: 51 AP: 78 Tbili: 0.8
AST: 62 LDH: 430
[**Doctor First Name **]: 146 Lip: 206
IMAGING:
CT A/P [**11-26**]: Noncontrast CT due to elevated creatinine, limiting
assessment. Peripancreatic inflammation, c/w pancreatitis.
Cannot assess parenchymal enhancement or vascular complications.
But no obvious large pseudocyst or abscess. Diffusely fatty
liver. Gallbladder with diffuse mural thickening and distended
with hyperdense material. No free air. Free fluid in pelvis.
[**12-3**] CXR:
As compared to the previous radiograph, all monitoring and
support
devices have been removed. There are persistent opacities at
both lung bases, right more than left, that are exaggerated by
relatively [**Name2 (NI) 15410**] breast tissue.
The changes could reflect minimal fluid overload or layering
pleural
effusions. No circumscribed focal parenchymal opacity suggesting
pneumonia.
No cardiomegaly. No lung nodules or masses.
[**12-3**] EGD:
Impression:
1. Erythema in the stomach body compatible with gastritis
(biopsy)
2. Mucosa suggestive of Barrett's esophagus (biopsy)
Brief Hospital Course:
[**11-26**]- Admitted to the TSICU after a reported 2.5 day EtOH
abstention ( ETOH level 255) with altered mental status, nausea
and vomiting. Intubated on arrival for confusion/hematemesis and
inability to protect airway. Reported episodes of hematemesis
prior to arrival prompted Protonix and Octreotide drips. IN the
Ed patient was started on Levophed w 12L resuscitation for
hypotension/ tachycardia in the ED. She was admitted to the ICU
with suspected EtOH hepatitis, acute pancreatitis with lipase
100, severe acidosis with lactate 22, ph 6.9. Sh was
hypernatremic to 150 qith acute renal failure Cr 2.3. Liver
function tests significant for ALT: 230 AP: 180 Tbili: 1.2 Alb:
AST: 485 Serum ASA, Acetaminophen, [**Last Name (LF) 2238**], [**First Name3 (LF) **], Tricyc Negative
CT scan showed severe pancreatitis and GB with edematous wall
filled w sludge vs blood. In the ICU an Axillary line and [**Last Name (un) 18821**]
monitor were placed, as well as a central line in the R IJ. A
Bicarb drip for PH 6.9 that was later stopped in the pm.
Thiamine and folate where repleted. Toxicology , general
surgery and Gi were consulted. Bladder pressure were checked for
evidence of compartment syndrome. With aggressive management she
improved overnight. Cardiac ECHO showed no evidence of
infarction.
[**11-27**]: By the am her ventilator was weaned to [**4-25**]. Fentanyl dc'd
and she was started on 3mg IV Ativan for intermittent agitation
and question of withdrawal. She had Elevated BPs 150-160's
overnight. Also started clonidine patch.
[**11-28**]: She was changed to Precedex gtt. IR attempt to make
Dobbhoff post pyloric unsuccessful so tube remained as NG.
[**11-29**] Extubated. A&Ox3. She was advanced to a regular diet.
Overnight pt with hallucinations (Visual/auditory) and she was
agitated requiring Valium. CIWA protocol was initiated. She was
also noted to have a drop in her platelets to the 69s, Her HSQ
was discontinued and HITT panel sent.
[**11-30**]: Patient was transferred to floor; psych and social work
c/s ordered to help facilitate substance abuse counseling.
Patient's abdominal pain slowly resolving.
[**12-1**]: After psychiatry and SW recommended 30 day substance
abuse rehab upon dc. GI consult recomended inpatient endoscopy
to evaluate the source of patient's reported UGIB. Recheck of
platelets showed recovery to 125 without intervention.
[**12-2**]: Upper Endoscopy. HITT pending. In the am pt complained of
mild SOB prompting a CXR.
[**12-3**]: CXR was negative for PNA. EGD demonstrated erythema in
the stomach body compatible with gastritis and mucosa suggestive
of Barrett's esophagus, biopsy were taken. Patient's diet was
advanced to regular and she was discharge home in stable
condition. Her PCP was [**Name (NI) 653**] prior discharge, and message
was left explaining patient's needs for prompt follow up with
PCP.
Medications on Admission:
[**Last Name (un) 1724**]: folic acid 1', thiamine 100', fluoxetine 10', MVI,
naltrexone 50'
Discharge Medications:
1. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. naltrexone 50 mg Tablet Sig: One (1) Tablet PO once a day for
1 weeks: Please do not drink alcohol while taking this
medication.
Disp:*7 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1. EtOH induced pancreatitis
2. Alcohol abuse
3. Alcohol withdrawal
4. Metabolic acidosis
5. Upper gastrointestinal bleeding
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call your doctor or nurse practitioner if you experience
the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Followup Instructions:
Please call Dr.[**Name (NI) 5067**] office at [**Telephone/Fax (1) 2998**] if you have any
questions.
.
Please follow up with [**Doctor Last Name 634**], PA (PCP) in 1 week after
discharge
.
Call [**Telephone/Fax (1) 13545**] in one week for the biopsy (EGD) results
Completed by:[**2120-12-3**]
ICD9 Codes: 5845, 2762, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3511
} | Medical Text: Admission Date: [**2142-5-21**] Discharge Date: [**2142-5-25**]
Date of Birth: [**2077-2-8**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6180**]
Chief Complaint:
Increased abdominal girth, lower extremity edema and shortness
of breath.
Major Surgical or Invasive Procedure:
Paracentesis
History of Present Illness:
The pt. is a 65 year-old female with metastatic hepatoma who
initially presented to clinic complaining of increased abdominal
girth, lower extremity edema and shortness of breath.
She has been non-compliant with diuretic therapy and only
recently restarted Lasix 20 mg daily. Over the last month PTA,
the pt. has noticed significant increase in her abdominal girth
as well as her pedal edema. Her appetite has been poor over this
time period. She also noted increasing shortness of breath and
an inability to ambulate more than a few feet secondary to lower
extremity edema and shortness of breath. She was seen in clinic
one week PTA at which time the dosages of diuretics were
increased; she refused a paracentesis. Despite the increased
dose of lasix and aldactone, the pt. has experienced volume
overload. She was admitted for further diuresis and a
therapeutic paracentesis.
On review of systems, the pt. denied recent fever, chills,
cough, chest pressure, nausea, vomiting, diarrhea, dysuria,
arthralgias or myalgias. She has noticed recent loss of
appetite, shortness of breath, and chronic right chest wall
pain.
Oncologic Hx: The pt. contracted hepatitis C due to a blood
transfusion approximately 15 years ago in [**Country 11150**]. She underwent
radiofrequency ablation of hepatomas in 8/[**2140**]. She was
initially treated with bevacizumab, oxaliplatin, and gemcitabine
from [**6-13**] to [**12-14**] but failed treatment on this protocol as
evidenced by rising AFP and worsening physical exam findings.
She underwent radiation to painful rib lesions in [**12-14**]. She was
then treated with Xeloda in [**1-13**]. She has been most recently
treated with weekly 5-FU and leucovorin in [**4-14**]. Her last dose
was on [**2142-4-26**] and it has been held since then due to
thrombocytopenia and fatigue.
*
She was transferred to the MICU for the development of
hypotension to 60/40 -BP on admission = 122/80, and increasing
O2 requirment on with gas = O2= 86 CO2 = 35 pH = 7.36 on 12 L
NRB. The patient underwent a diagnostic tap and then received
dopamine to maintain her BPs.
Past Medical History:
-hepatitis C due to a blood transfusion approximately 10 years
ago and hepatocellular carcinoma
-hypertension
-hypothyroidism
Social History:
Patient was born in [**Country 11150**], and has beenin the U.S. for over 10
years. Patient denies alcohol ortobacco or IV drug use.
Family History:
[**Name (NI) **] father passed away in his early 30's from homicide.
[**Name (NI) **] mother passed away four yearsago from unknown causes,
but did have angina and pacemaker. No family history of cancer.
Physical Exam:
Vitals: T: 97.3F P: 94 R: 24 BP: 122/80 SaO2: 98% on RA
General: Ill-appearing, awake, alert, NAD.
HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus
noted, MMM, no lesions noted in OP
Neck: supple, no JVD or carotid bruits appreciated
Pulmonary: Lungs with decreased breath sounds at bilateral
bases; scattered crackles throughout
Cardiac: RRR, nl. S1S2, III/VI HSM noted over precordium,
loudest at RUSB
Abdomen: Large ascites with positive fluid wave, NT/ND,
normoactive bowel sounds, no organomegaly appreciated through
ascites.
Extremities: 4+ LE edema bilaterally to thighs, 2+ radial, DP
and PT pulses b/l.
Lymphatics: No cervical, supraclavicular, axillary or inguinal
lymphadenopathy noted.
Skin: no rashes or lesions noted.
Neurologic:
-mental status: Alert, oriented x 3. Able to relate history
without difficulty.
-cranial nerves: II-XII intact
-motor: normal bulk, strength and tone throughout. Tremor noted
at rest; + fine asterixis
-sensory: No deficits to light touch throughout.
-DTRs: 2+ biceps, triceps, brachioradialis, patellar and 1+
ankle jerks bilaterally. Plantar response was flexor
bilaterally.
Pertinent Results:
Labs on admission:
[**2142-5-21**] 11:50AM WBC-2.6* RBC-2.38* HGB-8.8* HCT-27.1*
MCV-114* MCH-37.0* MCHC-32.5 RDW-22.5*
[**2142-5-21**] 11:50AM PLT COUNT-70*
[**2142-5-21**] 11:50AM GRAN CT-1260*
[**2142-5-21**] 11:50AM PT-19.7* INR(PT)-2.5
[**2142-5-21**] 11:50AM AFP-[**Numeric Identifier 11151**]*
[**2142-5-21**] 11:50AM TOT BILI-4.0*
Studies:
Abdominal US [**2142-5-21**]
RADIOLOGY Preliminary Report
US ABD LIMIT, SINGLE ORGAN [**2142-5-21**] 2:00 PM
US ABD LIMIT, SINGLE ORGAN
Reason: uncomfortable ascites
[**Hospital 93**] MEDICAL CONDITION:
65 year old woman with HCC
REASON FOR THIS EXAMINATION:
uncomfortable ascites
CLINICAL HISTORY: 65-year-old female with hepatocellular
carcinoma and uncomfortable ascites.
LIMITED ABDOMINAL ULTRASOUND: Targeted ultrasound of all 4
quadrants of the abdomen was performed to evaluate ascites.
There is a large volume of ascites visible throughout the
abdomen. The liver was not assessed on this study.
IMPRESSION: Large volume of ascites.
DR. [**First Name8 (NamePattern2) 306**] [**Last Name (NamePattern1) 11152**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 2601**]
*
RADIOLOGY Preliminary Report
DUPLEX DOPP ABD/PEL PORT [**2142-5-22**] 3:39 PM
DUPLEX DOPP ABD/PEL PORT
Reason: RUQ with dopplerspatent portal system?
[**Hospital 93**] MEDICAL CONDITION:
65 year old woman with metastatic hepatoma who presents with
worsening ascites and hypotension
REASON FOR THIS EXAMINATION:
RUQ with dopplerspatent portal system?
PORTABLE DOPPLER ULTRASOUND OF THE LIVER.
INDICATION: Metastatic hepatoma, worsening ascites and
hypotension.
FINDINGS: Limited portable Doppler ultrasound of the liver was
performed at the bedside.
Liver is nodular and shrunken, consistent with cirrhosis, with
moderate ascites.
Main portal vein is patent. Posterior branch of the right portal
vein is patent; however, the anterior branch of the right portal
vein is not visualized. Left portal vein is thrombosed. The
hepatic veins are grossly patent. Left and right hepatic artery
branches are likewise patent.
IMPRESSION: Patent main portal and posterior branch of the right
portal vein. Anterior right portal vein is not visualized, and
the left portal vein is thrombosed, possibly with tumor
thrombus.
Overall, the imaging findings are similar when compared with CT
scan dated [**2142-4-14**].
*
Admission Chest AP:
RADIOLOGY Preliminary Report
CHEST (PORTABLE AP) [**2142-5-22**] 12:11 PM
CHEST (PORTABLE AP)
Reason: check placement and r/o PTX
[**Hospital 93**] MEDICAL CONDITION:
65 year old woman s/p Right IJ CVL
REASON FOR THIS EXAMINATION:
check placement and r/o PTX
INDICATION: Status post right IJ line placement.
COMPARISON: Radiograph dated [**2142-3-14**].
SINGLE PORTABLE VIEW OF THE CHEST: There is interval placement
of a right IJ central venous line terminating in the right
atrium. No evidence of pneumothorax. There are bilateral pleural
effusions with bibasilar atelectasis and pulmonary vascular
congestion consistent with CHF. Note is made of 2 hairpins that
appear to be overlying the left side of the chest.
IMPRESSION:
1) Right IJ line terminating in the right atrium.
2) CHF.
*
Cardiology Report ECHO Study Date of [**2142-5-22**]
PATIENT/TEST INFORMATION:
Indication: Pericardial effusion.
Height: (in) 64
Weight (lb): 165
BSA (m2): 1.80 m2
BP (mm Hg): 89/43
HR (bpm): 107
Status: Inpatient
Date/Time: [**2142-5-22**] at 15:16
Test: Portable TTE (Complete)
Doppler: Full doppler and color doppler
Contrast: None
Tape Number: 2005W167-1:12
Test Location: West MICU
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] [**Doctor Last Name **]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *4.6 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *5.3 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: 5.0 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: 1.0 cm (nl 0.6 - 1.1 cm)
Left Ventricle - Inferolateral Thickness: 0.9 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.0 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 2.4 cm
Left Ventricle - Fractional Shortening: 0.40 (nl >= 0.29)
Left Ventricle - Ejection Fraction: >= 80% (nl >=55%)
Left Ventricle - Peak Resting LVOT gradient: *80 mm Hg (nl <= 10
mm Hg)
Aorta - Valve Level: 3.3 cm (nl <= 3.6 cm)
Mitral Valve - E Wave: 1.0 m/sec
Mitral Valve - A Wave: 1.8 m/sec
Mitral Valve - E/A Ratio: 0.56
Mitral Valve - E Wave Deceleration Time: 260 msec
INTERPRETATION:
Findings:
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Normal LV cavity size. Normal regional LV
systolic function.
Hyperdynamic LVEF. Severe resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic root diameter.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR. LV
inflow pattern
c/w impaired relaxation.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PERICARDIUM: No pericardial effusion.
Conclusions:
1. The left atrium is mildly dilated.
2. The left ventricular cavity size is normal. Regional left
ventricular wall
motion is normal. Left ventricular systolic function is
hyperdynamic (EF>75%).
There is a severe resting left ventricular outflow tract
obstruction, probably
secondary to the underfilled left ventricular with hyperdynamic
wall motion
and ejection fraction.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1445**], MD on [**2142-5-22**] 17:15.
[**Location (un) **] PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **].
([**Numeric Identifier 11153**])
Brief Hospital Course:
65 y/o female with PMH significant for metastatic hepatoma
admitted to [**Hospital1 18**] on [**5-21**] for increased abdominal girth, lower
extremity edema, and shortness of breath, transfered to MICU for
intensive therapy and monitoring, then transfered out of the
MICU for comfort care on the floor.
.
1. Metastatic hepatoma- Pt has been treated extensively. Had
spoken to her oncologist Dr. [**First Name (STitle) **] who was aware of the plan
for CMO.
.
2. CMO- Goal at time of transfer to floor was comfort care. Had
discussed this with the family who was in agreement and members
of her medical team (including oncology). This wish was
expressed by the pt prior to her increased lethargy. Recieved
input from the pallative care team. Utalized sublingual morphine
and then morphine drip and ativan as needed for comfort.
Continued scopolamine patch. No further medications, blood
draws, vital signs, or other studies were obtained while on the
floor. Patient expired comfortably in the morning. Her family
was present.
Medications on Admission:
CIPRO 500MG--One twice a day for fever
LASIX 40MG--2 every day
LISINOPRIL 30MG--One every day
MS CONTIN 15MG--One twice a day
PROTONIX 40MG--One at bedtime
ALDACTONE 100MG--One every day
Discharge Disposition:
Expired
Discharge Diagnosis:
Metastatic liver cancer
Discharge Condition:
Expired
Followup Instructions:
NA
ICD9 Codes: 5849, 4280, 2765, 2875, 4019, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3512
} | Medical Text: Admission Date: [**2117-9-13**] Discharge Date: [**2117-9-23**]
Date of Birth: [**2063-3-16**] Sex: M
Service: MEDICINE
Allergies:
Tenofovir Disoproxil Fumarate
Attending:[**First Name3 (LF) 13256**]
Chief Complaint:
fatigue, weakness
Major Surgical or Invasive Procedure:
upper endoscopy
History of Present Illness:
54 yo M with hx of HIV (last CD4 count of 97 in [**8-5**]) and Hep C
cirrhosis s/p liver transplant 4 years ago. He has undergone 2
treatment trials for hepatitis C and has had multiple liver bx,
most recently on [**8-24**] showing findings consistent with an
ongoing chronic allograft rejection vs cholestatic variant of
viral hep C. He has been treated in the past with steroids, ATG,
IVIG, and plasmapheresis with only transient improvement.
He presents today from clinic with complaints of increased
lethargy, fatigue, DOE, abdominal and lower extremity swelling
for the last week. Patient says that he is now unable to walk up
a flight of stairs or very far without having to stop to catch
his breath. He also noticed dark stools over the last 1-2 weeks,
denies bright red blood. Also reports feeling dizzy with quick
changes in position. Pt also says he has noticed periodic
cramping over lower extremities and fingers which resolve with
movement. Reports good po intake, but feels bloated with
enlarged abdomen. Pt denies fevers, chills, n/v/d, CP, SOB,
abdominal cramping.
Past Medical History:
HIV
HCV cirrhosis
HCC s/p RFA [**3-31**] (4.5x3.4 cm hepatoma, which was biopsy-proven
hepatocellular carcinoma (HCC).)
OLT [**6-1**] c/b portal vein thrombectomy and roux en y [**2113-6-25**]; c/b
acute rejection vs HSV infection in [**6-5**] - treated with
steroids, ATG, IVIg, Acyclovir, and Foscarnet
Recurrent HCV
Portal vein thrombosis - on coumadin
DM II
Appendectomy at age 18
multiple R inquinal hernia repairs x4
PTC [**2113-11-23**]
[**2114-1-1**] dilatation of hepaticojejunostomy site
Fanconi's syndrome [**1-27**] Tenofovir
HSV
Social History:
- lives alone in an apartment in [**Location 57226**]. No children
- high school graduate, previously worked as disk jockey in
[**Location (un) 86**] area
- on medical disability, unemployed
- denies current ETOH, tobacco or drug abuse (prior IV cocaine
use)
Family History:
unknown
Physical Exam:
ADMISSION EXAM
Vitals: 96.4 128/76 84 20 100% RA
General: jaundiced male in NAD
HEENT:NC/AT, sclera icteric, dry MM, OP clear
Neck: supple, no cervical lymphadenopathy
Heart: RRR, normal s1/s2, no murmurs appreciated
Lungs: CTAB, no wheezes
Abdomen:+BS, distended, +shifting dullness, non tender, no
rebound or guarding
Extremities: 1+ LE edema bilaterally
Neurological:A&Ox3, CN II-XII intact, no asterixis noted
Physical Exam on Discharge:
Vitals: 97.7, 97.3, 92/56, 72, 18, 96RA FBS 340
I/O=1900/1000+7BM
General: jaundiced male in NAD, comfortable appearing, sitting
up in his chair
HEENT: NC/AT, sclera icteric, dry MM, OP clear
Neck: supple, no cervical lymphadenopathy
Heart: RRR, normal s1/s2, no murmurs appreciated
Lungs: CTAB, scattered wheezes bilaterally.
Abdomen:+BS, distended, non tender, no rebound or guarding
Extremities: 3+ edema feet, taught/shiny skin, sensation intact-
ROM intact. Pitting edema above the knees as well.
Neurological:A&Ox3, CN II-XII intact, no asterixis noted
Pertinent Results:
ADMISSION LABS:
[**2117-9-13**] 04:25PM BLOOD WBC-4.0 RBC-2.12*# Hgb-5.9*# Hct-19.1*#
MCV-90 MCH-27.9 MCHC-31.0 RDW-17.8* Plt Ct-109*
[**2117-9-13**] 04:25PM BLOOD PT-21.2* PTT-30.5 INR(PT)-1.9*
[**2117-9-13**] 04:25PM BLOOD Glucose-518* UreaN-36* Creat-0.8 Na-132*
K-4.0 Cl-104 HCO3-17* AnGap-15
[**2117-9-13**] 04:25PM BLOOD ALT-85* AST-68* LD(LDH)-140 AlkPhos-526*
TotBili-24.7* DirBili-20.7* IndBili-4.0
[**2117-9-13**] 01:05PM BLOOD Albumin-2.7* Calcium-8.1* Phos-1.9*
Mg-1.9
[**2117-9-13**] 04:25PM BLOOD Hapto-26*
[**2117-9-13**] 01:05PM BLOOD tacroFK-9.6
Discharge Labs:
[**2117-9-23**] 04:35AM BLOOD WBC-3.3* RBC-2.82* Hgb-8.2* Hct-25.6*
MCV-91 MCH-28.9 MCHC-32.1 RDW-18.4* Plt Ct-82*
[**2117-9-23**] 04:35AM BLOOD PT-15.2* INR(PT)-1.3*
[**2117-9-23**] 04:35AM BLOOD Glucose-294* UreaN-38* Creat-1.9* Na-136
K-4.0 Cl-108 HCO3-15* AnGap-17
[**2117-9-23**] 04:35AM BLOOD ALT-44* AST-60* LD(LDH)-171 AlkPhos-620*
TotBili-36.6*
[**2117-9-23**] 04:35AM BLOOD Albumin-3.2* Calcium-8.3* Phos-2.0*
Mg-2.4
[**2117-9-23**] 04:35AM BLOOD tacroFK-10.7ertinent labs:
[**2117-9-18**] 12:38PM ASCITES WBC-40* RBC-225* Polys-46* Lymphs-13*
Monos-41*
[**2117-9-18**] 12:38PM ASCITES TotPro-0.3 Glucose-168 Creat-1.3
LD(LDH)-55 Amylase-236 TotBili-2.4 Albumin-LESS THAN
[**2117-9-14**] 04:45AM BLOOD tacroFK-7.7
[**2117-9-15**] 04:27AM BLOOD tacroFK-21.9*
[**2117-9-16**] 02:30AM BLOOD tacroFK-24.9*
[**2117-9-17**] 04:30AM BLOOD tacroFK-22.6*
[**2117-9-18**] 04:30AM BLOOD tacroFK-18.2
[**2117-9-20**] 10:28PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.016
[**2117-9-20**] 10:28PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-TR Ketone-NEG Bilirub-LG Urobiln-NEG pH-5.5 Leuks-NEG
[**2117-9-20**] 10:28PM URINE RBC-0 WBC-2 Bacteri-MOD Yeast-NONE Epi-0
TransE-<1
[**2117-9-20**] 10:28PM URINE Mucous-RARE
[**2117-9-17**] 10:16PM URINE Hours-RANDOM UreaN-780 Creat-72 Na-27
K-39 Cl-15
[**2117-9-17**] 10:16PM URINE Osmolal-539
Micro:
Ascites Fluid: GRAM STAIN (Final [**2117-9-18**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2117-9-21**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2117-9-24**]): NO GROWTH.
Fluid Culture in Bottles (Final [**2117-9-24**]): NO GROWTH.
HELICOBACTER PYLORI ANTIBODY TEST (Final [**2117-9-20**]):
NEGATIVE BY EIA.
(Reference Range-Negative).
IMAGING:
[**2117-9-13**] RUQ ULTRASOUND WITH DOPPLERS
1. Patent hepatic vasculature with appropriate waveforms and
direction of
flow. No evidence of thrombus.
2. Findings consistent with known cirrhosis.
3. Stable splenomegaly.
4. Stable dilated intrahepatic ducts and pneumobilia,
predominantly in the
left lobe of the liver.
[**2117-9-20**] Abdominal Ultrasound
Thin pockets of ascitic fluid are seen in the lower quadrants
bilaterally adjacent to bowel loops without sufficient quantity
for safe paracentesis.
9/20/11EGD:
Varices at the lower third of the esophagus
Varices at the fundus
Food in the fundus
Ulcer in the antrum
Normal mucosa in the whole duodenum
Otherwise normal EGD to second part of the duodenum
[**9-15**] EGD
Varices at the lower third of the esophagus
Varices at the fundus
Food in the fundus
Ulcer in the antrum
Normal mucosa in the whole duodenum
Otherwise normal EGD to second part of the duodenum
[**2117-9-21**] EGD
Varices at the lower third of the esophagus.
Gastric varices were seen on retroflexed view in the gastric
cardia. There was no evidence of bleeding. There was a single
overlying ulcer visualized on the mucosal surface. This finding
was reviewed the hepatology attending and the decision was made
not to attempt additional intervention.
Mild portal hypertensive gastropathy was seen.
[**9-21**] Colonoscopy
Large rectal varices were seen in the distal rectum.
The rectum and sigmoid colon appeared otherwise normal. Solid
stool was encountered in the descending colon. There was no
evidence of blood
Brief Hospital Course:
54 yo M with hx of hep C cirrhosis s/p transplant who presents
with worsening fatigue and weakness found to have anemia from
gastric variceal bleed.
.
ACTIVE ISSUES
# Gastric Variceal Bleed: The patient had 4 EGDs. On the initial
EGD the source of active bleeding was injected with epinephrine
however the patient's HCT continued to drop. During the third
EGD hemostasis was achieved with dermabond injections into the
large varix in the gastric fundus. He required a total of 6
units of pRBCs. Patient was started on octreotide gtt and
protonix IV BID. He was also started on cefrtiaxone for
prophylaxis. Patient remained hemodynamically stable and was
transferred back to the floor. His PPI was switched to po.
Ceftriaxone was switched to po cipro at treatment doses to
complete 5 day course and ultimately transitioned to
prophylactic doses. Later in his hospitalization he developed
marroon stools with a subsequent hct drop. He underwent a
colonoscopy and endoscopy which showed no sources of active
bleeding. He was continued on his octreotide which he completed
72 hours of, without any further episodes of hematochezia or
melena. He was tolerating a PO diet and had a stable HCT at the
time of discharge.
.
# [**Last Name (un) **]: Cr up to 1.7 from 0.9. Unclear etiology but thought to
be either prerenal given blood losses and poor po intake or
secondary to tacrolimus toxicity. FeNa showd 0.44%. His
Tacrolimus was held along with other medications that interfere
with clearance (HAART and fluconazole).
.
# Hep C s/p liver transplant: most recent viral load 13,900,000
IU/mL on [**8-24**]. Most recent bx c/w chronic rejection vs
cholestatic variant of Hep C. Patient was continued on cellcept
and prednisone. He was initially given tacro dose but this was
d/c after levels were in the 20s. At the time of discharge his
tacrolimus was still being held to be restarted as an
outpatient. Patient was also volume overloaded [**1-27**] cirrhosis
with ascites and lower extremity edema. Diuretics were not
initially started in the setting of GI bleed and later held
because of worsening renal function. He became more short of
breath following his blood transfusions and received lasix which
some improvement in his breathing, he never had an increased
oxygen requirement. Patient had multiple paracenteses, none of
which showed evidence of SBP however with his low total protein
he was started on cipro for SBP prophylaxis.
.
# Dermabond Pulmonary Embolisms: After the patient's dermabond
procedure a CXR showed multiple opacities that were consistent
with dermabond pulmonary embolisms. Likely occured from
vascular translocation during appication of dermabond to gastric
varix. Patient remained stable throughout hospital course.
.
# Elevated INR: Improved from 2.2 to 1.2 after vitamin K IV 5mg
X 2. Likely a combination of synthetic dysfunction with vitamin
K deficiency given longstanding poor PO intake. Unlikely to
absorb PO vitamin K given severe cholestasis.
.
# Diabetes: Started on home dose of NPH however was still having
very elevated sugars. Started NPH [**Hospital1 **]. His blood sugars were
difficult to control during his stay, and it was felt that
running a little on the higher side was better than him having
hypoglycemia. He was discharged on 35units NPH in the AM and 10
in the PM.
.
# Hyponatremia: Likely hypervolemic hyponatremia from liver
dysfunction. Remained stable throughout hospital stay.
.
# HIV (last CD4 count of 97 in [**8-5**]). Initially restarted on
HAART regimen, however held in the setting of elevated tacro
levels. His home regimen was restarted prior to discharge. Also
continued on ppx with bactrim, azithromycin and fluconazole.
.
# Herpes lesions: He was treated with acyclovir while in the
hospital but can go back on valtrex as an outpatient. Wound care
saw the patient and made the following recs:
- Cleanse wound with wound cleanser then [**Date Range **] dry
- apply aloe vesta as needed to moisturize dry skin
- apply Xeroform dressing to provide antimicrobial coverage and
dry out wound, place under pt - no need for additional dressing
or securement. change daily and prn
- Can use critic aid clear barrier ointment as well if pt
becomes
incontinent of stool
.
# Hypothyroidism: continued synthroid
.
Transitional Issues:
The following medication changes were made:
-START Ciprofloxacin 250mg by mouth once daily
-START Pantoprazole 40mg by mouth twice daily
-START Nadolol 20mg by mouth once daily
-CHANGE NPH insulin dose to 35U in the morning and 10U at night.
This should be further adjusted by your doctors to ensure [**Name5 (PTitle) **]
blood sugar control. Please continue to check your blood sugars
4 times a day at home and continue your sliding scale.
-STOP Famotidine
-STOP Fluconazole due to high tacrolimus levels until you meet
with Dr. [**Last Name (STitle) 497**] and Dr. [**Last Name (STitle) 724**]
[**Name (STitle) 66360**] Tacrolimus (prograf) until further instructed by Dr. [**Last Name (STitle) 497**]
Medications on Admission:
abacavir 300mg [**Hospital1 **]
azithromycin 1200mg po qThursday
famotidine 20mg po q12 hr prn - does not take regularly
fluconazole 400mg po daily
levothyroxine 25mcg po daily
lopinavir-ritonavir 50-200mg 2 tabs [**Hospital1 **]
cellcept 500mg po bid
raltegravir 400mg po bid
bactrim 800/160 [**12-27**] tab by mouth daily
tacrolimus 2mg po q tuesday night
valcyclovir 1000mg po TID
Tylenol PRN (do not exceed 2g daily)
calcium carbonate/D3
regular insulin SS
NPH 36U daily
Discharge Medications:
1. azithromycin 600 mg Tablet Sig: Two (2) Tablet PO 1X/WEEK
(TH).
2. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. mycophenolate mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
4. prednisone 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
5. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. valacyclovir 500 mg Tablet Sig: Two (2) Tablet PO three times
a day.
7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
8. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
9. NPH insulin human recomb 100 unit/mL Suspension Sig: Thirty
Five (35) Units Subcutaneous each morning.
10. NPH insulin human recomb 100 unit/mL Suspension Sig: Ten
(10) Units Subcutaneous each night.
11. insulin regular human 100 unit/mL Solution Injection
12. calcium carbonate-vitamin D3 Oral
13. nadolol 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
14. abacavir 300 mg Tablet Sig: One (1) Tablet PO twice a day.
15. raltegravir 400 mg Tablet Sig: One (1) Tablet PO twice a
day.
16. lopinavir-ritonavir 200-50 mg Tablet Sig: Two (2) Tablet PO
twice a day.
Discharge Disposition:
Home With Service
Facility:
Caregroup VNA
Discharge Diagnosis:
Primary:
-Gastric variceal bleed
-Hepatitis C cirhossis
-Tacrolimus toxicity
-Acute renal failure
-Diabetes
Secondary:
-Human immunodeficiency virus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 34850**],
You were admitted to the hospital for a gastrointestinal bleed.
The bleeding was stopped with an endoscopic procedure. Your
blood levels continued to decrease after this, but subsequently
stabilized and you have no further bleeding that was seen.
Your tacrolimus levels were also very high, which may be partly
to to interactions with your fluconazole, HIV medications, and a
recent tacrolimus dose increase. We temporarily held these
medications for a few days in the hospital. Please continue to
hold your tacrolimus and fluconazole after discharge, but please
restart your HIV medications TONIGHT (lopinavir-ritonavir,
raltegravir, abacavir) as previously prescribed. You have
scheduled follow up with Dr. [**Last Name (STitle) 497**] and Dr. [**Last Name (STitle) 724**] next week at
which point your labs will be checked.
Your blood sugars were also very high, and we have increased
your insulin doses. It is very important that you check your
blood sugars while at home and that your doctors monitor this at
follow up.
PLEASE call your doctors if [**Name5 (PTitle) **] experience any of the symptoms
listed below.
The following medication changes were made:
-START Ciprofloxacin 250mg by mouth once daily
-START Pantoprazole 40mg by mouth twice daily
-START Nadolol 20mg by mouth once daily
-CHANGE NPH insulin dose to 35U in the morning and 10U at night.
This should be further adjusted by your doctors to ensure [**Name5 (PTitle) **]
blood sugar control. Please continue to check your blood sugars
4 times a day at home and continue your sliding scale.
-STOP Famotidine
-STOP Fluconazole due to high tacrolimus levels until you meet
with Dr. [**Last Name (STitle) 497**] and Dr. [**Last Name (STitle) 724**]
[**Name (STitle) 66360**] Tacrolimus (prograf) until further instructed by Dr. [**Last Name (STitle) 497**]
Followup Instructions:
Department: TRANSPLANT
When: MONDAY [**2117-9-27**] at 11:40 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: TRANSPLANT
When: MONDAY [**2117-9-27**] at 1 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4861**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Name: [**Last Name (LF) 11006**],[**First Name3 (LF) 251**] P
Specialty: INTERNAL MEDICINE
Location: [**Hospital **] HEALTHCARE CENTER
Address: [**Street Address(2) **], [**Location **],[**Numeric Identifier 66357**]
Phone: [**Telephone/Fax (1) 11329**]
Appointment: WEDNESDAY [**10-7**] AT 4:15PM
Department: DERMATOLOGY
When: TUESDAY [**2118-8-23**] at 11:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2762**], MD [**Telephone/Fax (1) 1971**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 5789, 5849, 2761, 5715, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3513
} | Medical Text: Admission Date: [**2167-2-23**] Discharge Date: [**2167-2-28**]
Service: Medicine
ADMISSION DIAGNOSES:
1. Fall.
2. Stroke.
DISCHARGE DIAGNOSES:
1. Endocarditis.
2. Hemorrhagic stroke.
3. Sepsis.
4. Congestive heart failure.
5. Renal failure.
HISTORY OF PRESENT ILLNESS: The patient is an 81 year-old male
with no significant past medical history who presented to the
Emergency Room after experiencing right sided weakness after a
fall on the day of admission. The patient provides a vague
history, however, describes the event as follows, the patient
experienced left sided shoulder pain for approximately one week
in the subsequent developing swelling and a mass over his left
sternoclavicular joint. The patient went to his primary care
physician where [**Name Initial (PRE) **] reported x-ray of his shoulder was negative. On
the day of admission the patient reported continued right sided
lower extremity pain/numbness, which caused a fall. In the
Emergency Room he was noted to have a right facial droop. The
patient's last dental work was [**10-20**].
In the Emergency Room the patient was pan cultured and started
empirically on Vancomycin, Gentamycin for endocarditis and sent
for a CT to evaluate the patient's chest mass and a CT to
evaluate the patient's neurological deficits.
PAST MEDICAL HISTORY:
1. Depression.
2. Left sided shoulder bursitis.
3. No history of valve replacement.
4. Diabetes.
5. Cholesterol.
6. Stroke.
7. Cancer.
8. Rheumatic fever.
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Zoloft.
2. Oxycodone.
SOCIAL HISTORY: No alcohol, tobacco or intravenous drug use.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: Vital signs 96.5, blood pressure
126/53, heart rate 82, respiratory rate 16, 95% on 2 liters.
In general he is an elderly man lying in bed slightly
agitated. HEENT anicteric. Pupils are equal, round and
reactive to light. Extraocular movements intact. Mucosa
dry. Neck soft, supple. No JVD. No carotid bruits.
Cardiovascular regular rate and rhythm. S1 and S2. 2 out of
3 systolic murmur at the right upper sternal base. Chest is
clear to auscultation bilaterally. A 4 cm by 5 cm firm
lesion over the left sternoclavicular joint. Abdomen soft,
nontender, nondistended. Positive bowel sounds. Extremities
no cyanosis or edema. Neurologically slightly agitated,
alert and oriented times three with right sided facial droop,
right sided weakness. Extremities notice of splinter
hemorrhages in extremities.
LABORATORY: White blood cell count 22.9, hematocrit 38.3,
platelets 285 and 87, L 3, monocytes 1, 9 bands.
Electrolytes sodium 143, K 4.8, chloride 106, bicarb 24, BUN
48, creatinine 1.4, glucose 103, INR 1.3. Urinalysis hazy,
small leukocyte esterase, large blood, protein 30, greater
then 50 white blood cells, 6 to 10 red blood cells, many
bacteria. Electrocardiogram normal sinus rhythm at 80 beats
per minute, left axis, normal intervals, Qs in 1 and AVL. No
ST changes. No T wave inversions. Intraventricular
conduction delay. Chest x-ray showed no congestive heart
failure, infiltrate or obvious emboli. CT of the head showed
two intraparenchymal fossae of hemorrhage seen at the [**Doctor Last Name 352**]
and white matter junction one most posteriorly along the
phallic at the widex and the other within the left mid
parietal lobe. These findings likely consistent with the
patient's known history of septic emboli. CT of the chest
revealed joint effusion with enhancing margins and suggestion
of tiny focus of air within at the left sternoclavicular
joint. This likely represents an abscess, incidental node in
the lymph nodes in the prevascular space some of which are
borderline enlarged.
On [**2-22**] ALT 96, AST 74, LD 400, CK 133, alkaline phosphatase
308, amylase 308. Urine culture came back staph aurous coag
positive, resistant to Penicillin. Blood cultures came back
positive, staph aurous coag positive resistant to Penicillin.
Echocardiogram from [**2-23**] showed limited study, because the
patient was uncooperative. The images are poor, left
ventricular wall thickness are normal. The left ventricular
cavity size is normal. Overall left ventricular systolic
functio is normal. LVEF of greater then 55%, no mass or
vegetations are seen in the aortic valve, at least trace
aortic regurgitation is seen. The mitral valve appears
mildly thickened, mild 1+ mitral regurgitation is seen. No
pericardial effusion. Echocardiogram from [**2-24**] shows the left
atrium is normal. The left ventricular cavity size is
normal, over left ventricular systolic function appears
mildly depressed with probable distal septal hypokinesis,
right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets are mildly thickened,
moderate 2+ aortic regurgitation was seen. No abscess seen.
The mitral valve leaflets are mildly thickened, moderate 2+
mitral regurgitation is seen, moderate pulmonary arterial
systolic hypertension with trivial pericardial effusions.
There is a mobile echo dense mass seen on the ventricular
side of the anterior mitral leaflet, which may represent a
vegetation versus ruptured corti. Compared to the prior
study from [**2-23**] an echo dense may have been present in the
prior study, but images were suboptimal. Chest x-ray from
[**2-22**] mild upper zone redistribution with no pulmonary edema.
Chest x-ray from [**2-23**] consistent with slight left heart
failure. This is worsened in the interval. Chest x-ray from
[**2-24**] showed worsening left heart failure with early pulmonary
edema. Chest x-ray from [**2-26**] shows OG tip below the left
hemidiaphragm and increasing congestive heart failure. Chest
x-ray from [**2-27**] shows persistent left basilar opacity and
worsened right lower lung lobe zone patchy opacity indicating
worsening infiltrates with developing pneumonia to be
considered. Head CT on [**2-24**] possible slight progression of
left posterior frontal hemorrhage is noted. A question of a
new high right cerebral vertex subarachnoid hemorrhage. Head
CT from [**2-27**] showed a stable hemorrhagic region compared with
the prior study. There were new areas of hypodensity within
the left occipital lobe corresponding to a left PCA
distribution. These findings were discussed with the house
staff.
HOSPITAL COURSE: Neurological: The patient initially
evaluated by head CT, which showed areas of hemorrhagic
stroke initially thought likely due to septic emboli. The
patient continued on Vancomycin. Once sensitivities came
back from the urine and blood the patient's antibiotic
regimen was changed to Oxacillin once the sensitivity came
back. Changed to Oxacillin once the sensitivities came back
sensitive to Oxacillin. Ceftriaxone was later added in his
hospitalization on [**2-27**] when a chest x-ray showed possible
development of a pneumonia. The patient's symptoms were
thought likely due to septic emboli.
Cardiovascular: The patient presented with likely sequela
from septic emboli. An echocardiogram was performed on his
presentation.
Dictation cut off.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4446**]
Dictated By:[**Last Name (NamePattern1) 201**]
MEDQUIST36
D: [**2167-3-16**] 08:36
T: [**2167-3-20**] 10:37
JOB#: [**Job Number 49455**]
ICD9 Codes: 431, 4280, 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3514
} | Medical Text: Admission Date: [**2198-5-11**] Discharge Date: [**2198-5-15**]
Date of Birth: [**2126-10-21**] Sex: M
Service: SURGERY
Allergies:
Paba / Silvadene / Bacitracin
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Right leg claudication
Major Surgical or Invasive Procedure:
Thrombectomy of right iliofemoral graft and R femoral-above knee
popliteal bypass graft w/ dacron [**5-11**]
History of Present Illness:
This 71-year-old gentleman with a long history of peripheral
vascular disease has had an iliofemoral bypass on the right.
This clotted once before and
was revised with a jump graft into the profunda femoris artery.
This recently thrombosed again. The profunda femoris artery is
found to be essentially occluded. His popliteal artery
reconstitutes at the knee joint with posterior tibial run off
distally.
Past Medical History:
htn,
increase chol,
PVD,
DM - diet controlled,
[**Location (un) 260**] filter,
vena cava clipping,
r fem - op [**2176**],
R illio profunda bp '[**79**],
L fem BK [**Doctor Last Name **] with left arm vein ([**11-26**]),
vein patch angioplasty of l fem BK [**Doctor Last Name **] ([**1-24**])
Social History:
pos tobacco 1.5 ppd
rare alchohol
Family History:
Father deceased at 54 - stroke
Physical Exam:
Middle age male, looks his age
a/o x 3, nad
perrl, eomi
neck supple
cta b/l
rrr without murmers
soft, nt, nd, pos bs, neg cva
fem 1 plus b/l
neg bruits throughout
Post-operatively with palpable right DP and PT
Pertinent Results:
[**2198-5-11**] 08:13PM BLOOD WBC-11.4* RBC-3.93* Hgb-12.0*# Hct-35.0*#
MCV-89 MCH-30.5 MCHC-34.3 RDW-14.9 Plt Ct-132*
[**2198-5-13**] 03:45AM BLOOD WBC-13.3* RBC-3.89* Hgb-11.9* Hct-35.0*
MCV-90 MCH-30.5 MCHC-34.0 RDW-14.8 Plt Ct-116*
[**2198-5-12**] 02:49AM BLOOD PT-12.9 PTT-23.0 INR(PT)-1.1
[**2198-5-15**] 04:56AM BLOOD PT-13.8* PTT-24.1 INR(PT)-1.2*
[**2198-5-11**] 08:13PM BLOOD Glucose-136* UreaN-20 Creat-1.1 Na-140
K-3.8 Cl-106 HCO3-27 AnGap-11
[**2198-5-13**] 03:45AM BLOOD Glucose-180* UreaN-23* Creat-1.4* Na-136
K-3.6 Cl-98 HCO3-30 AnGap-12
[**2198-5-14**] 04:05AM BLOOD Glucose-150* UreaN-22* Creat-1.2 Na-137
K-3.3 Cl-99 HCO3-29 AnGap-12
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
CHEST PORT. LINE PLACEMENT [**2198-5-11**] 10:42 PM
Tip of the right jugular line projects over the SVC. Lung
volumes are appreciably lower today than on [**4-25**], which would
explain the left lower lobe atelectasis and increasing fullness
of the right hilus; however, when feasible, I would recommend
repeat routine radiographs with full inspiration.
Separation of the right jugular line from the trachea, which is
deviated slightly to the left is probably a longstanding
abnormality seen as early as [**2192-11-30**], such as an
enlarged right lobe of the thyroid gland rather than an acute
hematoma. No pneumothorax is present.
~~~~~~~~~~~~~~~~~~~~~~~
CHEST (PORTABLE AP) [**2198-5-13**] 8:33 AM
Consolidation in the right infrahilar lung and in the left lung
base has persisted since [**5-11**] following resolution of
previous mild pulmonary edema, now concerning for pneumonia.
Upper lungs clear. Heart size normal. Minimal if any pleural
effusion. No pneumothorax. Tip of the right jugular line
projects over the SVC.
~~~~~~~~~~~~~~~~~~~~~~~~
CHEST (PORTABLE AP) [**2198-5-14**] 6:44 PM
AP BEDSIDE CHEST. There is a consolidation involving the right
medial lung base and bibasilar subsegmental atelectasis. I
cannot exclude a small effusion particularly on the right. Heart
normal size. Bilateral apical vascular prominence probably
reflecting lordotic semi-erect positioning and no overt vascular
congestion. Tip of right IJ line is in mid SVC. No PTX. Since
exam one day previous the consolidation in right lower lobe has
progressed.
IMPRESSION: Short interval progression right lower lobe
pneumonia.
Brief Hospital Course:
The patient was admitted on the day of surgery. He underwent
thrombectomy of right iliofemoral graft and right femoral to
above knee popliteal artery bypass with 6 mm
Dacron graft. He tolerated the procedure well and was noted to
have palpable pulses distally of the RLE. He was monitored in
the VICU post-operatively without any acute issues. He was
noted to have a productive cough and had a chest x-ray that was
questionable for a developing pneumonia. He was started
empirically on a course of levoquin to continue for 7days. He
was out of bed with nursing and seen by physical therapy who
cleared him for home. He remained on low flow nasal cannula
overnight but had no requirement during the day or when
ambulating. This was consistent with his home regimen. He was
restarted on coumadin at his home dose. His incisions were
healing well and he was discharged to home on POD4 with
follow-up for staple removal. His INR/coumadin will be followed
by his primary care. He will have lab work on Friday.
Medications on Admission:
Lipitor, Norvasc, Univasc, Coumadin, HCTZ, Cilostazol, Univasc,
Advair, KCl, Wellbutrin
Discharge Medications:
1. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO BID (2 times a day).
6. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
7. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed.
Disp:*35 Tablet(s)* Refills:*0*
10. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
11. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO once a day
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA Carenetwork
Discharge Diagnosis:
Right lower extremity ischemia
Discharge Condition:
Good
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Lower Extremity Bypass Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
??????You should get up out of bed every day and gradually increase
your activity each day
??????Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
??????Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on:
??????Elevate your leg above the level of your heart (use [**12-29**] pillows
or a recliner) every 2-3 hours throughout the day and at night
??????Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
??????You will probably lose your taste for food and lose some weight
??????Eat small frequent meals
??????It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
??????To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
??????No driving until post-op visit and you are no longer taking
pain medications
??????Unless you were told not to bear any weight on operative foot:
??????You should get up every day, get dressed and walk
??????You should gradually increase your activity
??????You may up and down stairs, go outside and/or ride in a car
??????Increase your activities as you can tolerate- do not do too
much right away!
??????No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
??????You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over incision,
rinse and pat dry
??????Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
??????Take all the medications you were taking before surgery, unless
otherwise directed
??????Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
??????Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
??????Redness that extends away from your incision
??????A sudden increase in pain that is not controlled with pain
medication
??????A sudden change in the ability to move or use your leg or the
ability to feel your leg
??????Temperature greater than 100.5F for 24 hours
??????Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in 10 days for staple
removal. ([**Telephone/Fax (1) 18181**]
Please follow-up with your physician who follows your INR level
for your coumadin dosing. You should have your blood drawn
Friday to check your INR.
ICD9 Codes: 486, 496, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3515
} | Medical Text: Admission Date: [**2155-4-11**] Discharge Date: [**2155-4-17**]
Date of Birth: [**2082-9-17**] Sex: M
Service: MEDICINE
Allergies:
Benadryl
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
Shortness of breath.
Major Surgical or Invasive Procedure:
Intubation and mechanical ventilation
Trach placement
Bronchoscopy x2
History of Present Illness:
This is a 72-year-old gentleman with a history of HTN, DMII, CAD
s/p CABG in [**2154**] complicated by wound infection, repeat surgical
interventions requiring tracheostomy. The patiet developed
tracheal stenosis and now is status post cervical tracheal
resection and reconstruction that was subsequently complicated
by anastomotic necrosis and dehiscence, requiring reoperation
and t-tube placement. T-tube was removed and tubular silicone
y-stent placed with external fixation. He was recently admitted
to [**Hospital1 18**] from [**Date range (1) 20494**]/10 for a similar complaint of respiratory
distress. At that time, bronch revealed distal migration of the
stent exposing his areas of tracheal stenosis, resulting in
dyspnea. This was corrected with rigid bronch in the OR on [**3-4**]
with immediate resolution of symptoms.
Patient presented to the [**Location (un) **] ER on day of admission for 1
day of worsening SOB c/w previous stent migrations. He did
report some difficulty bringing up secretions. No fever, chest
pain, n/v, or diarrhea. At the OSH ED, pation was observed to
be in respiratory distress with report of stridor. He was given
nebs without improvement. CXR showed left lung white-out. He
was sedated and then intubated by anesthesia through his trach
stoma with a 7.0 ETT with improvement in his respiratory status.
He was transferred here for further work-up by IP.
In the ED, initial VS were: T97.5, 155/59, 77, RR 20-24, O2sat
100% on PS 10/5, FiO2 60%. Pt was in NAD, perhaps mild
increased WOB. Coarse BS b/l. Trach site draining
serosanguinous mucous. Exam otherwise unremarkable. Labs
notable for WBC 14, Creat 2.1 (baseline), CXR without obvious
consolidations, U/A neg with Foley in place. EKG at baseline.
ETT slightly deep but aerating lungs well. As unclear where
tracheal stenosis is, decided not to pull back. IP aware and
plans to bronch on day after admission; patient admitted to MICU
overnight for monitoring. On transfer, VS: afebrile, BP 158/68,
P 70, RR 12-16, O2sat 100% on PS 10/5, FiO2 50% with ABG
7.38/51/227/31.
In the ICU Mr. [**Known lastname 13144**] [**Last Name (Titles) 1834**] bronchoscopy, with IP
performing stent removal during which a large amount of
inflammation/necrotic tissue thought secondary to intubation
through stoma with button hole which had pushed through tissue.
#7 tracheostomy tube placed. He was subsequently weaned off the
vent on [**4-14**] AM and is now on humidified air through trach and
doing well. Of note, he did have moderate growth of MRSA on his
respiratory culture and started a course of vancomycin on [**4-13**],
which will go for a total of 8 days.
.
On arrival to the floor patient denied any SOB. Only complaints
was sore throat from constant coughing and abdominal pain from
muscle strain (also from coughing).
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies chest pain, chest
pressure, palpitations, or weakness. Denies nausea, vomiting,
diarrhea, constipation, abdominal pain, or changes in bowel
habits. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
- DM type II
- Diastolic CHF
- CAD s/p emergent CABG (w/ radial and venous grafts) c/b wound
infection, dehiscence "plastic surgery," c/b infection,
tracheostomy
- S/p intubation tracheal stenosis, s/p cervical tracheal
resection and reconstruction that was subsequently complicated
by anastomotic necrosis and dehiscence, requiring reoperation
and t-tube placement. T-tube was removed and tubular silicone
y-stent placed with external fixation.
- Asthma
- CRI
- Colon ca s/p partial colectomy
- S/p cholecystectomy
- Mild aplastic anemia
Social History:
Lives with friend [**Name (NI) **] ([**Telephone/Fax (1) 82870**]), has two sons, able to
do most ADLs (cooking, cleaning); denies smoking, no EtOH, used
to work as commercial photographer for [**Company 2676**].
Family History:
Mother and father both had CAD. Father also with leukemia.
Physical Exam:
On transfer to general medicine floor:
Vitals: T: 98.9, BP: 110/62, HR: 71, RR: 22, SP02: 100% on 10L
trach
Gen: Sitting upright comfortably, trached
HEENT: No scleral icterus, mmm, oropharynx clear
NECK: Trach site dressing is clean, dry, and intact. Some
mucous on NRB positioned below trach.
CV: RRR, nl S1, S2, no murmurs, rubs or gallops. CABG incision
well-healed.
LUNGS: Coarse breath sounds anteriorly. Decreased breath
sounds on left.
ABD: Soft, NT, obese but ND, nl BS, no HSM appreciated.
EXT: 1+ BLE edema (which patient states is chronic). 2+ DP
pulses BL.
NEURO: A&Ox3, nonfocal.
On discharge:
T: 97.8, HR: 67, BP 158/64, SP02: 100% on 10L trach mask
Gen: Sitting upright comfortably, trached
HEENT: No scleral icterus, mmm, oropharynx clear
NECK: Trach site dressing is clean, dry, and intact. Some
mucous on NRB positioned below trach.
CV: RRR, nl S1, S2, no murmurs, rubs or gallops. CABG incision
well-healed.
LUNGS: Coarse breath sounds bilaterally
ABD: Soft, NT, obese but ND, nl BS, no HSM appreciated.
EXT: 1+ BLE edema (which patient states is chronic). 2+ DP
pulses BL.
NEURO: A&Ox3, nonfocal.
Pertinent Results:
Labs on admission:
[**2155-4-11**] 08:50PM URINE AMORPH-FEW
[**2155-4-11**] 08:50PM URINE RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE
EPI-0-2
[**2155-4-11**] 08:50PM URINE BLOOD-LG NITRITE-NEG PROTEIN-150
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2155-4-11**] 08:50PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2155-4-11**] 08:50PM PLT COUNT-280
[**2155-4-11**] 08:50PM NEUTS-89.7* LYMPHS-5.8* MONOS-3.8 EOS-0.5
BASOS-0.3
[**2155-4-11**] 08:50PM WBC-13.6* RBC-4.23* HGB-12.4* HCT-36.9*
MCV-87 MCH-29.3 MCHC-33.6 RDW-15.5
[**2155-4-11**] 08:50PM URINE GR HOLD-HOLD
[**2155-4-11**] 08:50PM URINE HOURS-RANDOM
[**2155-4-11**] 08:50PM CK(CPK)-236
[**2155-4-11**] 08:50PM estGFR-Using this
[**2155-4-11**] 08:50PM GLUCOSE-283* UREA N-54* CREAT-2.1* SODIUM-140
POTASSIUM-5.0 CHLORIDE-106 TOTAL CO2-24 ANION GAP-15
[**2155-4-11**] 09:01PM GLUCOSE-273* LACTATE-1.4 K+-4.8
[**2155-4-11**] 11:22PM URINE HYALINE-0-2
[**2155-4-11**] 11:22PM URINE RBC- WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2155-4-11**] 11:22PM URINE BLOOD-LGE NITRITE-NEG PROTEIN-75
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2155-4-11**] 11:22PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.009
[**2155-4-11**] 11:39PM TYPE-ART TEMP-38.4 RATES-/21 O2-50 PO2-227*
PCO2-51* PH-7.38 TOTAL CO2-31* BASE XS-4 INTUBATED-NOT INTUBA
VENT-SPONTANEOU
ECG [**2155-4-11**]: Sinus rhythm with prolonged A-V conduction. Prior
inferior myocardial infarction. Possible prior anteroseptal
myocardial infarction. Compared to the previous tracing of
[**2155-2-22**] there is no significant change.
Portable CXR [**2155-4-11**]: FINDINGS: Consistent with the given
history, tracheostomy tube is in place. Subsegmental
atelectasis is seen in the left lung base. No focal
consolidation or superimposed edema is noted. There is calcified
plaque at the aortic arch. The cardiac silhouette is grossly
stable in size. No definite effusion or pneumothorax is noted.
Degenerative changes are seen throughout the thoracic spine.
IMPRESSION: Subsegmental left base atelectasis. No definite
consolidation or superimposed edema. Tracheostomy as above.
Portable CXR [**2155-4-13**]: FINDINGS: Comparison is made to previous
study from [**2155-4-11**]. Tracheostomy is identified. There is
tortuosity of thoracic aorta. There are no pneumothoraces or
focal consolidation. There is atelectasis at the left base.
Small left-sided pleural effusion is also seen and this is
unchanged.
Portable CXR [**2155-4-14**]: FINDINGS: In comparison with the study of
[**4-13**], the tracheostomy tube remains in place. There is
increasing opacification at the right base, most likely
consistent with atelectasis and pleural effusion. In the proper
clinical setting, supervening pneumonia must be considered. No
evidence of vascular congestion. The right lung and upper half
of the left lung are clear. Tracheostomy tube remains in place.
Tracheal tissue [**4-13**]: Squamous mucosa with acute and chronic
inflammation, granulation tissue, and focal necrosis.
Brief Hospital Course:
This is a 72-year-old gentleman with a pmhx of CAD, CABG, DMII,
HTN, with tracheal Y stent with external fixation presenting
with acute shortness of breath, likely mechanical from shifting
of stent, now s/p stent removal by IP on [**4-13**] and trach
placement.
.
# DYSPNEA/STRIDOR: Initial dyspnea in this patient may be
multifactorial, with contributions from stent migration (patient
has had similar complications in the past), infection/PNA, or
aspiration. The sudden-onset dyspnea that the patient
experienced most likely relates to the collapse of the left lung
seen on imaging from the OSH. This event may also have been
related to stent displacement occluding the left mainstem
bronchus or to mucous plugging, bronchomalacia, or other
mechanical event. This problem seems to have been corrected
following intubation, as CXR here shows generally clear lungs
although there appears to be a L-sided effusion or ?partial
collapse obscuring the left heart border. Patient has a history
of CAD and is s/p CABG, although last echo shows normal LVEF and
no overt evidence of CHF. Stridor suggests upper airway
constriction, which could be related to underlying
stenosis/post-surgical changes or to upward migration of the
stent. The patient was given albuterol MDI (in place of home
nebs), fluticasone, gabapentin, and sigulair. Mucomyst was held
to avoid bronchospasm and Tussin was held to assist the patient
with clearing secretions. Rigid bronchoscopy on [**4-13**] showed
stent migration, and the stent was removed; necrotic tissue at
the buttonhole was debrided. He was able to be weaned from the
ventillator and maintained on trach mask with good O2 sats. He
was therefore called out to the general medicine floor on [**4-14**].
He returned to the OR on [**2155-4-15**] for repeat rigid bronchoscopy,
during which time IP just "took a look" and saw continued
inflammation and necrotic tissue. The stent was not replaced at
that time, and patient was discharged with a trach. Mr.
[**Known lastname 13144**] will return to [**Hospital1 18**] next week for another
bronchoscopy, at which time stent may be replaced.
.
# LEUKOCYTOSIS: Patient had mild leukocytosis on admission with
elevated PMNs but no bands. This was felt possibly secondary to
inflammation induced by stent displacement vs. underlying
infection (pulmonary source most likely). Patient was afebrile
on admission. Sputum returned with coag + staph (speciated as
MRSA) and the patient developed increased secretions, so he was
covered with antibiotics. Vancomycin was started on [**4-13**]; Mr.
[**Known lastname 13144**] was discharged on doxycycline 100mg Q12 for the next 3
days to complete an 8 day course on [**4-20**].
.
# CHRONIC RENAL FAILURE: Creatinine trending up from baseline of
2.1 to 2.5 during admission, with a creatinine of 2.2 upon
discharge. Urine lytes with Na 56, FeNa 1.69%.
.
# ANEMIA: Likely secondary to chronic disease/renal
insufficiency. Patient takes Procrit injections as outpatient.
.
# MICROSCOPIC HEMATURIA: Patient has had similar findings on
multiple prior U/A's. Could relate to placement of Foley
(traumatic) but cannot exclude underlying bladder pathology.
Review shows large blood but minimal RBCs, ?hemo/myoglobinuria.
CK normal and normal coags. Repeat U/A during admission still
showed blood, but decreased amount from prior. This issue
should be further explored as an outpatient.
.
# DM II: Stable; though with some FS > 200. Home glargine
regimen was increased from 18units QAM to 20units QAM. Patient
was also maintained on an insulin sliding scale during
admission. However, blood sugars still ranged from ~140-250.
.
# CAD: Denied any chest pain. EKG at baseline. Continued on home
meds amlodipine, metoprolol, simvastatin.
.
# HTN: Well-controlled. Continued on Amlodipine 10mg daily and
Lasix 40mg daily.
.
# ASTHMA: Continued on fluticasone, singulair, and albuterol
nebs prn; mucomyst held as above given risks of bronchospasm.
Fexofenadine also held during this admission (loratadine not
formulary).
.
# INSOMNIA: Continued on home trazodone.
.
# ANEMIA: Patient carries a diagnosis of borderline aplastic
anemia. He gets procrit injections every 2 months. He is due
for blood work at Quest labs on [**4-28**], and his PCP will
decide whether or not he needs procrit at that time.
Medications on Admission:
Mucormyst neb 20% vial [**3-7**] mL TID
Albuterol neb 3 mL TID
Amlodipine 10mg daily
Fluticasone 50mcg 2 sprays each nostril twice daily
Lasix 40mg daily
Gabapentin 100 mg three times daily
Glargine 18 units AM
Humalog insulin sliding scale
Metoprolol tartrate 50mg twice daily
Singlulair 10mg daily
Simvastatin 80mg daily
Loratadine 10mg daily
Mucinex 1200 mg PO daily
Trazodone 100 mg PO daily
Tussin 2 tsp TID
Procrit injections Q 2 months (not due at this time)
Discharge Medications:
1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
2-4 Puffs Inhalation Q4H (every 4 hours) as needed for shortness
of breath or wheezing.
2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal [**Hospital1 **] (2 times a day).
4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day.
10. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
11. Procrit Injection
12. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
13. Mucinex 1,200 mg Tab, Multiphasic Release 12 hr Sig: One (1)
Tab, Multiphasic Release 12 hr PO once a day.
14. Humalog 100 unit/mL Solution Sig: One (1) Subcutaneous four
times a day: SLIDING SCALE. AS DIRECTED.
15. Lantus 100 unit/mL Solution Sig: One (1) 20 Units
Subcutaneous QAM.
16. Doxycycline Hyclate 100 mg Tablet Sig: One (1) Tablet PO
every twelve (12) hours for 3 days.
Discharge Disposition:
Extended Care
Facility:
Highgate Manor
Discharge Diagnosis:
Primary:
1. Acute onset dyspnea
.
Secondary:
- DM type II
- Diastolic CHF
- CAD s/p emergent CABG (with radial and venous grafts)
complicated by wound infection, dehiscence "plastic surgery,"
complicated by infection, tracheostomy
- S/p intubation tracheal stenosis, s/p cervical tracheal
resection and reconstruction that was subsequently complicated
by anastomotic necrosis and dehiscence, requiring reoperation
and t-tube placement. T-tube was removed and tubular silicone
y-stent placed with external fixation.
- Asthma
- Chronic renal insufficiency
- Colon ca s/p partial colectomy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 13144**],
It was a pleasure taking care of you on this admission. You
came to the hospital because of an acute episode of shortness of
breath. It is thought that your tracheal stent migrated into
the wrong position, and that your breathing was made difficult
because a lot of inflammation and edematous tissue in your
airway. The tracheal stent was removed and a tracheostomy was
placed. You will return to interventional pulmonology clinic on
[**4-25**] for further treatment and evaluation.
.
The following changes were made to your medication:
1. STOP taking Tussin
2. STOP taking Mucomyst
3. START taking glargine 20units in the AM
4. START taking albuterol inhaler instead of nebulizer
5. START docycycline 100mg every 12 hours for 3 days through
[**4-20**].
.
Please take all of your medication as provided. Please keep all
of your follow-up appointments.
.
Your oxygen saturation is fine on room air (~99%), but it is
important that you have HUMIDIFIED oxygen for comfort. You will
also need frequent suctioning of your trach.
.
Return to the hospital if you develop worsening shortness of
breath, cough, difficulty breathing, chest pain, nausea,
vomiting, diarrhea, headache, trouble swallowing, pain with
urination, blood in your stools, fever, chills, or any other
concerning signs or symptoms.
Followup Instructions:
Department: INTERVENTIONAL PULMONARY
When: FRIDAY [**2155-4-25**] at 8:00 AM [**Telephone/Fax (1) 3020**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: CHEST DISEASE CENTER
When: FRIDAY [**2155-4-25**] at 8:30 AM [**Telephone/Fax (1) 5072**]
Building: [**Hospital Ward Name 121**] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: CHEST DISEASE CENTER
When: FRIDAY [**2155-4-25**] at 9:00 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 5072**]
Building: [**Hospital Ward Name 121**] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
ICD9 Codes: 5180, 5859, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3516
} | Medical Text: Admission Date: [**2181-4-8**] Discharge Date: [**2181-4-19**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is an 83 year old
female who presents with an episode of shortness of breath
and dyspnea on exertion times three, first time in [**Month (only) 404**],
second time in [**Month (only) 956**] and the current episode. She was
admitted to an outside hospital in [**Location (un) 47**] where she
underwent cath on [**4-2**] that showed normal coronaries, severe
mitral regurgitation and ______________
PAST MEDICAL HISTORY: Status post lumpectomy of the right
breast in the [**2158**]. She was noted to have a right chest
wall mass on [**3-5**]. CT guided biopsy was nondiagnostic. Chest
CT with right upper lobe nodule as well. Hypertension.
Parkinson's. History of breast cancer. Right hip
replacement in [**2178**].
OUTPATIENT MEDICATIONS: Lopressor 50 mg twice a day,
Combivent, Protonix, Zestril 10 mg b.i.d., Lasix 80 mg
b.i.d., Sinemet 20/100 t.i.d.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: Temperature 96.3, heart rate 54,
respirations 18, blood pressure 104/52, 97% in room air. In
general, patient was alert and oriented times three, not in
acute distress. HEENT gingival abscess. Lungs clear to
auscultation bilaterally. Patient had a systolic murmur.
Abdomen positive bowel sounds, no distension, no tenderness.
Extremities pulses felt in bilateral dorsalis pedis and
radial arteries.
HOSPITAL COURSE: The patient was pre-oped by a dental
consult who cleared her. Patient was taken to the operating
room on [**2181-4-11**] where mitral valve repair was performed by Dr.
[**First Name (STitle) **] [**Last Name (Prefixes) **]. Patient left the O.R. requiring Levophed,
milrinone and propofol drips. She was also placed on
Neo-Synephrine for low blood pressure. Patient required
transfusion of packed red blood cells for postoperative
anemia. Patient's pacing wires and chest tubes were removed
at the appropriate time. Her diet was advanced. She was
placed back on her home medications.
When the appropriate time came, the patient was moved from
the cardiothoracic ICU to the regular cardiothoracic floor
where she did well. She was seen by physical therapy who
worked with her and felt patient would probably need a rehab
care facility post discharge. On [**2181-4-16**] patient complained
of right leg tenderness. Doppler ultrasound was performed
which showed a deep vein thrombosis in the superficial
femoral vein. Patient was seen by the vascular team who
recommended anticoagulation. Patient was started on heparin
and Coumadin loading.
It is now [**2181-4-19**] and the patient is being discharged to a
rehab facility which will be able to accommodate a heparin
drip and monitor her Coumadin loading. She has a goal INR of
1.5 to 2 and a goal PTT of 40 to 50. She is to see Dr. [**First Name (STitle) **]
[**Last Name (Prefixes) **] in four weeks. She is also to see her PCP in one
to two weeks and [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] in two to three weeks. She
is being discharged on the following medications.
DISCHARGE MEDICATIONS:
1. Coumadin to be titrated as necessary after daily INR
checks.
2. Heparin 800 units per hour with frequent daily PTT checks
to monitor need for change in dose.
3. Albuterol ipratropium one to two puffs q.six p.r.n.
4. Carbidopa/levodopa 25/100 one tab p.o. t.i.d.
5. Protonix 40 mg p.o. q.24.
6. Percocet.
7. Lopressor 12.5 mg p.o. b.i.d.
8. Colace 100 mg p.o. b.i.d.
9. Potassium chloride 20 mEq p.o. q.12.
10. Lasix 40 mg IV q.12.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern4) 98590**]
MEDQUIST36
D: [**2181-4-19**] 09:56
T: [**2181-4-19**] 09:58
JOB#: [**Job Number 105838**]
ICD9 Codes: 4240, 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3517
} | Medical Text: Admission Date: [**2104-4-8**] Discharge Date: [**2104-4-10**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
[**Age over 90 **] y/o M w/DM, CHF, who presented to the ED tonight c/o weakness
and falls x 2 days. His wife brought him in, stating that the
past 2 nights, she has heard him fall. He hasn't lost
consciousness, but has been unable to get up after falling. His
wife also notes that he has been coughing for the past couple of
days, and she doesn't think he has been himself. She's noted
that he is confused when he wakes up in the mornings, for the
past 2 mornings, but this has resolved over the course of each
day. However, she brought him to the ED today due to his falls
and weakness.
.
In the ED, his vitals were 100.6, BP mostly 90s/50s but as low
as 86/44, P 60s, RR 18-22, O2 sat 89%RA and 100%3L. He had a
head/C-spine CT which were negative for any acute process. CXR
showed a new LLL infiltrate superimposed on a chronic-appearing
reticular process. A CVL was placed, with an initial CVP of 8.
He was given 500 cc NS (vs 2 L NS, unclear documentation), CVP
improved to 11. He was given tylenol and levofloxacin, and
admitted to the MICU.
.
Currently, Mr. [**Known lastname **] has no complaints other than he is thirsty.
He denies any headache, neck pain, chest pain, shortness of
breath, cough, nausea, vomiting, abd pain.
Past Medical History:
1. Type 2 DM
2. CHF, EF >55% on TTE [**2100**]
3. Symptomatic bradycardia s/p PPM [**2096**]
4. HTN
5. Gout
6. Glaucoma
7. s/p appy
8. s/p cataract surgery
9. Chronic dyspnea: Has been seen in Pulmonary [**10-8**], who felt
that his limitation in exertion was more related to
musculoskeletal problems. O2 sat at that time 94%RA, crackles
[**2-6**] way up on exam, likely IPF vs burnt-out sarcoid (had
respiratory illness in [**Country 651**] in his 20s) but since it was not
limiting him, did not pursue further treatment/workup.
10. Degenerative disc disease: severe at L5-S1 seen on plain
film [**12-9**]
11. ?prostate cancer: PSA elevated at 7.8 in [**4-8**]
Social History:
Lives with his wife in [**Name (NI) **]. Is a former accountant. No hx
of tobacco use. No EtOH.
Family History:
father died at [**Age over 90 **] y/o from CHF. Mother died at 64 of cancer.
Brother died of aspiration pna.
Physical Exam:
T: 97.7 BP: 111/59 P: 72 R: 16 O2 sat: 99%2L CVP: 4
Gen: pleasant elderly gentleman in NAD. oriented to person,
knows it is [**2104-4-3**] but not which day, thinks he is at his
apartment. Knows his phone number.
HEENT: NC, AT, conjunctivae noninjected, MM very dry
Neck: supple, no LAD, JVD at 5 cm
Lungs: coarse crackles halfway up bilaterally
CV: RRR, I/VI systolic ejection murmur at RUSB
Abd: soft, nt/nd, +bs
Ext: no edema, 1+ distal pulses bilaterally
Neuro: Strength 5/5 x4, pt unable to cooperate with reflex exam
Pertinent Results:
[**2104-4-9**] 04:04AM BLOOD WBC-6.1 RBC-2.96* Hgb-11.7* Hct-34.9*
MCV-118* MCH-39.5* MCHC-33.5 RDW-14.4 Plt Ct-126*
[**2104-4-9**] 04:04AM BLOOD Neuts-76.2* Lymphs-16.6* Monos-7.0 Eos-0
Baso-0.1
[**2104-4-9**] 04:04AM BLOOD PT-14.2* PTT-65.4* INR(PT)-1.3*
[**2104-4-9**] 04:04AM BLOOD Glucose-102 UreaN-20 Creat-1.2 Na-140
K-3.7 Cl-106 HCO3-25 AnGap-13
[**2104-4-9**] 04:04AM BLOOD CK(CPK)-1328*
[**2104-4-8**] 02:39PM BLOOD CK(CPK)-1594*
[**2104-4-8**] 02:39PM BLOOD CK-MB-5 cTropnT-0.02* proBNP-1313*
[**2104-4-8**] 02:49PM BLOOD Lactate-2.0
.
EKG: v-paced
.
CXR [**2104-4-8**]: FINDINGS: The heart is again seen at the upper
limits of normal. A left-sided pacemaker is seen with leads in
standard position over the right atrium and right ventricle.
Bibasilar reticular opacities again identified consistent with
underlying interstitial lung disease such as IPF or collagen
vascular disease. A new opacity is identified in the left lower
lung field obscuring the left hemidiaphragm.
IMPRESSION:
1. New opacity within the left lower lung field with partial
obscuration of the hemidiaphragm consistent with pneumonia.
2. Bibasilar reticular opacities likely representing chronic
interstitial lung disease such as IPF or collagen vascular
disease.
.
Head CT [**2104-4-8**]: There is no hemorrhage, mass effect, shift of
the normally midline structures, or major vascular territorial
infarct. There are age-appropriate involutional changes.
Moderate periventricular white matter hypodensity is consistent
with chronic microvascular ischemia. A hypodensity in the right
basal ganglia likely represents a chronic lacunar infarct. The
overlying soft
tissues are unremarkable. The osseous structures are
unremarkable. There is _____ mucosal thickening of the frontal,
ethmoid, and maxillary air cells. Mild mucosal thickening as
well as likely air-fluid levels are seen within the sphenoid
sinus.
IMPRESSION:
1. No hemorrhage or mass effect.
2. Chronic microvascular ischemic changes.
3. Right basal ganglia lacunar infarct, likely chronic.
4. Paranasal sinus mucosal thickening as well as air-fluid
levels within the sphenoid sinuses which can be seen in the
setting of acute sinusitis.
.
C-spine CT [**2104-4-8**]: On sagittal images from the skull base to the
T2 vertebral bodies is clearly visualized. There are no
prevertebral soft tissue abnormalities. There is no fracture.
There is loss of the normal cervical lordosis. Mild grade 1
retrolisthesis of C5 on C6 and C6 on C7 is likely degenerative.
Moderate to severe degenerative changes are noted of the
cervical spine manifested less prominently at the C4 through C6
vertebral body levels by disc
space narrowing and large anterior osteophytes. At C2
uncovertebral joint, hypertrophy results in left neural
foraminal narrowing. Bilateral neural foraminal narrowing is
also noted at the C5 and C6 levels as well as mild spinal canal
stenosis. Scattered cervical chain lymph nodes do not meet CT
criteria for pathologic enlargement. Small bullae are seen at
the right lung
apex.
Again seen are air-fluid levels within the sphenoid sinus and
maxillary mucosal thickening.
IMPRESSION:
1. No fracture.
2. Moderate-to-severe degenerative changes of the cervical spine
resulting in multilevel neural foraminal narrowing and mild
spinal canal stenosis.
3. Air-fluid levels in the sphenoid sinuses, which can represent
acute sinusitis in the proper clinical setting.
4. Loss of normal cervical lordosis.
Brief Hospital Course:
A/P: [**Age over 90 **] y/o M w/DM, CHF, who presents with weakness, confusion,
and cough, found to be hypotensive in the ED.
.
1. Hypotension/Pneumonia: It was thought that his hypotension
was due to volume depletion in the setting of infection
(pneumonia) and his anti-hypertensives. His BP improved with
IVF. CXR showed a LLL PNA and he was treated with levofloxacin.
He should complete a 7 day course for CAP. A chest CT was done
as CXR showed evidence for pulmonary fibrosis that was confirmed
on CT. He should follow up in pulmonary clinic with Dr. [**First Name (STitle) 216**]
on [**2104-6-27**] at 3:00.
.
2. Confusion: Initially confused on arrival. Likely secondary to
hypovolemia +/- infectious process as patient's mental status
returned to baseline with return of blood pressure and treatment
with levofloxacin for pneumonia. He was alert and oriented upon
discharge.
.
3. Hypoxia: Oxygen saturation was 89% on RA in ED, but returned
to 99% on room air with improvement of hypotension and
antibiotic therapy. He did have occasional brief desaturations
while sleeping but would rapidly return to baseline. the patient
likely has some component of obstructive sleep apnea in addition
to his chronic lung disease.
.
4. Frequent falls: Per clinic notes, pt is very unsteady on his
feet, and ambulates with a walker at home. [**Month (only) 116**] have been
somewhat confused, and fell in setting of not using walker.
Given low BG levels, hypoglycemia may have also played a role.
The patient denies loss of conciousness or syncope. However, it
remains an unclear picture as the pt is not a great historian.
Head CT and C-spine are negative, no other signs of trauma on
exam. Seen by physical therapy who cleared him for home with 24
hour care. As his BG levels were low on his oral hypoglycemic
[**Doctor Last Name 360**], this was discontinued. The patient was advised to follow
up with his PCP upon discharge.
.
5. Elevated CK: Likely related to falls. MB and troponin were
negative.
.
6. ARF: Baseline creatinine 1.1-1.3, and was elevated to 1.4.
Given the hypotension and return to baseline with fluids, his
ARF was attributed to a pre-renal physiology.
.
7. CHF: Does not appear volume overloaded on exam, neck veins
flat, no edema, crackles at baseline per OMR notes, CVP 4. BNP
elevated but may be secondary to R heart strain from pulmonary
disease. Antihypertensives were held on discharge as patient
admitted with low SBPs. Will follow-up with PCP to determine
reintroduction of these medications.
.
8. Macrocytic anemia: Has undergone w/u as outpatient. Vitamin
B12 is normal in 600s, folate normal, methylmalonic acid high
(which can indicate b12 defic.) and homocysteine normal. Will
follow-up w/PCP for further [**Name Initial (PRE) **]/u if necessary.
.
The patient's case was discussed with his daughter throughout
his stay. He is being discharged home with 24 hour nursing care.
Medications on Admission:
aldactone 25 mg daily
allopurinol 150 mg daily
aspirin (enteric coated) 81 mg daily
glyburide 1.25 mg [**Hospital1 **]
hctz 25 mg daily
nitroglycerin prn
Discharge Medications:
1. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO once a day.
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1)
Sublingual as previously directed as needed for chest pain.
4. home care
Patient requires a home semi-electric bed with side rails
5. home care
Patient will need a home 3-in-1 commode
6. home care
patient will need wheelchair with elevated leg rests and
removable arm rests
7. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q48H (every
48 hours) for 6 days.
Disp:*3 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Pneumonia
Respiratory Distress
ARF
.
Secondary:
Type 2 DM
CHF
HTN
Gout
Glaucoma
Discharge Condition:
Good.
Discharge Instructions:
You were admitted to [**Hospital1 18**] for evaluation of
breathingdifficulties. The CAT scan of your chest whoed signs of
possible chronic infection and interstitial lung disease. You
should continue to take one pill of 750 mg Levofloxacin every 48
hours for a total of 7 days.
.
The CAT scan also showed some chronic changes that you should
have followed up by a Pulmonogist as an outpatient.
We would like you to stop taking your hydrochlorothiazide,
aldactone, and glyburide. Please see your PCP upon discharge to
address the issue of restarting these medications.
.
Please return to the ER if you experience shortness of breath,
worsening fever or cough or any other symptoms that concern you.
.
Please follow up with your PCP upon discharge.
Followup Instructions:
Please follow up with your primary care physician upon
discharge.
.
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2104-5-1**]
10:30
Provider: [**Name10 (NameIs) 1918**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 902**]
Date/Time:[**2104-5-1**] 11:00
With Pulmonary Clinic within 2 weeks.
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2104-6-27**]
3:00
Completed by:[**2104-4-10**]
ICD9 Codes: 486, 5849, 4280, 4019, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3518
} | Medical Text: Admission Date: [**2165-12-29**] Discharge Date: [**2166-1-4**]
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
difficulty speaking, R sided weakness
Major Surgical or Invasive Procedure:
IV tPA
History of Present Illness:
Mrs. [**Known lastname 7157**] is a [**Age over 90 **]-year-old right-handed woman, presenting
with Right sided weakness at 5 PM on a background of
hypertension, nephrectomy unilateral renal cell carcinoma
([**2151**]),
hypercholesterolemia.
The patient was at her communicative and mobile baseline on the
day of admission. he was having tea with her daughter when her
face suddenly became blank and she attempted to speak, making a
couple of
sounds, then became completely mute. she slumped over to the
right into a chair without falling or any injury. This was at 5
PM. EMS was called and she was brought to [**Hospital1 18**]. Her initial
vitals including SBP of 217 mmHg. She has been hypertensive to
190s over the last couple of weeks. Code stroke was called on
arrival at 5:11 PM. We (Neurology) were at the bedside within 5
minutes.
Time Code Stroke called: 17:11
Time Neurology at baseline for evaluation: 17:16
Time (and date) the patient was last known well: [**2165-12-29**], 17:00
NIH Stroke Scale Score: 22
Contraindications to t-PA: Hypertension, will control
t-[**MD Number(3) 6360**]: Yes
Time given: 18:00
I was present during the CT scanning and reviewed the images as
they were captured.
NIHSS:
1a. Level of Consciousness: 0
1b. LOC questions: 2
1c. LOC commands: 1
2. Best gaze: 1
3. Visual: 1
4. Facial palsy: 3
5a. Motor arm, left: 0
5b. Motor arm, right: 4
6a. Motor leg, left: 0
6b. Motor leg, right: 3
7. Limb ataxia: 0
8. Sensory: 1
9. Best language: 3
10. Dysarthria: 0
11. Extinction and inattention: 2
CT scan revealed hypodensity in the left basal ganglia. Exam and
imaging, were consistent with dense L MCA. She was given IV tPA
at 6:00pm. Interventional was considered but given the size of
the infarct, not undertaken.
Past Medical History:
- Depression
- Hypertension
- Hypercholesterolemia
- Valvular heart disease, with recent clinical heart failure
- Daughter denies prior stroke, irregular heart
- Renal cell carcinoma, s/p unilateral nephrectomy
- Renal failure, recently 2.0, now 2.4 two days ago
Social History:
Smoking: No.
Alcohol: Occasional.
Drugs: No.
Education and Language: Russian only.
Functional Baseline: Some assistance.
Family History:
Unable to be obtained
Physical Exam:
Physical Exam on Admission:
Vitals: HR 85 BPM; BP 177/97 mmHg; O2Sat 99 % 2L; RR 18 BPM
General Appearance: Restless.
HEENT: NC, OP clear, MMM.
Neck: Supple. No bruits. Normal ROM.
Lungs: CTA bilaterally. Normal respiratory pattern.
Cardiac: Regular. Normal S1/S2. No M/R/G.
Abdominal: Soft, NT, BS+.
Extremities: No edema, warm, normal capillary refill. Peripheral
pulses normal.
Skin: Normal appearances.
Neurologic Examination:
Mental status:
Level of Arousal: Awake. Normal level of arousal and alertness.
Attentiveness: Attentive. Globally aphasic.
Cranial Nerves:
I: Not tested.
II: Pupils symmetric, round and reactive to light, 3 to 2 mm
bilaterally. Visual fields are full to confrontation. Fundi are
normal.
III, IV, VI: Extraocular movements full, conjugate. Gaze
preference to left, not overcome with OCR.
V, VII: Right UMN facial paresis.
VIII: Orients to voice.
IX, X: unable
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius are of normal bulk and
strength bilaterally.
XII: unable
Tone and Bulk: Tone is normal throughout (arms, legs, neck).
Muscle bulk is normal.
Power: Left at least [**5-14**] throughout spontaneously.
Right UE extensor, LE elevates of bed spontaneously.
Sensation: Decreased on right to pain.
Coordination and Cerebellar Function: No major ataxia.
Gait: Unable
PHYSICAL EXAM AT TIME OF DEATH (3:40am on [**1-4**])
GEN: elderly woman with pale skin lying in bed, not moving
HEENT: pupils fixed and dilated
CV: no heart beat auscultated or palpated
PULM: no breath sounds auscultated or palpated
EXT: cool, clammy, not moving
Pertinent Results:
[**2165-12-29**] 07:22PM %HbA1c-5.6 eAG-114
[**2165-12-29**] 07:14PM URINE HOURS-RANDOM
[**2165-12-29**] 07:14PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2165-12-29**] 05:50PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2165-12-29**] 05:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-600
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2165-12-29**] 05:50PM URINE RBC-<1 WBC-2 BACTERIA-FEW YEAST-NONE
EPI-0
[**2165-12-29**] 05:50PM URINE HYALINE-1*
[**2165-12-29**] 05:50PM URINE MUCOUS-RARE
[**2165-12-29**] 05:26PM CREAT-2.4*
[**2165-12-29**] 05:26PM estGFR-Using this
[**2165-12-29**] 05:24PM GLUCOSE-109* NA+-139 K+-4.0 CL--108 TCO2-22
[**2165-12-29**] 05:15PM UREA N-53* TOTAL CO2-21*
[**2165-12-29**] 05:15PM ALT(SGPT)-16 AST(SGOT)-25 LD(LDH)-268*
CK(CPK)-93 ALK PHOS-139* TOT BILI-0.1
[**2165-12-29**] 05:15PM CK-MB-5 cTropnT-0.05*
[**2165-12-29**] 05:15PM ALBUMIN-3.6 CALCIUM-8.7 PHOSPHATE-5.5*
MAGNESIUM-2.4 CHOLEST-215*
[**2165-12-29**] 05:15PM VIT B12-490
[**2165-12-29**] 05:15PM TRIGLYCER-257* HDL CHOL-61 CHOL/HDL-3.5
LDL(CALC)-103
[**2165-12-29**] 05:15PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2165-12-29**] 05:15PM WBC-9.4 RBC-3.54* HGB-11.2* HCT-32.6* MCV-92#
MCH-31.5 MCHC-34.3 RDW-15.4
[**2165-12-29**] 05:15PM NEUTS-67.0 LYMPHS-24.1 MONOS-4.5 EOS-4.1*
BASOS-0.3
[**2165-12-29**] 05:15PM PLT COUNT-305
[**2165-12-29**] 05:15PM PT-11.5 PTT-21.1* INR(PT)-1.0
Noncontrast CT head [**12-29**]:
IMPRESSION: No hemorrhage or evidence of acute major vascular
territory
infarction. Consider MRI for strong clinical concern.
Noncontrast CT head [**12-29**]:
IMPRESSION: Subtle edema in the left basal ganglia, concerning
for early
acute infarction. No hemorrhage.
Brief Hospital Course:
Ms. [**Known lastname 7157**] was admitted to the ICU s/p IV tPA and observed
overnight. She continued to aphasic with dense right
hemiparesis. Given the poor prognosis and premorbid patient
wishes not to have feeding tube, family meeting was held with
daughter HCP and patient status was changed to CMO. She was
transfered to the floor on [**12-30**]. Palliative care was consulted
and recommended Morphine 5-10 mg SL Q1 prn, Hyoscyamine 0.125 mg
SL QID:PRN excess secretions, Zydis 5 mg SL TID prn agitation.
She remained stable and comfortable on this regimen. She died
peacefully at 3:40am on [**1-4**].
Medications on Admission:
Medications - Prescription
AMLODIPINE - 10 mg Tablet - 1 Tablet(s) by mouth once a day
ATENOLOL - 50 mg Tablet - 1 Tablet(s) by mouth twice a day
ATORVASTATIN - 10 mg Tablet - one Tablet(s) by mouth once a day
DARBEPOETIN ALFA IN POLYSORBAT [ARANESP (POLYSORBATE)] - 25
mcg/0.42 mL Syringe - inject s/c every 3 weeks
ERGOCALCIFEROL (VITAMIN D2) - 50,000 unit Capsule - 1 Capsule(s)
by mouth qmonth
FLUTICASONE - 50 mcg Spray, Suspension - one spray intranasal
each nostril qd
FUROSEMIDE - 20 mg Tablet - 1 Tablet(s) by mouth twice a day
HYDROCORTISONE [PROCTOSOL HC] - 2.5 % Cream - one unit rectally
once a day hs
LIDODERM - 5% Adhesive Patch, Medicated - USE AS DIRECTED
LISINOPRIL - 40 mg Tablet - one Tablet(s) by mouth once a day
LORATADINE - 10 mg Tablet - one Tablet(s) by mouth once a day
OLOPATADINE [PATANOL] - 0.1 % Drops - 1-2 drops ou three times a
day as needed for prn allergy
PANTANOL - 0.1% - TWICE A DAY TO BOTH EYES FOR ALLERGIES
SYRINGE - 1 ML SYRINGE - AS DIRECTED
TOLTERODINE [DETROL LA] - 2 mg Capsule, Ext Release 24 hr - one
Capsule(s) by mouth once a day
VENLAFAXINE - 150 mg Tablet Extended Rel 24 hr - 1 Tablet(s) by
mouth every morning
VENLAFAXINE [EFFEXOR XR] - 37.5 mg Capsule, Ext Release 24 hr -
1
Capsule(s) by mouth every morning in addition to a150-milligram
capsule
Medications - OTC
ACETAMINOPHEN - 500 mg Tablet - 1 Tablet(s) by mouth once-twice
a
day
DEXTRAN 70-HYPROMELLOSE [ARTIFICIAL TEARS] - Drops - 2 drops
ou
twice a day
MULTIVITAMIN - (Prescribed by Other Provider) - Tablet - 1
Tablet(s) by mouth every morning
Discharge Medications:
N/A pt expired on [**1-4**]
Discharge Disposition:
Expired
Discharge Diagnosis:
L MCA stroke
Discharge Condition:
N/A pt expired on [**1-4**]
Discharge Instructions:
N/A. pt expired on [**1-4**]
Followup Instructions:
N/A, pt expired on [**1-4**]
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
ICD9 Codes: 5859, 2720, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3519
} | Medical Text: Admission Date: [**2105-8-24**] Discharge Date:
Date of Birth: [**2075-6-29**] Sex: F
IDENTIFICATION: The patient was admitted to the Medical
Intensive Care Unit with a diagnosis of [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 23315**]
septic thrombophlebitis.
female transferred from [**Hospital6 23316**] with [**First Name5 (NamePattern1) **]
[**Last Name (NamePattern1) 23315**] septic thrombophlebitis associated with a central
venous catheter required for total parenteral nutrition. She
has a long history of abdominal surgeries required for
acolasia and complications of prior surgeries, who was at
baseline on total parenteral nutrition due to short bowel
syndrome, G-tube medications, minimal p.o. She went to an
month of fevers to 103 and chills, and purulence around the
J-tube. Chest CT on [**8-13**] showed multiple tiny nodules in
the right lung with ground-glass opacities, probable clot at
the right subclavian catheter, with air bubbles, possibly
representing infection, mediastinal and right hilar
paratracheal lymphadenopathy. The patient was initially
placed on vancomycin after blood cultures were done, but
discontinued once the blood cultures returned after four days
with [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 23315**]. On [**8-14**] a positive tip culture
from the removed Hickman on the right also grew [**First Name5 (NamePattern1) **]
[**Last Name (NamePattern1) 23315**]. The patient was switched from vancomycin to
fluconazole 400 mg intravenously q.d. on [**8-16**], after an
800-mg intravenously load, was changed to liposomal
amphotericin B on [**8-22**] when she developed right scapular
pain, neck pain. A chest CT from [**8-21**] showed multiple
right lung nodules and one on the left upper lobe unchanged,
a resolved infiltrate, superior vena cava clot with air
bubbles extending possibly slightly to the subclavian vein
with soft tissue swelling of the region in the right
subclavian vein. The patient had negative upper extremity
Duplex examination on [**8-19**] after she developed right
shoulder pain. Her temperatures and symptoms continued to
get worse on [**8-22**] to 102, and on [**8-23**] to 105.6. The
patient has had positive blood cultures on [**8-19**] with 1/2
bottles within one day with gram-positive cocci, consistent
with micrococcus. The patient also had a HIDA scan negative
on [**8-14**], and abdominal ultrasound negative on [**8-14**];
although, she had elevated alkaline phosphatase, and an
abdominal CT on [**8-13**] with retroperitoneal lymphadenopathy,
spinomegaly, and possible hepatomegaly, positive free pelvic
fluid, with an evaluation for hypercoagulable states
including a low protein C and a low protein S, and normal
AT3. J-tube was changed on [**8-23**]. She was refused by
Surgery at [**Hospital3 14325**] by Dr. [**Last Name (STitle) 20042**] by Surgery at
[**Location (un) **] [**State 350**], and she was not thought to be a
good surgical or thrombectomy candidate. She was admitted to
[**Hospital1 69**] Medical Intensive Care
Unit for medical management of her [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 23315**] septic
thrombophlebitis.
PAST MEDICAL HISTORY: (Significant for)
1. Acolasia, status post hilar myotomy in [**2098-3-11**]
with chronic reflux, Nissen fundoplication complicated by an
esophageal perforation in [**2101-3-12**], esophagectomy and
cervical esophagostomy in [**2101-3-12**], colonic
interposition surgery in [**2101-10-10**], revision of
esophagectomy anastomosis in [**2101-8-9**], debridement of
abdominal wound with skin graft in [**2101-8-9**], and multiple
operations and complications leading to short bowel syndrome.
2. The patient also has a history of asthma.
3. Narcotic abuse.
4. Depression/bipolar.
5. Heparin-induced thrombocytopenia.
6. Migraines.
7. Right ankle fracture in [**2099**].
MEDICATIONS ON ADMISSION: Medications upon admission were
Fentanyl patch 250 mcg q.24h., Dilaudid 8 mg p.o. q.4h.
p.r.n., Fioricet 2 tablets p.o. q.4h. p.r.n., clonazepam 1 mg
p.o. q.i.d., Compazine 10 mg p.o. q.6h. p.r.n., iron
sulfate 325 mg p.o. t.i.d., Neurontin 800 mg p.o. q.h.s.,
Luvox 100 mg p.o. b.i.d., Tylenol 650 mg p.o. q.4h. p.r.n.,
Ambien 10 mg p.o. q.h.s. p.r.n., and liposomal amphotericin B
268 mg intravenously q.d.
ALLERGIES: The patient's allergies include CODEINE,
PENICILLIN, SULFA, and HEPARIN.
SOCIAL HISTORY: The patient's social history revealed she
has a history of alcohol abuse; none in the last 10 years. A
history of smoking crack cocaine. A 2-pack-year of tobacco.
PHYSICAL EXAMINATION ON ADMISSION: On examination, the
patient was lying in bed, occasionally tearful, in pain, with
movement over neck. Her vital signs revealed she had a
temperature of 98.6, pulse of 84, blood pressure 109/54,
satting 95% on room air. HEENT revealed her left pupil was
greater than her right, but bilaterally reactive. There was
no visualized clot on funduscopy. A questionable corneal
abrasion on her right side. Visual fields were normal to
confrontation. She had a right EJ clot and tenderness.
Positive tenderness extending her right EJ to nearly the
midline and from her jaw to the below the clavicle. There
was erythema in a similar distribution, and her extraocular
movements were intact. Her lungs revealed poor inspiratory
effort, no clear rales. Cardiac examination revealed a
regular rate and rhythm, a 1/6 systolic ejection murmur.
Abdomen showed many surgical scars; although, her belly was
soft and nontender, positive bowel sounds. No
hepatosplenomegaly. Her J-tube was intact without exudate.
Extremities revealed there was no clubbing or cyanosis, 1+
edema in the right arm. No stigmata of emboli.
Neurologically, she was alert and oriented times three,
nonfocal.
LABORATORY ON ADMISSION: She had a white blood cell count
of 4, hematocrit 22.3, platelets 323. SMA-7 revealed sodium
of 136, potassium 4.2, chloride 106, bicarbonate 25, BUN 8,
creatinine 0.6. Liver function tests were normal except for
an alkaline phosphatase of 129. Calcium of 7.5, albumin 3,
magnesium 2, phosphorous 3.9.
HOSPITAL COURSE:
1. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] SEPTIC THROMBOPHLEBITIS: The patient
was initially presented an AmBisome. Infectious Disease was
consulted to see the patient. The patient was started back
on her intravenous fluconazole 400 mg intravenously. The
patient was also started on Lepurdin with a
transition to Coumadin for clot lysis due to the patient's
history of heparin-induced thrombocytopenia. The patient did
well in the Medical Intensive Care Unit. The patient was
transferred to the floor on [**8-26**]. The patient was on
intravenous fluconazole and Coumadin. The patient's target
INR was 2 to 3. The patient was doing well on Coumadin and
intravenous fluconazole, afebrile for multiple days. When
the patient had a desaturation to 68% with unknown etiology,
the patient had diffuse bilateral infiltrates. The patient
spiked to 104.8 degrees. The patient was sent back to the
Medical Intensive Care Unit; although, there was no known
etiology for the sudden desaturation and diffuse bilateral
infiltrates.
In the Medical Intensive Care Unit, the patient did well
satting near 90% on 40% face mask. The patient did not spike
in the Medical Intensive Care Unit. No antibiotics or
changed in medications were made. The patient was
transferred back to the floor, back on her current regimen.
On the floor the patient did well, however, required oxygen
to maintain saturations in the 90s. Pulmonary was consulted.
The patient was kept on her intravenous fluconazole and
Coumadin. The patient had a bronchoscopy on [**9-16**] with
bronchoalveolar lavage to identify any atypical
microorganisms. No organisms were identified as of yet. The
patient currently is doing well, satting in the 90s,
afebrile. Blood cultures/surveillance blood cultures since
admission have been negative without any growth of [**Female First Name (un) **].
The patient awaiting possible discharge home with visiting
nurse [**First Name (Titles) 23317**] [**Last Name (Titles) 23318**] acute inpatient rehabilitation.
2. GASTROINTESTINAL: The patient with a history of short
gut syndrome secondary to acolasia and multiple surgeries.
The patient required J-tube feeds. The patient was put on
Vivonex 20 cc per hour with a goal of 60 cc an hour. The
patient tolerated tube feeds inconsistently. The patient
became bloated at times. J-tube had persistent leakage at
times. Surgery was called after J-tube fell out while the
patient was on the floor. Surgery reinserted the J-tube.
The J-tube's position was confirmed by a contrast
gastrografin study. The patient continued to have J-tube
drainage; although, the patient was able to tolerate slow
increments in her tube feeds up to 50 cc an hour, but the
patient continued to be bloated at times. The patient was
started on an aggressive bowel regimen of Colace and
Dulcolax.
The patient had a CT of the abdomen to rule out any kind of
intraperitoneal abscess. As of [**9-17**], the patient was
tolerating tube feeds at 50 cc an hour Vivonex with a goal of
60 cc an hour.
3. INTRAVENOUS ACCESS: The patient had a PICC placed in her
left upper extremity on [**8-29**] for a prolonged course of
intravenous fluconazole. The patient was doing well,
although one of her ports was clotted off. T-PA was used to
lyse the other clot. The patient remained with a patent
port, receiving intravenous fluconazole until [**9-17**] when
the patient pulled the PICC line out by accident. The
patient was sent back to Interventional Radiology for
fluoroscopic-guided PICC replacement. The patient came back
to the floor with the PICC line in her right upper extremity
to allow for further intravenous antibiotic treatment. The
patient was to be discharged on intravenous fluconazole for
another three week using the PICC line for access.
4. HEMATOLOGY: The patient's hematocrit on presentation
was 22.3. The patient was transfused multiple units of
packed red blood cells. The patient with severe iron
deficiency, unable to take p.o. iron. The patient's
hematocrit went up to 33 but slowly trended back down to 22.
The patient was again transfused another 3 units. As of
[**9-17**], the patient's hematocrit was 29 and stable.
5. PAIN: The patient with a chronic narcotic use with
generalized body pains. The patient presented with severe
neck pain due to the [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 23315**] septic
thrombophlebitis. A Pain consultation was obtained. The
patient was started on a Dilaudid patient-controlled
analgesia pump. The patient tolerated this quite well. When
the patient was on the floor, the patient was switched to
Dilaudid p.o.; at first 12 mg to 16 mg p.o. q.4h. The
patient was slowly decreased back to her normal dose of 4 mg
to 8 mg of Dilaudid p.o. q.4h. The patient tolerated this
regimen well with minimal amounts of pain.
As of [**9-17**], this is where we stand.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 5587**]
Dictated By:[**Name8 (MD) 2439**]
MEDQUIST36
D: [**2105-9-17**] 15:29
T: [**2105-9-17**] 18:41
JOB#: [**Job Number 23319**]
ICD9 Codes: 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3520
} | Medical Text: Admission Date: [**2139-7-6**] Discharge Date: [**2139-7-15**]
Date of Birth: [**2075-5-2**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8790**]
Chief Complaint:
Hematuria, flank pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
64yF with history of left renal cell carcinoma presenting with
left flank pain and substernal chest pain. She was diagnosed
with renal cell carcinoma in [**5-/2139**] and started on Sutent 5 days
ago. After her first dose of Sutent, she noticed hematuria that
started after the dose and improved throughout the subsequent
day (until her next dose). After 3 doses, she had occasional
blood clots and even had difficulty urinating secondary to the
clots. She was seen in the ED on [**7-3**] and was sent home after a
negative workup. On the day of admission, she developed
abdominal/flank pain that was [**11-15**] in quality and constant in
nature. At the same time, she developed substernal chest
pressure, non-radiating, associated with nausea and one episode
of vomiting, but no shortness of breath or diaphoresis. As her
discharge instructions from the ED indicated that she should
come to the ED if she experienced any abnormal symptoms, her
family brought her to the ED.
.
In the ED, she received 1 liter normal saline, 4mg IV morphine x
2, and zofran 4mg x 1, with resolution of her symptoms. She was
admitted for pain control and rule out.
Past Medical History:
PAST ONCOLOGIC HISTORY:
- [**2138**]: Began noticing a "bulge" in her left flank which slowly
grew in size and discomfort.
- [**2139-5-14**]: CT abdomen/pelvis showed a very large left renal mass
about 16 cm in largest diameter with question of invasion of the
left renal vein. The lung bases showed multiple pulmonary
nodules, the largest of which was 15 mm in diameter, concerning
for pulmonary metastases.
- [**2139-5-29**]: CT chest confirmed multiple pulmonary nodules, the
largest of which was 16 x 16 mm in the left lung base. There
were also scattered subcentimeter nodules in the remainder of
both lungs.
.
PAST MEDICAL HISTORY:
Hypertension
[**5-14**] Successful Aflutter Ablation
Atrial Fibrillation
Asthma
Chronic low back pain
Arthritis
Hysterectomy
Tonsillectomy
Anxiety
Social History:
She is originally from [**Country 5881**]. She moved here about seven years
ago and currently lives with her daughter and son-in-law. She
is a former smoker, having quit within the past 2 months. She
was previously smoking [**4-9**] cigarettes per day. She denies any
alcohol or illicit drug use.
Family History:
Her father died of cardiovascular disease. She has five
siblings, all of whom are healthy to the best of her knowledge.
Her mother is alive at age 64 and essentially healthy. She
denies any known malignancies in a first or second-degree
relative.
Physical Exam:
Vitals: T98.9F, BP 182/40, HR 64, RR 20, Sat 94%RA
General: Appears older than stated age, no acute distress
HEENT: EOMI, PERRL, MMM, OP clear
Heart: RRR, normal S1/S2, 1-2/6 systolic murmur at LUSB
Lungs: CTA bilaterally
Abdomen: Soft, non-distended. Point of maximal tenderness over
large palpable mass in LUQ. No rebound/guarding.
Ext: Warm, well-perfused, no c/c/e
Pertinent Results:
[**2139-7-6**] 02:00PM BLOOD WBC-4.8 RBC-5.54* Hgb-13.8 Hct-42.9
MCV-78* MCH-24.9* MCHC-32.2 RDW-15.7* Plt Ct-156
[**2139-7-7**] 07:30AM BLOOD WBC-7.1 RBC-5.36 Hgb-13.9 Hct-41.7
MCV-78* MCH-26.0* MCHC-33.4 RDW-15.1 Plt Ct-156
[**2139-7-6**] 02:00PM BLOOD Neuts-70.5* Lymphs-21.8 Monos-3.9 Eos-3.4
Baso-0.5
[**2139-7-7**] 07:30AM BLOOD Neuts-73.2* Lymphs-16.7* Monos-6.5
Eos-3.3 Baso-0.2
[**2139-7-9**] 04:27AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-2+
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ Burr-2+
[**2139-7-6**] 02:00PM BLOOD PT-29.2* PTT-31.0 INR(PT)-2.9*
[**2139-7-7**] 07:30AM BLOOD PT-33.7* PTT-31.5 INR(PT)-3.4*
[**2139-7-6**] 02:00PM BLOOD Glucose-100 UreaN-22* Creat-1.0 Na-138
K-4.1 Cl-103 HCO3-23 AnGap-16
[**2139-7-7**] 07:30AM BLOOD Glucose-98 UreaN-18 Creat-1.2* Na-140
K-3.9 Cl-105 HCO3-27 AnGap-12
[**2139-7-6**] 02:00PM BLOOD ALT-34 AST-33 LD(LDH)-269* CK(CPK)-70
AlkPhos-68
[**2139-7-6**] 02:00PM BLOOD Lipase-26
[**2139-7-8**] 07:50AM BLOOD CK-MB-2
[**2139-7-7**] 07:30AM BLOOD CK-MB-3 cTropnT-<0.01
[**2139-7-6**] 02:00PM BLOOD cTropnT-<0.01
[**2139-7-7**] 07:30AM BLOOD CK(CPK)-51
[**2139-7-8**] 07:50AM BLOOD CK(CPK)-36
[**2139-7-6**] 02:00PM BLOOD Calcium-8.7 Phos-4.6* Mg-1.9
[**2139-7-10**] 05:20AM BLOOD Albumin-3.4* Calcium-8.7 Phos-3.3 Mg-2.2
UricAcd-3.8
[**2139-7-9**] 05:38AM BLOOD Hapto-44
[**2139-7-8**] 08:12PM BLOOD Lactate-1.0
[**2139-7-8**] 05:55PM URINE Color-[**Location (un) **] Appear-Cloudy Sp [**Last Name (un) **]-1.020
[**2139-7-8**] 05:55PM URINE Blood-LG Nitrite-POS Protein->300
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-1 pH-5.5 Leuks-NEG
[**2139-7-8**] 05:55PM URINE RBC->50 WBC-0-2 Bacteri-FEW Yeast-NONE
Epi-0
[**2139-7-6**] 03:30PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.009
[**2139-7-6**] 03:30PM URINE Blood-LG Nitrite-NEG Protein-75
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2139-7-6**] 03:30PM URINE RBC->50 WBC-0-2 Bacteri-FEW Yeast-NONE
Epi-0-2
[**2139-7-8**] 5:50 pm URINE Source: Catheter.
**FINAL REPORT [**2139-7-10**]**
URINE CULTURE (Final [**2139-7-10**]):
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
BLOOD CULTURES NEGATIVE TO DATE X2
.
CT OF THE ABDOMEN WITH IV CONTRAST: Within the visualized left
lower lobe are two pulmonary metastases, measuring 1.5 cm and
1.9 cm, which are larger compared to [**2139-5-29**], previously
measured 1.1 cm x 1.4 cm respectively. A pulmonary nodule also
within the right lower lobe (2:2) measures 1.4 cm, previously
measured 1.0 cm. Dependent atelectases are present. There is no
pleural effusion. The visualized heart and pericardium are
unremarkable, without pericardial effusion.
Redemonstrated is a large mass arising from the mid to upper
pole of the left kidney, which measures grossly 17 cm x 11 cm x
13 cm, which is not
significantly changed from prior study. The mass is
heterogeneous in
attenuation, with areas of low attenuation, likely reflective of
necrosis. Also scattered within the mass are linear and rounded
hyperdense foci, which on a chest CT, from [**2139-5-29**],
appears similar, and may reflect areas of calcification.
Extensive feeding vessels to the mass are seen. There is
invasion and extension into the left renal vein, similar to
prior study. Additionally, there is moderate hydronephrosis of
the left kidney, which demonstrates delayed excretion of
contrast. Within the collecting system are areas of
heterogeneous attenuation, which is concerning for tumor
invasion.
There is gallbladder wall edema, which is minimally distended.
There is also mild intrahepatic biliary duct dilatation. The
liver, spleen, pancreas, right adrenal gland, and right kidney
are unremarkable. The left adrenal gland is not well visualized,
and is obscured by the adjacent large mass.
The stomach, small and large bowel loops are unremarkable.
There is no free air or free fluid. Scattered mesenteric and
retroperitoneal
lymph nodes are not enlarged by CT size criteria. No
retroperitoneal hematoma
or hemoperitoneum is seen.
CT OF THE PELVIS WITH IV CONTRAST: The urinary bladder and
rectum are
unremarkable. There is no pelvic free fluid or adenopathy.
OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesions are
identified.
IMPRESSION:
1. Large left renal mass, not significantly changed in size
compared to prior MRI, with evidence of left renal vein
invasion.
2. Moderate left hydronephrosis with likely tumor invasion into
the
collecting system.
3. Mildly distended gallbladder, with gallbladder wall edema,
and mild
prominence of the intrahepatic ducts. Correlation with LFTS and
right upper quadrant symptoms is suggested. If clinical concern
for acute cholecystitis, consider ultrasound for further
evaluation.
4. Pulmonary metastasis, slightly increased in size from prior
study.
.
[**2139-7-9**] ECHO
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 diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic regurgitation. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. Mild (1+) mitral regurgitation is seen. There is
mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function. Mild mitral regurgitation. Mild pulmonary
hypertension.
.
[**2139-7-13**] BARIUM SWALLOW
IMPRESSION: Moderate esophageal dysmotility, with no evidence of
diverticulum, webs or strictures. A barium tablet passes freely
through the esophagus without any delay.
.
[**2139-7-14**] CXR
IMPRESSION: Clear improvement of temporary pulmonary congestion
pattern [**2139-7-8**], consistent with fluid overload and
temporary left-sided congestion.
Brief Hospital Course:
64yoF with newly diagnosed L renal cell carcinoma, just started
on Sutent, who was admitted with hematuria/urinary retention,
LUQ abdominal pain, and through admission found to be febrile
with AFib and RVR likely due to UTI.
.
1. Hematuria: Thought to be either from newly started Sutent
(~30% incidence) vs known tumor invasion into collecting system
on CT vs worsening of renal cell carcinoma (of note, pt also
with tumor invasion into L renal vein). She was having issues
with urinary retention at home and on admission, and so had a
Foley placed intermittently through admission, which was stopped
by discharge as she was seen to urinate without difficulty.
.
Sutent was held initially but restarted by discharge and she was
dischaged on Sutent, and not having any hematuria by discharge.
Of note, her Coumadin which was a home med given AFib/Flutter
issues, was held through admission and CONTINUES to be held, in
the setting of hematuria and potential for bleeding into renal
mass. This should be further assessed by PCP.
.
2. Admission to MICU for fevers, AFib with RVR, UTI: On day 2,
pt was noted to have fevers to 102 with subsequent AFib with
RVR. She remained hemodynamically stable and was transferred to
MICU for closer monitoring where she was found to have a
pansensitive Ecoli UTI and treated broadly at first, then
narrowed to IV Zosyn which she completed a full course for. She
was called out of MICU in stable condition and had no further
unstable events, although she did have occasional RVR which was
treated with nodal agents as below. All blood cultures were
negative.
.
3. AFib with RVR: S/p ablation in the past. Admitted in sinus,
however pt noted to have AFib with RVR and short bursts of
atrial tachycardia/non sustained supraventricular tachycardias.
In the ICU she was continued on her home Verapamil course but
was noted to have some pauses which required down titration of
her home dosage. After call out from MICU, her nodal [**Doctor Last Name 360**]
required uptitration and by discharge she was sent home on her
home dose of 240 mg ER.
.
IMPORTANTLY though, she was stopped on her home Coumadin dosage
due to a supratherapeutic INR which peaked to 5.0 and hematuria.
Her CHADS2 score was calculated at 1, but in discussion with her
PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 11139**], he recommended keeping her on Coumadin. The
risks/benefits were discussed with the family, and she was kept
OFF Coumadin by discharge, given she was still on Sutent. This
will need to be followed up. Her INR was normal by discharge,
she got PO Vitamin K.
.
4. LUQ abd pain: Likely due to very large renal mass, LFT's and
lipase were normal. No hemorrhage seen on CT. Pain was
controlled with MS Contin, which she was discharged on, with
short acting Morphine for breakthrough.
.
5. Chest pain: Cardiac enzyme negative x2 and without worrisome
EKG changes to suggest cardiac etiology. Also, had clean cath in
10/[**2138**]. Likely due to LUQ renal mass.
.
6. Hypoxia: During her trigger on day 2 for which she went to
MICU, she was noted to have hypoxia to the high 80's. She had an
echo with a normal EF >55%, mild MR, and mild pulmHTN. She was
variably on O2 by NC with good response. She also became
slightly volume overloaded by physical exam and CXR showing mild
volume overload and small bilateral pleural effusions and so was
gently diuresed with good improvement in her O2 sats to 95-96%
RA and also clearing of her CXR. By discharge she was satting
well on RA at rest and ambulating and appeared more euvolemic.
.
DISPO: She was discharged in stable condition and her family
endorsed that they would make f/u appointments with Dr. [**Last Name (STitle) 11139**].
A copy of this discharge summary will also be faxed to Dr. [**Name (NI) 77650**] office. She has f/u with [**Hospital1 18**] Hematology Oncology on
[**8-3**].
.
She was FULL CODE during admission.
Medications on Admission:
Sutent 50mg daily
Ferrous sulfate 325mg daily
Warfarin 5mg daily (10mg on Sunday)
Singulair 10mg daily
Celebrex 200mg daily
Verapamil 240mg daily
Citalopram 20mg daily
Zolpidem 10mg daily
Alprazolam 0.5mg Q8H PRN
Discharge Medications:
1. Sutent 50 mg Capsule Sig: One (1) Capsule PO daily ().
2. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One
(1) Tablet PO once a day.
3. Singulair 10 mg Tablet Sig: One (1) Tablet PO once a day.
4. Verapamil 240 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Xanax 0.5 mg Tablet Sig: One (1) Tablet PO three times a day
as needed for anxiety.
7. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
Disp:*60 Tablet Sustained Release(s)* Refills:*0*
8. Morphine 15 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*2*
11. Zofran 4 mg Tablet Sig: One (1) Tablet PO three times a day
as needed for nausea.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Left renal cell carcinoma
Hematuria
Urinary retention
Afib with RVR
Urinary tract infection
Chest pain of unlikely cardiac origin
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to BIDMD with hematuria, urinary retention,
and abdominal pain, all likely from your large renal cell
carcinoma. You spent some time in the intensive care unit due to
your fevers causing a rapid heart rate. You were treated for a
urinary tract infection and your fevers and heart rate resolved.
Your Sutent was held briefly, but restarted prior to admission.
You continue to have some blood in your urine.
The following medication changes were made while you were
admitted:
1. Please do not take coumadin. You continue to have blood in
your urine and this increases your tendency to bleed.
2. We started you on MS Contin for long acting pain control.
You may also take immediate release morphine for breakthrough
pain.
3. We gave you a supply of zofran to take if you have nausea.
Only take this medication if needed.
4. Take regular stool softners as you are likely to get
constipated from you pain medications.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5387**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2139-8-3**] 5:00
Provider: [**First Name4 (NamePattern1) 488**] [**Last Name (NamePattern1) 6401**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2139-8-3**] 5:00
Please contact your primary care doctor Dr. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) 11139**] at
[**Telephone/Fax (1) 11144**] and arrange for a follow up appointment in 1 to 2
weeks.
Completed by:[**2139-7-19**]
ICD9 Codes: 5990, 4019, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3521
} | Medical Text: Admission Date: [**2138-6-2**] Discharge Date: [**2138-6-4**]
Date of Birth: [**2089-3-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
chest pain, syncope
Major Surgical or Invasive Procedure:
Cardiac catheterization s/p thrombectomy
History of Present Illness:
Patient is a 49 yo M with a history of hypertension,
hypercholesterolemia with acute onset chest pain. He describes
today having poor PO intake and working at his construction job
digging ditches. Then today at approx 11:45 he began to have
heavy substernal chest pain, shortness of breath and dizziness.
When this started he quit working and drank fluids (Mountain
Dew). However, his discomfort persisted despite resting. He then
started walking and fell 3 times. Each time without loss of
consciousness or black vision (just felt weak). EMS was then
called and he came to the ED.
He has never had an episode like this before and was previously
able to work without difficulty in the weeks prior.
.
In the field he was found to have a run of Vtach (~6 sec), no
defibrillation. ? received nitroglycerin that improved chest
pain.
.
While in the ED, he received nitroglycerin, heparin, plavix
600mg, morphine, and integrillin bolus. His chest pain waxed and
waned; nitroglycerin was uptitrated numerous times but the pain
still persisted. Serial ECGs showed evolving ST elevations and
the patient was urgently taken to cardiac catherization.
.
In the cath lab, he was found to have irregular filling of the
left circumflex and had Quick Cat thrombectomy. He got 208 CC
contrast. Also received integrilin, nitroglycerin, heparin and
potassium.
.
On arrival to the floor he is chest pain free and feels well. No
current nausea, vomiting, fever, chills, shortness of breath. He
reports that the last time he had chest pain was in during the
beginning of the catherization.
Past Medical History:
Hypertension
Hyperlipidemia (never treated)
Social History:
He is a 1.5 ppd smoker. He stopped for 1 year, but restarted 1
year ago, previous to this he smoked for 24 years. He reports
occasional ETOH. Used cocaine frequently but none in 1 year. His
HCP is his girlfriend [**Doctor First Name 553**] with whom he lives in [**Name (NI) 3786**]. He
is a construction worker.
Family History:
His mother died of an MI at age 69. 1 brother has lymphoma,
another has diabetes. He does not know his father's history.
Physical Exam:
VS: T 97 BP 119/72 HR 86 RR 19 O2 98% RA
Gen: WDWN middle aged male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI, pupils constricted.
Conjunctiva were pink, no pallor or cyanosis of the oral mucosa.
No xanthalesma.
Neck: Supple with JVP of [**6-15**] cm. No carotid bruits
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: No c/c/e.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas. +
tattos
Groin: slow oozing of bright red blood, dressing in place and
soaked. Sheath is in place
Pertinent Results:
[**2138-6-2**] 05:44PM BLOOD ALT-50* AST-26 CK(CPK)-281* AlkPhos-100
TotBili-0.5
[**2138-6-2**] 05:44PM BLOOD CK-MB-7 cTropnT-0.22*
[**2138-6-3**] 06:22AM BLOOD Calcium-9.2 Phos-3.0 Mg-2.1 Cholest-210*
[**2138-6-3**] 06:22AM BLOOD %HbA1c-5.4
[**2138-6-3**] 06:22AM BLOOD Triglyc-194* HDL-33 CHOL/HD-6.4
LDLcalc-138*
.
Studies:
Cardiac Cath [**6-2**]:
1. Selective coronary angiography of this left dominant system
revealed
single vessel disease. The LMCA was a short vessel which was
free of
critical stenoses. The LAD was patent with mild luminal
irregularities.
The LCx had a lucent filling defect in the proximal vessel
(consistent
with thrombus) but with TIMI 3 flow. The RCA was non-dominant
and
patent.
2. Limited resting hemodynamics revealed moderately elevated
left heart
filling pressures with an LVEDP of 23mmHg in the setting of
systemic
arterial hypertension with an aortic SBP of 175mmHg.
3. Left ventriculography revealed a calculated LVEF of 50% with
mild
inferior hypokinesis. There was no mitral regurgitation.
4. The lesion in the proximal LCX was treated with thrombectomy
using a
Quick cat device. We also performed IVUS which did not reveal
any
significant residual lesion. The final angiogram showed TIMI III
flow
with no dissection and no embolisatio. (See PTCA comments) .
.
TTE [**6-2**]:
The left atrium is mildly dilated. The estimated right atrial
pressure is 5-10 mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size and systolic function
(LVEF>55%). Regional left ventricular wall motion is normal. No
masses or thrombi are seen in the left ventricle. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Physiologic mitral regurgitation is seen
(within normal limits). There is indeterminate pulmonary artery
systolic pressure. There is no pericardial effusion.
Brief Hospital Course:
ASSESSMENT AND PLAN, AS REVIEWED AND DISCUSSED IN
MULTIDISCIPLINARY ROUNDS:
Pt is a 49 yo M with HTN, Hyperlipidemia, tobacco use who
presents with acute onset chest pain and ST elevations.
.
1) Inferior myocardial infarction: Patient presented with
concerning clinical syndrome for an acute STEMI with ventricular
tachycardia prior to hospitalization (spontaneously converted to
NSR). The patient was urgently taken to the cath lab and found
to have irregular filling of the left circumflex artery. The
lesion was thrombectomized resulting in improvement of flow as
well as symptoms. He was continued integrellin for 18 hours
after catherization and improved with medical management. He
was started on aspirin, plavix, simvastatin, lisinopril,
metoprolol. Echocardiogram did not show any significant wall
motion abnormalities.
.
2) Rhythm: Currently normal sinus rhythm. Had episode of
ventricular tachycardia but spontaneously converted and has
known cause (MI). Had several episodes of AVIR after
thrombectomy that decreased in frequency with time.
.
3) Pump: no signs of congestive heart failure. Echo showed only
left ventricular hypertrophy.
.
4) Hyperlipidemia: Started high dose statin. Fasting lipid
panel showed elevated LDL at 136.
.
5) Hypertension: Started betablocker and ace inhibitor. Stressed
importance of medication adherance.
.
6) Tobacco dependence: Patient was counselled on multiple
occasions about smoking cessation. He expressed understanding
and a prescription for a nicotine patch taper was given.
.
7) hx cocaine: currently not using illicit drugs per patient and
tox screen negative.
.
8) Hypokalemia: resolved in the setting of hydration. He
presented significantly dehydrated.
Medications on Admission:
? prescription for Lisinopril (pt denies taking any meds)
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Zocor 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
6. Nicotine 21-14-7 mg/24 hr Patch Daily, Sequential Sig: One
(1) Transdermal once a day for 21 days: 21 mg patch for 7 days,
then 14 mg patch for 7 days then 7mg patch for 7 days.
DO NOT use patch if smoking.
Disp:*21 patches* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
STEMI s/p thrombectomy
Secondary Diagnosis:
HTN
Hyperlipidemia
Discharge Condition:
Stable to be discharged home.
Discharge Instructions:
You had a large heart attack and had the blood clot removed from
your artery during your cardiac catheterization.
.
Please refrain from lifting any object greater than 5 lbs or
heavy activity for 2 weeks as this may tear open the artery in
your groin.
You will need to take medications daily as instructed below.
Please contact your doctor if you are having difficulties
obtaining these medications.
If you develop chest pain, chest pressure, shortness of breath,
arm pain, lightheadedness or passing out, please call your
doctor or report to the ER immediately.
Followup Instructions:
Please follow up with your primary care doctor, Dr. [**Last Name (STitle) **], in [**2-11**]
weeks after discharge. Please call [**Telephone/Fax (1) **] to schedule
that appointment.
Please call Dr. [**Last Name (STitle) 10302**] and Dr. [**Last Name (STitle) 171**] (cardiologists). You
have an appointment. Please call and reschedule if you cannot
make this. Phone:[**Telephone/Fax (1) 1989**] Date/Time:[**2138-6-23**] 8:00
It is very important that you follow up with the cardiologist.
ICD9 Codes: 4271, 2768, 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3522
} | Medical Text: Admission Date: [**2113-10-3**] Discharge Date: [**2113-10-20**]
Date of Birth: [**2057-4-23**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
Pedestrian Struck
Major Surgical or Invasive Procedure:
First Operation
1. [**10-3**] TFN R Subtroch fx; IM Nail R tibia Fx ([**10-3**]) - [**Location (un) **]
Second operation [**10-9**]
1. Arthroscopic subacromial decompression.
2. Open reduction internal rotation greater tuberosity
fracture.
Third operation [**10-10**]
1. ORIF of right zygomaticomaxillary complex fracture.
2. ORIF of right orbital floor fracture.
3. Complex wound closure right upper eyelid.
History of Present Illness:
Mr. [**Known lastname 75087**] is a 56 year-old man who was transferred from St.
[**Hospital 11042**] Hospital in [**Location (un) 8117**], NH after being struck by a car
traveling approximately 35 mph. There was no loss of
consciousness. Imaging at St. [**Doctor Last Name 11042**] demonstrated multiple
bilateral facial fractures, dislocated left shoulder, left chest
wall hematoma. He was transferred to [**Hospital1 18**] for further
evaluation and treatment. Notable, physical exam and
radiological injury demonstrated the following injuries:
1. R zygoma & zygomatic arch fx
2. fx roof, lateral, medial R orbit
3. anterior, medial, lateral R maxillary sinus fxs
4. L sphenoid bone fx extending into post/inf wall L orbit
5. superior L maxillary sinus fx
6. B/L medial & lateral pterygoid plate fxs
7. fx [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] coronoid process fx with maintained mandibular
integrity
8. Small subarachnoid hemmorhage L sylvian fissure
9. R femur fx
10. R tib/fib fx
11. L shoulder dislocation
12. L Greater tuberosity fx
Past Medical History:
Anxiety
Depression
?Bipolar/schizo
Substance abuse
Social History:
Lives alone, works on a farm. He has children.
1 ppd x 30 years. Occasional drink every few weeks.
Family History:
non-contributory
Physical Exam:
Physical Exam on Admission:
Vitals: HR 83 BP: 160/70 RR: 14 O2: 100% FM
HEENT: L pupil 3mm, R eye closed
Chest: Equal breath sounds bilaterally.
Abd: Soft, NT/ND.
MSK: R hip tender to palpation.
Vasc: Decreased femoral pulse on Right.
GU: + Foley
Skin: Right eye ecchymoses, edema. Left shoulder abrasions.
Pertinent Results:
[**2113-10-3**] 02:35AM BLOOD WBC-28.6* RBC-4.12* Hgb-13.2* Hct-37.7*
MCV-91 MCH-31.9 MCHC-34.9 RDW-13.9 Plt Ct-344
[**2113-10-3**] 12:38PM BLOOD WBC-19.7* RBC-3.53* Hgb-11.1* Hct-34.3*
MCV-97 MCH-31.4 MCHC-32.4 RDW-13.7 Plt Ct-294
[**2113-10-3**] 08:42PM BLOOD WBC-12.3* RBC-2.51*# Hgb-8.0*# Hct-23.6*#
MCV-94 MCH-32.0 MCHC-34.1 RDW-13.9 Plt Ct-193
[**2113-10-4**] 02:00AM BLOOD WBC-12.1* RBC-2.37* Hgb-7.4* Hct-21.9*
MCV-92 MCH-31.0 MCHC-33.6 RDW-13.9 Plt Ct-184
[**2113-10-5**] 12:53AM BLOOD WBC-12.4* RBC-2.82* Hgb-8.9* Hct-25.9*#
MCV-92 MCH-31.4 MCHC-34.1 RDW-14.7 Plt Ct-170
[**2113-10-10**] 07:00AM BLOOD WBC-16.0*# RBC-2.85* Hgb-8.6* Hct-25.8*
MCV-91 MCH-30.3 MCHC-33.3 RDW-14.0 Plt Ct-666*#
[**2113-10-3**] 02:35AM BLOOD PT-11.7 PTT-21.8* INR(PT)-1.0
[**2113-10-6**] 07:15AM BLOOD Plt Ct-185
[**2113-10-3**] 02:35AM BLOOD UreaN-23* Creat-0.8
[**2113-10-5**] 12:53AM BLOOD Glucose-91 UreaN-11 Creat-0.7 Na-144
K-3.8 Cl-110* HCO3-29 AnGap-9
[**2113-10-10**] 07:00AM BLOOD Glucose-160* UreaN-10 Creat-0.6 Na-137
K-4.5 Cl-103 HCO3-28 AnGap-11
[**2113-10-3**] 02:35AM BLOOD ALT-34 AST-51* AlkPhos-86 Amylase-56
TotBili-0.2
[**2113-10-3**] 02:35AM BLOOD Lipase-19
[**2113-10-10**] 07:00AM BLOOD Calcium-8.2* Phos-4.2 Mg-2.4
[**2113-10-13**] 04:00PM BLOOD VitB12-328 Folate-8.5
[**2113-10-13**] 04:00PM BLOOD TSH-2.5
[**2113-10-3**] 02:35AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2113-10-3**] 02:38AM BLOOD Glucose-222* Lactate-2.0 Na-144 K-3.9
Cl-107 calHCO3-24
[**2113-10-3**] 04:10AM BLOOD Hgb-13.1* calcHCT-39
[**2113-10-3**] 02:38AM BLOOD freeCa-1.04*
CT HEAD W/O CONTRAST
Reason: eval for change in SAH
[**Hospital 93**] MEDICAL CONDITION:
56 year old man with MVC
REASON FOR THIS EXAMINATION:
eval for change in SAH
CONTRAINDICATIONS for IV CONTRAST: None.
HEAD CT
ADDENDUM: There is a small hypodensity within the central pons,
which may represent an infarct of indeterminate chronicity.
INDICATION: 56-year-old man with motor vehicle collision.
Evaluate for change in subarachnoid hemorrhage.
COMPARISON: Outside hospital CT head.
TECHNIQUE: Non-contrast CT of the head.
FINDINGS: There is a small hyperdense linear area within the
left sylvian fissure, similar in size compared to outside
hospital study consistent with subarachnoid hemorrhage. No
additional intracranial hemorrhage is identified. There is no
mass effect, shift of midline structures. The ventricles are
normal in size and symmetric. [**Doctor Last Name **]-white matter differentiation
is preserved.
There are fractures of the anterior, medial, and lateral wall of
the right maxillary sinus. There are fractures of the zygoma and
zygomatic arch on the right. There are fractures of the medial,
lateral, superior, and inferior and posterior orbital wall.
There are fractures of the medial and lateral pterygoid plates
bilaterally. There is a sliver of bone fractured off of the
right coranoid process of the mandible. There is a left sphenoid
fracture at the junction of the left temporal bone. All of these
fractures have been previously described in prior facial CT.
The mastoid air cells are clear.
IMPRESSION:
1. Stable left sylvian fissure subarachnoid hemorrhage.
2. Multiple facial fractures as previously described on facial
CT.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10270**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST [**2113-10-3**] 3:28 AM
CT SINUS/MANDIBLE/MAXILLOFACIA
Reason: evaluate facial fractures
[**Hospital 93**] MEDICAL CONDITION:
56 year old man peds struck w/ multiple facial fractures, incl
temporal bones as well
REASON FOR THIS EXAMINATION:
evaluate facial fractures
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 56-year-old man with multiple facial fractures.
Please evaluate.
No comparison studies.
TECHNIQUE: MDCT acquired axial images of the facial bones were
obtained without IV contrast with soft tissue and bone windows.
Coronal and sagittal reformations were obtained.
FINDINGS: There is a comminuted blowout fracture of the floor of
the right orbit with the fractures involving the infraorbital
canal. There is herniation of obital fat inferiorly and the
inferior rectus muscle is abutting bony fragments. There is a
comminuted fracture of the lateral wall of the right orbit.
Multiple fractures of the superior wall with intracranial and
right frontal sinus extension is also noted. A tiny bubble of
gas is noted intracranially. Medial blowout fracture with
herniation of orbital fat is present. Blood is seen along the
superolateral orbit. There is no evidence of nerve impingement.
There are comminuted fractures of the anterior, medial, and
lateral walls of the right maxillary sinus. There are multiple
fractures of the right zygoma and zygomatic arch. A nondisplaced
fracture of the posterior wall of the left maxillary sinus is
noted.
There are bilateral lateral and medial pterygoid plate
fractures.
There is a small approximately 1 cm fracture fragment of the
right coranoid process of the mandible with preserved integrity
of the entire mandible.
Nasal bone fractures are noted, which may be old.
There is marked soft tissue swelling overlying the entire right
side of the face and to a lesser extent over the left face.
There is moderate subcutaneous emphysema distributed over the
orbit and maxilla. There is a tiny amount of right retroorbital
air along with a small approximately 1 cm right retroorbital
hematoma.
At the junction of the left sphenoid and temporal bones, there
is a minimally displaced fracture with adjacent subcutaneous
emphysema, best appreciated on series 2, image 65. The fracture
extends to the posterior/inferior wall of the left orbit.
Air/fluid levels are seen in the frontal sinuses and the left
maxillary sinus are seen. Fluid/soft tissue change of the
ethmoid, sphenoid, and right maxillary sinuses are also noted.
There is a 1.2 x 0.8 cm cystic lesion of the maxilla to the
right of midline which may represent an incisive canal cyst.
IMPRESSION:
1. Fractures of all walls of the right orbit and right maxilla.
Small bubble of air intracranially adjacent to a fracture of the
superior wall.
2. Right retroorbital hematoma and inferior rectus muscle
abutting fracture fragments.
3. Fractures of the right zygoma and zygomatic arch.
4. Bilateral medial and lateral pterygoid plate fractures.
5. Right mandibular coronoid process fracture with maintained
mandibular integrity.
6. Left sphenoid bone fracture at the junction of the temporal
and sphenoid bones with extension into posterior/inferior wall
of the left orbit and the left maxillary sinus.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10270**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
CT UP EXT W/O C [**2113-10-5**] 9:11 AM
CT UP EXT W/O C
Reason: eval for L shoulder hematoma
[**Hospital 93**] MEDICAL CONDITION:
56 year old man admitted with left shoulder dislocation
REASON FOR THIS EXAMINATION:
eval for L shoulder hematoma
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Pedestrian struck with left shoulder dislocation.
Please evaluate for left shoulder fracture.
TECHNIQUE: Multidetector CT images were obtained through the
left shoulder without contrast. Coronal and sagittal reformatted
images were obtained.
CT LEFT SHOULDER WITHOUT CONTRAST: There is a comminuted
fracture through the superolateral humeral head. There are
multiple fracture fragments located superiorly and medially
within the glenohumeral joint. The humeral head is posteriorly
subluxed with respect to the glenoid. The imaged portion of the
scapula and clavicle are unremarkable. There is blood tracking
within the teres major muscle without a discrete hematoma. There
is a large amount of edema within the axilla which tracks along
the neurovascular bundle, along the left lateral chest wall and
within the subcutaneous tissues.
Within the imaged portion of the left lung is seen peripheral
tree-in-[**Male First Name (un) 239**] airspace opacities which may represent
bronchiolitis. Additionally, there are dependent changes seen
along the path posterior lung fields. Atherosclerotic
calcifications are seen within the imaged portion of the left
common carotid artery.
IMPRESSION:
1. Comminuted fracture of the superolateral humeral head with
fracture fragments around and within the glenohumeral joint.
2. Posterior subluxation of the humeral head.
3. Marked soft tissue edema about the left shoulder as described
above. Blood tracking within the teres major muscle.
4. Tree-in-[**Male First Name (un) 239**] opacities within the visualized portion of the
left lung suggest acute bronchiolitis.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 5998**]
DR. [**First Name (STitle) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
FEMUR (AP & LAT) RIGHT; TIB/FIB (AP & LAT) RIGHT
Reason: r/o fractures
[**Hospital 93**] MEDICAL CONDITION:
56 year old man s/p peds struck, severe R leg pain
REASON FOR THIS EXAMINATION:
r/o fractures
INDICATION: 56-year-old man with severe right leg pain. Rule out
fractures.
COMPARISON: Portable pelvic plain film from one hour prior.
THREE VIEWS OF THE RIGHT FEMUR: There is a fracture of the
prioximal shaft extending from the subtrochanteric region. There
are three fracture line visualized, with medial displacement and
varus angulation of the distal fragment.
FIVE VIEWS OF THE RIGHT KNEE AND TIBIA AND FIBULA: There is
mildly displaced oblique tibial fracture. There is mildly
displaced comminuted high fibular fracture.
Three views of the right foot demonstrate no evidence of acute
bony injury. Evaluation of the lateral malleolous is limited due
to overlying metallic fixation hardware.
SINGLE VIEW OF THE PELVIS: Aside from the right proximal femoral
fracture, no additional acute bony injury is demonstrated.
Contrast is present within the urinary bladder.
he study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10270**]
DR. [**First Name8 (NamePattern2) 814**] [**Name (STitle) 815**]
SHOULDER 1 VIEW LEFT [**2113-10-13**] 11:40 AM
SHOULDER 1 VIEW LEFT
Reason: post op eval.just AP view please, pt's L arm cannot be
moved
[**Hospital 93**] MEDICAL CONDITION:
56 year old man with 56M s/p ped struck, no LOC, transferred
from St. [**Hospital 11042**] hospital with multiple facial fractures, R
tib/fib fxs, L shoulder fx, SAH.
REASON FOR THIS EXAMINATION:
post op eval.just AP view please, pt's L arm cannot be
movedplease do not allow pt to move L arm during shooting, so
pure AP view can be obtained
HISTORY: Trauma, to compare with previous study.
FINDING: In comparison with the study of [**2113-10-10**], there is no
significant change. Again there is an avulsed bony fragment from
left greater tuberosity fracture that is projecting in the
acromiohumeral interval. No metallic fixation device is seen.
IMPRESSION: No significant interval change.
DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Brief Hospital Course:
Pt. was a transfer from St. [**Hospital 11042**] Hospital in [**Location (un) 8117**], NH via
EMS. As noted above, Mr. [**Known lastname 75087**] was brought into the trauma
bay by EMS with a number of notable orthopaedic injuries. He
was AOx3 at the time and hemodynamically stable. After initial
stabilization, he was taken to radiology for further
investigation of his injuries. Pertinent films are listed
above. His treatment, organized by problems, consisted of:
#SAH--> Pt was noted to have a small-moderate Subarachnoid
hemmorhage with a normal neurological exam. Neurosurgery was
emergently consulted, and the patient was loaded with IV
dilantin and continued on a stable PO regimen of this
medication. Serial examinations were normal, and a repeat CT
showed no worsening of his hemmorhage. After a 10 day course
his Dilantin was discontinued. He has had no further
neurological events.
#Leg--> Pt. had comminuted fractures in his L LE, treated via
ORIF of femur, tib as noted above. Pt. had no complications of
this surgery, and has been improving with PT in the post-op
period.
#Shoulder--> Pt initially maintained on a sling for comfort.
Eventually on [**10-9**] he was taken to the OR for repair of his
aforementioned shoulder injuries. Please see the detailed op
note for full proceding of this operation. He had no post-op
complications and has been participating with PT. He is
maintained in a abduction sling currently, and will need ortho
f/u as indicated in his discharge paperwork.
#Facial Fractures--> The pt. was seen emergently by plastic
surgery in response to his multiple facial fractures. He was
initially maintained on sinus precautions and amoxicilln. On
[**10-10**] he was taken to the OR for repair, as described above. He
was treated with post-op augmentin and has completed that
course. He will f/u with plastics as described. Ophthalmology
saw the patient before his operation, and cleared him from the
standpoint of intra-ocular lesions.
#Pysch--> Psych has followed the patient in house. At no time
was he section 12 or suffering from suicidal or homicidal
ideation. He has had no behavioural problems while in house.
Psychiatry felt that his psychosis was stable; it required no
further medications, and he required no specialized psychiatric
hospitalization. He did well in a shared room on an open floor.
A number of labs were sent, including folate, b12, tsh; all of
these were normal. Please see his psychiatric and social work
notes for extensive details of his history. he will need local
psych f/u in NH.
#FEN--> at time of discharge patient is able to tolerate a PO
diet without difficulty; he is taking a diabetic diet and has
recieved diabetic teaching from the nutritionist.
#DM---> [**Last Name (un) **] was involved in his DM care. He was initially
started on a SS regimen, but this had to be increased twice due
to continually high FSG. He was started on Metformin on [**10-17**],
and his FSG began to decrease. [**Last Name (un) **] suggested that his
sliding scale insulin be decreased and possibly discontinued at
rehab, as his metformin will take a week for full effect to be
realized.
He was discharged from [**Hospital1 18**] today with his vital signs within
normal limits and he will follow up as previously described.
Medications on Admission:
Unknown
Discharge Medications:
1. Bacitracin-Polymyxin B 500-10,000 unit/g Ointment Sig: One
(1) Appl Ophthalmic Q8H (every 8 hours).
2. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q6H (every 6 hours) as needed.
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
4. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: 1-2 MLs Mucous
membrane QID (4 times a day).
5. Hydromorphone 2 mg Tablet Sig: 3-4 Tablets PO Q3H (every 3
hours) as needed for pain.
6. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours): give for a total of 4 weeks.
7. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
10. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
11. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Menthol-Cetylpyridinium Cl 2 mg Lozenge Sig: One (1) Lozenge
Mucous membrane Q6H (every 6 hours) as needed.
13. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
14. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
15. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
16. Insulin Lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED).
17. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
18. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 **] hospital
Discharge Diagnosis:
1. R zygoma & zygomatic arch fx
2. fx roof, lateral, medial R orbit
3. anterior, medial, lateral R maxillary sinus fxs
4. L sphenoid bone fx extending into post/inf wall L orbit
5. superior L maxillary sinus fx
6. B/L medial & lateral pterygoid plate fxs
7. fx [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] coronoid process fx with maintained mandibular
integrity
8. Small subarachnoid L sylvian fissure
9. R femur fx
10. R tib/fib fx
11. L shoulder dislocation
12. L Greater tuberosity fx
Discharge Condition:
stable
Discharge Instructions:
Keep your left arm in the sling and do not bear weight on it.
You may bear full weight on your right leg as tolerated.
You will require a decrease in your regular insulin sliding
scale within 1-2 days given your current dosage of po metformin.
Continue taking lovenox for a total of 4 weeks.
[**Name8 (MD) **] MD for chest pain, shortness of breath, increased pain,
redness or drainage around your surgical wounds, or for any
other symptoms that concern you or your family.
Followup Instructions:
F/u Dr. [**Last Name (STitle) 2719**] and Dr. [**Last Name (STitle) **] of Orthopaedic Surgery in 2
weeks. Call [**Telephone/Fax (1) 1228**] to schedule this appointment.
Follow up with a mental health provider (Social Work,
psychiatry, or psychology) at rehab.
Pt will need to be set up with a PCP in [**Name9 (PRE) **].
ICD9 Codes: 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3523
} | Medical Text: Admission Date: [**2178-8-5**] Discharge Date: [**2178-8-10**]
Service: CCU
CHIEF COMPLAINT: Transfer for high-risk cardiac
intervention.
HISTORY OF PRESENT ILLNESS: The patient is an 86 year old
male with a history of coronary artery disease, severe
chronic obstructive pulmonary disease, diabetes mellitus and
hypertension, who was in his usual state of health until 2
a.m. the morning of [**2178-8-2**], when he awoke with
shortness of breath and diaphoresis. At that time, he took
Combivent without help and went back to sleep. He then again
awoke at 04:00 a.m. with worsening dyspnea that was not
responsive to his Albuterol and Atrovent nebulizers. At that
time, he then went to [**Hospital3 1280**] Hospital where he was
treated for chronic obstructive pulmonary disease
exacerbation with Solu-Medrol, Albuterol/Atrovent nebulizers
and antibiotics. While at [**Hospital3 1280**], he had an episode of
acute shortness of breath and at that time it was felt that
that he was in flash pulmonary edema.
An EKG on [**2178-8-3**], showed transient anterior ST
elevations and T wave inversions. At this time, his cardiac
enzymes were positive with a peak creatinine kinase of 202 on
[**2178-8-4**]. Cardiac catheterization at this time
revealed the following: Left main with 80% stenosis; right
coronary artery 70% ostial lesion; patent ductus arteriosus
80% lesion; diffuse left anterior descending and left
circumflex disease. The patient was then transferred to [**Hospital1 1444**] for possible PCI versus
coronary artery bypass graft surgery.
The patient was then evaluated by Cardiac Surgery and they
felt that he was a poor surgical candidate given his history
of severe chronic obstructive pulmonary disease; thus, the
management of these lesions were those of undergoing a PCI of
the right coronary artery and left main.
The patient's post catheterization course had also been
complicated by a right groin hematoma. A subsequent
ultrasound was negative for pseudo-aneurysm, and a CT scan of
the abdomen was also negative for retroperitoneal bleed. The
patient was then transferred to the Coronary Care Unit Team
for which he actually went to the Medical Intensive Care Unit
for further monitoring in anticipation of high risk left main
coronary artery intervention on [**2178-8-6**].
Upon transfer to the Floor, the patient continued to
experience shortness of breath and was given Albuterol and
Atrovent nebulizers with minimal relief. The patient was
then given 40 mg intravenously of Lasix and had minimal urine
output. The patient was then stared on Bi-PAP on 14/9 with
improvement of dyspnea and O2 saturation of 96%.
Upon initial evaluation by the Coronary Care Unit team the
patient was resting comfortably on Bi-PAP mask and denying
any chest pain.
Of note, prior to this hospitalization, the patient had
noticed a recent increase in his lower extremity swelling and
a productive cough.
PAST MEDICAL HISTORY:
1. Coronary artery disease: Cardiac catheterization on
[**2178-8-4**], please see HPI for findings.
2. Chronic obstructive pulmonary disease: The patient has
pulmonary function test as of [**2178-7-14**], revealed an
FEV1 of 0.78.
3. Asthma.
4. Diabetes mellitus of unknown age and complications
unknown.
5. Hypertension.
PAST SURGICAL HISTORY:
1. Status post carotid endarterectomy on the right in [**2164**].
2. Status post femoral popliteal bypass on the left.
MEDICATIONS AT HOME:
1. Procardia XL 90.
2. Lasix 40 mg p.o. q. day.
3. Losartan 150.
4. Aspirin 81 mg p.o. q. day.
5. Imdur 60 mg p.o. q. day.
6. Albuterol and Atrovent nebulizers q. four hours.
MEDICATIONS AT TRANSFER:
1. Nitroglycerin drip.
2. Aspirin 325 mg p.o. q. day.
3. Cozaar 50 mg p.o. q. day.
4. Verapamil 240 mg p.o. q. day.
5. Albuterol and Atrovent nebulizers q. four hours.
6. Solu-Medrol 60 mg three times a day.
7. Doxycycline 100 mg p.o. twice a day.
8. Protonix 40 mg p.o. q. day.
9. Regular insulin sliding scale.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: The patient lives at home with wife. The
patient is a reformed smoker with a 40 pack year smoking
history. The patient denies any ETOH use; the patient denies
any intravenous drug use.
PHYSICAL EXAMINATION: Vital signs on admission, temperature
97.0 F.; pulse rate 82; blood pressure 119/53; respiratory
rate 17; oxygen saturation 94% on four liters. In general,
the patient is an elderly Italian male in mild respiratory
distress. HEENT examination: Mucous membranes dry;
oropharynx clear. Pupils are equal, round and reactive to
light. Extraocular muscles are intact. Neck is notable for
a jugular venous distention up to 7 centimeters at a 30
degree angle, supple, no lymphadenopathy. Chest: Diffuse
wheezing bilaterally, prolonged expiratory phase, use of
accessory muscles. Heart: Distant heart sounds; regular
rate, no rubs or gallops appreciated. Normal S1, S2, no S3,
S4. Abdomen soft, nontender, nondistended, positive bowel
sounds in all four quadrants. Extremities with trace one
plus edema bilaterally, Doppler-able pulses bilaterally of
the lower extremities. Groin, of note, on the right, from
the anterior iliac spine down through the scrotum has diffuse
ecchymoses and resolving hematoma. Neurological: The
patient is alert and oriented times three with normal speech,
moving all extremities, without any focal deficits.
LABORATORY: On admission, sodium 140, potassium 4.4,
chloride 97, bicarbonate 32, BUN 74, creatinine 1.7, glucose
153, white blood cell count was 15.7, hematocrit 35.1,
platelets 150. Creatinine kinase was trended at 41, repeat
was 42.
EKG was a normal sinus rhythm at 82, normal axis, normal
intervals, early R wave progression, diffuse T wave
flattening. No ST elevations or depressions.
Chest x-ray notable for flat diaphragms, mild cephalization,
no pneumonia.
CT scan of the abdomen with no retroperitoneal bleed, right
groin hematoma.
Femoral ultrasound with no pseudo-aneurysm, no arteriovenous
fistula.
ASSESSMENT AND PLAN: On admission, the patient is an 86 year
old male with known three-vessel coronary artery disease
including left main disease, severe chronic obstructive
pulmonary disease, diabetes mellitus, hypertension,
peripheral vascular disease, who was admitted for high-risk
cardiac catheterization.
HOSPITAL COURSE:
1. Cardiovascular: Upon admission, the patient was
continued on aspirin, Captopril, nifedipine and Lipitor. The
patient was weaned off of the Nitroglycerin drip. Beta
blockers were held secondary to chronic obstructive pulmonary
disease and the GTB3A inhibitors were held secondary to his
right groin hematoma. His cardiac enzymes were cycled and
remained flat and there was no evidence of acute ischemia on
his repeat electrocardiograms.
On hospital day number two, the patient was taken to the
Cardiac Catheterization Laboratory and stents were placed to
his left main, 4.5 centimeters; right coronary artery (4.5
millimeters to 13 millimeters) and posterior descending
artery (2.5 millimeters by 18 millimeters). The patient was
then continued on Integrilin for the next 18 hours.
Of note, the patient was switched from nifedipine to
Diltiazem 240 mg p.o. q. day. The patient then continued to
remain chest pain free throughout the remainder of his
hospital course and was chest pain free up to the projected
discharge date.
Myocardium: The patient's ejection fraction at the outside
hospital showed a 60% preserved ejection fraction and his ACE
inhibitors were titrated up throughout this hospital stay as
tolerated.
Rhythm: The patient had no rhythm issues throughout the
majority of his hospital stay. However, of note, the two
nights prior to discharge, the patient had a 13 beat run of
nonsustaining ventricular tachycardia. The patient was
asymptomatic at the time, with stable vital signs and it
occurred while the patient was sleeping. The patient
continued to be monitored rigorously on Telemetry for signs
of any further episodes of ventricular tachycardia.
2. Pulmonary: The patient had severe chronic obstructive
pulmonary disease with FEV1 of less than 1. The patient was
continued on his Albuterol and Atrovent nebulizers q. six
hours with Albuterol and Atrovent inhalers q. four hours as
needed p.r.n. The patient was also continued on Bi-PAP
overnight as needed, and a Prednisone taper was begun at the
time of admission. The patient reported remaining slightly
below or near his baseline as far as his subjective symptoms
of dyspnea throughout the hospital course, and will be
discharged on his current outpatient regimen.
3. Renal: The patient was admitted with mild renal
insufficiency with a creatinine of 1.1. His creatinine was
monitored throughout the course of his hospital stay and his
kidney function actually improved status post myocardial
infarction with improvement in his hemodynamics.
4. Endocrine: The patient has diabetes mellitus of unknown
duration with complications at this time unknown. He was
continued on four times a day fingersticks and on a Regular
insulin sliding scale throughout his hospital stay, with
excellent control of his blood pressures throughout the
hospital course.
5. Hematology: As per HPI the patient was admitted with a
resolving hematoma of his right groin area that was negative
for pseudo-aneurysm or retroperitoneal bleed. The patient's
hematocrits were followed throughout the majority of his
hospital stay and remained stable throughout that time. At
the time of discharge, the hematoma is resolving and
hematocrits are stable.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To rehabilitation facility.
DISCHARGE DIAGNOSES:
1. Myocardial infarction.
2. Chronic obstructive pulmonary disease.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg p.o. q. day.
2. Lisinopril 20 mg p.o. q. day.
3. Lipitor 10 mg p.o. q. day.
4. Plavix 75 mg p.o. q. day times 30 days.
5. Albuterol and Atrovent inhalers, two puffs q. four to six
hours p.r.n.
6. Albuterol and Atrovent nebulizers q. four hours.
7. Prednisone 50 mg p.o. q. day times two days, then
Prednisone 40 mg q. day times three days; then 30 mg q. day
times three days; then 20 mg q. day times three days, then 10
mg times three days then 5 mg times three days.
DISCHARGE INSTRUCTIONS:
1. The patient should follow-up with Cardiology, with
potential catheterization in three months. A Cardiologist
and appointment time for follow-up will be noted on the Page
one referral form.
2. The patient will also undergo Physical Therapy and
rehabilitation as per plan of rehabilitation facility.
DR.[**First Name (STitle) **],[**First Name3 (LF) **] 11-691
Dictated By:[**Last Name (NamePattern1) 33696**]
MEDQUIST36
D: [**2178-8-9**] 16:12
T: [**2178-8-9**] 16:32
JOB#: [**Job Number 44003**]
ICD9 Codes: 4280, 496, 4271, 4439 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3524
} | Medical Text: Admission Date: [**2197-5-29**] Discharge Date: [**2197-6-3**]
Date of Birth: [**2163-5-13**] Sex: F
Service: [**Hospital1 **] MEDICINE
CHIEF COMPLAINT: Presented [**5-29**] with [**Month (only) **] hematemesis
x2 and melena.
HISTORY OF PRESENT ILLNESS: A 34-year-old female status post
gastric bypass in [**2196-9-4**] with a recent
Enterococcus faecalis endocarditis complicated by cerebral
emboli (status post cerebrovascular accident) presenting with
two episodes of hematemesis, melena. Had been on aspirin and
Vioxx and drinking occasional alcohol at home. Initially
hemodynamically stable on arrival. Her initial hematocrit
was 30 with a normal coags, and subsequently dropped to 22.5.
Patient was transferred to the Medical Intensive Care Unit
for further management.
PAST MEDICAL HISTORY:
1. Status post gastric bypass operation in [**2196-9-4**]
for morbid obesity. Procedure was a Roux-en-Y (lost 260
pounds down from 502 pounds).
2. Enterococcus faecalis endocarditis, leading to stroke,
aortic insufficiency, mitral regurgitation. On ampicillin
for three months.
3. Cerebrovascular accident in [**2196-11-4**]; with
residual Broca's aphasia and right hemiplegia. Received TPA
for embolic endocarditis.
4. Hypertension.
5. Obesity.
6. Obstructive-sleep apnea; uses CPAP at night.
7. Severe aortic insufficiency; surgery planned in
approximately six months to a year. Echocardiogram from
[**2197-3-4**] shows a preserved ejection fraction with left
atrial enlargement, a 4+ aortic insufficiency, mild mitral
regurgitation.
MEDICATIONS ON ADMISSION:
1. Aspirin 325 mg po q day.
2. Ranitidine 150 mg po bid.
3. Celexa 40 mg po q day.
4. Captopril 25 mg po tid.
5. Lasix 40 mg po q day.
6. Vicodin prn.
7. Vioxx 12.5 mg [**Hospital1 **].
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Married, has one daughter, occasional
alcohol use, smokes a half a pack per day. No IV drug use.
PHYSICAL EXAMINATION ON ADMISSION: General: In no acute
distress. Vital signs: Temperature 99.0, heart rate 77,
blood pressure 122/47, respiratory rate 18, and O2 saturation
is 100% on room air. HEENT: Normocephalic, atraumatic.
Extraocular muscles are intact. Moist mucous membranes.
Neck: Supple, no lymphadenopathy. Pulmonary: No wheezes,
crackles. Cardiac: Normal S1, S2, early blowing diastolic
murmur at apex, mid systolic murmur at base. Laterally
displaced PMI. Abdomen: Soft, nontender, nondistended,
normoactive bowel sounds. Extremities: No clubbing,
cyanosis, or edema. Neurologic: Right lower extremity
paresis, paralysis of right upper extremity. Alert and
oriented times three.
LABORATORY FINDINGS ON ADMISSION: White blood cell count of
11.2, hematocrit 30.3, platelets 326. MCV 90, INR 1.2, PTT
28.9, sodium 138, potassium of 5.8, chloride of 107, bicarb
of 20, BUN 45, creatinine 1.2, glucose 83.
ELECTROCARDIOGRAM ON ADMISSION: Normal sinus rhythm, normal
axis, Q wave in III, small Q in II, T-wave inversions in III.
Nonspecific ST changes (old findings).
HOSPITAL COURSE: The patient was treated supportively with
blood products in the Intensive Care Unit. She is status
post 8 units of packed red blood cells there. An EGD was
performed with periprocedure ampicillin/gentamicin. The
procedure demonstrated a large clot distal to the anastomosis
from the bypass. There was active bleeding from the area.
The precise pathology underlying the clot could not be seen.
The bleeding site was injected and cauterized (patient was
intubated for the procedure secondary to agitation and for
airway protection. Note: This was elective). Patient was
subsequently transferred to the floor. There she had a
repeat episode of hematemesis, and she was transferred back
to the MICU for closer monitoring. At that time, she had a
temperature spike of 101.3. Fever workup yielded positive
urinalysis and she was started on Bactrim.
While monitoring in the Intensive Care Unit, she had several
ensuing episodes of bright red blood per rectum. Her
hematocrit had a slow drift as well. Therefore, a relook EGD
was performed on [**6-1**] that showed significant mucus at
the anastomosis site. However, no active bleeding.
Therefore, it is likely the bleed was just residual blood
from the initial bleed that was slow to transit through the
bowel. Patient was subsequently transferred to the floor.
She remained hemodynamically stable there. She had no
further episodes of hematemesis nor melena nor bright red
blood per rectum.
With respect to her urinary tract infection, she completed a
course of Bactrim. With respect to her aortic insufficiency,
she has a wide pulse pressure at baseline. She had no
evidence of congestive failure throughout her hospital course
and throughout her transfusions.
With respect to her sleep apnea, she was maintained on her
CPAP throughout her hospitalization.
DISCHARGE DIAGNOSES:
1. Gastrointestinal bleed at gastric bypass anastomosis site.
2. Severe aortic insufficiency.
3. Urinary tract infection.
4. Obstructive-sleep apnea.
FOLLOWUP: The patient should follow up with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 36603**], [**Telephone/Fax (1) 36604**], her primary care physician. [**Name10 (NameIs) **] should
also followup with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at GI at [**Hospital1 346**].
DISCHARGE INSTRUCTIONS: The patient is to seek medical
attention immediately with any signs of GI bleeding.
DISCHARGE MEDICATIONS:
1. Protonix 40 mg po q day.
2. Celexa 40 mg po q day.
3. Vicodin prn.
4. Bactrim double strength one tablet [**Hospital1 **] x2 days.
5. Captopril 25 mg po tid.
6. Lasix 40 mg po q day.
[**Doctor Last Name **] [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5712**]
Dictated By:[**Name8 (MD) 22959**]
MEDQUIST36
D: [**2197-6-2**] 21:15
T: [**2197-6-6**] 08:12
JOB#: [**Job Number 36605**]
ICD9 Codes: 2851, 5990, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3525
} | Medical Text: Admission Date: [**2119-9-8**] Discharge Date: [**2119-9-11**]
Date of Birth: [**2058-5-23**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 602**]
Chief Complaint:
Chief Complaint: CP
.
Reason for MICU transfer: hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
60 year old male with pmh of seizure disorder, ESRD on HD (MWF),
nonischemic cardiomyopathy (EF~20-30%), h/o CAD and CVA,
hepatitis B who presented with hypotension and chest pain from
HD. Pt was receiving dialysis this am and started to c/o chest
pain. On arrival to [**Name (NI) **] pt denied chest pain, but stated that he
has a headache for 3 days. Per patient, he fell flat on his
face on Wednesday after receiving dialysis. He did not loose
conciousness. Not long after arriving to ED, he was triggered
for hypotension, down to 60's systolic. He reported that he had
on/off chest pain over past 2 days. PT also c/o non-bloody
diarrhea 4x per day, loss of appetite for 4 days, and has not
been eating, + chills. PT denies vomiting, sweats, changes in
vision. Pt feels he is not thinking well as he usually does,
and feels he has had decreased mental status for 2 days.
.
In ED, he was noted to have initial vitals of 96.9 100 138/105
16 100% 4L. He was noted to have a repeated BP down to as low
as 60s, now in 90s after IVF. EKG showed sinus @ 90, LAD, LBBB,
no scarbosa. Exam was notable for multiple small ~1cm sq skin
ulcerations on buttocks near anus. CT head showed no acute
pathology. CXR was unchanged from prior. Guaiac was noted
positive. Nephrology was consulted and Dr. [**Last Name (STitle) 17159**] will follow.
He was given 1 gram vancomycin, 1 gram ceftriaxone due to the
small pressure ulcer on back and hypotension. He recieved total
of 2.25 L in 500cc boluses, good BP response to SBP of 96. He
was admitted to MICU for potential sepsis workup. Access: left
femoral CVL triple lumen and Dilaysis Port Left Chest wall.
Precautions: MRSA and VRE.
.
On the floor, he appears to be in good spirit.
Past Medical History:
- Seizure disorder since mid [**2097**]'s after starting dialysis
- MSSA HD line infection with septic lung emboli [**9-1**] with left
pleural effusion
- H/o Hepatitis B, treated
- Non-ischemic cardiomyopathy, last EF 20-30%
- MI [**2086**] per pt
- CVA [**2086**] per pt (?residual LE weakness)
- ESRD on hemodialysis [**1-25**] HTN. EDW 80 kg as of [**2118-1-3**].
- Multiple thrombectomies in LUE and R thigh AV fistula
- Graft excision for infected thigh graft [**2117-5-26**]
- Hungry bone syndrome status post parathyroidectomy
- Pituitary mass
- Anemia of chronic disease
- s/p PEG tube placement [**2117-10-29**]
- Admission to MICU in [**10-2**] for seizure and hypotension
- Swab positive for MRSA and VRE at left groin site in [**10-2**] and
MRSA positive from same site [**11-2**]
.
Social History:
Retired piano and organ teacher. Has 2 PhDs (history and music)
and prefers to be called "Dr. [**Known lastname 2026**]." Walks with a walker at
baseline. Never smoker, no other drug use. Drinks 1 drink/week.
Has 2 sisters that live out of state, son died 3 years ago ("was
shot to death").
Family History:
Father with DM, mother died at age 41 of renal failure
Physical Exam:
Admission PE:
Vitals: T: 97.2 BP:121/74 P: 81 R: 18 O2: 100
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, DMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, hyperactive bowel
sounds present, no rebound tenderness or guarding, no
organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Discharge PE:
VS: 96.9 111/52 66 18 100 on RA
General: pleasant gentleman, NAD, laying comfortably in bed
HEENT: Sclera anicteric, moist mucous membranes
Neck: supple, JVP not elevated, no LAD
Chest: L HD site no erythema, no tenderness to palpation
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, hyperactive bowel
sounds present
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2119-9-8**] 08:37PM GLUCOSE-92 UREA N-53* CREAT-10.1* SODIUM-141
POTASSIUM-4.5 CHLORIDE-99 TOTAL CO2-17* ANION GAP-30*
[**2119-9-8**] 08:37PM ALT(SGPT)-9 AST(SGOT)-15 LD(LDH)-147
CK(CPK)-185 ALK PHOS-116
[**2119-9-8**] 08:37PM CK-MB-4 cTropnT-0.13*
[**2119-9-8**] 08:37PM CALCIUM-8.7 PHOSPHATE-8.2*# MAGNESIUM-1.9
[**2119-9-8**] 08:37PM WBC-11.5* RBC-5.17 HGB-14.8 HCT-46.2 MCV-89
MCH-28.5 MCHC-32.0 RDW-14.1
[**2119-9-8**] 08:37PM NEUTS-84.7* LYMPHS-8.6* MONOS-4.1 EOS-2.3
BASOS-0.3
[**2119-9-8**] 08:37PM PLT COUNT-275
[**2119-9-8**] 08:37PM PT-13.9* PTT-28.3 INR(PT)-1.2*
[**2119-9-8**] 12:39PM LACTATE-2.9*
[**2119-9-8**] 12:15PM GLUCOSE-102* UREA N-45* CREAT-9.5*#
SODIUM-139 POTASSIUM-3.9 CHLORIDE-91* TOTAL CO2-17* ANION
GAP-35*
[**2119-9-8**] 12:15PM estGFR-Using this
[**2119-9-8**] 12:15PM ALT(SGPT)-11 AST(SGOT)-18 ALK PHOS-143* TOT
BILI-0.4
[**2119-9-8**] 12:15PM cTropnT-0.16*
[**2119-9-8**] 12:15PM ALBUMIN-4.6 CALCIUM-10.2 PHOSPHATE-6.3*#
MAGNESIUM-2.0
[**2119-9-8**] 12:15PM DIGOXIN-0.2*
[**2119-9-8**] 12:15PM WBC-13.5*# RBC-5.88 HGB-16.5 HCT-52.4* MCV-89
MCH-28.1 MCHC-31.5 RDW-14.1
[**2119-9-8**] 12:15PM NEUTS-89.5* LYMPHS-6.1* MONOS-2.7 EOS-1.5
BASOS-0.2
[**2119-9-8**] 12:15PM PLT COUNT-300#
[**2119-9-8**] 12:15PM PT-14.2* PTT-53.6* INR(PT)-1.2*
Brief Hospital Course:
60 year old male with pmh of seizure disorder, ESRD on HD (MWF),
nonischemic cardiomyopathy (EF~40-45%), h/o CAD and CVA,
hepatitis B admitted with chest pain and hypotension. Chest
pain resolved after arrival to the ED and did not recurr.
#Hypotension:
The patient was hypotensive in the setting of taking off excess
fluid in HD. His pressures responded to volume repletion with
3L IVF. This extra net negative fluid balance was also
exacerbated by the patient's diarrhea and poor PO intake in the
4-5 days preceding presentation. He continued to have loose
bowel movements while he was in the MICU. Stool cultures and
OVA/Parasites were sent. Blood cultures were drawn in the ED,
given the fact that the patient has a HD line and systemic
infection needed to be ruled out in the setting of his
hypotension. He was started on empiric Vanc and Ceftriaxone in
the unit and was continued on antibiotics until his blood
cultures were negative for 48 hours. While on the floor the
patient's blood pressures were in the low 100s. He was
triggered for pressures in the 60s, but it is unclear whether
these readings were accurate. He was completely asymptomatic
during this episode and was mentating normally. He was bolused
500 cc x2, and his repeat pressures using an automated BP
machine were in the low 100s. The patient remained in the low
100s during the rest of his admission after his antibiotics were
discontinued. He also remained afebrile. He will follow up with
Nephrology at which time midodrine may be added if hypotension
continues to be a problem.
.
# chest pain: The patient's chest pain resolved while in the ED
and he was ruled out for MI while in MICU with negative
troponins. The patient did not endorse chest pain during the
hospitalization. As per the MICU admission, the patient did
have transient changes in the ED on EKG, but his chest pain has
since resolved. Cardiology saw the patient and was not
concerned given the lack of symptoms. The patient's troponin
peaked at 0.16 and trended down to 0.14. Of note, his recent
baseline troponin within last year was 0.12-.014.
.
# diarrhea: While in the unit, the patient was still having
diarrhea. Stool cultures and ova and parasite, as well as Cdiff
were all sent. The patient was started on empiric Flagyl. Upon
transfer to the floor, the patient was no longer having diarrhea
and his empiric Flagyl was stopped. He was also found to be
Cdiff toxin negative.
.
# ESRD on HD: The patient was continued on his M, W, F dialysis
schedule while in patient. Renal was following and his volume
status was closely followed. All medictions were renally dosed
and neprhotoxic agents were avoided. The patient was also
started on nephrocaps during this admission.
.
# CAD/CHF: The patient's last ECHO was in [**12/2118**] with an EF
25-30%. He was ruled out for MI with negative troponins. The
patient is not on Lisinopril secondary to his low blood
pressures.
.
Chronic Issues:
.
# gout: The patient was continued on his home gout medications.
.
# seizure d/o: The patient was continued on his home
anti-seizure medications.
.
Transitional Issues:
.
# hypotension: The patient's blood pressures tend to run on the
lower side. Consider midodrine as outpatient in order to
prevent recurrence of hypotensive episodes.
.
# CAD:: The patient's CAD is not medically optimized, as he is
not on an ACE. If his pressures can tolerate it, consider
adding low dose Lisinopril. He is also not on a beta blocker.
Medications on Admission:
bisacodyl 5 mg Two Tablet PO DAILY
senna 8.6 mg Tablet Sig: One (1) Tablet PO once a day PRN
calcium acetate 667 mg Capsule Sig: Four (4) Capsule PO TID
W/MEALS
folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY
ferrous sulfate 300 mg PO DAILY
sevelamer HCl 400 mg Tablet Sig: Four (4) Tablet PO TID W/MEALS
gabapentin 100 mg Capsule Sig: Two (2) Capsule PO Q24H
levetiracetam 500 mg Tablet Sig: One (1) Tablet PO TID
levetiracetam 500 mg Tablet Sig: One (1) Tablet PO MWF
oxcarbazepine 150 mg Tablet Sig: Two (2) Tablet PO TID
aspirin 81 mg PO DAILY
oxcarbazepine 150 mg Tablet Sig: Two (2) Tablet PO MWF
simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
omeprazole 20 mg PO DAILY (Daily).
digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H PRN
gabapentin 100 mg Capsule 2 Capsule(s) by mouth Daily
Discharge Medications:
1. senna 8.6 mg Tablet Sig: One (1) Tablet PO once a day as
needed for constipation.
Disp:*14 Tablet(s)* Refills:*0*
2. bisacodyl 5 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*28 Tablet(s)* Refills:*2*
3. calcium acetate 667 mg Capsule Sig: Four (4) Capsule PO three
times a day: TID with meals.
Disp:*360 Capsule(s)* Refills:*0*
4. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
5. sevelamer HCl 400 mg Tablet Sig: Four (4) Tablet PO three
times a day.
Disp:*360 Tablet(s)* Refills:*0*
6. gabapentin 100 mg Capsule Sig: Two (2) Capsule PO once a day.
7. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO three
times a day.
Disp:*60 Tablet(s)* Refills:*0*
8. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO as
directed: one tablet M,W, F with dialysis.
9. oxcarbazepine 150 mg Tablet Sig: Two (2) Tablet PO three
times a day.
Disp:*120 Tablet(s)* Refills:*0*
10. oxcarbazepine 150 mg Tablet Sig: Two (2) Tablet PO as
directed: 2 tablets PO MWF with dialysis.
11. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*14 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
12. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*28 Tablet(s)* Refills:*2*
13. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*14 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
14. digoxin 125 mcg Tablet Sig: One (1) Tablet PO every other
day.
Disp:*10 Tablet(s)* Refills:*0*
15. allopurinol 100 mg Tablet Sig: One (1) Tablet PO every other
day.
Disp:*10 Tablet(s)* Refills:*0*
16. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO q6h PRN
as needed for fever or pain.
Disp:*20 Tablet(s)* Refills:*0*
17. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*14 capsules* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
primary diagnosis:
hypotension
end stage renal disease on hemodialysis
secondary diagnosis:
seizure disorder
nonischemic cardiomyopathy
Discharge Condition:
Activity Status: ambulates with walker, uses wheelchair
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Discharge Instructions:
Dear Dr. [**Known lastname 2026**],
It was a pleasure taking care of you while you were hospitalized
at [**Hospital1 18**]. You were initially admitted to the intensive care
unit because you blood pressures in the emergency department
were very low. It was unclear whether your low blood pressures
were due to not having enough fluid in your body (you were
reporting diarrhea and not drinking as much fluid) or if you had
a severe infection. While in the intensive care unit, we gave
you fluids and also started you on strong antibiotics. We drew
blood samples as well to check for any bacteria in your blood.
Once your blood pressures were stabilized, you were transferred
to the general medicine floor. On the floor you pressures have
been good, except for one episode when they dropped low.
However, your blood pressure responded well to fluids that we
gave you through you veins.
While you were in the hospital, the kidney doctors were also
following you and we continued your M, W, F dialysis schedule.
The following changes were made to your medications:
-START Nephrocaps 1 capsule daily by mouth
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Please keep all follow-up appointments as below:
.
Department: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 250**]
When: THURSDAY [**2119-9-21**] at 10:30 AM
With: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] South [**Hospital **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
NOTE: 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
.
You will be followed by your nephrologist, Dr [**First Name (STitle) 805**] during
your upcoming dialysis appointment:
HD on M/W/F at [**Last Name (un) **] Dialysis Center in [**Location (un) **]
Completed by:[**2119-9-19**]
ICD9 Codes: 5856, 4254, 4280, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3526
} | Medical Text: Admission Date: [**2161-3-23**] Discharge Date: [**2161-3-27**]
Date of Birth: [**2128-10-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7055**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
PTCA, no intervention
Swan-Ganz Catheterization
History of Present Illness:
32 M with PMH HTN, obesity presents with chest pressure and SOB.
Patient has had chronic baseline SOB since Xmas, but SOB became
noticeably more severe starting last Thurs (6 days ago). Chest
pressure in L chest started at 2 pm yesterday, [**2165-3-14**], radiated
mildly to L shoulder, worse with exertion but occurred while
defecating, no association to food or position, feels very
different from heartburn burning. Chest pressure persisted for
2.5 hrs while lying in bed. Pt called ambulance and came to ED.
In ambulance, nitro spray relieved pressure to [**1-20**]. No
N/V/diaphoresis/abdominal pain. Baseline SOB occurs while
walking [**5-20**] feet. +PND, no orthopnea, no peripheral edema.
.
In the [**Name (NI) **], pt had 200s/110s, was given IV and PO lopressor with
BP improvement to the 180s. Given nitro sl, ASA, was chest
pain-free. EKG showed flattened T waves in V5-V6, TWI AVL. Pt
had 45 beat NSVT run, in which pt was asymptomatic and
hemodynamically stable.
.
ROS: +chronic headaches, +cough. No F/C, blood on tissue after
defecating, no blood in urine, no dysuria.
Past Medical History:
HTN - diagnosed 10 years ago; on no medications
Obesity
GERD - takes Tagamet for relief
Social History:
Single. Works as maintenance worker. Drinks 10 hard alcohol
drinks/day when he drinks, which is sporadic. 10 pky smoking hx.
Currently smokes marijuana, used to snort cocaine 2.5 years ago,
no heroin.
Family History:
HTN in almost every member of his first and second degree
family, DM in mother. Mother passed away at age 51 of
"aneurysm".
Physical Exam:
99.0 / 114 / 26 / 156/89 / 92% RA
Gen: obese, NAD
HEENT: PERRL, EOMI, clear OP, unable to assess JVP because of
neck habitus
Heart: Distant heart sounds, RRR, no m/r/g
Lungs: Distant breath sounds, CTA B
Abd: Soft, NT, ND, +BS
Ext: No c/c/e, 2+ DP bl
Neuro: [**5-15**] motor
Pertinent Results:
CXR: No consolidation, no effusion, mild CHF, cardiomegaly.
CK 127, 245, 205
MB 15, 35, 29
Trop 0.28, 0.56, 0.46
.
EKG: sinus 122, nl axis, nl intervals, TW flattening in V5-V6,
TWI AVL, LVH, good R wave progression
.
UA: 100 protein, tr ketone, few bact, [**3-15**] wbc, neg leuk/nitrite,
many calOx
.
Serum/urine tox negative
.
TTE: EF 30%
Dilation of all 4 [**Doctor Last Name 1754**], mild symmetric LVH, moderate to
severe global left ventricular hypokinesis. [**1-12**]+ MR, 2+ TR.
Small to moderate pericardial effusion, circumferential, no
tamponade.
.
PCW 29
RA 14
AO 157/119
PA 65/37
LV 152/9, end 29
.
[**2161-3-23**] 06:57PM URINE HOURS-RANDOM
[**2161-3-23**] 06:57PM URINE HOURS-RANDOM
[**2161-3-23**] 06:57PM URINE GR HOLD-HOLD
[**2161-3-23**] 06:57PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2161-3-23**] 06:57PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.027
[**2161-3-23**] 06:57PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-NEG
[**2161-3-23**] 06:57PM URINE RBC-0-2 WBC-[**3-15**] BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2161-3-23**] 06:57PM URINE GRANULAR-0-2 FINE GRANULAR CASTS
[**2161-3-23**] 06:57PM URINE CA OXAL-MANY
[**2161-3-23**] 06:57PM URINE MUCOUS-MANY
[**2161-3-23**] 06:04PM GLUCOSE-152* UREA N-12 CREAT-1.0 SODIUM-142
POTASSIUM-4.0 CHLORIDE-106 TOTAL CO2-25 ANION GAP-15
[**2161-3-23**] 06:04PM CK(CPK)-127
[**2161-3-23**] 06:04PM cTropnT-0.28*
[**2161-3-23**] 06:04PM CK-MB-15* MB INDX-11.8*
[**2161-3-23**] 06:04PM CALCIUM-9.2 PHOSPHATE-3.4 MAGNESIUM-2.1
[**2161-3-23**] 06:04PM TSH-2.2
[**2161-3-23**] 06:04PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2161-3-23**] 06:04PM WBC-12.8* RBC-5.07 HGB-14.8 HCT-42.7 MCV-84
MCH-29.2 MCHC-34.7 RDW-14.0
[**2161-3-23**] 06:04PM NEUTS-82.3* LYMPHS-11.8* MONOS-3.3 EOS-1.6
BASOS-0.9
[**2161-3-23**] 06:04PM PLT COUNT-306
[**2161-3-23**] 06:04PM PT-11.9 PTT-21.6* INR(PT)-1.0
Brief Hospital Course:
32 M with PMH obesity, HTN presents with hypertensive emergency
and NSTEMI.
.
# NSTEMI:
1. Ischemia: Patient had clean coronary arteries on cardiac
catheterization. Cardiac enzymes were initially elevated up to
Troponin 0.56, but then trended down. Troponin elevation was
most likely from stress from HTN. Patient was kept on ACE for
afterload reduction. Patient was on dobutamine for CI 1.8 on
admission. Patient was encouraged to maintain lifestyle/diet
modifications, and to stop EtOH and cocaine.
.
2. Pump: EF 30%, Class IV Heart Failure
Etiology of heart failure and depressed EF is likely combination
of dilated cardiomyopathy from alcohol and hypertensive
cardiomyopathy. Differential included multiple etiologies, such
as EtOH, HTN, cocaine, pheo, pulm HTN from OSA, viral. The
patient was fluid overloaded on admission, was diuresed
successfully with lasix 20 IV (patient is lasix naive).
Hydralazine was started for afterload reduction. Morphine [**1-12**]
mg was given prn. Urine output was wnl during admission.
.
3. Rhythm: PVCs on tele. 45 beat NSVT on admission
During the patient's 45 beat NSVT run on admission, the patient
was asymptomatic, no dizziness, no CP, no SOB, and was
hemodynamically stable the entire time. Patient was monitored
on tele, which showed occasional PVCs.
.
# HTN urgency:
Patient's SBP was around 200, and ACE was uptitrated for goal
SBP < 140. Given the patient's extensive family history of HTN,
as well as young age of onset of HTN at around 20 yo, etiologies
such as hyperaldosteronism and renovascular HTN were considered.
HTN was most likely etiology of patient's chronic headaches.
Headaches were at baseline, and resolved once patient's BP was
under better control. Patient will follow with endocrine for
workup.
.
# Shortness of breath:
Etiology of patient's SOB is likely a combination of dilated
cardiomyopathy, hypertensive cardiomyopathy, or OSA. Patient's
PCWP was 27. Patient will follow with sleep study as
outpatient.
.
# EtOH history:
Patient required only very minimal amounts of Ativan on CIWA
scale.
Medications on Admission:
cc: Chest pain
.
HPI: 32 M with PMH HTN, obesity presents with chest pressure and
SOB. Patient has had chronic baseline SOB since Xmas, but SOB
became noticeably more severe starting last Thurs (6 days ago).
Chest pressure in L chest started at 2 pm yesterday, [**2165-3-14**],
radiated mildly to L shoulder, worse with exertion but occurred
while defecating, no association to food or position, feels very
different from heartburn burning. Chest pressure persisted for
2.5 hrs while lying in bed. Pt called ambulance and came to ED.
In ambulance, nitro spray relieved pressure to [**1-20**]. No
N/V/diaphoresis/abdominal pain. Baseline SOB occurs while
walking [**5-20**] feet. +PND, no orthopnea, no peripheral edema.
.
In the [**Name (NI) **], pt had 200s/110s, was given IV and PO lopressor with
BP improvement to the 180s. Given nitro sl, ASA, was chest
pain-free. EKG showed flattened T waves in V5-V6, TWI AVL. Pt
had 45 beat NSVT run, in which pt was asymptomatic and
hemodynamically stable.
.
ROS: +chronic headaches, +cough. No F/C, blood on tissue after
defecating, no blood in urine, no dysuria.
.
PMH:
HTN - diagnosed 10 years ago; on no medications
Obesity
GERD - takes Tagamet for relief
.
Medications on Admission:
None.
.
ALL:
NKDA
.
SH: Single. Works as maintenance worker. Drinks 10 hard alcohol
drinks/day when he drinks, which is sporadic. 10 pky smoking hx.
Currently smokes marijuana, used to snort cocaine 2.5 years ago,
no heroin.
.
FMH: HTN in almost every member of his first and second degree
family, DM in mother. Mother passed away at age 51 of
"aneurysm".
.
Physical exam:
99.0 / 114 / 26 / 156/89 / 92% RA
Gen: obese, NAD
HEENT: PERRL, EOMI, clear OP, unable to assess JVP because of
neck habitus
Heart: Distant heart sounds, RRR, no m/r/g
Lungs: Distant breath sounds, CTA B
Abd: Soft, NT, ND, +BS
Ext: No c/c/e, 2+ DP bl
Neuro: [**5-15**] motor
.
.
LABS:
CXR: No consolidation, no effusion, mild CHF, cardiomegaly.
CK 127, 245, 205
MB 15, 35, 29
Trop 0.28, 0.56, 0.46
.
EKG: sinus 122, nl axis, nl intervals, TW flattening in V5-V6,
TWI AVL, LVH, good R wave progression
.
UA: 100 protein, tr ketone, few bact, [**3-15**] wbc, neg leuk/nitrite,
many calOx
.
Serum/urine tox negative
.
TTE: EF 30%
Dilation of all 4 [**Doctor Last Name 1754**], mild symmetric LVH, moderate to
severe global left ventricular hypokinesis. [**1-12**]+ MR, 2+ TR.
Small to moderate pericardial effusion, circumferential, no
tamponade.
.
PCW 29
RA 14
AO 157/119
PA 65/37
LV 152/9, end 29
.
.
A/P:
32 M with PMH obesity, HTN presents with hypertensive emergency
and NSTEMI.
.
# Cardiac:
Ischemia: Clean coronaries on cath. Cardiac enzyme elevation,
now trending down, NSTEMI likely from HTN.
- On ACE for afterload reduction
- On dobutamine for CI 1.8 on admission
- Lifestyle/diet modifications, stop EtOH and cocaine
.
Pump: EF 30%, Class IV Heart Failure
- Likely combination of dilated cardiomyopathy from alcohol and
hypertensive cardiomyopathy.
DDx: EtOH, HTN, cocaine, pheo, pulm HTN from OSA, viral, HIV.
- Fluid overloaded, lasix 20 IV x1 since naive
- Start hydralazine for afterload reduction, can start morphine
1-2 mg prn, can start nitro gtt
- Monitor UO, goal -1-2 L
.
Rhythm: PVCs on tele. Had 45 beat NSVT on admission, pt was
asymptomatic and hemo stable.
- Monitor on tele
.
# HTN emergency:
- Uptitrate ACE for goal SBP < 140
- Endocrine curbside for workup of HTN
- Given extensive family hx and age of onset around 20 yo,
consider hyperaldosteronism, renovascular HTN, OSA
- HTN control should improve headaches
.
# SOB:
Likely due to combination of dilated/HTN CM, OSA.
- Sleep study as outpatient, PCWP 27
.
# EtOH history:
Minimal Ativan used, on CIWA scale
.
FEN: Cardiac diet, diuresing, no IVF
PPX: Heparin sc, PPI, bowel regimen
CODE: Full
ACCESS: PIV
DISPO: HTN control and med regimen.
Discharge Medications:
1. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
3. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day.
Disp:*30 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice
a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Congestive heart failure
2. Dilated Cardiomyopathy
3. HTN
Discharge Condition:
Stable, improved.
Discharge Instructions:
You have been prescribed many new medications. Take these as
prescribed.
Follow up with Dr. [**Last Name (STitle) 1147**] in the next 2-4 weeks. He may be
able to help you with your medicines.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 1147**] in [**2-14**] weeks. Call next week to set
up an appointment. [**0-0-**]
Completed by:[**2161-7-2**]
ICD9 Codes: 4280, 4254, 4271 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3527
} | Medical Text: Admission Date: [**2125-3-11**] Discharge Date: [**2125-3-19**]
Date of Birth: [**2067-10-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
fever, mental status changes, headache
Major Surgical or Invasive Procedure:
endotracheal intubation, mechanical ventilation, lumbar puncture
lumbar puncture
History of Present Illness:
57 yo M with PMHX of nonischemic CM, CRI, anemia [**1-4**] plasma cell
dysplasia who presents today from OSH with fever and mental
status changes and transferred from OSH.
.
Unable to obtain hx from patient. History obtained from OSH
records and his girlfriend.
.
Per the girlfriend who is his HCP, yesterday at 9am he was
coherent and conversing normally. He became confused transiently
while going to the donut store and didn't remember the day of
the week. However, he was conversing normally. He then around
11am was in the bathroom and came out short of breath and in
abdominal pain, throwing up "coffee material". He was sitting on
a chair bent over secondary to pain. He also complainted of a
terrible headache and light was bothering him. He also had a
stomach ache at the same time. Her girlfriend waited for about
1/2 hour and then called the ambulance yesterday around 1pm and
he was taken to [**Location (un) **] ED.
.
At [**Location (un) **], his initial vitals were noted to be 101.0, 59,
157/71, 15, 98% on RA. His initial complaints to the OSH ED per
their records were abdominal pain [**7-12**] and vomiting with
questionable blood in vomit. Head CT was showed right
mastoiditis but no ICH. CXR showed multifocal PNA and slightly
increased effusions from [**3-10**], cardiomegaly. CT abdomen with
po/IV contrast showed bilateral lower lobe infiltrates, CHF.
Also showed an inflammatory process in left posterior pararenal
space with mild sigmoid diverticulosis without diverticulitis.
His labs were remarkable for WBC 28.9 and BUN 40/cr 1.4 and BNP
1870. He also grew gram positive cocci [**3-6**] blood cultures -
alpha hemolytic strep. He was given ceftriaxone 2g IV x 1,
azithromycin 500 mg IV x 1, vancomycin 1g IV x 1, hydrocortisone
100 mg IV x 1. Ativan 1mg IV x 1 for agitation. and then
transferred here for further care.
.
Of note, he was d/c'd from [**Hospital1 2177**] on [**2-21**] for new diagnoses of
nonischemic dilated CM and kappa light chain gammopathy/plasma
cell dyscrasia - monoclonal. He had a renal and BM bx this
admission which are pending, had a SPEP/UPEP, and flow cytometry
confirming these diagnoses and started on prednisone for concern
of a vasculitic process.
Past Medical History:
1. Nonischemic dilated CM - EF 47%
2. CRI
3. light chain gammopathy/plasma cell dyscrasia - monoclonal via
SPEP/UPEP - had renal bx/BM bx
4. Anemia with baseline hct 28
5. Alcohol abuse - while back
6. HTN
7. MVA with trauma to the right leg with back flap to right
anterior calf. Also with right radial artery to right leg. On
chronic narcotics including methadone and percocet
8. Hyperlipidemia
Social History:
No EtOH since [**2116**], but heavy use prior. No cigarettes.
Occasional cigars. Motorcycle driver. On disability s/p MVA. Had
worked in the iron industry and as a carpenter.
Family History:
Mother with CHF. No premature CAD/sudden death.
Physical Exam:
98.3, 101, 137/98, 16, 97% on 2LNC
GEN- lying in bed at 30 degrees extremely agitated, moving all 4
extremities, keeping eyes shut majority of time, not following
any commands
Neck - stiff but unclear if not cooperating and pushing back or
truly stiff
Chest- bilateral crackles R>L
Abd- soft, NT/ND, +BS
Ext- no edema, right leg skin grafts
Neuro - PERRL 3->2 mm, neck stiff, not following any commands,
moving all 4 extremities, withdrawing to pain, bilateral upgoing
toes, hard to assess reflexes as trying to kick physicians and
nurses
rectal - OSH - black, guiac positive
Pertinent Results:
ADMISSION LABS;
ABG on arrival 7.50/33/66
CBC: WBC 28.9 w/ 17% bands, 81% neutrophils, hct 38.5, plt 445
Chem 7 latest 137, 4.3, 101, 26, 30, 1.3, 178. alb 2.1. AST 14,
ALT 24, alk P 146, lipase 95.
BUN 40/cr 1.4 and BNP 1870.
.
CXR showed multifocal PNA (LUL, RLL, ?RML) and slightly
increased effusions from [**3-10**], cardiomegaly.
.
EKG - LAD, sinus tachy @ 120, nl intervals, LVH,
.
CT abdomen with po/IV contrast showed bilateral lower lobe
infiltrates, CHF. Also showed an inflammatory process in left
posterior pararenal space with mild sigmoid diverticulosis
without diverticulitis. (of note, last CT at [**Hospital1 2177**] with pararenal
hematoma after biopsy, lung bases pneumonitis)
.
CT head at OSH: possible R mastoiditis, otherwise unremarkabel
awith no intracranial mass or hemorrhage
ABG - 7.55/32/79 at OSH on RA -> 7.51/34/73 few hrs later ->
7.55/29/69 this AM
.
UA large blood, 100 protein, neg nitrites/LE
.
Influenza test negative.
.
CK 5, Trop I 0.25 ((0.1-1.5 - borderline on OSH labs)
.
TTE:
1.The left atrium is mildly dilated. The left atrium is
elongated.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity is moderately dilated. There is severe global
left ventricular hypokinesis with inferior wall akinesis.
Overall left ventricular systolic function is severely
depressed. [Intrinsic left ventricular systolic function is
likely more depressed given the severity of valvular
regurgitation.]
3. Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
4.The aortic root is mildly dilated.
5. The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. No masses or vegetations are seen on the
aortic valve. No aortic regurgitation seen.
6.The mitral valve leaflets are mildly thickened. No mass or
vegetation is seen on the mitral valve. Moderate (2+) mitral
regurgitation is seen.
7.There is a trivial/physiologic pericardial effusion.
IMPRESSION: Compared with the findings of the prior study
(images reviewed) of [**2124-12-29**], the LV function has decreased
substantially with now global hypokinesis with inferior wall
akinesis. There is no echocardiographic evidence of endocarditis
seen.
.
MR CONTRAST GADOLIN [**2125-3-16**] 6:24 PM
MR HEAD W & W/O CONTRAST; MR CONTRAST GADOLIN
Reason: Evaluate for mastoiditis, mass lesion, possible
vasculitis/a
Contrast: MAGNEVIST
[**Hospital 93**] MEDICAL CONDITION:
57 year old man with possible mastoiditis, recently dx'd with
bacterial meningitis, continues to have mild confusion. Is
currently getting worked up at OSH for vasculitis.
REASON FOR THIS EXAMINATION:
Evaluate for mastoiditis, mass lesion, possible
vasculitis/amyloid
CONTRAINDICATIONS for IV CONTRAST: None.
EXAM: MRI brain.
CLINICAL INFORMATION: Patient with possible mastoiditis with
bacterial meningitis continues to have mild confusion, for
further evaluation.
TECHNIQUE: T1 sagittal and axial and FLAIR T2 susceptibility and
diffusion axial images of the brain were obtained before
gadolinium. T1 sagittal, axial and coronal images were obtained
following the administration of gadolinium. There are no prior
similar examinations for comparison.
FINDINGS: Diffusion images demonstrate no evidence of slow
diffusion to indicate acute infarct. There is evidence of slow
diffusion within the posterior portion of both lateral
ventricles as well as in the fourth ventricle and cisterna magna
indicative of cellular debris possibly related to meningitis.
Following gadolinium administration subtle meningeal enhancement
is seen. Meningeal enhancement is predominantly seen along the
superior aspect of the right petrous temporal bone. There are
soft tissue changes within the right mastoid air cells which
could be related to the history of mastoiditis. No evidence of
cerebritis is seen in the right temporal lobe or cerebellum.
There is moderate ventriculomegaly which indicates a
communicating hydrocephalus. No evidence of periventricular
edema is seen.
IMPRESSION:
1. Increased signal within the posterior portion of both lateral
ventricles, fourth ventricle and cisterna magna indicative of
cellular debris possibly related to history of meningitis. 2. No
evidence of cerebritis or acute infarct. 3. Right mastoid soft
tissue changes and subtle meningeal enhancement along the right
petrous temporal bone could be related to mastoiditis. 4.
Moderate ventriculomegaly indicative of communicating
hydrocephalus. No evidence of periventricular edema.
Brief Hospital Course:
Mr. [**Known lastname 22873**] is a 57 yo M with non-ischemic CM and other medical
problems who presented from [**Hospital3 **] with fevers,
altered mental status/agitation, and report of headache,
photophobia and confusion at home.
[**Hospital Unit Name 13533**]:
The patient was transferred here from an outside hospital
after approximately 24 hours there. At the OSH blood cultures
were drawn and the patient was started empirically on meningitis
doses of ceftriaxone, although LP was not performed. Head CT
there showed only R sided possible mastoiditis. CXR showed
multifocal bilateral pneumonia, however the patient was recently
treated for pneumonia at [**Hospital1 2177**] and it is cunclear what his CXR
looked like at that time. Upon arrival here it was immediately
clear that the patient was so agitated he would not tolerate LP.
He was therefore intubated for sedation to attempt LP. The
patient was empirically started on vancomycin, ampicillin,
ceftriaxone and acyclovir. LP was not able to be obtained by
several teams over two days and was finally obtained via
fluoroscopy by interventional radiology. After OSH blood
cultures revealed strep pneumonia, dexamethasone was started for
a planned total of 16 doses. CSF was consistent with bacterial
meningitis, despite the patient being on antibiotics for
approximately three days. We stopped empiric ampicillin and
continued acyclovir only until HSV PCR was negative. The
patient continued on IV ceftriaxone and vancomycin, had a PICC
placed and was transferred to the floor.
Echo performed while in the ICU showed EF 20% and new global
and inferior hypopkinesis. The patient has a known history of
nonischemic cardiomyopathy with last echo in [**Month (only) **] showing EF
of 35-40% and a clean catheterization at that time. We continued
hte patien's home blood pressure medications, but decreased his
lisinopril to 40mg po qday, and continued his home lasix.
The patient is being worked up as an outpatient at [**Hospital1 2177**] for
possible vasculitis versus intrinsic renal disease with renal
biopsy results pending. He is on prednisone 40mg po qday as an
outpatient for this possible vasculitis and therefore will be
maintained on this dose. He is also being worked up at [**Hospital1 2177**] for
likely plasma cell dyscrasia with light chain gammopathy.
.
General Medicine Course:
Pt was stable throughout course. He continued to complain of
difficulty with hearing, but ENT was consulted and felt that
this was not acute. ID was consulted to assist in defining
treatment course for meningitis and pneumonia. An HIV test was
done given multiple infections over past few months.
Medications on Admission:
methadone 20 tid, ferrous sulfate 325 qd, metoprolol XL 50 mg po
qd, lasix 20 po qd, lisinopril 60 qd, percocet 1 tab q4h prn,
prednisone 40 qd, kcl 20 meq po qd
Discharge Medications:
1. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*0*
3. Methadone 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
4. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Penicillin G Potassium 20,000,000 unit Recon Soln Sig: 4 MU
Recon Solns Injection Q4H (every 4 hours) for 5 days.
Disp:*QS Recon Soln(s)* Refills:*0*
6. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily): while on prednisone.
Disp:*30 Tablet(s)* Refills:*2*
7. PICC Care
PICC care per protocol
8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO twice a
day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 486**]
Discharge Diagnosis:
Meningitis
Pneumonia
Discharge Condition:
Sstable
Discharge Instructions:
Continue your antibiotics as directed.
Followup Instructions:
Follow up with your primary care doctor at the appointment
[**2125-3-29**].
.
Follow up with your kidney doctor, Dr. [**First Name (STitle) **] as planned - [**2125-3-28**]
at 11am.
.
Follow up with cardiologist Dr. [**Last Name (STitle) 11493**] [**2125-3-20**] at 2:15.
.
Dr. [**Last Name (STitle) 6955**] will refer you to a hematologist/oncologist to help
you with your bone [**Last Name 15482**] problem.
.
Follow up with Infectious Disease Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] TAN
Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2125-4-13**] 10:00 at [**Hospital1 771**].
.
Completed by:[**2125-3-26**]
ICD9 Codes: 7907, 5849, 4240, 4280, 5859, 4254, 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3528
} | Medical Text: Admission Date: [**2106-10-12**] Discharge Date:
Service: Medicine, [**Hospital1 **] Firm
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 110736**] is an
85-year-old female with coronary artery disease, aortic
stenosis, congestive heart failure, and asthma who is status
post recent hospitalization for pulmonary edema and pneumonia
who presented one day after discharge with a chief complaint
of increased shortness of breath. She was found to have
desaturation to the 60s on room air at her nursing home.
On admission, a chest x-ray showed a new right upper lobe
infiltrate as well as progression of her old right lower lobe
pneumonia. She presented to the Emergency Department and was
transferred to the floor and started on ciprofloxacin and
vancomycin. She was intubated on hospital day four for
respiratory distress with desaturation to the 70s on 3 liters
nasal cannula. Her arterial blood gas at that time was 7.17,
PCO2 86, PO2 65 on 100% nonrebreather. She was continued on
ciprofloxacin and vancomycin on the unit and was successfully
extubated on [**10-17**].
On transfer to the floor the patient had a chief complaint of
sore throat which she blamed on intubation. She denied
shortness of breath.
PAST MEDICAL HISTORY:
1. Coronary artery disease, 3-vessel disease. Cardiac
catheterization in [**2106-9-20**] revealed 80% left main,
100% middle left anterior descending artery, 80% proximal
circumflex. She is not an intervenable or operable
candidate.
2. History of congestive heart failure, diastolic ejection
fraction equals 50%.
3. Aortic stenosis, valve area of 0.9 cm2.
4. Paroxysmal atrial fibrillation.
5. Pacemaker.
6. Right cerebrovascular accident.
7. Breast cancer, status post left mastectomy.
8. Hypercholesterolemia.
9. Hypertension.
10. Asthma.
MEDICATIONS ON TRANSFER: Procainamide 500 mg p.o. four times
a day, Colace 100 mg p.o. b.i.d., K-Dur 20 mEq p.o. q.d.,
lactulose 30 cc p.o. t.i.d., Coumadin 1 mg p.o. q.d.,
Protonix 40 mg p.o. q.d., iron sulfate 325 mg p.o. q.d.,
Lopressor 37.5 mg p.o. b.i.d., Neurontin 200 mg p.o. b.i.d.,
Atrovent nebulizers q.4h. p.r.n., aspirin 325 mg p.o. q.d.,
Alphagan eyedrops b.i.d., Trusopt eyedrops b.i.d.,
Synthroid 50 mcg p.o. q.d., Diflucan 100 mg p.o. q.d.,
levofloxacin 250 mg intravenously q.d., vancomycin 1 g
intravenously q.12h.
ALLERGIES: EPINEPHRINE, PENICILLIN, and BACTRIM.
PHYSICAL EXAMINATION ON PRESENTATION: Temperature 98.6,
blood pressure 112/60, heart rate 68, respirations 18,
saturation 98% on 4 liters. In general, she was in no
apparent distress. Pupils were equally round and reactive to
light. Extraocular movements were intact. The oropharynx
was clear. Neck had no jugular venous distention,
lymphadenopathy, or carotid bruits. Cardiac revealed a
regular rate and rhythm, a 2/6 systolic murmur maximal at the
base and apex without radiation to the neck. No gallops.
Lungs had bilateral wheezes and crackles. The abdomen was
soft, nontender, and nondistended. No organomegaly or
masses. Normal active bowel sounds. Extremities had no
edema, 1+ distal pulses.
LABORATORY DATA ON PRESENTATION: White blood cell count 7,
hematocrit 30.5. INR 2.8. Sodium 139, potassium 3.3,
bicarbonate 32, BUN 9, creatinine 0.7. Last arterial blood
gas on [**10-16**] was 7.4/48/111. Sputum Gram stain had
greater than 25 polys, 2+ gram-positive cocci in pairs and
clusters, 1+ gram-negative rods. Sputum culture had sparse
oropharyngeal flora. Urinalysis had 3 to 5 white blood
cells, few bacteria. Urine cultures were negative.
RADIOLOGY/IMAGING: Chest x-ray on [**10-16**] revealed no
acute congestive heart failure of pneumonia.
Chest x-ray on [**10-19**] revealed interval development of
bilateral patchy alveolar infiltrates most prominent in the
left lower lobe and lingula.
HOSPITAL COURSE:
1. INFECTIOUS DISEASE: Pneumonia. The patient's admission
chest x-ray showed new right upper lobe pneumonia and
progression of old right lower lobe pneumonia. She was
started on ciprofloxacin and vancomycin. The ciprofloxacin
was discontinued and substituted with levofloxacin on
[**10-15**]. The vancomycin was continued for seven days and
then discontinued after sputum cultures revealed that the
gram-positive cocci were oropharyngeal flora. Flagyl was
added on [**10-18**] for concern for aspiration pneumonia. At
the time of this dictation, which is [**10-20**], she is on
day five of levofloxacin, day three of Flagyl, and status
post seven days of vancomycin which has been discontinued.
The patient also has [**Female First Name (un) **] esophagitis and has been on
Diflucan for this.
2. PULMONARY: A respiratory care was consulted, and the
patient has been receiving Atrovent nebulizers. She does not
tolerate some pathomimetics and has not been receiving
albuterol.
3. CARDIOVASCULAR: The patient has severe coronary artery
disease but is not a candidate for intervention or coronary
artery bypass graft. She is also very preload dependent
because of her aortic stenosis. She continues on aspirin and
Lopressor for her coronary artery disease. She has a history
of not tolerating nitrates in the past, and we have been
holding these. She has recurrent episodes of chest pain
which may be angina or related to her pneumonia. Her
creatine kinases have remained flat during this
hospitalization. She has been given low doses of morphine
for her chest pain p.r.n. She also has a history of
paroxysmal atrial fibrillation and has been on procainamide
for this. She is currently rate controlled. Given her
current tenuous respiratory status and history of asthma, if
she were to need more rate control would recommend trying
diltiazem instead of increasing her Lopressor. She has also
been receiving Lasix for her history of congestive heart
failure.
4. ANTICOAGULATION: The patient is on Coumadin.
5. GASTROINTESTINAL: The patient has a history of severe
constipation and is on a very aggressive bowel regimen.
6. FLUIDS/ELECTROLYTES/NUTRITION: The patient is not
tolerating p.o. at this time and is an aspiration risk. She
is currently receiving tube feeds via nasogastric tube.
7. CURRENT CLINICAL ISSUES: On [**10-20**], the patient had
acute shortness of breath and desaturations to the 80s on 3
liters nasal cannula. She required 100% nonrebreather for a
period of time. Her arterial blood gas while on the
nonrebreather mask was pH of 7.3, PCO2 63, PO2 78. She was
given intravenous Lasix 20 mg with good urine output and
morphine intravenously. Her chest x-ray during this episode
showed bilateral diffuse infiltrates which were read as
asymmetric pulmonary edema and underlying emphysema. Her
electrocardiogram at this time showed atrial fibrillation
with a rate of 100.
After treatment, she showed clinical improvement and was
weaned to oxygen by nasal cannula. Her second gas was pH of
7.41, PCO2 of 52, PO2 of 56; which was taken when she was on
4 liters oxygen by nasal cannula with a saturation in the low
90s. The patient's respiratory distress is due to congestive
heart failure superimposed on pneumonia, asthma, and possibly
emphysema. She has severe cardiac disease as well.
Her clinical course is deteriorating, and her prognosis is
very poor. She remains full code, per her son, who wants
aggressive measures. There have been multiple lengthy
discussions with her son regarding the futility of further
aggressive measures, but he is not yet ready to change her
code status at this time. He has consented to speak with the
palliative care consultation, however, to discuss future
options. At this point in time, however, she does remain
full code and may need to be transferred to the unit if her
respiratory status declines.
This is an interval Discharge Summary. Please see addendum
for further clinical course.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3022**], M.D. [**MD Number(1) 3023**]
Dictated By:[**Name8 (MD) 4925**]
MEDQUIST36
D: [**2106-10-20**] 14:35
T: [**2106-10-22**] 07:28
JOB#: [**Job Number **]
(cclist)
ICD9 Codes: 5070, 4280, 4241 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3529
} | Medical Text: Admission Date: [**2171-11-12**] Discharge Date: [**2171-12-19**]
Date of Birth: [**2102-7-11**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Cipro
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
[**2171-11-12**] Left heart and Right heart cardiac catheterization,
coronary abgiography
[**2171-11-16**] Extraction of 6 teeth
[**2171-11-20**] Coronary artery bypass graft x2(left internal mammary
artery to left anterior descending artery and saphenous vein
graft to obtuse marginal artery), Aortic valve replacement(19mm
St. [**Male First Name (un) 923**] mechanical valve),Mitral valve repair(26mm CG Future
mitral band). Endoscopic harvesting of the long saphenous vein.
tracheostomy/percutaneous gastrostomy tube placement [**2171-12-12**]
History of Present Illness:
This 69 year old female with dilated cardiomyopathy with LVEF
20-25%, moderate mitral regurgitation, moderate tricuspid
regurgitation and moderate aortic stenosis presented for right
and left heart cardiac cath in the setting of prorressively
worsening dyspnea and fatigue. She initially presented in [**Month (only) 116**] of
[**2169**] to Dr. [**Last Name (STitle) **] in [**Location (un) 5450**], NH for evalution of her
progressive SOB. The plan was medical treatment at the time and
to have cardiac cath. She did not want to have cardiac cath and
she was lost of follow-up.
Her dyspnea has progressively worsened over the last few weeks.
She can walk [**Age over 90 **] yards on the flat at her own pace, and up 1
flight of stairs at home, but has to sit down then. She
occasionally gets associated pressure in the upper chest. She
was referred for a right and left side heart cath. Her cardiac
catheterization showed left main disease w/70-80% occlusion, LAD
50% and Circ 99%. Her recent echo also showed dilated left
ventricle with severe global systolic dysfunction, probable
aortic stenosis w/ mild to moderate aortic regurgitation,
moderate to severe mitral regurgitation.
Past Medical History:
Hodgkins Lymphoma [**2139**] with Radiotherapy, splenectomy.
Hypothyroidism
Anxiety
Social History:
SOCIAL HISTORY: Pt lives with husband
Lives with:Husband
Occupation: Owned a shoe business with her husband. Retired
teacher
Cigarettes: Smoked no
Other Tobacco use:denies
ETOH: < 1 drink/week
Illicit drug use:denies
Family History:
Mother with hypertension
Physical Exam:
VS: T= 98 BP= 107/68 HR= 100 RR= 16 O2 sat= 98% 2L
GENERAL: NAD, mildly tachpneic with accessory work of breathing.
Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 10 cm above sternal angle.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. 3/6 systolic murmur heard throughout
precordium. No thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
with decreased volumes. Crackles at bases with intermittent
wheezes as well.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: Right leg wound with superficial ulceration.
PULSES: Faint, 1+
Pertinent Results:
TTE [**2171-11-20**]
LEFT ATRIUM: Moderate LA enlargement. No thrombus in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Normal LV wall thickness. Moderately dilated LV
cavity. Severely depressed LVEF. False LV tendon (normal
variant).
RIGHT VENTRICLE: Mildly dilated RV cavity. Mild global RV free
wall hypokinesis.
AORTA: Focal calcifications in aortic root. Normal ascending
aorta diameter. Normal descending aorta diameter. Simple
atheroma in descending aorta. No thoracic aortic dissection.
AORTIC VALVE: Moderately thickened aortic valve leaflets.
Mechanical aortic valve prosthesis (AVR). AVR leaflets move
normally. Moderate AS (area 1.0-1.2cm2) Moderate (2+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mitral
valve annuloplasty ring. Mild mitral annular calcification. Torn
mitral chordae. Severe (4+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate [2+]
TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
Mild PR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I Conclusions
PRE-CPB:
The left atrium is moderately dilated. No thrombus is seen in
the left atrial appendage. No atrial septal defect is seen by 2D
or color Doppler.
Left ventricular wall thicknesses are normal. The left
ventricular cavity is moderately dilated. Overall left
ventricular systolic function is severely depressed (LVEF= 20-25
%). The basal inferoseptal wall appears diskinetic. All
mid-papillary segments except for the anterior and anterolateral
segments appear severely hypokinetic. The right ventricular
cavity is mildly dilated with mild global free wall hypokinesis.
There are simple atheroma in the descending thoracic aorta. No
thoracic aortic dissection is seen. The aortic valve leaflets
(3) are moderately thickened. There is moderate aortic valve
stenosis (valve area 1.0-1.2cm2). Moderate (2+) aortic
regurgitation is seen.
The mitral valve leaflets are mildly thickened. Torn mitral
chordae are present. The mitral leaflets fail to coapt, leading
to severe (4+) mitral regurgitation. This is likely due to LV
dilation.
Moderate [2+] tricuspid regurgitation is seen.
POST-CPB:
A mechanical valve is seen in the aortic position. The valve
appears to be well-seated with normally mobile leaflets. There
are no paravalvular leaks. There is no AI. The peak gradient
across the aortic valve is 27mmHg, the mean gradient is 11mmHg
with CO of 4.7.
A mitral valve annuloplasty ring is present. There is mild
mitral stenosis with mean gradient of 4mmHg across the mitral
valve. The mitral regurgitation is now mild.
The patient is on milrinone, vasopressin, norepinephrine and
epinephrine infusions. The LV systolic function remains severely
depressed, estimated EF=25%. The RV systolic function appears
mildly improved from pre-bypass.
The tricuspid regurgitation remains moderate.
Brief Hospital Course:
Following admission she was diuresed with a Lasix drip at 10-15
mg/min which was then switched to torsemide. More than 5L were
diuresed with weight loss of about 3 kg. Her JVD returned to
near normal, breathing much easier, and she was no longer
tachypneic. Additionally she underwent cardiac catheterization
for preoperative evaluation [**11-12**] and was found to have coronary
artery disease, she had no chest pain preoperatively.
She had a dental consult and subsequently had teeth extracted
on[**11-17**] in preparation for valve surgery. She had a right leg
ulcer on her shin from traumatic injury over one month ago.
Dermatology performed a biopsy with cultures growing out
pan-sensitive pseudomonas. The wound does not appear infected
with clean base and edges. She was treated with cefepime as
recommended by infectious disease for 3 days peri operatively.
Additionally surgery was delayed due to increased creatinine
which peaked at 2.1 on [**1-19**] with BUN 39, the diuretic was held
over the next few days and creatinine decreased to 1.6 on [**11-20**]
and she was taken to the Operating Room.
She underwent aortic valve replacement, mitral valve repair, and
coronary artery bypass graft. See operative report for further
details. She was taken to the intensive care unit on
vasopressin, Milrinone, norepinephrine and Propofol. She
remained intubated overnight due to hemodynamic instability and
was able to be weaned and extubated on post operative day one.
Additionally her inotropes and pressors were progressively
weaned as tolerated and discontinued on Day 3 with stable
hemodynamics. She went into a rapid atrial fibrillation and
given an Amiodarone bolus and drip on POD#3. She converted to a
sinus rhythm later in the day and was started on low dose beta
blockers. Hydralazine was started for afterload reduction as
blood pressure tolerated (ACE-I was not started due to increased
creatinine.) On POD#4 pacing wires were pulled and she was
started on Heparin bridge later that day for mechanical AVR.
Coumadin was initiated and she was anticoagulated to a goal of
2.5-3.5 for mechanical AVR and afib. She was aggressively
diuresed with a Lasix drip due to CXR showing pulmonary edema
and respiratory issues. She was taken off the Lasix drip and
started on Spironolactone due to her heart failure.
Pleural chest tubes remained in place due to high serous
drainage for several days post op. They were discontinued when
protocol was met. Her respiratory status slowly improved and she
was transferred to the floor on POD 7. She had a poor oral
intake and she was given Glucerna for additional nutrition
support. Physical Therapy was consulted for evaluation of her
strength and mobility. For two days on the step down unit
Ms.[**Known lastname 13534**] [**Last Name (Titles) 3780**] worsening renal function and failure to
thrive. On [**11-29**] she was transferred back to the CVICU for
further monitoring. She was ultimately reintubated secondary to
pulmonary edema and requiring pressor support on [**11-30**].
Nephrology was consulted for acute renal failure with rising
creatinine. A temporary hemodialysis line was placed for
anticipation of possible dialysis. She responded to diuresis and
never required dialysis. GI was consulted for c. diff colitis
and GI bleed. Vancomycin and Flagyl were given for c.diff
treatment.An EGD revealed that the patient likely had oozing
from the antral gastritis in the setting of high PTT. Heparin,
initiated for mechanical valve bridging, was held. A PPI drip
was continued along with supportive care. Electrophysiology was
consulted for evaluation and management of heart failure and
for possible BiV pacemaker, which will be reevaluated as an
outpatient. After several days of failure to wean on the
ventilator, Thoracic surgery was consulted for Trach and PEG.
On [**2171-12-12**] she underwent a Percutaneous tracheostomy tube and
percutaneous endoscopic gastrostomy tube placement/Bronchoscopy
with bronchoalveolar lavage. Nutrition was consulted for tube
feed recommendations. She continued on antibiotics for C-Diff
and surveillance cultures were followed. She continued to very
slowly progress. Her amiodarone was increased for paroxysmal
atrial fibrillation and ultimately on POD# 21 she converted back
into normal sinus rhythm. She remained hemodynamically stable
and was fully anticoagulated for mechanical AVR/PAF, without
futher bleeding. Three negative c. diff cultures were obtained
after treatment was discontinued and precautions were stopped.
She remains neurologically intact. She was cleared for
discharge to [**Hospital1 91591**] on post-operative day 29
for further progression of her recovery. All follow up
appointments were advised. She was tolerating one and a half
hour trach collar trials at this time.
Medications on Admission:
FUROSEMIDE 40 mg daily
LEVOTHYROXINE 100 mcg daily
LISINOPRIL 5 mg daily
METOPROLOL SUCCINATE 25 mg daily
CHOLECALCIFEROL (VITAMIN D3) 400 unit daily
OMEGA-3 FATTY ACIDS-FISH OIL 300 mg-1,000 mg Capsule - 1 Capsule
daily
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
3. chlorhexidine gluconate 0.12 % Mouthwash Sig: Five (5) ML
Mucous membrane [**Hospital1 **] (2 times a day).
4. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
5. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for gas pain.
6. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**12-9**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
7. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety .
8. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day.
9. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. docusate sodium 50 mg/5 mL Liquid Sig: [**12-9**] ml PO BID (2
times a day).
11. warfarin 1 mg Tablet Sig: as ordered by INR Tablet PO Once
Daily at 4 PM.
12. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
2-4 Puffs Inhalation Q4H (every 4 hours) as needed for wheeze.
13. furosemide 10 mg/mL Solution Sig: Four (4) ml(40mg)
Injection DAILY (Daily).
14. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
15. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. levothyroxine 50 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
17. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
18. Prevacid 24Hr 15 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO once a day.
19. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] hospital
Discharge Diagnosis:
Aortic stenosis
s/p aortic valve replacement
Mitral regurgitation
s/p mitral valve repair
Coronary artery disease
s/p coronary artery bypass grafts
postoperative renal failure
s/p gastrointestinal bleeding
acute on chronic systolic and diastolic heart failure
Hypothyroidism
Anxiety
Hodgkins Lymphoma [**2139**] with Radiotherapy
s/p splenectomy
Discharge Condition:
Alert and oriented x3, nonfocal
Unable to stand
Incisional pain managed with Ultram
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema: trace
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr.[**First Name (STitle) **] ([**Telephone/Fax (1) 170**]) on [**12-24**] at 1:30 pm
Cardiologist: Dr.[**Last Name (STitle) **] ([**Telephone/Fax (1) 62**]) on [**2172-1-6**] at 1:40 pm
Please call to schedule appointments with your
Primary Care Dr [**Last Name (STitle) **] in [**3-12**] weeks ([**Telephone/Fax (1) 74697**])
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication mechanical AVR/atrial
fibrillation
Goal INR 2.5-3.5
First draw [**2171-12-19**]
Coumadin follow up to be arranged upon discharge from rehab
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2171-12-19**]
ICD9 Codes: 5849, 4254, 2875, 2761, 4168, 4241, 4240, 4280, 2449, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3530
} | Medical Text: Admission Date: [**2136-1-26**] Discharge Date: [**2136-1-30**]
Date of Birth: Sex:
Service: ACOVE
HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname 44755**] is a [**Age over 90 **] year-old
woman with a history of hypertension, cellulitis and
gastrointestinal bleed who presents from [**Location (un) **] Home via
EMS with shortness of breath. In the Emergency Department
she was found to be in atrial fibrillation and on chest x-ray
had bilateral moderate pleural effusions. She was rate
controlled with Diltiazem effectively and transferred to
ACOVE unit for further medical management. Mrs. [**Known lastname 44755**]
was in good health living independently with her sister until
six to eight weeks prior to admission when she developed
cough and decreased appetite. She was soon after
hospitalized for a leg cellulitis. She was discharged to
rehabilitation, but then readmitted for worsening cellulitis
to [**Hospital1 336**] on [**1-11**], for which she was treated with Unasyn.
On [**1-17**] she spiked a fever and a chest x-ray
demonstrated pneumonia. Unasyn was at that point switched to
Zosyn and Levofloxacin was added for concern of hospital
acquired pneumonia. She was also given one dose of Linezolid
for sputum growing VRE, although this was subsequently felt
to be a contamination and Linezolid was discontinued. She
was discharged to [**Hospital3 2558**] on [**2136-1-20**] and
Levofloxacin and Zosyn, but it is unclear if she finished her
course of Zosyn at [**Hospital3 2558**] or did not get this
medication there. Again on the 23rd she developed shortness
of breath and was found to be in respiratory distress and
found to be in atrial fibrillation with rapid ventricular
response. Chest x-ray demonstrated bilateral pleural
effusions right greater then left and a left lower lobe
consolidation. On Seven Felberg the patient was maintained
on Levofloxacin for her pneumonia as well as Oxacillin for
her bilateral lower extremity cellulitis. She had a right
upper extremity ultrasound at the outside hospital that
demonstrated superficial thrombophlebitis. This was repeated
while on the floor here and was negative for deep venous
thrombosis or superficial thrombophlebitis. On [**1-28**] te
patient demonstrated worsening respiratory distress and was
transferred to the Intensive Care Unit for further
management.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Cellulitis.
3. Gastrointestinal bleed.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Lopressor 12.5 mg b.i.d.,
Levofloxacin 250 mg q day, Oxycodone 5 mg prn subQ heparin,
colace, Trazodone and Albuterol and Atrovent.
SOCIAL HISTORY: The patient previously lived independently
with her sister. [**Name (NI) **] son is her health care proxy. His name
is [**Name (NI) **]. His cell phone number is [**Telephone/Fax (1) 46004**], home
phone [**Telephone/Fax (1) 46005**].
PHYSICAL EXAMINATION ON ADMISSION: Afebrile, vital signs are
stable. Pulse tachycardic at 111. 96% on 4 liters. Heart
is tachycardic and regular with systolic ejection murmur at
the apex. Lungs are without crackles, but with decreased
breath sounds at the bases. She has a grade two decubitus on
her buttocks. Neurological cranial nerves II through XII are
intact. Oriented to person and place. 4 out of 5 strength
in the upper and lower extremities.
LABORATORIES ON ADMISSION: White blood cell count 6.4,
hematocrit 32.2, creatinine 0.7, INR 1.1, CK 33, troponin
0.5. Electrocardiogram demonstrates atrial fibrillation with
a rate of 165. No ST or T wave changes and chest x-ray with
bilateral effusions right greater then left.
HOSPITAL COURSE: As noted above on the 25th the patient
began to suffer from worsening respiratory distress. She had
been evaluated and prepared for thoracentesis of her
bilateral pleural effusions, which are felt most likely
secondary to her congestive heart failure, although also
possibilities include a peripneumonia effusion. Over the
course of the day she went from oxygen saturations of the 90s
on 4 liters to requirement of 100% nonrebreather with
saturations dropping into the mid 80s. She was transferred
to the Intensive Care Unit for likely intubation. Prior to
this her code status had been DNR/DNI, but discussion with
her son in the setting of a potentially reversible pneumonia,
it was decided to change her code status to intubate if
necessary, but still DNR. A chest x-ray on the floor
demonstrated continued bilateral pleural effusions, stable
congestive heart failure and worsening left lower lobe
infiltrate. She was administered 40 mg of intravenous Lasix
with urine output of 1200 cc. With respiratory therapy given
some chest physical therapy, some increased cough, nebulizer
treatment and with the diuresis of 1200 cc the patient began
to saturate 100% on the 100% nonrebreather, but was still
transferred to the Intensive Care Unit for more close
monitoring.
1. Cardiac: The patient initially noted to be in atrial
fibrillation with rapid ventricular response treated
initially with 30 mg q.i.d. of Diltiazem. Echocardiogram
demonstrated an EF of greater then 55% with mild symmetric
left ventricular hypertrophy and [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5660**] dilated. This
was done on [**1-27**]. On the increased dose of Diltiazem
the patient had a period of bradycardia into the 30s and
Diltiazem was subsequently tapered to off. The patient
remained with heart rates in the 50s to 60s with occasional
drops to the 30s off of all cardiac medications. She is
continuing to have paroxysmal atrial fibrillation, but
remains in normal sinus rhythm for the majority of the time.
Heparin GTT is being continued while the discussion of long
term anticoagulation are ensuing. No further diuresis was
initiated and it is unclear how much diuresis the patient
received on the floor (secondary to computers being down
during that time). The patient continues to have good urine
output and to hold good blood pressures.
2. Pulmonary: A: Pneumonia, this is a hospital acquired
versus aspiration pneumonia. The patient had a bedside
swallow test on [**1-27**] for which she failed clear
liquids. A video oropharyngeal swallow study was initiated
on [**1-30**] and at that point she again failed clear
fluids, but she can have thickened solids and nectar
consistency liquids. She should not eat any meats. As of
[**1-30**], we are continuing Pseudomonas coverage with day
number three of Ceftazidine and MRSA coverage with day number
three Vancomycin. We have been unable to receive a sputum
sample as the patient is not coughing up anything of
substance. We will also continue day number three of Flagyl
for possibility of aspiration pneumonia.
B: Also concern of pulmonary embolism given bilateral lower
extremity cellulitis and a history of superficial
thrombophlebitis in the past. Leni's were negative, but will
perform CT angiogram today to rule out PE. This will help
with decision on whether or not to anticoagulate this woman
who may have a large fall risk.
2. Pleural effusion likely secondary to congestive heart
failure in the setting of atrial fibrillation (which was in
the setting of a pneumonia), right decubitus film initially
without significant layers, but will repeat today. The
patient may need thoracentesis to alleviate the large fluid
burden on her lungs.
3. Cellulitis: Patient with bilateral lower extremity
cellulitis and a grade two ulcer on her left lower extremity.
Will continue dressing changes, have started zinc and vitamin
C and is having good coverage of potential cellulitis
pathogens with her current regimen of Vancomycin and
Ceftazidime.
4. Neurological status: The patient remains agitated, but
oriented times three. Have continued Risperdal, which was
started on the floor and are giving Haldol prn.
5. Fluids, electrolytes and nutrition: Again the patient
failed clear liquids, but will continue nectar substance
liquids as well as pureed thickened solids.
6. Access: Single port PICC line placed on [**1-27**].
7. Prophylaxis with intravenous heparin and Protonix.
CODE STATUS: DNR.
COMMUNICATION: With the son who is seeming overwhelm with
the decision on what to do with his mother who has been
functionally independent all of her life. Social work
consulted to discuss with the patient and family.
MEDICATIONS: Ceftazidine 1 gram intravenous q 12 hours,
Flagyl 500 mg intravenous q 8 hours, Vancomycin 1 gram
intravenous q 24 hours, Nystatin ointment q.i.d., zinc
sulfate 220 mg po q day, ascorbic acid 500 mg po q day,
Haloperidol 2.5 to 5 mg intravenous q 4 hours prn.
Pantoprazole 40 mg po q 24 hours, Risperidone 0.5 mg po q
day.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-ADF
Dictated By:[**Last Name (NamePattern1) 43302**]
MEDQUIST36
D: [**2136-1-30**] 12:00
T: [**2136-1-30**] 13:19
JOB#: [**Job Number 46006**]
ICD9 Codes: 5070, 4280, 2765, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3531
} | Medical Text: Admission Date: [**2169-8-16**] Discharge Date: [**2169-8-29**]
Date of Birth: [**2093-4-23**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1854**]
Chief Complaint:
generalized weakness, gait difficulty
Major Surgical or Invasive Procedure:
Right frontal craniotomy with excision of lesion
History of Present Illness:
Mr [**Known lastname **] is a 76 yo male who presents from the onc clinic with
progressive generalized weakness. He reports that he noted a
decline in his functional status about 4 months ago. He began to
feel more fatigued and weak around this time. He notes that it
was about this time that he began to have trouble walking,
getting out of bed, and doing his daily activities. In the last
4 weeks, he notes that his weakness and fatigue has gotten
worse. He reports significant amount of difficulty ambulatingm
and cites episdoes of sinking to the floor and not being able to
get up.
.
He also reports a new tremor, and headache. His headache is
worse in teh mornings and improved with tylenol. He also reports
urinary incontinence, mildly worse from the past, as he has a hx
of prostate ca s/p brachytherapy. He also reports not being able
to make it to the bathroom in time for his BMs. No associated
numbness, tingling, back pain.
.
He also notes a new subcutaenous nodule in his inner right
thigh.
Past Medical History:
1. Melanoma per Dr.[**Name (NI) 22252**] note:
1. Resection of a primary melanoma from the posterior aspect of
his left upper arm [**2150**].
2. Recurrence of disease in the left supraclavicular lymph nodes
in 06/[**2163**].
3. One cycle of biochemotherapy in [**5-/2165**], interrupted due to
development of pancreatitis and severe orthostatic
hypotension. He was continued on single [**Doctor Last Name 360**] DTIC which was
ultimately terminated in [**5-/2165**] because of disease progression
in the left supraclavicular region.
4. Resection of bulky left supraclavicular lymph nodes by Dr.
[**Last Name (STitle) 1837**].
5. Resumption of DTIC, which resulted in stabilization of his
lung metastases.
6. Pulmonary embolus in 06/[**2166**]. This was detected on a
surveillance CT scan but was quite symptomatic. The patient was
treated with heparin and subsequently put on Coumadin.
7. Resection of a right subscapular mass by Dr. [**Last Name (STitle) 519**] and
subsequent radiation therapy to this site.
8. Treatment with the phase 1 reagent RTA-402 (seven cycles)
[**9-/2168**]/[**2168**].
9. Sutent given [**9-/2168**] through [**3-/2169**] and stopped because of
development of subcutaneous metastases.
10. Status post CyberKnife treatment to right infrahilar lymph
nodes 04/[**2168**]. Lymph nodes had nearly occluded right lower lobe
bronchus.
11. Status post removal of subcutaneous scalp nodules by Dr.
[**Last Name (STitle) 1837**] [**2169-5-22**].
2. prostate cancer [**2162**] s/p seed implants c/b radiation
proctitis
3. hypercholesterolemia
4. psoriasis s/p UV tx
5. pancreatitis secondary to chemo [**11-30**] s/p subtotal
pancreatectomy
6. non tension ptx [**11-30**]
8. h/o PE and DVts 10y ago
.
Social History:
divorced, 4 kids, GF=HCP, GF x 34 yeras, retired- president of A
and P food stores, h/o ETOH, sober x 34 years (AA),no tobacco
Family History:
He has two brothers and two sisters. One sister
died of a gynecologic cancer. He is unsure of the type. He has
four children, three sons and one daughter, all in good health.
None of the siblings or his children ever had a diagnosis of
melanoma or other skin cancer.
Physical Exam:
Vitals- Afebrile HR 100 BP 110/60
General- Well appearing male in NAD
HEENT- PERRLA, EOMI, mucous membrane dry
Neck- Supple, no LAD
Pulm- Clear to ascultation
CV- RRR nl s1 s2
Abd- Soft, nontender, nondistended, guaiac negative, good rectal
tone.
Extrem- +palpable nodule in right inner thigh
Neuro- CN II-XII grossly in tact, [**4-1**] muscle strength of UE
flexor/extensors, [**4-1**] bilateral hip flexor/extensors, quads.
Normal sensation to light touch. 2+ brachial reflex, 1+ patellar
reflex, +Intention tremor, no dysmetria, +Rhomberg
.
Pertinent Results:
Admission Laboratories:
[**2169-8-16**] 02:42PM GLUCOSE-230* UREA N-22* CREAT-1.3* SODIUM-137
POTASSIUM-4.7 CHLORIDE-101 TOTAL CO2-28 ANION GAP-13
[**2169-8-16**] 02:42PM estGFR-Using this
[**2169-8-16**] 02:42PM ALT(SGPT)-16 AST(SGOT)-14 LD(LDH)-131 ALK
PHOS-118* TOT BILI-0.3
[**2169-8-16**] 02:42PM ALT(SGPT)-16 AST(SGOT)-14 LD(LDH)-131 ALK
PHOS-118* TOT BILI-0.3
[**2169-8-16**] 02:42PM WBC-11.3* RBC-3.85* HGB-13.3* HCT-39.1*
MCV-102* MCH-34.5* MCHC-33.9 RDW-13.0
[**2169-8-16**] 02:42PM PLT COUNT-522*
.
Imaging:
MRI Head [**2169-8-16**]:
1) Irregular enhancing mass of the right frontal lobe is
associated with significant secondary mass effect and subfalcine
herniation. There are small foci of enhancement extending to the
frontal [**Doctor Last Name 534**] of the right lateral ventricle and T2
hyperintensity extending into the corpus callosum. There is
overlying leptomeningeal enhancement, which may represent tumor
extension vs engorged vessels. Given the presence of other
likely metastasis, this mass likely represents metastasis.
However, a glial tumor should be considered in the differential.
Multivoxel spectroscopy of the peritumoral region may help in
the evaluation.
2) Round enhancing mass lesion of the right cerebellum with mild
surrounding edema is consistent with metastatic disease. There
are areas of abnormal enhancement along the folia of cerebellum
which might represent leptomeningeal seeding/engorged vessels.
Continued follow up is recommended.
3) Pathologically enlarged node of the right posterior cervical
space which may represent metastasis.
.
CT Chest/Abdomen/Pelvis:
No significant interval change in size to right lower lobe
pulmonary nodule, right infrahilar dominant mass, and
mediastinal/hilar lymphadenopathy. No new metastatic lesions
identified.
.
EKG [**2169-8-18**]:
Sinus rhythm. Right atrial abnormality. Borderline left axis
deviation.
Possible left anterior fascicular block. Compared to previous
tracing
of [**2169-3-16**] multiple abnormalities as noted persist without major
change.
.
MRI [**8-25**]:
1. Minimal amount of nodular enhancement along the posteromedial
aspect of the right frontal resection cavity which represents
post-surgical changes.
2. Cerebellar mass and right cervical mass again visualized.
Brief Hospital Course:
A/P: 76yo M w/ a PMH of metastatic melanoma p/w FTT and
generalized weakness, now found to have brain metastases and
cerebral edema.
<br>
# BRAIN MASSES: The patient presented with headache and
generalized weakness. He underwent brain MRI on the evening of
admission and was found to have an irregular enhancing mass of
the right frontal lobe measuring 32 x 32 mm in axial dimension
with associated severe cerebral edema and 16 mm sub- falcine
herniation. He was also found to have a round enhancing lesion
of the right cerebellum measures 18 x 16 mm. These lesions were
felt to be consistent with metastatic disease from his known
diagnosis of melanoma. On neurologic exam he was found to have
evidence of diplopia, left sided facial weakness, left sided
pronator drift, left sided upper and lower extremity motor
weakness and difficulty with finger-nose-finger and rapid
alternating movements bilaterally L>R. He was immediately
started on high dose IV dexamethasone for cerebral edema. The
neurosurgical service was consulted who recommended against
starting mannitol for cerebral edema. His neurologic exam was
monitored closely. He showed significant clinical improvement
during his MICU course and on transfer to oncology had
significant improvement in his motor weakness. His headache had
resolved. He continued to have evidence of cerebellar
dysfunction as manifested by difficulty with finger-nose-finger
and rapid alternating movements. He also continued to have a
mild left sided facial droop.
<br>
He underwent a right frontal craniotomy with excision of his
frontal lesion on [**8-23**]. He tolerated the procedure well with no
evidence of residual tumor on post-op MRI. Preliminary path
showed spindle cell tumor. He was set up with an appointment in
the Brain [**Hospital 341**] Clinic, where his cerebellar tumor will be
addressed. He will have his sutures removed 7-10 days post-op.
<br>
# MENTAL STATUS CHANGES: The patient presented with mental
status changes which he described as increased ability to "do
anything." He was noted on exam to have a flat affect and
difficulty with concentration. It was felt that his
presentation was likely secondary to his metastastic disease,
specifically his large frontal lobe lesion with associated
edema. He had no localizing symptoms of infection. His
electrolytes were within normal limits. His urinalysis and
culture were normal. His RPR was non-reactive. He was
continued on his home doses of donepazil, fluoxetine and
clonazepam. His mental status significantly improved after
starting on steroids and was close to baseline at time of
transfer.
<br>
# MELANOMA: The patient reports a new subcutaneous mass on his
thigh and possibly his neck which likely represent metastatic
disease. He has no been on treatment for the past several
months and has known metastatic disease in his lung and
subcutaneous tissue. MRI of the brain performed on admission
showed evidence of new lesions in the brain. He underwent CT of
the chest/abdomen and torso which showed evidence of a
previously known pulmonary lesion but no knew lesions. MRI of
the spine to evaluate further for metastatic disease was
deferred during his MICU course but may be considered during
this hospitalization given that on presentation the patient
noted some mild bowel incontinence (but in the setting of
diarrhea). He will see Dr. [**Last Name (STitle) 519**] as an outpatient to have his
thigh lesion evaluated.
<br>
# 2ND DEGREE HEART BLOCK: The patient has a history of
Wenckebach phenomenon. On admission the patient was noted to be
in this rhythm on telemetry. He was asymptomatic and
hemodynamically stable. His was monitored on telemetry and did
not have any concerning events. His electrolytes were monitored
closely and repleted and all nodal agents were held.
<br>
# HYPERLIPIDEMIA: He was continued on his home dose of
atorvastatin.
<br>
# ANEMIA: On admission the patient had evidence of a mild
macrocytic anemia with an MCV of 101 and hematocrit of 37.3
which is approximately his baseline. B12 and Folate were normal
on this admission as were iron studies. Reticulocyte count was
1.2 which is slightly decreased in the setting of anemia. The
etiology of his anemia is unclear. [**Name2 (NI) **] further workup was
pursued.
<br>
# PULMONARY EMBOLUS: The patient has a remote history of
pulmonary embolus for which he is on coumadin. On admission his
INR was supratherapeutic and his coumadin was held in the
setting of the likely need for surgical intervention for his
brain lesions. Neurosurgery was consulted who recommended
against the urgent reversal of his anticoagulation.
<br>
# ARF: On admission the patient's creatinine was 1.3. After
fluid hydration it had decreased to 0.8 which is his baseline.
It was felt that his acute renal failure was thus of prerenal
etiology secondary to dehydration.
<Br>
# CODE: FULL - confirmed in clinic on admission
<br>
# DISPO: Discharged to rehab.
Medications on Admission:
1. Fluoxetine 40mg daily
2. Coumadin 5mg daily
3. Klonopin 0.5mg daily
4. Aricept 10mg daily
5. Lipitor 20mg daily
6. Multivitamin daily
7. Vitamin C
8. Vitamin B complex
9. Vitamine E
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain: Hold for sedation. Do
not exceed 4g Tyelenol a day.
Disp:*60 Tablet(s)* Refills:*0*
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
4. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
6. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
7. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
8. Dexamethasone 1.5 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours).
9. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**11-29**]
Drops Ophthalmic QID (4 times a day).
Discharge Disposition:
Extended Care
Facility:
Charwell House
Discharge Diagnosis:
Metastatic melanoma to brain
Discharge Condition:
Neurologically stable. Slight left pronator drift but otherwise
intact strength.
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR CRANIOTOMY
?????? Have a family member check your incision daily for signs of
infection
?????? Take your pain medicine as prescribed
?????? Exercise should be limited to walking; no lifting, straining,
excessive bending
?????? You may wash your hair only after sutures and/or staples have
been removed
?????? You may shower before this time with assistance and use of a
shower cap
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
?????? If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? New onset of tremors or seizures
?????? Any confusion or change in mental status
?????? Any numbness, tingling, weakness in your extremities
?????? Pain or headache that is continually increasing or not
relieved by pain medication
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
?????? Fever greater than or equal to 101?????? F
Followup Instructions:
Follow up for suture removal in 10 days post-operatively: on or
around [**9-2**] (or have them removed at [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] if you are
still there).
You have an appointment in the Brain [**Hospital 341**] Clinic scheduled as
follows:
1. MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2169-9-25**] 2:05
2. Provider: [**Name10 (NameIs) 5005**] [**Last Name (NamePattern4) 5342**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2169-9-25**] 4:00
Finally, have an appointment with Dr. [**Last Name (STitle) 519**] in the cutaneous
oncology clinic for evaluation of your thigh lesion at 10:30 am
on [**2169-8-30**]; phone [**Telephone/Fax (1) 19462**].
Completed by:[**2169-8-29**]
ICD9 Codes: 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3532
} | Medical Text: Admission Date: [**2120-12-13**] Discharge Date: [**2121-1-4**]
Service: MEDICINE
Allergies:
Benzodiazepines / Heparin Agents
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
respiratory distress, hypotension
Major Surgical or Invasive Procedure:
Endotracheal intubation
Swan-ganz catheter placement
Blood component transfusions
History of Present Illness:
Pt is an 88 yo male h/o CAD, MI, AAA (s/p repair, no leak)
recent AICD for syncopal episode NOS ([**11-11**]), severe
cardiomyopathy EF 10%, who originally presented to OSH with
epigastric pain found to be hypotensive there to 60s systolic.
He was then intubated for hypoxic respiratory failure with ABG
7.26/52/41 (was DNR/DNI). He was transferred to the [**Hospital1 **] CCU. A
CTA was done to rule out AAA and did not show any leak but
aneurysm of 6.5 cm and stable.
.
Pt was treated for his shock which was of unclear etiology. He
was started on Zosyn and Vancomycin on [**2120-12-13**] and vancomycin
was d/cd as sputum from [**2120-12-14**] grew GNR not further speciated.
There was not found to be any other source of infection. In the
CCU, pressors were weaned off [**2120-12-17**]. Pt was started on
steroids on [**2120-12-14**] for inappropriate cortisol stimulation test
though it appears not drawn correctly.
.
Called by floor team today as pt with "[**10-15**]" abdominal pain
that was sharp and radiated to his back x 10 minutes. Their exam
revealed pain out of proportion to it and concern was for
mesenteric ischemia. Lactate on a VBG was noted to be up to 2.4
but repeat with ABG is 1.7. Pt says that he vomited x 1 today,
did not notice the color. +mild sob. +dry cough that started
today. +abdominal pain [**9-15**] when I saw pt.
Past Medical History:
CAD s/p CABG
PAF
AAA (s/p repair)
severe cardiomyopathy-EF 10%
s/p AICD for sick sinus syndrome([**11-11**])
s/p biV pacer
HTN
GERD
hypercholesterolemia
PVD s/p iliac stent placement bilaterally
h/o DVT/PE in past
Social History:
wife in [**Name (NI) **], former smoker
Family History:
non-contributory
Physical Exam:
T: 97 (r); BP: 106/70; HR: 88; RR: 22; O2 98 2L
Gen: Sitting up in bed tachypnic speaking in full sentences
HEENT: EOMI; sclera anicteric; OP clear
Neck: No LAD. JVD not appreciated at 80 degrees
CV: Irregularly irregular, S1S2. I-II/VI systolic murmur at LUSB
and apex
Lungs: Good air flow. Crackles at left base. No change to
percussion
Abd: NABS. Soft, ND. Mild tenderness to deep palpation in
epigastric area. No rebound or guarding
Back: No spinal, paraspinal, CVA tenderness
Ext: No edema. DP 2+
Neuro: CN II-XII tested and intact. "[**12-19**]" "[**2110**]". Knew
he was at a hospital, though not which one.
Pertinent Results:
CTA [**2120-12-13**]-IMPRESSION:
1. No evidence for aortic dissection or pulmonary embolus.
2. 6.5-cm infrarenal abdominal aortic aneurysm with evidence of
graft repair distally. No evidence of aneurysm rupture or leak.
3. Pulmonary vascular congestion, intra-abdominal ascites,
periportal edema, and anasarca suggest congestive heart failure
versus volume overload or both.
4. Cardiomegaly.
5. Bibasilar subsegmental atelectasis with small bilateral
pleural effusions.
.
Echo [**2120-12-13**]-The left atrium is elongated. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. Left ventricular wall thicknesses are normal. The
left ventricular cavity is moderately dilated. There is severe
global left ventricular hypokinesis, EF 10-15%. No masses or
thrombi are seen in the left ventricle. There is no ventricular
septal defect. The right ventricular cavity is mildly dilated.
There is mild global right ventricular free wall hypokinesis.
The ascending aorta is mildly dilated. The mitral valve leaflets
are mildly thickened. There is no mitral valve prolapse. Mild to
moderate ([**1-8**]+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. Moderate [2+] tricuspid
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
.
CXR AP (not official read)- enlarged heart s/p sternotomy wires.
There are b/l pleural effusions. ? left retrocardiac opacity.
.
CTA wet read from radiology: SMA is patent. [**Female First Name (un) 899**] cant see [**2-8**]
graft. No post-ischemic changes. Free fluid in abdomen and
anasarca, all unchanged. No change from prior.
Brief Hospital Course:
In Brief, the patient is an 88 year old man with severe ischemic
cardiomyopathy s/p BiV-ICD placement, atrial flutter, CAD,
chronic kidney disease who presented with hypoxic respiratory
failure and shock which was stablized. His course was further
complicated by acute abdomial pain, psoas muscle hematoma, upper
GI bleed, acute on chronic renal failure, heparin induced
thrombocytopenia with upper extremity DVT, intermittent hypoxia,
and urinary retention.
.
1) Shock - Patient intially presented in shock requiring
vasopressors. Cardiac index was normal with decreased SVR which
were not consistent with cardiogenic shock. The likely cause of
was distributive/septic shock of unclear source of infection.
He completed a full course of empiric antibiotics. He completed
7 days of hydrocortisone/fludrocort for sub-optimal response to
ACTH. BP stablized by time of discharge.
.
2) Respiratory Failure: The patient initially presented in
hypoxic respiratory failure likely secondary to CHF,
hypoventilation and decreased mental status. He was intubated
prior to transfer to [**Hospital1 18**]. He was weaned from the ventilator
successfully. He did have intermittent hypoxia largely
secondary to pulmonary edema from inadequate diuresis. He was
stabilized on standing twice daily lasix. He was started on
BiPaP at night for hypoventilation.
.
3) Abdominal pain - During the hospital stay he developed acute
severe epigastric pain. He was transfered to the MICU for
concern for mesenteric ischemia. An abominal CTA was negative
for this. A surgery consult was obtained and recommended no
surgical intervention. The pain resolved without specific
intervention. He was subsequently found to have an psoas muscle
hematoma and required several blood transfusions with
appropriate response in his hematocrit.
4) Cardiovascular:
a. CAD- history of MI s/p CABG. will continue ASA, simvastatin,
beta-blocker.
.
b. Pump- Severe ischemic cardiomyopathy with EF 10-15% s/p
BiV-ICD placement. No evidence of cardiogenic shock upon initial
presenation as C.I. was normal. Medically managed CHF with
ACEi, beta-blocker, digoxin, spironolactone, furosemide.
.
c. rhythm- [**Hospital1 **]-V paced with underlying rhythm is atrial
flutter/fibrillation. Started on amiodarone for maintenance of
sinus rhythm to maximize likelihood of atrial kick. Also,
amiodarone to decrease in-appropriate shocks from ICD.
5) Upper GI bleed - The patient did develop guaiac positive
stools in the setting of anticoagulation for the atrial
fibrillation. The hematocrit drop was largely due to the psoas
hematoma as above. The patient refused EGD. If the patient
develops recurrent melenotic stools he could be referred to GI
for endoscopy. He will continue on a PPI.
.
6)Acute on Chronic Renal failure - Initial creatinine down from
admission to peak 2.5 this was likely from pre-renal secondary
to shock state; no evidence of ATN. By time of discharge, the
creatinine had resolved to baseline.
.
7) Anemia- In addition the the acute blood loss anemia as
described above. The patient has a chronic microcytic anemia.
Iron studies were consistent with anemia of chronic disease
(labs drawn before blood transfusions were given). Also with
regard to the significant microcytosis and his Italian
extraction, hemoglobin electrophoresis was performed to evaluate
for thallasemia. These results were pending at time of
discharge.
.
8) Thrombocytopenia - HIT type II. PF4 positive on [**2120-12-27**],
Platelets stable at around 70K with subsequent recovery to
greater than 150K. He did have a left upper extremity venous
clot although the developement of this was after his platelets
had stabilized. Started argatroban on [**2120-12-27**] with transition
to coumadin. He continued on argatroban until his INR on
combined anti-coagulation was >4. At which time he was
maintained on coumadin alone.
.
9) Urinary retention: - The patient has no prior history of
urinary retention, nocturia, frequency or related BPH symptoms.
During one attempt at removing the foley catheter he had
decreased urine output with a large volume detected on bladder
scan. The foley was replaced. He was started on finasteride,
not wanting to use an alpha-blocker that would likely cause
hypotension when added to his extensive cardiac regimen. The
catheter was left in at discharge. This should be removed in
[**2-9**] days followed by confirmation that the patient can urinate.
.
10) Code Status: DNR/DNI confirmed with patient and HCP.
.
11) Dispo: the patient was discharged to rehab
Medications on Admission:
Hydrocortisone Na 50 mg IV q6
RISS
Ipratropium MDI prn
Tylenol prn
Albuterol prn
Lactulose 30 mg po q8 prn
Pantoprazole 40 mg po q24 hr
Amiodarone 200 mg po qday
ASA 81 mg po qday
Colace 100 mg [**Hospital1 **]
Senna [**Hospital1 **]
Fludrocortisone 0.05 mg po qday
Simvastatin 40 mg po qday
Heparin gtt
Zosyn 2.25 mg IV q6
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed: to maintain at least 1BM per day.
7. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
8. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
9. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for sleep.
10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): hold for sbp <95.
13. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q4H (every 4 hours) as needed for wheezing, dyspnea.
14. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
15. Warfarin 5 mg Tablet Sig: One (1) Tablet PO at bedtime:
titrate to INR goal [**2-9**].
16. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Compazine 5 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for nausea.
18. Outpatient Lab Work
Please draw PT/INR daily for 3 days and thereafter per protocol
for INR goal [**2-9**]
19. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
20. BiPaP
BiPAP with mask at night 10cmH2O PS, 5 cmH2O PEEP. Titrate FIO2
to keep O2sat >95%
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary:
Septic Shock
Hypoxic respiratory failure
Secondary:
Heparin induced thrombocytopenia
Acute blood loss anemia from Psoas muscle hematoma
Urinary retention
Upper extremity venous clot
Ischemic cardiomyopathy
Atrial fibrillation/ Atrial flutter
Congestive heart failure - systolic, compensated
Microcytic Anemia
Discharge Condition:
good. stable vital signs. tolerating oral medications and
nutrition. ambulating with minimal assist.
Discharge Instructions:
You have been evaluated for respiratory distress, and very low
blood blood pressure. These resolved with time, antibiotics,
and close management of your chronic heart disease. Your course
was complicated by a bleed into a hip muscle, a reaction to a
medication called heparin, and difficulty urinating. These were
all stablized over the course of the hospital stay.
Please take the medications as prescribed.
Please make and attend your recommended follow-up appointments.
If you develop any concerning symptom particularly chest pain,
shortness of breath, bloody or tarry stools please seek medical
attention.
Followup Instructions:
Please contact your primary doctor Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 58623**] at
[**Telephone/Fax (1) 58624**] to be seen within the next 1-2 weeks.
In the meantime you will be evaluated by the physicians at the
rehab facility.
ICD9 Codes: 0389, 5849, 5859, 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3533
} | Medical Text: Admission Date: [**2171-9-8**] Discharge Date: [**2171-10-7**]
Date of Birth: [**2088-3-20**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Benadryl / Prednisone / Reglan
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
AAA,leak
Major Surgical or Invasive Procedure:
EVAR [**2171-9-8**]
right axillo femoral bpg with PTFE [**2171-9-8**]
fem-fem bpg [**2171-9-9**]
primary closeure of left faciotomy wounds, rt. faciotomy wounds
closed with split thickness skin graft. Vac dressing to rt.
wounds [**2171-9-24**]
History of Present Illness:
Ms. [**Known lastname 79272**] is an 83F with a known 6cm AAA who presented to
Caritas [**Hospital6 **] on [**9-7**] with ~36 hours of low back
pain. Of note, her blood pressure there was 180/100. A CT scan
of her abdomen was done there and confirmed a 6cm infrarenal AAA
beginning 5cm below the R renal artery and extending to the
level
of the bifurcation, surrounded by hyperdense material suggestive
of a leak. In additional, parastomal and pelvic ventral hernias
were noted without evidence of bowel obstruction.
She was transferred to [**Hospital1 18**] for further care. Upon arrival she
complained of severe low back and had a blood pressure of
220/110. She was taken directly to CT scan.
Past Medical History:
history of congestive heart failure, systolic, chronic
history of PVD
history of COPD
history of diverticulitis with abcess s/p colestomy [**2168**]
history of right hip surgery
history of rt. ankle fx
history of heavy tobacco use-current (100 pack years)
Social History:
she lives in a downstairs apartment of a two-family
house in Metheun, with her niece [**Name (NI) **] upstairs. She states
[**Known firstname **] helps with the cooking and cleaning and is generally pt's
main support. Pt also states she has had VNA at home and
describes being used to a fairly independent lifestyle with
support from niece. Also current heavy tobacco use, denies
ETOH.
Family History:
unknown
Physical Exam:
Vital signs: P-90-110 B/P 220/110
GEN: patient in distress/pain
ABD: obese colostomy LLQ, moderate tenderness to palpation
Pulses: dopperable throughout.
Pertinent Results:
[**2171-9-8**] 09:05AM BLOOD WBC-8.6 RBC-3.08* Hgb-9.4* Hct-25.5*
MCV-83 MCH-30.6 MCHC-36.9* RDW-14.9 Plt Ct-151
[**2171-9-8**] 04:36PM BLOOD WBC-10.5 RBC-2.87* Hgb-8.9* Hct-23.8*
MCV-83 MCH-30.9 MCHC-37.2* RDW-15.3 Plt Ct-140*
[**2171-9-8**] 10:18PM BLOOD WBC-16.4*# RBC-4.05*# Hgb-11.8*#
Hct-33.7*# MCV-83 MCH-29.1 MCHC-34.9 RDW-15.8* Plt Ct-158
[**2171-9-9**] 03:16AM BLOOD WBC-11.7* RBC-3.13* Hgb-9.5* Hct-26.0*
MCV-83 MCH-30.2 MCHC-36.4* RDW-15.9* Plt Ct-128*
[**2171-9-9**] 11:03AM BLOOD WBC-10.2 RBC-3.26* Hgb-9.8* Hct-26.9*
MCV-83 MCH-30.0 MCHC-36.3* RDW-15.5 Plt Ct-119*
[**2171-9-9**] 04:24PM BLOOD WBC-9.9 RBC-3.77* Hgb-11.2* Hct-31.3*
MCV-83 MCH-29.7 MCHC-35.8* RDW-15.2 Plt Ct-99*
[**2171-9-9**] 09:13PM BLOOD Hct-30.2*
[**2171-9-10**] 01:05AM BLOOD WBC-6.4 RBC-2.88* Hgb-8.5* Hct-23.6*
MCV-82 MCH-29.5 MCHC-35.9* RDW-15.6* Plt Ct-81*
[**2171-9-10**] 01:29AM BLOOD Hct-22.9*
[**2171-9-10**] 04:45AM BLOOD Hct-28.2*
[**2171-9-10**] 03:49PM BLOOD Hct-25.7*
[**2171-9-10**] 06:31PM BLOOD Hct-27.9*
[**2171-9-11**] 01:59AM BLOOD WBC-5.6 RBC-3.27* Hgb-9.8* Hct-26.9*
MCV-82 MCH-29.9 MCHC-36.3* RDW-17.1* Plt Ct-75*
[**2171-9-11**] 09:01AM BLOOD Hct-28.2*
[**2171-9-11**] 09:01AM BLOOD Hct-28.2*
[**2171-9-12**] 01:57AM BLOOD WBC-6.6 RBC-3.20* Hgb-9.5* Hct-26.5*
MCV-83 MCH-29.8 MCHC-36.0* RDW-17.1* Plt Ct-76*
[**2171-9-13**] 03:07AM BLOOD WBC-8.2 RBC-3.17* Hgb-9.4* Hct-26.4*
MCV-83 MCH-29.7 MCHC-35.6* RDW-16.7* Plt Ct-107*
[**2171-9-13**] 08:43PM BLOOD Hct-26.9*
[**2171-9-14**] 03:06AM BLOOD WBC-6.9 RBC-3.18* Hgb-9.4* Hct-27.0*
MCV-85 MCH-29.5 MCHC-34.7 RDW-15.8* Plt Ct-119*
[**2171-9-15**] 03:37AM BLOOD WBC-6.8 RBC-3.27* Hgb-9.6* Hct-27.6*
MCV-84 MCH-29.3 MCHC-34.7 RDW-16.2* Plt Ct-148*
[**2171-9-16**] 05:48AM BLOOD WBC-6.7 RBC-3.19* Hgb-9.2* Hct-27.4*
MCV-86 MCH-28.9 MCHC-33.6 RDW-16.1* Plt Ct-163
[**2171-9-17**] 04:34AM BLOOD WBC-7.5 RBC-3.15* Hgb-9.2* Hct-27.1*
MCV-86 MCH-29.1 MCHC-33.8 RDW-15.9* Plt Ct-192
[**2171-9-18**] 04:11AM BLOOD WBC-10.9 RBC-2.97* Hgb-8.9* Hct-25.7*
MCV-87 MCH-30.1 MCHC-34.8 RDW-16.0* Plt Ct-202
[**2171-9-18**] 04:03PM BLOOD Hct-23.9*
[**2171-9-19**] 05:36AM BLOOD WBC-14.3* RBC-2.98* Hgb-8.9* Hct-25.9*
MCV-87 MCH-29.8 MCHC-34.4 RDW-16.1* Plt Ct-219
[**2171-9-20**] 04:47AM BLOOD WBC-13.9* RBC-2.78* Hgb-8.3* Hct-23.6*
MCV-85 MCH-29.8 MCHC-35.0 RDW-16.6* Plt Ct-249
[**2171-9-20**] 06:41PM BLOOD Hct-25.7*
[**2171-9-21**] 04:40AM BLOOD WBC-11.3* RBC-3.12* Hgb-9.4* Hct-26.3*
MCV-84 MCH-30.1 MCHC-35.8* RDW-16.6* Plt Ct-240
[**2171-9-22**] 04:06AM BLOOD WBC-13.0* RBC-3.18* Hgb-9.4* Hct-26.7*
MCV-84 MCH-29.6 MCHC-35.2* RDW-16.6* Plt Ct-323
[**2171-9-23**] 05:35AM BLOOD WBC-9.3 RBC-2.88* Hgb-8.5* Hct-25.1*
MCV-87 MCH-29.5 MCHC-33.8 RDW-16.4* Plt Ct-324
[**2171-9-23**] 09:00PM BLOOD Hct-25.4*
[**2171-9-24**] 04:09AM BLOOD WBC-9.0 RBC-2.92* Hgb-8.3* Hct-24.8*
MCV-85 MCH-28.3 MCHC-33.3 RDW-17.1* Plt Ct-261
[**2171-9-24**] 04:05PM BLOOD Hct-22.4*
[**2171-9-25**] 04:14AM BLOOD WBC-9.6 RBC-3.31* Hgb-9.9* Hct-27.7*
MCV-84 MCH-30.0 MCHC-35.9* RDW-16.9* Plt Ct-288
[**2171-9-26**] 12:20AM BLOOD Hct-26.3*
[**2171-9-26**] 07:21AM BLOOD WBC-7.3 RBC-3.18* Hgb-9.3* Hct-26.7*
MCV-84 MCH-29.1 MCHC-34.8 RDW-17.0* Plt Ct-288
[**2171-9-27**] 04:52AM BLOOD WBC-7.2 RBC-2.93* Hgb-8.7* Hct-25.3*
MCV-87 MCH-29.6 MCHC-34.2 RDW-16.6* Plt Ct-275
[**2171-9-28**] 06:42AM BLOOD WBC-7.4 RBC-3.22* Hgb-9.3* Hct-27.8*
MCV-86 MCH-28.8 MCHC-33.4 RDW-16.6* Plt Ct-281
[**2171-9-28**] 01:10PM BLOOD WBC-8.1 RBC-3.27* Hgb-9.5* Hct-27.9*
MCV-85 MCH-29.2 MCHC-34.1 RDW-16.5* Plt Ct-286
[**2171-9-30**] 05:00AM BLOOD WBC-7.7 RBC-2.93* Hgb-8.7* Hct-25.6*
MCV-88 MCH-29.6 MCHC-33.8 RDW-16.8* Plt Ct-283
[**2171-10-1**] 05:56AM BLOOD WBC-7.0 RBC-2.84* Hgb-8.5* Hct-24.6*
MCV-86 MCH-29.7 MCHC-34.4 RDW-17.3* Plt Ct-313
[**2171-10-2**] 06:00AM BLOOD WBC-7.4 RBC-2.85* Hgb-8.5* Hct-25.0*
MCV-88 MCH-29.7 MCHC-33.9 RDW-16.8* Plt Ct-305
[**2171-10-4**] 12:00AM BLOOD WBC-7.7 RBC-3.34*# Hgb-9.8*# Hct-28.4*
MCV-85 MCH-29.5 MCHC-34.7 RDW-17.2* Plt Ct-332
[**2171-10-4**] 05:18AM BLOOD WBC-7.2 RBC-3.22* Hgb-9.7* Hct-27.4*
MCV-85 MCH-30.0 MCHC-35.3* RDW-17.2* Plt Ct-318
[**2171-10-4**] 10:27PM BLOOD Hct-28.5*
[**2171-10-5**] 05:24AM BLOOD WBC-8.0 RBC-3.37* Hgb-9.9* Hct-28.7*
MCV-85 MCH-29.4 MCHC-34.6 RDW-17.3* Plt Ct-355
[**2171-10-6**] 06:50AM BLOOD WBC-8.3 RBC-3.51* Hgb-10.5* Hct-30.5*
MCV-87 MCH-30.0 MCHC-34.4 RDW-17.0* Plt Ct-359
[**2171-9-8**] 09:05AM BLOOD ALT-5 AST-10 CK(CPK)-61 AlkPhos-49
TotBili-0.9
[**2171-9-8**] 04:36PM BLOOD ALT-8 AST-26 CK(CPK)-1049* AlkPhos-51
Amylase-27
[**2171-9-8**] 10:18PM BLOOD CK(CPK)-9379*
[**2171-9-9**] 03:16AM BLOOD ALT-25 AST-91* CK(CPK)-8909* Amylase-24
TotBili-0.6
[**2171-9-10**] 01:05AM BLOOD ALT-53* AST-214* LD(LDH)-740*
CK(CPK)-[**Numeric Identifier **]* AlkPhos-41 Amylase-20 TotBili-0.7
[**2171-9-10**] 08:09AM BLOOD CK(CPK)-[**Numeric Identifier 79273**]*
[**2171-9-10**] 09:33AM BLOOD CK(CPK)-[**Numeric Identifier 79274**]*
[**2171-9-10**] 05:25PM BLOOD CK(CPK)-[**Numeric Identifier 79275**]*
[**2171-9-10**] 10:31PM BLOOD CK(CPK)-[**Numeric Identifier 79276**]*
[**2171-9-11**] 09:01AM BLOOD CK(CPK)-[**Numeric Identifier 35232**]*
[**2171-9-13**] 03:07AM BLOOD CK(CPK)-[**Numeric Identifier 79277**]*
[**2171-9-16**] 05:48AM BLOOD CK(CPK)-5857*
[**2171-9-17**] 04:34AM BLOOD CK(CPK)-3861*
[**2171-9-18**] 04:11AM BLOOD CK(CPK)-2544*
[**2171-10-2**] 04:57PM BLOOD ALT-14 AST-24 CK(CPK)-317* AlkPhos-66
Amylase-27 TotBili-0.4
[**2171-9-8**] 09:05AM BLOOD Glucose-116* UreaN-27* Creat-1.3* Na-137
K-4.8 Cl-111* HCO3-21* AnGap-10
[**2171-9-8**] 04:36PM BLOOD Glucose-121* UreaN-28* Creat-0.9 Na-139
K-5.0 Cl-110* HCO3-21* AnGap-13
[**2171-9-9**] 03:16AM BLOOD Glucose-111* UreaN-30* Creat-1.8* Na-138
K-4.5 Cl-109* HCO3-21* AnGap-13
[**2171-9-9**] 04:24PM BLOOD Glucose-90 UreaN-29* Creat-1.9* Na-137
K-4.9 Cl-111* HCO3-19* AnGap-12
[**2171-9-9**] 09:13PM BLOOD UreaN-31* Creat-2.0* HCO3-19*
[**2171-9-10**] 01:05AM BLOOD UreaN-31* Creat-2.1* Cl-108 HCO3-21*
[**2171-9-11**] 01:59AM BLOOD Glucose-107* UreaN-32* Creat-2.7* Na-137
K-5.0 Cl-110* HCO3-18* AnGap-14
[**2171-9-13**] 03:07AM BLOOD Glucose-75 UreaN-39* Creat-3.2* Na-136
K-4.5 Cl-96 HCO3-30 AnGap-15
[**2171-9-14**] 03:06AM BLOOD Glucose-82 UreaN-43* Creat-3.4* Na-137
K-3.7 Cl-93* HCO3-33* AnGap-15
[**2171-9-15**] 03:37AM BLOOD Glucose-103 UreaN-45* Creat-3.0* Na-138
K-3.7 Cl-96 HCO3-31 AnGap-15
[**2171-9-16**] 05:48AM BLOOD Glucose-132* UreaN-51* Creat-2.8* Na-137
K-3.8 Cl-96 HCO3-34* AnGap-11
[**2171-9-17**] 04:34AM BLOOD Glucose-112* UreaN-45* Creat-2.2* Na-137
K-3.4 Cl-97 HCO3-31 AnGap-12
[**2171-9-18**] 04:11AM BLOOD Glucose-145* UreaN-42* Creat-2.1* Na-136
K-3.2* Cl-96 HCO3-29 AnGap-14
[**2171-9-19**] 05:36AM BLOOD Glucose-149* UreaN-44* Creat-1.9* Na-135
K-4.5 Cl-99 HCO3-25 AnGap-16
[**2171-9-20**] 04:47AM BLOOD UreaN-44* Creat-2.0*
[**2171-9-21**] 04:40AM BLOOD Glucose-117* UreaN-44* Creat-1.9* Na-135
K-3.6 Cl-98 HCO3-30 AnGap-11
[**2171-9-22**] 04:06AM BLOOD Glucose-97 UreaN-42* Creat-1.8* Na-134
K-3.8 Cl-96 HCO3-30 AnGap-12
[**2171-9-23**] 05:35AM BLOOD Glucose-89 UreaN-38* Creat-1.6* Na-137
K-3.9 Cl-97 HCO3-29 AnGap-15
[**2171-9-24**] 04:09AM BLOOD Glucose-90 UreaN-33* Creat-1.3* Na-137
K-4.1 Cl-101 HCO3-29 AnGap-11
[**2171-9-25**] 04:14AM BLOOD Glucose-103 UreaN-32* Creat-1.3* Na-136
K-3.9 Cl-100 HCO3-28 AnGap-12
[**2171-9-26**] 07:21AM BLOOD Glucose-99 UreaN-29* Creat-1.2* Na-137
K-3.8 Cl-101 HCO3-28 AnGap-12
[**2171-9-27**] 04:52AM BLOOD Glucose-105 UreaN-28* Creat-1.2* Na-138
K-3.7 Cl-102 HCO3-29 AnGap-11
[**2171-9-28**] 06:42AM BLOOD Glucose-103 UreaN-27* Creat-1.2* Na-138
K-4.1 Cl-101 HCO3-29 AnGap-12
[**2171-9-30**] 05:00AM BLOOD Glucose-87 UreaN-32* Creat-1.2* Na-136
K-4.3 Cl-101 HCO3-29 AnGap-10
[**2171-10-1**] 05:56AM BLOOD Glucose-95 UreaN-35* Creat-1.3* Na-138
K-4.2 Cl-103 HCO3-27 AnGap-12
[**2171-10-2**] 06:00AM BLOOD Glucose-99 UreaN-36* Creat-1.4* Na-134
K-4.4 Cl-103 HCO3-27 AnGap-8
[**2171-10-4**] 05:18AM BLOOD Glucose-93 UreaN-39* Creat-1.3* Na-138
K-4.4 Cl-103 HCO3-27 AnGap-12
[**2171-10-4**] 10:27PM BLOOD Creat-1.2* K-4.6
[**2171-10-6**] 06:50AM BLOOD Creat-1.3* K-4.9
[**2171-10-7**] 02:09AM BLOOD Glucose-92 UreaN-44* Creat-1.3* Na-135
K-4.1 Cl-102 HCO3-26 AnGap-11
[**2171-10-2**] 04:57PM BLOOD ESR-79*
[**2171-9-8**] 04:36PM BLOOD PT-14.0* PTT-76.1* INR(PT)-1.2*
[**2171-9-9**] 04:24PM BLOOD PT-14.0* PTT-56.3* INR(PT)-1.2*
[**2171-9-10**] 01:05AM BLOOD PT-14.5* PTT-80.7* INR(PT)-1.3*
[**2171-9-10**] 05:50AM BLOOD PT-13.8* PTT-47.4* INR(PT)-1.2*
[**2171-9-10**] 03:49PM BLOOD PT-13.0 PTT-38.3* INR(PT)-1.1
[**2171-9-12**] 01:57AM BLOOD PT-12.8 PTT-39.5* INR(PT)-1.1
[**2171-9-14**] 03:06AM BLOOD PT-12.5 PTT-55.3* INR(PT)-1.1
[**2171-9-15**] 03:37AM BLOOD PT-12.6 PTT-57.8* INR(PT)-1.1
[**2171-9-16**] 05:48AM BLOOD PT-12.6 PTT-64.6* INR(PT)-1.1
[**2171-9-16**] 03:00PM BLOOD PTT-61.2*
[**2171-9-18**] 04:11AM BLOOD PT-13.4 PTT-58.3* INR(PT)-1.2*
[**2171-9-19**] 05:36AM BLOOD PT-17.2* PTT-71.1* INR(PT)-1.6*
[**2171-9-21**] 07:15PM BLOOD PT-18.3* PTT-57.3* INR(PT)-1.7*
[**2171-9-22**] 04:06AM BLOOD PT-15.9* PTT-50.1* INR(PT)-1.4*
[**2171-9-23**] 09:00PM BLOOD PT-14.1* PTT-54.8* INR(PT)-1.2*
[**2171-9-24**] 04:09AM BLOOD PT-14.3* PTT-66.7* INR(PT)-1.2*
[**2171-9-25**] 04:14AM BLOOD PT-14.6* PTT-67.2* INR(PT)-1.3*
[**2171-9-25**] 09:59AM BLOOD PT-15.4* PTT-75.1* INR(PT)-1.4*
[**2171-9-26**] 12:20AM BLOOD PT-16.8* PTT-75.5* INR(PT)-1.5*
[**2171-9-26**] 07:21AM BLOOD PT-17.5* PTT-77.9* INR(PT)-1.6*
[**2171-9-30**] 05:00AM BLOOD PT-20.0* PTT-34.2 INR(PT)-1.9*
[**2171-10-1**] 05:56AM BLOOD PT-25.4* PTT-37.5* INR(PT)-2.5*
[**2171-10-2**] 06:00AM BLOOD PT-30.1* PTT-39.8* INR(PT)-3.1*
[**2171-10-3**] 05:26AM BLOOD PT-28.3* PTT-47.1* INR(PT)-2.8*
[**2171-10-4**] 05:18AM BLOOD PT-25.7* PTT-63.4* INR(PT)-2.5*
[**2171-10-4**] 10:27PM BLOOD PT-30.3* INR(PT)-3.1*
[**2171-10-5**] 05:24AM BLOOD PT-31.4* PTT-43.0* INR(PT)-3.2*
[**2171-10-5**] 05:24AM BLOOD PT-31.4* PTT-43.0* INR(PT)-3.2*
[**2171-10-6**] 06:50AM BLOOD PT-31.6* PTT-44.4* INR(PT)-3.3*
[**2171-10-7**] 02:09AM BLOOD PT-32.0* PTT-59.0* INR(PT)-3.3*
[**2171-9-8**] 09:05AM BLOOD CK-MB-NotDone cTropnT-0.01
[**2171-9-8**] 04:36PM BLOOD CK-MB-8 cTropnT-0.02*
[**2171-9-8**] 10:18PM BLOOD CK-MB-37* MB Indx-0.4 cTropnT-0.03*
[**2171-9-9**] 03:16AM BLOOD CK-MB-33* MB Indx-0.4 cTropnT-0.03*
[**2171-9-10**] 08:09AM BLOOD CK-MB-80* MB Indx-0.3 cTropnT-0.09*
[**2171-9-10**] 09:33AM BLOOD cTropnT-0.10*
[**2171-9-10**] 05:25PM BLOOD cTropnT-0.20*
[**2171-9-10**] 10:31PM BLOOD CK-MB-72* MB Indx-0.3 cTropnT-0.25*
[**2171-10-2**] 04:57PM BLOOD TSH-12*
[**2171-9-8**] 04:54AM BLOOD Type-ART pO2-340* pCO2-44 pH-7.36
calTCO2-26 Base XS-0 Intubat-INTUBATED
[**2171-9-8**] 06:27AM BLOOD Type-ART pO2-273* pCO2-46* pH-7.33*
calTCO2-25 Base XS--1 Intubat-INTUBATED Vent-CONTROLLED
[**2171-9-8**] 12:49PM BLOOD Type-ART pO2-116* pCO2-44 pH-7.35
calTCO2-25 Base XS--1
[**2171-9-10**] 08:57PM BLOOD Type-ART pO2-82* pCO2-34* pH-7.32*
calTCO2-18* Base XS--7
[**2171-9-12**] 02:09AM BLOOD Type-ART pO2-89 pCO2-41 pH-7.42
calTCO2-28 Base XS-1
[**2171-9-14**] 05:32AM BLOOD Type-ART pO2-64* pCO2-54* pH-7.41
calTCO2-35* Base XS-7
[**2171-9-15**] 02:26PM BLOOD Type-ART pO2-97 pCO2-55* pH-7.41
calTCO2-36* Base XS-7
[**2171-9-8**] 09:05AM BLOOD ALT-5 AST-10 CK(CPK)-61 AlkPhos-49
TotBili-0.9
[**2171-9-8**] 04:36PM BLOOD ALT-8 AST-26 CK(CPK)-1049* AlkPhos-51
Amylase-27
[**2171-9-8**] 10:18PM BLOOD CK(CPK)-9379*
[**2171-9-10**] 01:05AM BLOOD ALT-53* AST-214* LD(LDH)-740*
CK(CPK)-[**Numeric Identifier **]* AlkPhos-41 Amylase-20 TotBili-0.7
[**2171-9-10**] 08:09AM BLOOD CK(CPK)-[**Numeric Identifier 79273**]*
[**2171-9-13**] 03:07AM BLOOD CK(CPK)-[**Numeric Identifier 79277**]*
[**2171-9-18**] 04:11AM BLOOD CK(CPK)-2544*
[**2171-10-2**] 04:57PM BLOOD ALT-14 AST-24 CK(CPK)-317* AlkPhos-66
Amylase-27 TotBili-0.4
GRAM STAIN (Final [**2171-9-23**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
WOUND CULTURE (Final [**2171-9-29**]):
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
AZTREONAM REQUESTED BY DR.[**Last Name (STitle) **].
AZTREONAM SENSITIVE BY [**Doctor Last Name **]-[**Doctor Last Name **].
ANAEROBIC CULTURE (Final [**2171-9-29**]):
BACTEROIDES FRAGILIS GROUP. MODERATE GROWTH.
BETA LACTAMASE POSITIVE.
RAPID PLASMA REAGIN TEST (Final [**2171-10-3**]):
NONREACTIVE.
Reference Range: Non-Reactive.
[**2171-9-10**] 09:33AM URINE Blood-LG Nitrite-POS Protein->300
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-0.2 pH-5.5 Leuks-NEG
[**2171-9-10**] 09:33AM URINE RBC-0-2 WBC-0-2 Bacteri-MANY Yeast-NONE
Epi-0
[**2171-9-10**] 09:33AM URINE Color-Brown Appear-Cloudy Sp [**Last Name (un) **]-1.015
[**2171-9-8**] CT ABD PELVIS: Large, ruptured, 6 x 6 cm infrarenal
abdominal aortic aneurysm with extensive intramural thrombus and
retroperitoneal hematoma.
Severe atherosclerotic disease of the abdominal aorta and its
branches,
including near-occlusion of the right common iliac artery.
[**2171-9-9**] CXR: Indwelling devices are in standard position, and
cardiomediastinal contours
are not substantially changed allowing for technical differences
between the
studies. Worsening opacity in lower left hemithorax is likely a
combination
of pleural effusion and atelectasis. No pneumothorax is evident
on this
supine view.
[**2171-9-22**] ECG: Sinus rhythm. Prolonged Q-T interval. No previous
tracing available for comparison.
[**2171-10-4**] CT ABD/PELVIS: 1. Bilateral superficial proxmal
thigh/inguinal fluid collections, appearance
c/w hematomas. 2. Open soft tissue wound on the left groin area
with communication to the left groin fluid collection and one of
the two femoro-femoral PTFE grafts. 3. Uncomplicated ventral
hernia. 4. Mild interval decrease of aortic aneurysmal sac
diameter.
Brief Hospital Course:
[**2171-9-8**] Evaluated in ER
8/31/0 EVAR with fem-fem bpg, transfused for blood loss anemia,
acute [**Numeric Identifier 79278**] loss of rt. foot pulse with progressive ischemic
changes. Returned to [**Location 79279**].Right axillo-femoral bpg. dopperable
DP/PT with good capillary refill. dopperableleft DP absent left
PT. Transfered to SICU intubated.
[**2171-9-9**] POD#1 Remains intubated on IV ngt. gtt for SBP controll.
NTG in place. low urinary out put volume resustated. Troponin
0.03 IV insulin gtt.,propofol 40mcg/kg/min. fentyl 75mcg /hr
gtt. Vanco/cipro antibiotic coverage.
Left lower extremity ischemia Returns to OR for redo fem-fem
bpg.and bilateral fasciotomies.Transfused
[**2171-9-10**] POD#2 Transfused remain in ICU. increasing creatinine
Renal consulted.
Renal faillure secondary to ATN and rhabolomyosis and contrast
during inital endovascular repair.Recommend fluid resustation no
hemodialysis at this time.
[**2171-9-11**] POD#3 increase urinary out put with fluid resustation
and IV lasix.Nutritional consult.recommend tube feeds.IV heparin
.Sedation weaning began.
[**Hospital1 **] carb gtt for urine alklization. propfolol off. Ck's trending
down [**Hospital1 **].
[**2171-9-12**] POD#4 antibiotics and IV heparin continued. creatinine
@ 3.0
[**2171-9-13**] POD#5 [**Hospital1 **] carb gtt d/c'd. diuresis continues. continues
with tube feed. await swallow evaluation.fentyl gtt d/c'd. Iv
heparin continued. lasix continued but frequency
decreased.Antibiotics continued. Remains intubated and in ICU.
Swallow evaluation at bed side negative for aspiration.
recommended po diet of thin liquids and soft solids.Extubated.
[**2171-9-14**] POD#6 cr. 3.4 IV heparin continued. diuresuis cibtinued
for 20kg above preop wt.creatinine plateaued.
[**2171-9-15**] POD#7 cr. 3.0 today. VAC dressings to faciotomy sites.
[**2171-9-16**] POD#8 Transfered to VICU. tube feed at goal. 40cc/hr. Iv
heparin continued.
wound care consulted for left gluteal decubti.
[**2171-9-17**] POD#9 wound care suggestions instuted. creatinine
trending downward, 2.2
Pt continues to work with patient.Tube feed cycling began. Po's
continue and calorie counts monitered.
[**2171-9-18**] POD# 10 right leg wound vac changed secondary to wound
bleeding.repeat spontanious bleed , hemostasis obtained and
wound vac discontinued.
patient transfused for a Hct. 23.0
[**2171-9-19**] POD#11 post transfusion Hct. 25.1 wounds without
bleeding.
[**2171-9-20**] POD# 12 left wound vac discontinued and zeroform form
dressings and dry steral dressing with ace wraps instuted.
Patient had an episode of rt. facitoomy site bleeding requiring
surgi-sel for hemostatis.
[**2078-9-19**] POD# 13-15 continued antibiotics. patient self D/c'd her
feeding tube. which will required to be replaced secondary to
poor caloric intake by calorie counts.
patient proceeded to surgery [**2171-9-23**]
[**2171-9-23**]- [**2171-5-25**] POD#15-17 right faciotomy closure with STSG and
VAC dressing,left faciotomy closure primary.Seen by skin care
team. for colostomy site care and left decubitus cheel skin
changes.Coumadization began . IV heparin gtt continued.
Multipodis boots placed for heel protection. Left groin wound
noted to be open and exudative.
[**2171-9-26**] [**Month/Day/Year 197**]-heparin bridge continued. Monitering
graft donor site. Calorie counts ordered to assess adequacy of
PO intake
[**2171-9-27**] PO intake improved with encouragement. Wound vac
removed from graft site & dry dressing placed.
[**2171-9-30**]: Transfered to the floor. L groin wound debrided at
bedside.
[**2171-10-2**]: Sacral ulcer sharply debrided at bedside, moist to
dry dressing changes begun. Woundvac placed by team to left
groin, all surgical staples removed.
[**2171-10-4**] Pt received 2U PRBC for a falling HCT. Woundvac
changed by wound care nurse. [**First Name (Titles) 197**] [**Last Name (Titles) **] changed to
alternating 3mg/5mg doses for supratherapeutic INR on 5mg daily.
[**2171-10-7**] Pt is being discharged to [**Hospital3 **] in stable
condition with ostomy, woundvac, central line in place. Of note
is a post-op L paraplegia likely secondary to ischemia during
aortic cross-clamping, neurology consult did not reveal a
reversible cause.
Medications on Admission:
lasix & potassium
Discharge Medications:
1. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Hospital3 **]: Six (6)
Puff Inhalation Q6H (every 6 hours).
2. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
3. Aspirin 325 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Miconazole Nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed.
5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: One (1) neb Inhalation Q6H (every 6 hours) as
needed.
6. Calcium Carbonate 500 mg Tablet, Chewable [**Hospital1 **]: One (1)
Tablet, Chewable PO Q 8H (Every 8 Hours).
7. Nicotine 14 mg/24 hr Patch 24 hr [**Hospital1 **]: One (1) Patch 24 hr
Transdermal DAILY (Daily).
8. [**Hospital1 197**] 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO every other day.
9. Miconazole Nitrate 2 % Cream [**Hospital1 **]: One (1) Appl Topical [**Hospital1 **] (2
times a day): to groin and peri-rectal area .
10. [**Hospital1 197**] 1 mg Tablet [**Hospital1 **]: Three (3) Tablet PO every other
day.
11. Furosemide 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
12. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: 1 [**1-9**] Tablet PO TID (3
times a day).
13. Amlodipine 5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily).
14. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Month/Day (2) **]: One (1) NEB Inhalation Q4H (every 4 hours) as
needed for shortness of breath or wheezing.
15. Acetaminophen 325 mg Tablet [**Month/Day (2) **]: 1-2 Tablets PO Q4H (every 4
hours) as needed.
16. Aspirin 325 mg Tablet, Delayed Release (E.C.) [**Month/Day (2) **]: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
17. Docusate Sodium 100 mg Capsule [**Month/Day (2) **]: One (1) Capsule PO BID
(2 times a day).
18. Magnesium Hydroxide 400 mg/5 mL Suspension [**Month/Day (2) **]: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
19. Alprazolam 0.25 mg Tablet [**Month/Day (2) **]: 1-2 Tablets PO QHS (once a
day (at bedtime)) as needed for insomia or anxiety.
20. Oxycodone-Acetaminophen 5-325 mg Tablet [**Month/Day (2) **]: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
21. Aztreonam 1 gram Recon Soln [**Month/Day (2) **]: One (1) gram Injection Q8H
(every 8 hours) for 4 days: Total 14 day course. Wound care
assessment to consider extending antibiotic past day 14.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **]
Discharge Diagnosis:
abdominal aortic aneurysem
postoperative right lower extremity acute ischemia
postoperative left foot ischemia
postoperative acute blood loss anemia, transfused, corrected
postoperative acute renal failure [**2-9**] hypovolemia,hypotension
and rhabolmyosis
postoperative failure to thrive- Tf started
postoperative left gluteal decubitus.
postoperative rt. faciaotomy wound bleed, hemostasis obtained
Discharge Condition:
Stable
Discharge Instructions:
moniter INR for goal 2.0-3.0
INR@ d/c: 3.3
Wound Care:
Site: L LE
Type: Surgical
Cleansing [**Doctor Last Name 360**]: Saline
Dressing: Gauze - dry
Change dressing: [**Hospital1 **]
Site: L groin
Type: Surgical
Change dressing: every 2-3 days
Comment: Wound Vac at 75mmHg, black foam
Site: R groin
Type: Surgical
Change dressing: [**Hospital1 **]
Comment: Clean with sterile saline and cover with dry gauze in
fold to keep area dry
Site: R calf
Type: Surgical
Change Dressing: [**Hospital1 **]
Comment: cover with dry gauze and monitor for signs of
infection or necrosis of the graft
Site: R thigh
Type: Surgical--Skin Graft Donor Site
Cleansing [**Doctor Last Name 360**]: Saline
Comment: Open to air, may cover with dry gauze
Site: Sacrum
Type: Bedsore / Pressure Wound
Cleansing [**Doctor Last Name 360**]: Saline
Comment: moist to dry dressing changes daily. Monitor for
signs of infection.
Continue ostomy care
Incision Care: Keep clean and dry.
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
-If you have staples, they will be removed during at your follow
up appointment.
.
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
Followup Instructions:
2-3 weeks Dr. [**Last Name (STitle) 1391**], call for an appointment [**Telephone/Fax (1) 1393**]
Completed by:[**2171-10-7**]
ICD9 Codes: 2851, 5845, 4280, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3534
} | Medical Text: Admission Date: [**2141-2-23**] Discharge Date: [**2141-2-24**]
Date of Birth: [**2087-7-6**] Sex: M
Service: OTOLARYNGOLOGY
Allergies:
Bactrim
Attending:[**First Name3 (LF) 7729**]
Chief Complaint:
mass at tongue base (suspected squamous cell carcinoma),
supraglottic edema
Major Surgical or Invasive Procedure:
1. intubation
2. s/p biopsies of tongue
3. EGD
4. PEG tube placement
History of Present Illness:
Mr. [**Known lastname 23110**] is a 53yo M with PMH of HIV on Atripla (most recent
CD4 count 240 on [**9-/2140**]), and recent diagnosis of tongue cancer,
who is s/p direct laryngoscopy with biopsies at the posterior
base of the tongue, and EGD with PEG tube placement presents s/p
OR for supraglottic edema. Pt had planned procedure today in OR.
He required awake intubation with some possible irritation to
the vocal cords. He had direct laryngoscopy with biopsies of the
tongue (suspected source of squamous cell carcinoma) in addition
to EGD and PEG tube placement. PEG was placed with GI given
planned chemo and radiation in the near future. Besides the
laryngeal edema, no other complications. He had 15cc blood loss
and received 1L crystalloid fluids. Per discussion with ENT
resident, plan to keep intubated until tomorrow morning and
Decadron 10mg IV qh8rs. Pt was placed on Propofol in the OR, and
is doing well with no hemodynamic instability. Per d/w GI, plan
to not use PEG for 24hours, and they will reassess in the am.
.
On arrival to the ICU, vital signs T 94.1, BP 134/71, HR 85, RR
16, )2 sat 99%.He is intubated and sedated. Vent settings AC
FiO2 100%, Tv 500, Rate 14, PEEP 5 (no ABG yet sent on these
settings). His eyes are close, but nods to questions, follows
commands.
.
Review of systems: unable to obtain given intubated and sedated
Past Medical History:
Past Medical History:
- HIV, CD4 count 240 ([**9-/2140**])
- tongue squamous cell carcinoma. PET scan on [**2141-2-14**] that
showed marked FDG-avid mass near the base of the tongue that
measured approximately 33 x 26 mm as well as some residual
FDG-avid uptake at the site of the prior lymph node. Primary
site thought to be tongue
- HLD
.
Past Surgical History:
- s/p excisional biopsy of left cervical Lymph node [**2141-2-10**]
- EGD & PEG [**2141-2-23**]
- laryngoscopy, bx tongue [**2141-2-23**]
Social History:
He smoked for approximately 20 years. He quit in [**2124**] after
smoking approximately 1 pack per day. He works as an executive
director of the Synagogue. He has been with the same partner
[**Name (NI) **] for 32 years. He drinks a couple of glasses of wine a day.
Family History:
no history of cancer, CAD in Father
Physical Exam:
Admission Physical in ICU:
Vitals: T: 94.1 BP: 134/74 P: 85 R: 16 O2: 99%
General: intubated, eyes closed, following simple commands, in
NAD
HEENT: intubated through right nare, Sclera anicteric, MMM
Neck: supple, JVP not elevated
Lungs: Clear to auscultation bilaterally anteriorly, no wheezes,
rales, rhonchi
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: presence of PEG tube, hypoactive BS, soft, non-tender,
non-distended, no rebound tenderness or guarding, no
organomegaly
GU: foley in place
Ext: warm, dry, well perfused, 2+ DP pulses, no clubbing,
cyanosis or edema
Neuro: intubated, follows simple commands, squeezes fingers and
moves toes
Discharge Exam:
General: NAD
HEENT: extubated, Sclera anicteric, MMM
Neck: supple, JVP not elevated
Lungs: extubated, breathing comfortably, clear to auscultation
bilaterally, no wheezes, rales, rhonchi
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: PEG tube without erythema or tenderness at exit site,
hypoactive BS, soft, non-tender, non-distended, no rebound
tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, dry, well perfused, 2+ DP pulses, no clubbing,
cyanosis or edema
Pertinent Results:
Admission Labs:
[**2141-2-23**] 10:15AM BLOOD WBC-4.7 RBC-4.26* Hgb-13.0* Hct-37.0*
MCV-87 MCH-30.6 MCHC-35.2* RDW-13.4 Plt Ct-212
[**2141-2-23**] 10:15AM BLOOD Neuts-75.4* Lymphs-20.4 Monos-2.6 Eos-1.3
Baso-0.3
[**2141-2-23**] 10:15AM BLOOD Glucose-132* UreaN-13 Creat-0.8 Na-139
K-4.0 Cl-104 HCO3-28 AnGap-11
[**2141-2-23**] 10:15AM BLOOD ALT-46* AST-25 LD(LDH)-151 AlkPhos-92
TotBili-0.2
[**2141-2-23**] 10:15AM BLOOD Albumin-4.2 Calcium-9.2 Phos-1.8* Mg-2.1
[**2141-2-23**] 11:16AM BLOOD Type-ART Rates-14/ Tidal V-550 PEEP-5
FiO2-100 pO2-538* pCO2-39 pH-7.47* calTCO2-29 Base XS-5
AADO2-146 REQ O2-34 -ASSIST/CON Intubat-INTUBATED
[**2141-2-23**] 06:50PM BLOOD Type-ART pO2-165* pCO2-42 pH-7.43
calTCO2-29 Base XS-3
[**2141-2-23**] 11:16AM BLOOD Lactate-0.9
Discharge Labs:
[**2141-2-24**] 03:30AM BLOOD WBC-9.9# RBC-4.34* Hgb-13.5* Hct-38.1*
MCV-88 MCH-31.1 MCHC-35.5* RDW-13.4 Plt Ct-234
[**2141-2-24**] 03:30AM BLOOD PT-11.6 PTT-28.3 INR(PT)-1.1
[**2141-2-24**] 03:30AM BLOOD Glucose-137* UreaN-11 Creat-0.6 Na-139
K-4.3 Cl-104 HCO3-26 AnGap-13
[**2141-2-24**] 03:30AM BLOOD Calcium-8.5 Phos-3.8# Mg-2.3
Imaging:
[**2141-2-23**] CXR: The patient has been intubated. The tip of the
endotracheal tube projects 5 cm above the carina. There is no
evidence of complications, notably no pneumothorax. Otherwise,
normal chest radiograph, borderline size of the cardiac
silhouette, no pulmonary edema, no pulmonary nodules, no
pneumonia.
[**2141-2-24**] CXR: In comparison with the study of [**2-23**], the
endotracheal tube remains well positioned above the carina.
There is a band of atelectasis developing at the left base.
However, there is no evidence of acute focal pneumonia, vascular
congestion, or pleural effusion.
EGD [**2141-2-23**]: A 24FR percutaneous gastrostomy tube (PEG) was
placed successfully using standard techniques at the stomach
body.
Impression: Blood in the esophagus, stomach, and duodenum (from
PEG placement) Recommendations: Do not use PEG tube today.
Please come to [**Hospital Ward Name 1950**] 4 for teaching and PEG evaluation
sometime between 8 am and 4pm on [**2-24**].
Pathology: Biopsy of tongue pending on discharge.
Brief Hospital Course:
Brief Course:
Mr. [**Known lastname 23110**] is a 53yo M with PMH of HIV on Atripla (most recent
CD4 count 240 on [**9-/2140**]), and recent diagnosis of tongue cancer,
who is s/p direct laryngoscopy with biopsies at the posterior
base of the tongue, and EGD with PEG tube placement presents s/p
OR for supraglottic edema. He was admitted to the ICU for airway
management.
.
# Supraglottic edema: Likely [**3-9**] intubation, not an unexpected
complication per ENT, given difficult intubation. He was
monitored in the ICU and kept intubated overnight with VAP care.
He was started on Dexamethasone 10mg IV q8hrs to minimize upper
airway edema. ENT reassessed the patient the following morning
and he was extubated without complication. S/p extubation, ENT
performed a larygnoscopy that showed mild edema of the base of
the tongue and an open airway without edema of the vocal cords.
# Squamous cell carcinoma: Seen by cervical LN biopsy on [**2141-2-10**].
Likely primary is tongue and now s/p posterior tongue biopsies
on [**2141-2-23**]. Pt's Oncologist Dr. [**Last Name (STitle) **], and PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]
were notified of the admission. Pathology remained pending on
discharge.
# Nutrition: s/p PEG placement on [**2141-2-23**] with GI. The tube was
re-evaluated on [**2141-2-24**] with GI and on discharge, patient was
instructed to go to 7 [**Hospital Ward Name 1950**] for PEG tube teaching. The site
was nonerythematous, clean, dry, and intact on discharge.
# HIV: Most recent CD4 count 240 (8/[**2140**]). HIV viral load not
detected from 8/[**2140**].
Plan to restart Atripla once able to use PEG.
# HLD: Held Pravachol overnight, plan to restart Pravastatin
once able to use PEG.
.
Transitional Issues:
- Patient is to receive PEG tube teaching on discharge.
- He has ENT follow up next week and was given the phone number
to schedule GI follow up as well.
- PCP is aware of the patient's admission.
Medications on Admission:
- Atripla 1 tablet daily
- Flonase 50mcg 2 sprays each nostril [**Hospital1 **]
- Pravastatin 10mg daily
Discharge Medications:
1. ATRIPLA [**Telephone/Fax (3) 567**] mg Tablet Sig: One (1) Tablet PO once a
day.
2. pravastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Flonase 50 mcg/Actuation Spray, Suspension Sig: Two (2)
sprays Nasal twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Tumor at the base of the tongue.
Secondary Diagnosis: HIV, Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 23110**],
It was a pleasure taking care of you at [**Hospital1 827**]. You came to the hospital for placement of a
feeding tube and for biopsies of the base of your tongue. During
the procedure involving your tongue, you were noted to have
swelling of your vocal cords and upper airway. The Ear Nose and
Throat specialists were concerned that you would not be able to
breathe without the help of the breathing tube, and so you were
monitored for a day in the ICU with the breathing tube in place.
The following day, the breathing tube was removed without any
problem. [**Name (NI) **] are safe to go home with follow up (see upcoming
appointment below).
Please continue all home medications as prescribed. No changes
have been made to your medications.
Prior to leaving the hospital, please go to [**Hospital Ward Name 1950**] 4 for
feeding tube teaching.
Followup Instructions:
Please call to make your other follow up appointments as
previously instructed.
Department: OTOLARYNGOLOGY-AUDIOLOGY
When: FRIDAY [**2141-3-3**] at 11:10 AM
With: [**First Name4 (NamePattern1) 177**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 41**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 895**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
ICD9 Codes: 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3535
} | Medical Text: Admission Date: [**2176-5-1**] Discharge Date: [**2176-5-13**]
Date of Birth: [**2104-2-16**] Sex: F
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: This is a 72-year-old female
patient with a long-standing history of peripheral vascular
disease referred for an outpatient cardiac catheterization to
evaluate cardiomyopathy. The patient was noted to have an
abnormal EKG during a routine office visit. Follow-up
echocardiography revealed dilated cardiomyopathy of unknown
etiology with an ejection fraction of 15-20%. She was also
noted at that time to have an inferobasilar aneurysm and was
started on Coumadin. The patient subsequently had a positive
dobutamine stress echocardiogram which led to cardiac
catheterization.
PAST MEDICAL HISTORY: 1. Hypertension. 2.
Hypercholesterolemia. 3. Former cigarette smoker. 4. The
patient has had a totally occluded left internal carotid
artery and two small intracerebral aneurysms which were
reportedly not amenable to surgery. 5. Peripheral vascular
disease. 6. Prior cerebrovascular accidents with loss of
vision in her left eye.
PAST SURGICAL HISTORY: 1. Status post right carotid
endarterectomy in [**2174-12-17**]. 2. Status post laser eye
surgery. 3. Status post cesarean section.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON ADMISSION: 1. Lisinopril 10 mg p.o. q.d. 2.
Trental 400 mg p.o. t.i.d. 3. Zocor 20 mg p.o. q.d. 4.
Coreg 6.25 mg b.i.d. 5. Maxzide 75/50, ?????? tablet p.o. q.d.
6. Coumadin 4 mg q.d.
LABORATORY DATA: Her laboratory studies upon admission to
the hospital were unremarkable.
HOSPITAL COURSE: The patient underwent cardiac
catheterization on [**2176-5-1**] which revealed an 80% mid
distal left anterior descending coronary artery occlusion and
occluded mid left circumflex, subtotally occluded mid right
coronary with collaterals, left renal artery with 80%
stenosis and diffusely diseased aorta with an 80% stenosed
right iliac artery as well. Cardiac catheterization also
revealed left ventricular ejection fraction of approximately
40%.
The patient was taken to the operating room on [**2176-5-2**]
where she underwent coronary artery bypass grafting x 4 with
a left internal mammary artery to the left anterior
descending coronary artery, saphenous vein to the diagonal,
sequentially to the obtuse marginal and saphenous vein to the
posterior descending coronary artery. Postoperatively the
patient came out of the operating room on milrinone and
Neo-Synephrine IV drip to the cardiac surgery recovery unit,
where she was atrially paced via her epicardial wires.
Neo-Synephrine was readily weaned off. The patient remained
on a milrinone drip for the next day or so from which she was
ultimately weaned. The patient was weaned and extubated from
mechanical ventilation on postoperative day one.
On postoperative day two she was noted to be in atrial
fibrillation for which she received IV Lopressor. This
caused some bradycardia which required atrial pacing via her
epicardial wires.
On postoperative day three the patient's chest tubes were
removed. The patient remained in the cardiac surgery
recovery unit over the next few days due to some hypotension
requiring IV Neo-Synephrine drip. On postoperative day five,
[**5-7**], the patient was transferred to the telemetry floor
in good condition off the Neo-Synephrine drip, in normal
sinus rhythm, no longer requiring pacing. She was beginning
to be diuresed and tolerating that well. The patient
subsequently has had more episodes of atrial fibrillation
while on the telemetry floor, which were treated with
increasing doses of IV Lopressor, which she has subsequently
tolerated.
On postoperative day seven the patient was ultimately begun
on IV heparin drip and Coumadin was restarted. Her atrial
pacing wires were removed as she had still had some episodes
of atrial fibrillation at that time. The patient remained
hemodynamically stable and had been started on her Carvedilol
p.o. which she was on preoperatively. Amiodarone was
continued due to the atrial fibrillation postoperatively and
she remained in good condition. The patient had some
intermittent episodes of hematuria for which the heparin was
discontinued. She remained on Coumadin.
The patient's condition today, on [**2176-5-13**] remains as
follows: Temperature 97, pulse 70, in normal sinus rhythm.
She has not had atrial fibrillation for a number of days now.
Respiratory rate is 18, blood pressure 128/72, room air
oxygen saturation 93%. Her weight today is 62.1 kg which is
essentially the same as her preoperative weight. Her most
recent laboratory values reveal a white blood cell count of
7.5 thousand, hematocrit 36, platelet count 262,000, sodium
134, potassium 4.4, chloride 96, CO2 28, BUN 25, creatinine
1.1, glucose 136. Her INR today is 1.4. Her most recent
chest x-ray from [**5-12**] shows resolving small bilateral
effusions and left lower lobe atelectasis.
Physical examination shows neurologically the patient is
grossly intact with no apparent deficits. Pulmonary status
shows decreased breath sounds in her left base, otherwise her
lungs are clear to auscultation bilaterally. Her coronary
examination is regular rate and rhythm. Her abdomen is
benign. Her extremities are with trace pedal edema
bilaterally.
DISCHARGE MEDICATIONS:
1. Enteric-coated aspirin 81 mg p.o. q.d.
2. Colace 100 mg p.o. b.i.d.
3. Lasix 20 mg p.o. b.i.d. x 5 days.
4. Potassium chloride 20 mEq p.o. b.i.d. x 5 days.
5. Percocet 5/325 one p.o. q. 4 hours p.r.n.
6. Trental 400 mg p.o. t.i.d.
7. Amiodarone 200 mg p.o. b.i.d.
8. Captopril 6.25 mg p.o. t.i.d.
9. Simvastatin 20 mg p.o. q.d.
10. Carvedilol 6.25 mg p.o. b.i.d.
11. Coumadin 4 mg today, [**5-13**] and tomorrow, [**5-14**],
then she is to have a PT/INR drawn in Dr.[**Name (NI) 49687**] office,
who will be continuing to dose the Coumadin following her
blood levels.
CONDITION ON DISCHARGE: Good.
DISCHARGE DIAGNOSES:
1. Coronary artery disease status post coronary artery bypass
grafting x 4 on [**5-2**].
2. Postoperative atrial fibrillation.
3. Peripheral vascular disease.
FOLLOW UP: The patient is to follow up with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 70**] of cardiothoracic surgery in five to six weeks.
The patient is to follow up with her primary cardiologist,
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5293**] in one to two weeks. Also she is to
follow with Dr. [**Last Name (STitle) 5293**] for Coumadin dosing. She is also to
follow up with Dr. [**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) 911**] regarding future need for an
iliac stent placement. His office number is [**Telephone/Fax (1) 4022**] and
the appointment should be made to see Dr. [**Last Name (STitle) 911**] in about a
month after discharge.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Name8 (MD) 964**]
MEDQUIST36
D: [**2176-5-13**] 11:34
T: [**2176-5-13**] 12:20
JOB#: [**Job Number 49688**]
ICD9 Codes: 4111, 4280, 4254, 9971, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3536
} | Medical Text: Admission Date: [**2150-3-15**] Discharge Date: [**2150-3-24**]
Date of Birth: [**2075-1-1**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
New onset atrial fibrillation, poor urine output
Major Surgical or Invasive Procedure:
RIJ CVL placement and removal
Arterial line placement
RIJ temporary HD catheter placement
R PICC placement
Hemodialysis
History of Present Illness:
75 yo M h/o obesity, DM2, CRI (baseline cr 2.5), CHF,
chronically vent dependent [**1-17**] [**12-23**] PNA, presented from [**Hospital 671**]
Rehab after pt was noted to be in new atrial fibrillation. Pt's
available medical records are minimal at this time. Pt was
admitted to [**Location 1268**] VA in [**12-23**] for hypoxemic and subsequent
hypercarbic respiratory failure, ultimately requiring two
intubations.During that hospitalization, because of failure to
wean, pt was trached. Pt was diagnosed with VAP (microorganism
unknown), treated with cefepime. Pt was discharged ([**2-9**]) to
[**Hospital 671**] Hospital for longterm vent management/weaning. The
patient developed a gradual decline in his urine output. Labs at
the time revealed a cr elevated to 5.3. The patient was admitted
to [**Hospital6 **] on [**2-20**] for further evaluation of his
renal failure. During that admission the patient became volume
overloaded and was admitted to the MICU for initiation of HD.
The patient's course was complicated by citrobacter and VRE
bacteremia as well as acinetobacter growing from the sputum. The
pt was started on a 2 week course of linezolid and imipenem. The
pt's UOP improved to the point he no longer needed dialysis. He
was discharged [**3-4**]. Following discharge the pt was stable until
today when it was noted that his UOP had fallen to less than 20
130s (A fib) with stable BP. He was transferred to [**Hospital1 **] for futher
management.
Past Medical History:
# DM2
# CRI (baseline 2.5)
# CHF
# Trached and vent dependent [**1-17**] PNA
# Morbid obesity
Social History:
lives with wife, who is HCP
Family History:
Non-contributory
Physical Exam:
# VS: T102.4, BP117/65, HR151, RR32, O2sat 91, PS 15/10 Fi 100%
Gen: slightly anxious, mouthing answers to questions
appropriately
HEENT: MM dry
CV: irreg irreg, tachy, no murmurs
Chest: diffusely poor air movement, minimal at bases
Abd: obese, soft, NT, ND, +BS
Ext: brawny edema in LE, venous stasis changes
Neuro: following commands
Pertinent Results:
Admission Labs:
[**2150-3-15**] 09:05PM BLOOD WBC-10.7 RBC-3.73* Hgb-10.4* Hct-32.8*
MCV-88 MCH-27.9 MCHC-31.8 RDW-18.7* Plt Ct-174
[**2150-3-15**] 09:05PM BLOOD Neuts-86.2* Bands-0 Lymphs-8.9*
Monos-1.7* Eos-3.0 Baso-0.3
[**2150-3-15**] 09:05PM BLOOD PT-15.0* PTT-31.5 INR(PT)-1.3*
[**2150-3-15**] 09:05PM BLOOD Glucose-129* UreaN-129* Creat-4.4* Na-137
K-4.7 Cl-99 HCO3-24 AnGap-19
[**2150-3-15**] 09:05PM BLOOD ALT-5 AST-13 CK(CPK)-11* AlkPhos-169*
TotBili-0.3
[**2150-3-15**] 09:05PM BLOOD CK-MB-3 proBNP-[**Numeric Identifier **]*
[**2150-3-15**] 09:05PM BLOOD cTropnT-0.20*
[**2150-3-15**] 09:05PM BLOOD Albumin-2.6* Calcium-8.4 Phos-4.6* Mg-2.2
.
Studies:
CXR [**3-15**]: Markedly limited study. A PICC line from a right upper
extremity approach is evident with the line extending at least
to the superior vena cava. The exact tip is not seen. There is
diffuse interstitial and alveolar edema. A left lower lobe
consolidation cannot be excluded. Small bilateral pleural
effusions are noted
.
EKG [**3-15**]: afib, rate 127, VPCs, RBBB
.
Renal US [**3-17**]:
Note is made that this is an extremely limited ultrasound due to
the patient's body habitus. The left kidney was not visualized
on this examination. The right kidney measures 12.0 cm, and no
hydronephrosis is appreciated. Ultrasound is unable to further
characterize the kidney due to the poor visualization.
.
Bronchoscopy [**3-24**]:
No evidence of trauma, thin frothy pink secretions consistent
with pulmonary edema.
Brief Hospital Course:
A/P: 74M h/o morbid obesity, DM2, CRI, chronic vent dependency,
p/w poor UOP and A fib, now with clinical picture concerning for
sepsis
.
# Sepsis: Patient met SIRS criteria with temperature >102 and
hypotension with SBP 80s. He was given broad spectrum abx
including linezolid given his h/o VRE,
cefepime for broad gram neg coverage in this longterm rehab and
hospital resident, as well as his home flagyl. His cefepime was
changed to meropenem per ID given his h/o resistant
acinetobacter. A RIJ CVL was placed for pressors and CVP
monitoring. He was given IVF to maintain CVP>8 and initially
required neo to maintain MAP >60. Pressors were weaned off on
HD #2. The patient was pan-cultured including urine, blood and
sputum. In addition, his R PICC line was removed and tip was
sent for culture. His urine was felt to be the source as
cultures returned positive for >100,000 colonies of
pan-sensitive pseudomonas. He was continued on meropenem and
his flagyl and linezolid were discontinued. Stool was c diff
negative. In addition, the patient had 2 species of GNR in his
sputum, these were not identified at the time of transfer. The
patient remained hemodynamically stable and afebrile for the
remainder of his hospital stay. Blood cultures were negative at
the time of transfer. He was continued on meropenem to cover
possible pulmonary infection as well as UTI, last dose to be
given [**2150-3-25**].
.
# Acute on chronic renal failure: Cr on admission was elevated
to 4.4 which was above his baseline of 1.9. His acute renal
failure was felt to be in the setting of sepsis. On prior admit
he required aggressive treatment with pressors to resume UOP
after being oliguric for a period. A renal consult was obtained
who felt that his renal failure was [**1-17**] ischemic ATN in the
setting of sepsis. A renal US was obtained that showed a normal
right kidney without hydronephrosis. Left kidney was not
visualized due to body habitus. His Cr continued to trend up
and was 4.8 on [**3-20**]. A trial of diuresis with diuril 500mg and
lasix 160mg was attempted per renal with only 60cc of UOP.
Given his volume overload and oliguria a temporary RIJ HD line
was placed by IR on [**3-20**] and HD was initiated the same day. His
last HD session was [**3-23**] which he tolerated well. His
medications were renally dosed.
.
# Respiratory distress: Admission CXR showed possible b/l
infiltrates vs. pulmonary edema, however was extremely limited
due to body habitus. Was on broad-spectrum antibiotics with GNR
in sputum. He was primarily maintained on PS ventilation 12/5,
however patient was subjectively SOB and his pressure support
was increased to 15 on [**3-20**] despite stable O2 sats. He was tried
on trach collar, however the patient requested to be placed back
on vent due to SOB. He did not have a significant amount of
secretions and remained afebrile and his b/l infiltrates were
felt to be [**1-17**] pulmonary edema rather than infection. He was
initiated on HD for fluid removal on [**3-20**]. Anxiety was felt to
be contibuting significantly to his inability to wean from the
vent. He was started on Klonopin and Celexa on [**3-21**] to be
uptitrated as necessary. On [**3-23**] the patient developed some
bloody secretions from his trach in the setting of initiating
anticoagulation. A bronch was performed on [**3-24**] that showed
****. His coumadin was held and decision to restart deferred
*****.
.
# Atrial fibrillation: new onset in the setting of sepsis.
Remained in afib throughout his hospital stay. He was started
on low dose BB for rate control with good effect. Once his PICC
and HD line were placed he was started on coumadin. His BB was
uptitrated as his BP tolerated to a dose of 50mg tid. His HR
remained well-controlled with HR 80s-90s. INR on day of
discharge was 2.5 on a dose of 5mg coumadin. He should continue
his coumadin dose with close INR monitoring - every three days
for the first two weeks, and then prn for appropriate coumadin
dose adjustments to keep INR at goal of [**1-18**].
.
# hemoptysis: on the day of discharge the patient was having
scant hemoptysis and bronchoscopy was performed. He had pink
frothy secretions consistent with pulmonary edema and no
evidence of trauma. The etiology of his scant hemoptysis is
likely pulmonary edema only.
.
# DM2: He was maintained on his outpatient regimen of lantus
54units qam and RISS.
.
# FEN: He was continued on TFs per nutrition
.
# ppx: he was kept on PPI while in-house but this is
discontinued as of [**3-24**], no heparin to be given after discharge
as he is therapeutic on warfarin.
.
# Access: R IJ removed [**3-19**], R PICC placed [**3-19**], RIJ temp HD line
placed [**3-20**].
.
# Comm: son [**Name2 (NI) **] and wife/HCP [**Name (NI) 77789**] [**Telephone/Fax (1) 77790**]
.
# Code: Full (per discussion with wife and son)
Medications on Admission:
lantus 54 units QAM
pro-amatine 5 mg daily
aranesp 40 mcg
novolog sliding scale
lactulose 30 mL qid
combivent 4 puffs qid
silvadene
desenex
vitamin c
dulcolax
phoslo 667 mg tid
nexium 40 mg daiily
asa 81 mg daily
flagyl 500 mg tid
tylenol
bicitra 30 ml [**Hospital1 **]
heparin 5000 tid
zocor
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
2. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff
Inhalation Q6H (every 6 hours).
3. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Four (4)
Puff Inhalation QID (4 times a day).
4. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day): Hold for SBP<100 or HR <65.
7. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Titrate dose to goal INR [**1-18**].
8. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-17**] Sprays Nasal
QID (4 times a day) as needed.
9. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID PRN ()
as needed for anxiety.
11. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
12. Meropenem 500 mg Recon Soln Sig: 500mg Recon Solns
Intravenous Q12H (every 12 hours) for 1 days.
13. Insulin Glargine 100 unit/mL Solution Sig: Fifty Four (54)
units Subcutaneous qam.
14. Insulin Regular Human 100 unit/mL Solution Sig: per sliding
scale per sliding scale Injection with meals.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Sepsis
Acute on Chronic Kidney Disease
Atrial fibrillation, new onset
Pseudomonas UTI
Chronic respiratory failure, vent dependent
Diabetes
Morbid obesity
Discharge Condition:
Afebrile. Vent dependent.
Discharge Instructions:
You were admitted to the medical ICU with rapid heart rate and
low urine output. You were found to have an infection in your
urine that was likely causing your symptoms. You were started
on an IV antibiotic called meropenem and will need to complete a
10-day course. You have 1 more day of antibiotics.
.
You were also found to be in an irregular heart rate called
atrial fibrillation. You were started on a medication called
metoprolol to help control your heart rate. Given your
increased risk of stroke you were also started on a
blood-thinning medication called coumadin. This will have to be
monitored closely by your doctor to keep the level between [**1-18**].
.
We also started you on two new medications for your anxiety.
These are called celexa and Klonopin. Your doctors [**Name5 (PTitle) **] adjust
the doses of these to help with your anxiety.
.
Your kidney function declined in the setting of your infection
and the kidney doctors followed [**Name5 (PTitle) **] for this. It was decided to
initiate dialysis and a temporary catheter was placed and you
were started on dialysis. This will have to be continued
indefinitely or until your kidney function improves.
.
Please take all of your medications as prescribed.
.
Please keep you follow up appointments as below.
Followup Instructions:
Please follow up with your PCP for coumadin dosing, which will
be adjusted based on bloodwork.
.
Please follow up with nephrology regarding ongoing dialysis.
.
Please check INR in three days and every three days for the next
2 weeks, then as needed to monitor coumadin dosing.
Completed by:[**2150-3-24**]
ICD9 Codes: 0389, 5845, 2762, 5990, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3537
} | Medical Text: Admission Date: [**2193-12-23**] Discharge Date: [**2194-1-18**]
Date of Birth: [**2130-5-22**] Sex: M
Service: SURGERY
Allergies:
Ceftriaxone / Piperacillin Sodium/Tazobactam / Heparin Agents
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
aortoenteric fistula
Major Surgical or Invasive Procedure:
[**12-27**] ex lap, NAIS (Neo-Aorto-Iliac Surgery, [**Last Name (un) 72148**] procedure),
primay duodenal & pyloric exclusion, G & J tubes
[**1-2**] ex lap, duodenostomy tube placement
[**1-10**] percutaneous CT guided abdominal abscess drainage
[**1-12**] ex lap, end duodenostomy, small bowel resection x2, G
tube, J tube, repair of aortic tear
multiple central line, arterial line and swan placements
History of Present Illness:
63M s/p ruptured mycotic AAA repair with Dacron tube graft [**3-27**],
now with infected AAA graft site by CT & MR. His symptoms
include sharp epigastric and mid-back pain, low grade fevers and
general failure to thrive.
Past Medical History:
PMH: htn, etoh abuse (recently stopped drinking 1 month ago),
hyperlipidemia
PSH: bilateral inguinal hernias, endo AAA repair x 2 ([**3-27**])
Social History:
pos smoker / recently quit
pos drinker
Family History:
n/c
Physical Exam:
ON PRESENTATION
PE: v/s 98.9 87 124/76 20 95RA
Gen: thin male in intermittant severe distress with movement,
NAD
when perfectly still, well-appearing
HEENT: NC/AT, PERRLA bilat., slight L lateral strabismus, MMM,
soft neck without LAD
Cor: RRR without m/g/r, no bruits, no JVD
Lungs: CTA bilat., no w/r/[**Initials (NamePattern4) **]
[**Last Name (NamePattern4) **]: +BS, soft, NT, ND, no masses, 'swiss cheese' type
incisional hernia at midline laparotomy incision
Rectal: guaiac negative
PVasc: warm feet, no edema
Pulses: fem [**Doctor Last Name **] PT DP
R palp palp palp palp
L palp palp palp palp
Ext: no tissue loss
Neuro: grossly intact and non-focal
Pertinent Results:
review carevue
Brief Hospital Course:
review chart for specfics
[**12-23**]: admitted to vascular. ID, neurosurg consulted
[**12-27**]: operative repair of infected AAA. NAIS procedure
performed. intraop surgical consult for duodenal involvement
[**1-2**]: ex lap for duodenal leak - THAL patch performed
[**1-10**]: EC fistula from duodenal repair & intraaabdominal abscess
drained by CT
[**1-12**]: aortic rupture. shock, UGIB, abddominal distension.
taken to OR for ex alp, aortic repair & SB resection x 2
[**1-18**]: repear aortic rupture. shock, abddominal distension,
blood from JP's, blown pupil. patient made CMO after discussion
with family, who declined autopsy. ME & NEOB declined case.
Medications on Admission:
atorvastatin 20mg qd
ASA 81mg qd
mirtazapine 45mg qhs
levofloxacin 500mg qd (prophylaxis)
metoprolol 12.5mg [**Hospital1 **]
methylprednisolone 4mg qd
docusate 100mg [**Hospital1 **]
lactobacillus ii [**Hospital1 **]
fentanyl patch 12mg tp q72h
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
aortoenteric fistula
ruptured AAA
stroke
hemodynamic collapse
hemorrhagic shock
septic shock
respiratory failure
postop atelectasis
enterocutaneous fistula
heparin induced thrombocytopenia
blood loss anemia
bacteremia
line infection
intraabdominal abscess
Discharge Condition:
deceased
Discharge Instructions:
n/a
Followup Instructions:
n/a
Completed by:[**2194-1-18**]
ICD9 Codes: 0389, 5789, 2851, 5185, 5180 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3538
} | Medical Text: Admission Date: [**2133-4-8**] Discharge Date: [**2133-4-12**]
Date of Birth: [**2068-5-1**] Sex: F
Service: CARDIOTHORACIC
Allergies:
environmental
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Asymptomatic
Major Surgical or Invasive Procedure:
[**2133-4-8**] Mitral Valve Repair, PFO closure
History of Present Illness:
64 year old female who was found to have a new heart murmur on
physical exam in [**Month (only) 1096**]. An echocardiogram was performed which
revealed severe posterior leaflet mitral valve regurgitation.
She was referred to Dr. [**Last Name (STitle) 1655**] who performed a cardiac
catheterization which showed no significant coronary artery
disease however it confirmed severe mitral regurgitation noting
severe pulmonary hypertension. Given the severity of her mitral
valve disease, she has been referred for surgery. She presents
today for pre-admission testing prior to surgery.
Past Medical History:
Mitral regurgitation
Migraine headaches
Arthritis
Tubal ligation
Periodontal surgery
Social History:
Race: Caucasian
Last Dental Exam: Recently, undergoing extractions
Lives with: Widowed x3 years. 2 Children. Lives in [**Location 47**].
Occupation: Admistrative Assistant
Tobacco: [**2-15**] ppd quit in [**2098**]
ETOH: None
Family History:
Noncontributory
Physical Exam:
Pulse: 62 O2 sat: 98%
B/P Left: 137/80
Height: 5'3" Weight: 126lbs
General: NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur 4/6 SEM radiating to
carotids
Abdomen: Soft [x] non-distended [x] non-tender [x]+ BS [x]
Extremities: Warm [x], well-perfused [x] Edema: none
Varicosities: None [x]
Neuro: Grossly intact- nonfocal exam
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit- referred murmur
Pertinent Results:
[**4-8**] Echo: Pre Bypass: The left atrium is mildly dilated. No
mass/thrombus is seen in the left atrium or left atrial
appendage. A patent foramen ovale is present. A left-to-right
shunt across the interatrial septum is seen at rest. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. Regional left ventricular wall motion is
normal. [Intrinsic left ventricular systolic function is likely
more depressed given the severity of valvular regurgitation.]
The ascending aorta is mildly dilated and the st junction
appears partially effaced. There are three aortic valve
leaflets. There is no aortic valve stenosis. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are myxomatous.
There is partial Posterior mitral leaflet flail of P2 and
possibly part of P3 with a torn chordae seen. An eccentric,
anteriorly directed jet of Moderate to severe (3+) mitral
regurgitation is seen. Due to the eccentric nature of the
regurgitant jet, its severity may be significantly
underestimated (Coanda effect).
Post Bypass: Patient is in sinus rhythm on phenylepherine
infusion. There is a partial annuloplasty ring on the mitral
valve, which is also status post partial posterior leaflet
resection. There is trace/minimal mitral regurgitation. Peak
mitral gradients 4, mean 1 mm Hg. AI remains mild. TR remains
mild. PFO is now has tiny flow from left to right s/p closure.
LVEF 50-55%. Aortic contours intact. Remaining exam is
unchanged. All findings discussed with surgeons at the time of
the exam.
[**2133-4-12**] 06:35AM BLOOD WBC-5.2 RBC-2.82* Hgb-9.2* Hct-26.7*
MCV-95 MCH-32.7* MCHC-34.6 RDW-14.2 Plt Ct-103*
[**2133-4-8**] 01:43PM BLOOD WBC-8.1 RBC-2.14*# Hgb-6.9*# Hct-20.2*#
MCV-94 MCH-32.1* MCHC-34.1 RDW-14.1 Plt Ct-94*#
[**2133-4-12**] 06:35AM BLOOD PT-20.4* INR(PT)-1.9*
[**2133-4-8**] 01:43PM BLOOD PT-15.3* PTT-36.6* INR(PT)-1.3*
[**2133-4-12**] 06:35AM BLOOD UreaN-8 Creat-0.5 Na-138 K-3.5 Cl-102
[**2133-4-8**] 02:55PM BLOOD UreaN-10 Creat-0.4 Na-141 K-4.1 Cl-118*
HCO3-20* AnGap-7*
Brief Hospital Course:
Ms. [**Known lastname **] was a same day admit after undergoing pre-operative
work-up as an outpatient. On [**4-8**] she was brought to the
operating room where she underwent a Mitral valve repair with a
triangular resection of the middle scallop of the posterior
leaflet/Mitral valve annuloplasty with a 28 mm Physio II ring/
Closure of PFO with Dr.[**Last Name (STitle) **]. Please refer to operative report
for further details.She tolerated the procedure well and was
transferred to the CVICU for further invasive monitoring in
stable condition. Within 24 hours she was weaned from sedation,
awoke neurologically intact and extubated. Beta blockade and
aspirin were resumed. All lines and drains were discontinued in
a timely fashion. She was gently diuresed towards her
preoperative weight. She continued to progress and was
transferred to the step down unit for further monitoring on
POD#1. The physical therapy service was consulted for assistance
with her postoperative strength and mobility. On POD#2 she went
into postoperative atrial fibrillation. She was administered
Amiodarone and became bradycardic. Amiodarone was discontinued
and her home medication, Nadolol, was resumed. Her atrial
fibrillation was rate controlled and she was asymptomatic. After
24 hours of remaining in Atrial fibrillation anticoagulation was
initiated with Coumadin. She continued to make steady progress
and was discharged home on postoperative day #4. All follow up
appoinments were advised.
Medications on Admission:
Nadolol 20mg daily
Imitrex
Vitamins
Calcium
Discharge Medications:
1. furosemide 20 mg [**Last Name (STitle) 8426**] Sig: One (1) [**Last Name (STitle) 8426**] PO once a day for
5 days.
Disp:*5 [**Last Name (STitle) 8426**](s)* Refills:*0*
2. potassium chloride 10 mEq [**Last Name (STitle) 8426**] Extended Release Sig: Two
(2) [**Last Name (STitle) 8426**] Extended Release PO once a day for 5 days.
Disp:*10 [**Last Name (STitle) 8426**] Extended Release(s)* Refills:*0*
3. aspirin 81 mg [**Last Name (STitle) 8426**], Delayed Release (E.C.) Sig: One (1)
[**Last Name (STitle) 8426**], Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 [**Last Name (STitle) 8426**], Delayed Release (E.C.)(s)* Refills:*2*
4. ranitidine HCl 150 mg [**Last Name (STitle) 8426**] Sig: One (1) [**Last Name (STitle) 8426**] PO BID (2
times a day).
Disp:*60 [**Last Name (STitle) 8426**](s)* Refills:*2*
5. warfarin 1 mg [**Last Name (STitle) 8426**] Sig: [**Name8 (MD) **] MD [**First Name (Titles) 8426**] [**Last Name (Titles) **] Once Daily at 4
PM: INR goal =[**3-19**] for postop Atrial Fibrillation.
Disp:*90 [**Month/Day (3) 8426**](s)* Refills:*2*
6. warfarin 2.5 mg [**Month/Day (3) 8426**] Sig: One (1) [**Month/Day (3) 8426**] PO once a day for
2 days: 2.5 mg po today [**2133-4-12**] and 1 tab po [**2133-4-13**] .
Disp:*2 [**Month/Day/Year 8426**](s)* Refills:*0*
7. nadolol 20 mg [**Month/Day/Year 8426**] Sig: Two (2) [**Month/Day/Year 8426**] PO DAILY (Daily).
8. oxycodone-acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed for pain.
Disp:*qs ML(s)* Refills:*0*
9. potassium chloride 20 mEq [**Month/Day/Year 8426**], ER Particles/Crystals Sig:
One (1) [**Month/Day/Year 8426**], ER Particles/Crystals PO once a day for 5 days.
Disp:*5 [**Month/Day/Year 8426**], ER Particles/Crystals(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Mitral regurgitation and PFO s/p Mitral Valve repair and PFO
closure
Past medical history:
Migraine headaches
Athritis
s/p Tubal ligation
s/p Periodontal surgery
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesia
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] #[**Telephone/Fax (1) 170**], office will call you to
arrange follow up appointment at MWMC
Cardiologist: Dr. [**Last Name (STitle) 1655**] #[**Telephone/Fax (1) 6256**] -office will call you to
arrange follow up appointment
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 349**] in [**5-19**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Hospital 197**] Clinic at MWMC to be arranged for INR/Coumadin dosing
INR 1st draw by VNA on Tues:[**2133-4-14**], Please call INR results to
[**Hospital 88272**] [**Hospital 197**] Clinic# main number= [**Telephone/Fax (1) 6256**]
INR goal [**3-19**]
Indication: postoperative Atrial Fibrillation
Completed by:[**2133-4-12**]
ICD9 Codes: 4240, 4168, 9971 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3539
} | Medical Text: Admission Date: [**2118-11-12**] Discharge Date: [**2118-11-20**]
Date of Birth: [**2069-6-7**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
bilateral PE w/left DVT.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
49 yo M w/ h/o left ankle injury transferred from [**Hospital1 66318**] for continued management of bilateral PE w/ a
left DVT. Patient states he noticed left leg swelling and SOB
last night and in the morning his wife insisted he go to the
hospital. CTA at OSH w/ bilateral upper lobe PEs and LENI w/
left LE DVT. Patient denies c/o palpitations or dizziness. Over
the past couple days he has noticed considerable increase in SOB
and has noticed pleuritic CP, which is new. No hemoptysis. No
BRBPR since being on heparin. He reports he has been ambulating
and denies any recent surgeries. He has never had a clot in the
past. Mr. [**Known lastname 66319**] has had a cough productive of yellow sputum x 3
weeks. He has also had concurrent rhinorrhea. He has not
received any antibx to date for his sx. He denies h/o F. No
noticable weight loss. ABG at OSH: 7.44/39/68 on 2 L NC. In ED
he received IV heparin, morphine 2 mg IV, and an albuterol neb.
.
Allergies: NKDA
Past Medical History:
## h/o trauma to left ankle 1 yr ago w/ ligamentous tear
## neuropathic pain in left leg due to h/o trauma
## GERD
## h/o pilonidal cyst s/p surgical intervention as a child
## s/p appy as a child
## h/o back pain, s/p discectomy (Dr. [**Last Name (STitle) 66320**] 1.5 yrs ago
Social History:
Mother [**Name (NI) 2419**] h/o CVA at age 72, father w/ h/o pancreatic CA at age
62
Family History:
no etoh
+ tob: 3 ppd x 30 yrs
Unemployed. Married w/ kids.
Physical Exam:
T 100.1 hr 101-113 bp 146/90 rr 26-30 O2 97% on 4L NC
wt 265 lbs
genrl: increased WOB but o/w in nad
heent: perrla, op clear, mmm, upper dentures in place
neck: no JVD
cv: rrr, no m/r/g
pulm: decreased BS at both bases, poor air movement bilaterally,
no wheezes/ronchi
abd: nabs, diffusely tender to palpation w/o rebound/guarding
extr: 1+ pitting edema left leg
neuro: a, ox3, maew
Pertinent Results:
Admission labs:
CBC: WBC-14.3* RBC-5.04 Hgb-14.5 Hct-42.9 Plt Ct-174
Diff: Neuts-74.5* Lymphs-18.2 Monos-5.1 Eos-1.7 Baso-0.4
Coags: PT-13.7* PTT-34.6 INR(PT)-1.3
Chem10: Glucose-107* UreaN-21* Creat-1.1 Na-138 K-4.3 Cl-99
HCO3-27
Calcium-9.3 Phos-4.0 Mg-2.2
ABG: Type-ART pO2-131* pCO2-42 pH-7.39 calHCO3-26 Base XS-0
Cardiac enzymes: troponinT<0.01x3
Iron studies: calTIBC-160* Ferritn-478* TRF-123* Fe-34*
Discharge labs:
CBC: WBC-10.5 RBC-4.67 Hgb-13.1* Hct-39.3* Plt Ct-271
Coags: PT-17.0* PTT-104.6* INR(PT)-2.0
Chem7: Glucose-98 UreaN-20 Creat-1.2 Na-138 K-4.2 Cl-101 HCO3-28
EKG: sinus tach at 100 bpm, normal axis/intvls, new TWI III, +
PVC
Imaging:
OSH left LE U/S: + DVT involving left popliteal v up to mid
femoral v
OSH CTA: small bilateral subsegmental pulmonary emboli involving
upper lobes, small right pleural effusion, and right basilar air
space dz
OSH ECHO: preserved LV function, no note of RV strain
[**Hospital1 18**] CXR: poor inspiration w/ bibasilar atelectasis, bilateral
blunting of costophrenic angles, no obvious infiltrate
Brief Hospital Course:
Assessment: 49 yo man w/ history of left ankle injury 1 yr ago
transferred from an outside hospital for continued management of
bilateral pulmonary emboli with left deep venous thrombosis
without hemodynamic instability.
Hospital course is reviewed below by problem:
1. Bilateral PE w/ left DVT - On admission, he was
hemodynamically stable w/o right heart strain by EKG or OSH
ECHO. He was monitored in the ICU on heparin gtt + coumadin. His
risk factors included obesity, tobacco use, and h/o trauma to
ankle. Would strongly recommend a hypercoagulable workup as an
outpatient, including colonoscopy, PSA, and hypercoagulable
labs. He was discharged when his INR was therapeutic on coumadin
(with goal [**2-10**]) for 2 days. His PCP's office was contact[**Name (NI) **] to
get in touch with him for follow-up.
2. Cough w/ sputum - He was admitted with a cough productive of
sputum and leukocytosis but no fevers. He had a CXR without
obvious infiltrate. His sputum culture grew moraxella, but he
was otherwise asymptomatic. As it was unclear whether this was
colonization vs infection, he was not treated. He did report
chest pain, which was thought to be secondary to his PEs. He was
treated with nebulizers, then inhalers, and acetaminophen with
codeine. He initially needed additional pain medications but had
not taken any for several days prior to discharge.
3. Nicotine dependence - The patient was strongly encouraged
throughout his hospital stay to stop smoking. He was educated on
smoking cessation and given a prescription for the nicotine
patch on discharge. He endorsed the concept of quitting at the
time of discharge.
4. GERD - He was treated with a PPI but discharged without
(return to aciphex).
5. Code status - full
Medications on Admission:
aciphex
[**Doctor First Name 130**]
cymbalta 60 mg po qd (started Friday for neuropathic pain)
Discharge Medications:
1. Nicotine 21 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
Disp:*30 Patch 24HR(s)* Refills:*2*
2. Acetaminophen-Codeine 120-12 mg/5 mL Elixir Sig: 12.5-25 MLs
PO Q4H (every 4 hours) as needed for 1 weeks.
Disp:*qs ML(s)* Refills:*0*
3. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation every twelve (12) hours as needed for cough for
2 weeks.
Disp:*qs * Refills:*0*
4. Warfarin 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1) Acute pulmonary emboli
2) Deep Venous Thrombosis
Secondary:
3) Anemia - unspecified, perhaps iron deficiency or anemia of
chronic disease
4) chronic low back pain with neuropathic pain extending into
left lower extremity, s/p surgery in past
Discharge Condition:
Good; no further chest pain, improved cough, good oxygen
saturation on room air, stable vital signs.
Discharge Instructions:
Take all medications as prescribed below.
Follow up with your primary care provider as scheduled, ask him
to schedule you for a colonoscopy.
Call your doctor or return to the hospital if you have any
shortness of breath, worsening cough, chest pain, new or
worsening leg pain, dizziness or lightheadedness, bright red
blood in your stool or black stools, nausea, vomiting, or any
other concerning symptoms.
Followup Instructions:
You need a colonoscopy and perhaps an EGD to look at your colon
and perhaps your stomach and small intestine to further evaluate
the cause of your anemia (low blood count). It is important to
ensure you have no evidence of colon cancer or other type of
malignancy (cancer).
You must have your blood checked to monitor your coumadin
dosing. It is essential that you call your primary care
physician and get your 'INR' checked this week so that he can
adjust your coumadin as needed.
You should call the [**Hospital **] clinic after discharge to arrange
for a consultation with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 9645**]) to discuss
any further evalution for a predisposition to forming blood
clots.
You have the following appointment scheduled:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 20928**], MD ([**Telephone/Fax (1) 1669**]) Date/Time:[**2118-11-29**]
3:00
ICD9 Codes: 2859, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3540
} | Medical Text: Admission Date: [**2114-10-11**] Discharge Date: [**2114-10-23**]
Date of Birth: [**2044-2-3**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: This is a 70-year-old female
with metastatic breast cancer, who developed tachycardia
while at Interventional Pulmonology for thoracentesis. The
patient noted an increase in shortness of breath for a few
days and a chest x-ray revealed a new left pleural effusion.
She went for a diagnostic, therapeutic tap on the day of
admission. Prior to the thoracentesis, she noted a
significant increase in shortness of breath. After the
procedure, she was noted to be tachycardic to the 160s, with
a blood pressure in the 80s. The patient was then
transferred to the Emergency Department.
The patient at that time stated that she had an increased
dyspnea on exertion as well as shortness of breath for two
days. She denied chest pain, palpitations, nausea, vomiting,
diaphoresis, diarrhea, dysuria, cough, fevers, or chills. In
the Emergency Department, she was given adenosine and 5 mg of
diltiazem followed by 10 mg of diltiazem. This dropped her
heart rate from the 150s to the 80s, but she had a transient
decrease in blood pressure. Blood pressure responded to IV
fluids.
PAST MEDICAL HISTORY:
1. Metastatic breast cancer diagnosed in [**2105**] treated with
lumpectomy and XRT, [**2108**] with a recurrence left mastectomy
that was followed by Taxol/carboplatin x6 cycles, followed by
Xeloda x4 cycles, followed by Taxotere.
2. Hashimoto's thyroiditis.
3. Status post TAH/BSO with ovarian cysts and fibroids.
4. Pleural effusions, scheduled for pleurocentesis on day of
admission which was performed.
5. Biopsy proven lung metastases in [**2114-7-19**].
MEDICATIONS:
1. Levoxyl 137 mcg q day.
2. Compazine prn.
ALLERGIES: Clindamycin and penicillin which causes hives and
itching.
SOCIAL HISTORY: Lives with a friend, [**Name (NI) 17133**]. [**Name2 (NI) **] alcohol or
tobacco.
FAMILY HISTORY: Significant for breast cancer in maternal
aunt, who died in her 40's. Brother who passed away of head
and neck cancer in his 60's.
CODE STATUS: DNR/DNI.
PHYSICAL EXAMINATION: Heart rate 92, blood pressure 119/74,
respiratory rate 34, 99% on room air. General examination:
Pleasant white female in no apparent distress, slightly
tachypneic, wearing nasal cannula O2. Mucous membranes
moist. Pupils are equal, round, and reactive to light and
accommodation. Extraocular muscles are intact. No
lymphadenopathy, no jugular venous distention noted in the
neck. Lungs: Decreased breath sounds at the bases.
Cardiovascular shows regular, rate, and rhythm, S1, S2, no
murmurs, rubs, or gallops. Abdomen is soft, nontender,
nondistended with active bowel sounds. Extremities: No
cyanosis, clubbing, or edema, warm, 2+ pulses. Neurologic:
cranial nerves II through XII are grossly intact and
nonfocal.
LABORATORIES ON ADMISSION: White count 4.9, hematocrit 34.8,
platelets of 253, neutrophils 85%, lymphocytes 7.6, monocytes
6.7. Sodium 137, potassium 4.4, chloride 100, bicarb 21, BUN
34, creatinine 10, glucose of 170. Calcium of 9.3, magnesium
of 2.2, phosphorus of 4.5, AST of 48, alkaline phosphatase of
91. TSH of 1.4. CK 35, troponin less than 3. Pleural fluid
demonstrated 20-50 white blood cells, 6,000 red blood cells,
6 polys, 33 lymphocytes, 21 monocytes, 20 mesothelial cells,
protein 3.6, glucose of 112, LDH of 474 with a pH of 7.3.
Chest x-ray on [**10-11**] with decreased pleural effusion and
increased aeration when compared to [**10-14**] which showed
a left pleural effusion with collapse.
CT scan of the chest of [**2114-7-19**], nodule new left lower
lobe, old lingular, in the left base increased ground glass.
Electrocardiogram: First and second with rates in the 150s
and 160s, question of MAT versus atrial fibrillation. Three
showed atrial fibrillation at 101 with normal axis and
intervals, no acute changes, and the fourth showed sinus at
97 with multiple P-wave formations, question of atrial
pacemaker.
HOSPITAL COURSE: This 70-year-old woman with metastatic
breast cancer status post thoracentesis was admitted with
increased heart rate and decreased blood pressure, was
admitted for observation. She was kept on Telemetry, her
enzymes were cycled, and was given diltiazem as needed for
blood pressure as well as rate control. Her shortness of
breath on admission was likely due to the tachycardia, as
well as the pleural effusion which improved post-tap. It was
noticed on the day following admission, on examination
patient had alternating loud versus soft heart sounds,
bedside echocardiogram was obtained which demonstrated a
pericardial effusion, the patient was emergently transferred
to the catheterization laboratory, where a pericardial drain
was placed. At that point, equalization of RA and
pericardial pressures was confirmed which diagnosed
tamponade. Bloody fluid of 525 cc was removed and sent for
analysis. Patient was transferred to the CCU with the
pericardial drain.
The catheterization report specifically said pericardial
pressure was decreased from 20 mm Hg to less than 0 mm Hg,
and the right atrial pressure decreased from 18 mm Hg to
[**4-27**], P.A. saturation increased from 53 to 64%.
In the CCU, the patient continued to have intermittent
episodes of atrial fibrillation for which he was treated with
diltiazem prn. Due to her current bouts of atrial
fibrillation, it was determined to start her on amiodarone in
hopes of better control of her atrial fibrillation. The
patient was continued to be monitored in the CCU, the
pericardial drain was removed on [**10-13**] without difficulty
since the drainage was minimal.
While in the CCU, the patient had recurrence of her pleural
effusions, she developed a large right sided effusion, at
which time Interventional Pulmonology was consulted. On
[**10-15**], a therapeutic tap of the right pleural effusion
was performed without complications. Serous fluid 750 cc was
removed at that time.
On the 28th, a followup echocardiogram was also performed
which demonstrated decreased size of pericardial effusion,
without evidence of tamponade. Due to the patient's history
of metastatic breast cancer, with recurrent pleural
effusions, as well as patient's symptomatic improvement
post-thoracenteses, on [**10-16**], Interventional
Pulmonology performed a left sided pleurodesis.
Patient remained in the CCU, with intermittent episodes of
both atrial fibrillation as well as hypotension in the 70s,
concern was for recurrence of the pericardial effusion. The
repeat echocardiogram based on this episode of hypotension on
the 30th, was negative for recurrent pericardial effusion.
The patient was then transferred back to the floor.
On the evening, the patient continued to have episodes of
atrial fibrillation in the 140s, even though she had been
started on an amiodarone drip in the unit, and converted to
an amiodarone po load followed by amiodarone 400 tid. Thus
she was given diltiazem x2 followed by a diltiazem drip which
resolved in sinus rhythm, but hypotension. The drip was
discontinued, and she was given fluid boluses. Of note, with
the chest tube in place following the pleurodesis, the
patient continued to have significant drainage of 350 cc per
24 hours, thus, more talc was infused via chest tube on
[**10-19**]. The patient continued to remain comfortable.
In order to help control the atrial fibrillation, amiodarone
was continued, and metoprolol 12.5 mg po bid was added for
better control.
The patient continued to remain stable, and relatively
remained in normal sinus on the amiodarone and metoprolol.
The patient was asymptomatic and feeling comfortable, but the
chest tube was still in as of [**10-20**]. The patient
continued to have followup echocardiograms with no evidence
of pericardial effusion reaccumulation.
On the 4th, the chest tube was eventually removed without
complications. The followup chest x-ray did not demonstrate
any evidence of pneumothorax or effusion reaccumulation.
Patient did have an elevated white count, though likely due
to a talc infusion, and the patient was afebrile, the patient
was started on levofloxacin 500 q day as prophylaxis.
Patient remained stable, with only intermittent episodes of
atrial fibrillation, although she remained asymptomatic, it
was determined that the patient, due to her malignancy
pericardial effusion, as well as pleural effusions requiring
pleurodesis, patient when stable was discharged home with
hospice on [**10-23**].
The patient was to followup with primary care physician, [**Last Name (NamePattern4) **].
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**], phone number [**Telephone/Fax (1) 10492**].
DISCHARGE DIAGNOSES:
1. Metastatic breast cancer.
2. Malignant pleural and pericardial effusions.
3. Atrial fibrillation.
4. Hypothyroidism.
DISCHARGE MEDICATIONS:
1. MSIR concentrate 20 mg/cc 2-20 mg sublingual q1h prn.
2. Ativan 0.25-2 mg sublingual q4-6h prn.
3. Scopolamine 5 mg/cc 0.1-0.2 cc transdermal q8h prn.
4. Metoprolol 12.5 mg po bid.
5. Amiodarone 400 mg po bid.
6. Levofloxacin 500 mg po q day x5 days.
7. Percocet 1-2 tablets po q4-6h prn.
8. Pantoprazole 40 mg po q day.
9. Neutra-Phos one packet po bid.
10. Ambien prn.
11. Levothyroxine 137 mcg po q day.
12. Tylenol prn.
13. Procloperazine prn.
DISCHARGE STATUS: Improved symptomatically, stable with
hospice.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**]
Dictated By:[**Name8 (MD) 17134**]
MEDQUIST36
D: [**2115-2-28**] 13:40
T: [**2115-3-1**] 06:47
JOB#: [**Job Number 17135**]
ICD9 Codes: 4271 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3541
} | Medical Text: Admission Date: [**2191-11-22**] Discharge Date: [**2191-11-30**]
Date of Birth: [**2117-9-11**] Sex: F
Service: MEDICINE
Allergies:
Hydralazine / Opioid Analgesics / Compazine
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Removal of hemodialysis catheter, replacement with tunnelled
catheter
Pulmonary Intubation
Placement of PICC line
Cardiac cathteterization: 3VD
History of Present Illness:
74 yo W with PMH of DM, ESRD on HD, HTN, SVC stenosis s/p
dilation presents from HD with acute dyspnea. She reports
malaise the past 5 days. In dialysis, she had a low-grade temp
of 99, and developed chills and respiratory distress with sats
80's on NRB at which time she was sent to ED for further
evaluation.
.
In the ED, VS: T 100.6, HR 117, BP 170/84, RR 38, Sat 90% on
NRB. She reported chest pain. She had evidence of new LBBB with
discordant ST elevations <5mm in V2-V4. CODE STEMI was called.
She received ASA 325mg, Plavix 600mg load, heparin bolus+gtt,
nitro gtt. She also received 1 gm Vanco for presumed line
sepsis. She was intubated with Etomidate and Rocuronium and
transferred to the cath lab for intervention.
.
In the cath lab, she was found to be right dominant with no
disease in left main. Serial 90% lesions in LAD with TO at mid
LAD. She has left-to-left collaterals. Minimal disease in circ.
RCA with 30% mid occlusion and 90% at origin of PDA. Lesion in
RCA could be crossed wire but not ballon due to tortous nature.
CT [**Doctor First Name **] was recommended. Post-cath, the LBBB was resolved and HR
was lower. LVEDP was elevated at 35. Patient was transferred to
the CCU for further monitoring.
Past Medical History:
1. Hypertension
2. Hypothyroidism: [**2-5**] thyroidectomy in [**2173**] for benign growth;
TSH 5.4 in [**3-12**]
3. DM type II: For >10yrs; [**2189**] HgbA1c 6.9
4. ESRD: on HD (T, Th, Sat); s/p left loop forearm AV graft in
[**2187**], now using Tunelled HD Line
5. CVA [**2186**]: left caudate infarct; mini-strokes before that
6. Gait disorder: shaky and unsteady when she walks
7. Splenectomy in [**2145**] [**2-5**] trauma
8. SVC stenosis
9. Cataract surgery bl
Social History:
Patient lives alone at home but daughter [**Name (NI) **]([**Telephone/Fax (1) 108910**])
is extensively involved in her care. She has 7 other children.
She uses a walker at baseline, but has been wheelchair bound for
several months per the daughter because patient is afraid of
falling. She denies current or past tobacco, alcohol or illicit
drug use.
Family History:
Mother: died 5 year ago (cause unknown to pt)
Father: died when pt was 17 (cause unknown to pt)
Children have no major medical problems
Physical Exam:
VS: T=98.3 BP=159/66 HR=82 RR=19 O2 sat= 95% on AC 500/16/5/1
HENT: Pupils 4->3 mm, equal. Scleral edema
GEN: Intubated. Responds to commands. Breathing comfortably
on vent.
CV: RRR. nl S1 S2. II/VII systolic murmur at LUSB without
radiatation to carotids.
P: Good airation bilaterally. Diffuse ralles.
ABD: S NT ND
EXT: 1+ edema
NEUR: PERRL, EOMI, (+) cough & gag. Moves all four extremities
with command with grossly normal strength and sensation.
Pertinent Results:
[**2191-11-27**] 06:16AM BLOOD WBC-28.5* RBC-3.43* Hgb-10.6* Hct-32.7*
MCV-96 MCH-30.8 MCHC-32.3 RDW-14.1 Plt Ct-495*
[**2191-11-29**] 07:20AM BLOOD WBC-19.8* RBC-3.03* Hgb-9.6* Hct-28.9*
MCV-95 MCH-31.7 MCHC-33.2 RDW-14.5 Plt Ct-342
[**2191-11-22**] 12:03PM BLOOD Neuts-93.2* Lymphs-2.7* Monos-3.8 Eos-0.1
Baso-0.1
[**2191-11-29**] 07:20AM BLOOD PT-17.9* PTT-33.1 INR(PT)-1.6*
[**2191-11-29**] 07:20AM BLOOD Glucose-195* UreaN-20 Creat-3.6*# Na-136
K-3.9 Cl-95* HCO3-24 AnGap-21*
[**2191-11-22**] 12:03PM BLOOD ALT-20 AST-22 LD(LDH)-352* CK(CPK)-39
AlkPhos-119* TotBili-0.3
[**2191-11-27**] 06:16AM BLOOD Calcium-9.1 Phos-4.3 Mg-1.9
[**2191-11-22**] 01:29PM BLOOD %HbA1c-6.9*
BCx [**11-22**]: PANTOEA SPECIES. NGTD since then
Influenza neg
C Diff neg x 3
CXR [**11-29**]
No evidence for CHF or pneumonia. Minimal bibasilar atelectasis
and mild pulmonary vascular congestion.
CT ABD [**11-27**]:
1. Slight thickening of the gastric antrum. This is very likely
due to
underdistension and much less likely due to antral gastritis.
2. No bowel obstruction. No evidence of fluid collection.
3. Colonic diverticula, most prominent in the sigmoid colon. No
evidence for diverticulitis.
4. Stable renal hypodensities since the prior study. These are
indeterminate by CT criteria and may be further evaluated with
renal ultrasound.
5. Rounded tissue density adjacent to the SMA as detailed. This
is unchanged from multiple prior studies and may represent an
adrenal nodule. Contrast enhanced study may aid.
ECHO [**11-22**]: The left atrium is normal in size. The interatrial
septum is aneurysmal. No atrial septal defect is seen by 2D or
color Doppler. There is mild symmetric left ventricular
hypertrophy with normal cavity size. There is mild regional left
ventricular systolic dysfunction with focal hypokinesis of the
distal inferior wall, distal septum and apex. The remaining
segments contract normally (LVEF = 55 %). The estimated cardiac
index is normal (>=2.5L/min/m2). Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen. There
is moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2189-10-26**], a mild regional left ventricular wall motion
abnormality is now seen c/w CAD, Moderate pulmonary artery
systolic hypertension is now present.
CATH [**11-22**]:
1. Two vessel coronary artery disease.
2. Diastolic dysfunction and elevated systemic blood pressure.
3. Unsuccessful attempts to rervascularize the RPDA and LAD.
4. Cardiac surgery was consulted for CABG.
Brief Hospital Course:
74 yo W with PMH of DM, ESRD on HD, CVA, HTN presents with
NSTEMI and pulmonary edema in setting of GNR bacteremia.
BACTEREMIA: Pt found to have Pantoea spp in multiple cultures on
[**11-22**]. As pt continued to be febrile with climbing WBC, his
hemodialysis line was removed and thought to be the culprit
infectious source as she developed rigors with removal. The line
was replaced after line holiday of 3 days. Upon removal of the
line, the cuff was retained. This was evaluated by the
transplant surgeons who determined that this was not concerning
and it would not act as a nidus of infection. Pt was treated
with meropenem for 2 week course (end [**12-7**]) from first negative
blood culture on [**11-23**], and midline was placed to continue the
course as an outpt. Given the persistent elevated WBC, pt was
screened for C Diff and although was negative x 3, was treated
empirically with PO flagyl while on Meropenem for the
bacteremia. At time of discharge WBC was trending down and pt
was afebrile.
PUMP: On presentation pt was hypoxic with SOB, and showed signs
of pulmonary edema on CXR, in the setting of demand ischemia.
Echo showed normal EF, interatrial aneusym and mild regional
left ventricular systolic dysfunction with focal hypokinesis of
the distal inferior wall, distal septum and apex. Pt was
uptitrated on ACE inhibitor and beta-blocker prior to discharge.
HYPOXIC RESPIRATORY FAILURE: On presenation, pt was intubated,
but had marked improvement in respiratory status following
antibiotics and diuresis. Patient was extubated without
difficulties, and continued to sat well afterwards.
HYPERTENSION: As an outpatient, Ms. [**Known lastname 108904**] was on several
medications for blood pressure control. As an inpatient, her
blood pressure has been well controlled on Metoprolol and
Lisinopril with SBPs in 110-120s. There is some concern that
Ms. [**Known lastname 108904**] may have not been adherent to her regimen at home.
CORONARIES: Pt was determined to have demand ischemia given
bacteremia. Initially she was thought to have an NSTEMI
(elevated troponin and new LBBB). Given cath with severe
flow-limiting lesions not amenable to PCI that appear chronic,
more likely to be demand ischemia, especially given bacteremia.
Pt was medically managed with ASA, statin, beta-blocker and ACE
inhibitor and evaluated for CABG by CT surgery. She will need
outpt follow up for preop workup and scheduling.
RHYTHM: Pt remained in NSR the majority of the hospitalization
except several episodes of atrial tachycardia controlled with IV
betablocker. She remained hemodynamically stable throughout.
GI BLEED: Had guaiac positive stool but HD and labs stable.
Scope/workup deferred until after CABG. C diff was sent and
negative x 3 but per ID recs, given high white count and broad,
will continue getting prophylactic flagyl dosed at hemodialysis
while on 2 week meropenem course.
ESRD on HD: Pt was followed by renal team with dialysis as
needed. She was continued on nephrocaps and calcium acetate.
- Patient will need HD on Saturday.
DIABETES: Blood sugars were treated with insulin sliding scale
while oral meds were held.
HISTORY OF STROKE: Pt was continued on warfarin and heparin
bridge for line removal and replacement.
HYPOTHYROIDISM - Pt was continued on levothyroxine.
Medications on Admission:
1. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO HS.
2. Clonidine 0.3 mg/24 hr Patch TD QMON.
3. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO QAM
4. Lactulose 30ml PO PRN for constipation.
5. Levothyroxine 100 mcg PO daily.
6. Lisinopril 40mg PO QAM.
7. Calcium Acetate 667 mg 2 tabs PO TID
8. MVI PO DAILY (Daily).
9. Docusate 100mg Capsule PO BID
10. Minoxidil 10 mg PO QAM
11. Metoprolol Tartrate 150 mg PO BID.
12. Lorazepam 0.5 mg PO Q6H as needed.
13. Losartan 100 mg PO QAM
14. Glipizide 5.0 mg Tablet PO BID
15. Lansoprazole 30 mg Tablet,Rapid Dissolve, PO DAILY.
16. Warfarin 7.5 mg Tablet Sig: One (1) Tablet PO once a day.
17. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day.
18. Sevelamer 800mg (1) tab PO TID with meals
Discharge Medications:
1. Outpatient Lab Work
Please check CBC, Chem 7, LFT's on [**2191-12-3**] at dialysis and call
results to Dr. [**Last Name (STitle) 1366**] (nephrology) at ([**Telephone/Fax (1) 773**]
2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
3. Renagel 800 mg Tablet Sig: One (1) Tablet PO three times a
day.
4. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: 4,000-11,000
unit dwell Injection PRN (as needed) as needed for line flush:
For use by dialysis ONLY.
7. Prevacid 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
8. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for Anxiety.
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for Fever, pain.
10. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
11. Warfarin 7.5 mg Tablet Sig: One (1) Tablet PO Once Daily at
4 PM.
12. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
13. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
14. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO HD
PROTOCOL (HD Protochol): Last day [**2191-12-7**].
15. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours): last day [**2191-12-7**]. On
dilaysis days, give after dialysis.
16. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush: For use
with PICC.
17. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: 1.5
Tablet Sustained Release 24 hrs PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Demand coronary ischemia, not STEMI
End Stage Renal Disease on Hemodialysis
Bacteremia with Pantoea, on Meropenem
Gastroenteritis/Diarrhea
Diabetes Mellitus
Hypertension
Discharge Condition:
stable.
stable.
K 3.3 (repleted)
BUN 33
Creat 5.4
WBC 19.8
Hct 29.8
Discharge Instructions:
You had some strain on your heart because you were so sick, your
heart function has recovered now. You developed an infection in
your blood, you will need intravenous antibiotics to treat this.
You also have gastroenteritis, possibly from the antibiotics.
You are on a medicine to treat this as well. It has been
recommeded that you have bypass surgery to fix the blockages in
your coronary arteries. This will need to be done after you have
finished your antibiotics and after an EGD/Colonoscopy is
performed.
.
New Medicines:
1. Miropenem: to treat the infection in your blood
2. Flagyl: to prevent a bowel infection while you are on the
Miropenem
3. Atorvastatin: to lower your cholesterol
Please stop taking:
1. Minoxidil
2. Losartan
3. Clonidine
4. Amlodipine
These medicines will be added back on as your blood pressure
improves.
Followup Instructions:
Nephrology:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1366**], MD Phone: ([**Telephone/Fax (1) 773**]. Pt will see Dr. [**Last Name (STitle) 1366**]
at dailysis.
Primary Care:
[**Name6 (MD) 4370**] [**Name8 (MD) **], MD Phone: [**Telephone/Fax (1) 250**] Date/time: Please make an
appt to see after you get out of rehabilitation.
Cardiology:
Dr. [**First Name8 (NamePattern2) 5987**] [**Last Name (NamePattern1) **] Phone: [**Telephone/Fax (1) 62**] Date/Time: Friday [**12-23**] at 11:40am. [**Hospital Ward Name 23**] clinical Center, [**Location (un) 436**].
.
Cardiac Surgery:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 914**], MD Phone: [**Telephone/Fax (1) 170**] Date/time: [**2191-12-13**] at
2pm
.
Gastroenterology:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 572**], MD Phone: [**Telephone/Fax (1) 87101**] Date/time:
[**2191-12-16**] at 8;30am. [**Hospital Unit Name **] Suite 8E, [**Location (un) **].
Completed by:[**2191-11-30**]
ICD9 Codes: 5856, 2762, 4280, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3542
} | Medical Text: Admission Date: [**2124-5-29**] Discharge Date: [**2124-6-2**]
Service: MEDICINE
Allergies:
Ace Inhibitors / Nitroglycerin Transdermal
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
admit from home for elective peripheral procedure
Major Surgical or Invasive Procedure:
Cath and renal artery stenting
History of Present Illness:
80 year old woman with DM, HTN, choles, prior CVA, carotid
disease, PVD s/p failed ? left leg bypass, moderate AS, CAD< s/p
CABG in [**2116**] (LIMA-->LAD,SVG-->OM2, OM1-->diagonal), Prior PCI,
admitted in [**2124-4-28**] (d/c'd [**5-13**]) with NSTEMI, had Cx
stented with Cypher. Also noted to have severe right RAS.
Direct admit from home today to have MRA of left leg, hydration
overnight and then Peripheral procedure with Dr [**Last Name (STitle) **] as a 1st
case tomorrow.
Since d/c, notes progressive cooling of left foot. Notes an
aching, cramping pain, along her left buttock and lateral thigh,
occuring consistently after several steps. Her left foot will
ensuingly becomes numb and painful. Symptoms remit with rest.
Does not have consistent rest pain, though has had some trouble
on occasion sleeping [**3-1**] pain. Hanging feet over edge of bed
does not help.
Denies leg, or calf cramping or pain. Qulatity of pain is not
burning, numbness, or tingling
On detailed review of symtpoms, she mentions an episode of SSCP
lasting several minutes, releived with Sl NTG. Had no associated
N/V, diaph, SOB. This pain was not as intense as the crushing
pain with which she presentted in [**5-2**]. Notes [**5-2**] transient
episodes of chest pain w/ either rest or exertion since
discharge [**5-13**]. Has uses prn Sl NTG for these episodes with
resolution of symptoms.
She also complains of pain along the site of her hernia. Does
not note a buldge in her inguinum, nor necorosis. Has been
evaluated by her surgeon who plans to operate following
cardiovascular work up.
Past Medical History:
CAD s/p CABG in [**2116**] LIMA-->LAD, SVG-->OM1, OM2-->diag
Left CEA [**2116**]
shunt and patch from Left carotid to ascending aorta [**2116**]
[**2121**] NSTEMI in setting of SVT, stent for 80% LMA blockage
CHF with EF of 45-50% with moderate TR/MR
RFA for AV nodal tachycardia--successful
COPD on home O2 at night 2L
Hypothyroidism
HTN
CRI, baseline Cr 1.4
PVD
Left Iliofem bypass and aorto-fem bypass [**2111**]
Ant tibial bypass
CVA x 2 with some residual right-sided weakness
osteoporosis
ventral hernia repair x 4
s/p TAH
s/p left ORIF of hip
anemia of CD
Diabetes
Hyperlipidemia
Social History:
widowed, lives alone, no EtOH, quit tobacco 15 yrs ago
Family History:
non-contributory
Physical Exam:
Gen: Pleasant. NAD. PSeaking in complete sentences
VS: 98.3, 116/64, 61, 18, 98%RA
HEENT NCAT, PERRL
NECK: no JVD
Chest: CTA
CV: rrr, [**3-5**] HSM
ABD: s, nt, nd, Right lower ventral budge w/ strain, easily
reduceable, no incarceration, no necrosis
EXT:
-bilateral femoral bruits
-popliteal pulses 1+ B/L
-trace RIGHT DP, cannot palpate PT pulse. Pedals palpable on
right
-no dependant rubor
-unable to assess capillary refill given baseline
onychomycotic changes to nails
-skin in b/l feet moderately cool L>R, skin atrophic, hairless
-moderate tenderness to palpation diffusely along left thigh and
as well as dorsum and lateral left foot. most tender along
hallux, no point tenderness at dorsum.
-no erythema, warmth
-no sensation loss to light touch
NEURO: CN 2-12 intact
Brief Hospital Course:
##Arterial occlusive disease: Pt has claudication by history. No
evidence of acute arterial thrombotic/occlusion that would
threaten this limb acutely. Had hypotension following procedure,
brief CCU stay, BP improved quickly.
##Unilateral Severe RAS: Pt has chronic kidney disease. Creatine
improved after hydration. She had a unilateral renal artery
stent placed during this admission, pt tolerated procedure
without difficulties.
##CAD: s/p CABG, recent stenting. With several epoisodes of CP
at home (last while travelling here) relieved with NTG. OMR note
of several episodes of rest pain of unclear etiology (?
vasospasm) post cath and prior to d/c on last admit. Pt has not
had any further episodes of chest pain in-house. Cardiac enzymes
are negative x3
##ENDO: DM II and hypothyroid. No issues while here.
##COPD: nightly home 02. No issues while here
Medications on Admission:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Levothyroxine Sodium 88 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Atenolol 50 mg Tablet Sig: One (1) Tablet PO twice a day.
8. Atacand 32 mg Tablet Sig: One (1) Tablet PO once a day.
9. Pravastatin Sodium 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Insulin Regular Human 100 unit/mL Solution Sig: as dir
Injection ASDIR (AS DIRECTED): as dir.
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Levothyroxine Sodium 88 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Atenolol 50 mg Tablet Sig: One (1) Tablet PO twice a day.
8. Atacand 32 mg Tablet Sig: One (1) Tablet PO once a day.
9. Pravastatin Sodium 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Insulin Regular Human 100 unit/mL Solution Sig: as dir
Injection ASDIR (AS DIRECTED): as dir.
Discharge Disposition:
Home With Service
Facility:
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **]
Discharge Diagnosis:
renal artery stenosis
DM II
CAD
COPD
Discharge Condition:
stable
Discharge Instructions:
Resume previous activity
Followup Instructions:
PCP [**Last Name (NamePattern4) **] [**1-30**] weeks
ICD9 Codes: 4280, 496, 412, 2449, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3543
} | Medical Text: Admission Date: Discharge Date:[**2193-7-24**]
Service:ORTHO
CHIEF COMPLAINT: Wound infection.
HISTORY OF PRESENT ILLNESS: This is an 82 year old woman
with a history of multiple medical problems who is ventilator
dependent who came under the care of the orthopedic spine
fusion on [**2193-4-26**]. Her postoperative course at that time
was complicated by pulmonary edema and a fall. She was
transferred to rehabilitation initially and readmitted for
revision on [**2193-5-28**].
Her postoperative course was complicated by respiratory
failure ultimately resulting in trache/peg placement. The
is noted that the patient had purulent drainage for some time
from the wound.
PAST MEDICAL HISTORY: Congestive heart failure with ejection
fraction approximately 55%, restrictive lung disease,
osteoporosis, kyphoscoliosis, gastroesophageal reflux
disease, history of falls, question of dementia. Past
medical history also includes hypertension, history of
methadone resistant Staph aureus infections. CMV pneumonia.
Methicillin resistant Staphylococcus aureus wound infection.
PAST SURGICAL HISTORY: Posterior spinal fusion on [**2193-4-26**]
and then revision [**2193-5-28**], percutaneous endoscopic
gastrostomy trache placement.
MEDICATIONS ON ADMISSION: Lisinopril 10 once a day, Imdur 20
twice a day, Epo 40 twice a day, Colace 200 mg twice a day,
Glutamine three scoops t.i.d., heparin subcutaneous q.d.,
Fosamax 10 q.d., vitamin C, iron, Fentanyl, morphine [**1-30**],
codeine, Tylenol, Atenolol, Vancomycin.
ALLERGIES: Morphine causes GI upset.
DATA: White count 12, hematocrit 22, creatinine 0.5, K 3.7,
albumin 2.2., coags are normal.
Chest x-ray showed pleural effusion read as atelectasis
versus pneumonia.
Posterior skin wound showed dehiscence of the wound with
purulent drainage.
HOSPITAL COURSE: The patient admitted to the hospital with a
diagnosis of wound infection and taken to the Operating Room
after receiving medical clearance for incision, irrigation
and debridement of posterior wound infection on [**2193-6-28**],
see op date for details of procedure.
Postoperatively the patient was covered by intravenous
antibiotics of Vanco with a VAC dressing in place. The
patient had a lengthy postoperative course which involved
Plastic Surgery becoming involved in her care. Prior to
discharge, the patient's events included;
Cardiac. The patient had episodes of bradycardia which
initially were treated by pacer but subsequently she
stabilized from the standpoint and the Cardiology team
decided that this would not be necessary. They followed her
throughout her admission.
Infectious Disease. The patient who was initially admitted
for wound infection received multiple debridements of the
wound with VAC change while she was here and finally closure
by Plastic Surgery two days prior to her discharge to
rehabilitation facility. She also, during her course, spiked
a fever to 103 degrees and grew out Pseudomonas from her [**3-31**]
blood cultures as well as from her urine. She was followed
throughout her course by the Infectious Disease team who
managed her antibiotic dosage.
FOLLOW-UP: The patient is discharged to rehabilitation,
doing well. The patient will follow-up with the Plastic
Surgery Service regarding her wound prior to discharge. The
patient will follow-up with Dr. [**Last Name (STitle) 363**] regarding her spine
tremors. The patient will follow-up with Infectious Disease
Team and Cardiology Teams.
DISCHARGE MEDICATIONS:
1. Ativan 1 mg p.r.n.
2. Hydralazine 10 mg intravenous.
3. KCL.
4. Vitamin C.
5. Subcutaneous heparin b.i.d.
6. Gluconate.
7. Nystatin.
8. Lisinopril 40 once a day.
9. Lasix 10 once a day.
10. Simethicone 40 twice a day.
11. Tylenol.
12. Colace
13. Epogen 40,000 units q. week.
14. Zoloft once a day.
15. Nystatin powder.
16. Fosamax 10 once a day.
17. Ceftazidime two tabs t.i.d.
18. Vancomycin 750 mg intravenous.
WOUND CARE: Per Plastic Surgery. Dressing changes p.r.n.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 3863**]
Dictated By:[**Last Name (NamePattern1) 102752**]
MEDQUIST36
D: [**2193-7-24**] 09:15
T: [**2193-7-24**] 11:29
JOB#: [**Job Number 102753**]
ICD9 Codes: 486, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3544
} | Medical Text: Admission Date: [**2142-4-27**] Discharge Date: [**2142-5-7**]
Date of Birth: [**2075-9-27**] Sex: M
Service: Cardiothoracic Service
HI[**Last Name (STitle) 2710**]OF PRESENT ILLNESS: Patient is a 66-year-old man,
who had developed nocturnal dyspnea and congestive heart
failure starting about six months ago with increasing
frequency since [**Month (only) 404**]. In early [**Month (only) 958**], he developed chest
pain and was admitted to [**Hospital1 **] for rule out MI. He was
cathed at that time. Catheterization showed 80% occlusion of
the RCA, 80% occlusion of the LAD, 90% occlusion of the OM,
and subtotal diagonal-1 occlusion with preserved LV function.
At that time, he was referred to Dr. [**Last Name (Prefixes) **] for coronary
artery bypass grafting.
PAST MEDICAL HISTORY:
1. Hypertension.
2. An ablation for SVT in [**2133**].
3. L4-5 compression fracture.
4. BPH.
5. Hypercholesterolemia.
6. Diabetes mellitus.
7. Chronic renal insufficiency.
MEDICATIONS PREOPERATIVELY:
1. Imdur 60 mg q.d.
2. Lisinopril 40 mg q.d.
3. Lasix 80 mg b.i.d.
4. Potassium chloride 20 mEq b.i.d.
5. Labetalol 300 mg b.i.d.
6. Allopurinol 300 mg 3x a week.
7. Glucovance 2.5/500 one tablet q.d.
8. Lantus insulin 30 units q.p.m.
9. Enteric-coated aspirin one q.d.
10. Multivitamin one q.d.
11. Saw [**Location (un) 6485**] one q.d.
12. Flaxseed oil 1000 units q.d.
13. Plavix 75 mg q.d.
14. Zinc chloride 80/5 one tablet q.d. recently discontinued.
ALLERGIES: Patient states an allergy to penicillin.
FAMILY HISTORY: Significant for coronary artery disease.
His father had a CABG in the past.
OCCUPATION: He is a retired machinist.
SOCIAL HISTORY: Denies tobacco and alcohol use. Lives at
home with his wife.
PHYSICAL EXAM: Height 5'7", weight 250 pounds. General: No
acute distress. Skin: Warm and dry, no lesions, rashes, or
abrasions. HEENT: Pupils are equal, round, and reactive to
light. Extraocular movements are intact. Mucous membranes
moist. Neck is supple, no lymphadenopathy, no bruits, no
JVD. Chest was clear to auscultation bilaterally. Heart:
Regular rate and rhythm, no murmurs, rubs, or gallops.
Abdomen is soft, nontender, and nondistended with positive
bowel sounds. Extremities are warm, well perfused with no
clubbing, cyanosis, or edema. No varicosities.
Neurological: Alert and oriented times three, nonfocal exam.
Pulses are 1+ throughout.
EKG: Sinus rhythm with no acute changes.
Chest x-ray: Preoperatively showed a normal sized heart, a
tortuous aorta, normal pulmonary vasculature, no effusions,
no pneumothorax. Degenerative changes noted in the thoracic
spine.
LABORATORY DATA: White count 7.7, hematocrit 49, platelets
233. PT 14, PTT 36, INR 1.3. Sodium 143, potassium 4.4,
chloride 98, CO2 31, BUN 17, creatinine 1.0. Urinalysis is
negative. Total bilirubin 0.7, albumin 4.4..
HOSPITAL COURSE: Patient was scheduled to be a postoperative
admit and on [**4-27**], he was admitted to the osteoporosis,
where he underwent coronary artery bypass grafting x3.
Please see the OR report for full details. In summary, the
patient had a CABG x3 with LIMA to the LAD, saphenous vein
graft to OM-1, and saphenous vein graft to the RCA with a
right carotid endarterectomy. Patient's bypass time was 137
minutes with a cross-clamp time of 103 minutes. He tolerated
the operation well, and was transferred from the operating
room to the Cardiothoracic Intensive Care Unit.
At the time of transfer, the patient's mean arterial pressure
was 77 with a CVP of 13. He was A-V paced at 80 beats per
minute, and at that time, he had Neo-Synephrine at 0.5
mcg/kg/minute and propofol at 20 mcg/kg/minute. Patient did
well in the immediate postoperative period. His anesthesia
was reversed. He was weaned from the ventilator and
successfully extubated.
On postoperative day one, the patient remained
hemodynamically stable. He was weaned from vasoactive IV
medications. He was started on oral pain medications as well
as metoprolol, however, he continued to complain of severe
incisional pain, and was therefore begun on PCA. For that
reason, he was kept in the Intensive Care Unit.
On postoperative day two, the patient continued to be
hemodynamically stable. However, it was noted that he did
have postoperative atrial fibrillation. At that time, his
metoprolol was increased, and he was begun on amiodarone.
Patient continued to have periods of atrial fibrillation and
first degree A-V block following the initiation of
amiodarone.
By postoperative day three, the patient was hemodynamically
stable, and was felt to be ready to be transferred from the
Cardiothoracic Intensive Care Unit to the floor for
continuing postoperative care and cardiac rehabilitation. At
that time, his central lines were removed. His chest tubes
were removed, and his pacing wires remained in place.
Once on the floor with the assistance of Physical Therapy and
the nursing staff, the patient's activity level was
increased. However, on postoperative day four, the patient
became increasingly confused and agitated requiring Ativan
and Haldol intravenously, and he again went into atrial
fibrillation at times with a ventricular rate of 120 and a
blood pressure of 120-140/60. In order to more closely
monitor his cardiac status as well as his neurologic status,
the decision was made to transfer the patient back to
Intensive Care Unit at that time. Infusion workup was
initiated at that time. Patient's electrolytes, LFTs, and
blood cultures all returned within normal limits. Patient
remained in the Intensive Care Unit for three additional days
during which time he was begun on IV amiodarone following
which he converted to a normal sinus rhythm.
His confusion cleared and on postoperative day seven, the
patient was transferred back to [**Hospital Ward Name 121**] 2 for continued
postoperative care and cardiac rehabilitation. Again with
the assistance of the nursing staff and Physical Therapy, the
patient's activity level was increased. It was noted that
the patient did have a small amount of serous drainage from
the distal pole of his sternal wound. This was felt to be
due to thrashing incurred during the patient's agitated
episodes. The wounds were painted with Betadine and covered
with dry sterile dressings. There was no erythema noted at
that time. Additionally, the patient did receive one dose of
vancomycin following which a bright red rash was noted. The
vancomycin was discontinued and clindamycin was begun at that
time.
Over the next several days, the patient had an uneventful
hospital course. He remained hemodynamically stable and
afebrile. On postoperative day 10, it was decided that the
patient would be stable and ready for transfer to
rehabilitation for continuing postoperative recovery.
At time of transfer, the patient's physical exam was as
follows: Vital signs: Temperature 98.2, heart rate 76 sinus
rhythm, blood pressure 143/79, respiratory rate 20, and O2
saturation 96% on room air. Weight preoperatively was 112
kg, at discharge 116 kg. Laboratory data: White count 10.6,
hematocrit 32.3, platelets 446. Sodium 140, potassium 3.8,
chloride 101, CO2 29, BUN 26, creatinine 1.2, glucose 134.
Physical exam: Alert and oriented times three, moves all
extremities. Follows commands. Respiratory: Clear to
auscultation bilaterally. Cardiac: Regular rate and rhythm,
S1, S2 with no murmur. Sternum is stable. Incision with a
small open area at the base of the incision. Minimal amount
of serous drainage. Abdomen is soft, nontender, and
nondistended with normoactive bowel sounds. Extremities are
warm and well perfused with 2-3+ edema. Saphenous vein graft
sites with Steri-Strips, draining serous fluid bilaterally
left greater than right.
DISCHARGE MEDICATIONS:
1. Lasix 40 mg IV b.i.d.
2. Potassium chloride 20 mEq b.i.d.
3. Lisinopril 40 mg b.i.d.
4. Amiodarone 400 mg q.d. x2 weeks, then 200 mg q.d.
5. Enteric-coated aspirin 325 mg q.d.
6. Plavix 75 mg q.d. x3 months.
7. Pantoprazole 40 mg q.d.
8. Allopurinol 150 mg q.d.
9. Glucovance 2.5/500 one tablet q.d.
10. Clindamycin 600 mg q.8h. x1 week.
11. Flagyl 500 mg q.8h. x1 week.
12. Metoprolol 100 mg b.i.d.
13. Regular insulin-sliding scale and glargine 30 units
q.h.s.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: He is to be discharged to rehabilitation.
FO[**Last Name (STitle) **]P INSTRUCTIONS: He is to followup with Dr. [**Last Name (Prefixes) 411**] in four weeks and follow up with Dr. [**Last Name (STitle) 12614**] at
[**Hospital1 **] in [**4-12**] weeks.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Name8 (MD) 415**]
MEDQUIST36
D: [**2142-5-7**] 09:53
T: [**2142-5-7**] 10:05
JOB#: [**Job Number 12615**]
ICD9 Codes: 4280, 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3545
} | Medical Text: Admission Date: [**2183-1-8**] Discharge Date: [**2183-1-10**]
Date of Birth: [**2125-1-18**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: This is a 58 year old female
with a history of coronary artery disease and multiple stents
complicated by thrombosis and restenosis who last underwent
cardiac catheterization at [**Hospital6 2910**] in
[**2182-4-30**] at [**Hospital6 **] for right coronary artery
restenosis. The area was dilated, complicated by dissection,
treated with Cypher drug-eluding [**Hospital6 **] and metal [**Hospital6 **]. In
[**2182-5-30**] the patient had recurrent angina, now occurring on
a daily basis, worse with exertion. There was pain lying
flat, so using four pillows at home. Presenting MIBI with
fixed anteroseptal defect and reversible inferior and
inferoseptal defect, now admitted to CMI for catheterization.
At catheterization right coronary artery arthrectomy placed
complicated by right coronary artery perforation, treated
with [**Year (4 digits) **]. Echocardiogram without pericardial effusion. No
symptoms now, also a large right inguinal hematoma.
ALLERGIES: Sulfa, Plavix, Codeine.
CURRENT MEDICATIONS AT HOME: Aspirin 81, Monopril 40 q.h.s.,
Metformin 1000 b.i.d., Pravachol 40 q.h.s., Verapamil 240
q.h.s., Lexapro 20 q.h.s., NPH 30, q. AM, 30 q.h.s., Humalog
10 q. dinner, Ambien 10 q.h.s., Ticlid 250 b.i.d., Zantac 150
b.i.d., Lasix 20 q. AM, Nitroglycerin prn.
PAST MEDICAL HISTORY: 1. Diabetes; 2.
Hypercholesterolemia; 3. Hypertension; 4. Coronary artery
disease, right coronary artery [**Year (4 digits) **] in [**2179**], [**2179-12-1**]
[**Last Name (un) **]/stenting right coronary artery, [**2181-5-16**], 80%
right coronary artery and [**Year (4 digits) **] restenosis, status post [**Year (4 digits) **]
complicated by thrombosis treated with a [**Last Name (LF) **], [**2182-4-30**]
positive angina, positive ETT MIBI, in-[**Year (4 digits) **] restenosis, to
[**Hospital6 **], stenosis dilated, Cypher [**Hospital6 **] and metal
[**Hospital6 **] placed; 5. Obesity; 6. Status post bladder suspension
surgery; 7. Left frozen shoulder; 8. Depression; 9. Hiatal
hernia; 10. Gastritis; 11. Tonsillectomy; 12. Bilateral
carpal tunnel release; 13. Arthroscopic left knee surgery.
SOCIAL HISTORY: Married, quit smoking tobacco ten years ago.
FAMILY HISTORY: Father died at 71 with coronary artery
disease. Grandfather died at 52 with a history of coronary
artery disease. Uncle with coronary artery bypass graft in
his 50s.
PHYSICAL EXAMINATION: Vital signs, temperature 97.7, heart
rate 98, respirations 13, 94% on room air saturations, blood
pressure 141/71. General: Obese and pleasant female, in no
acute distress. Head, eyes, ears, nose and throat:
Extraocular movements intact, pupils equal, round and
reactive to light and accommodation. Mucous membranes, moist
and pink. Neck: No jugulovenous distension appreciated.
Pulmonary: Clear to auscultation bilaterally. Abdomen:
Large, round, soft, nontender, nondistended. Bowel sounds
present. Cardiovascular: Regular rate and rhythm, no
murmurs, rubs or gallops appreciated. Extremities: Left
hand with petechiae, lower extremities with no cyanosis,
clubbing or edema.
LABORATORY DATA: Diagnostic studies reveal electrocardiogram
interpretation, sinus rhythm with left bundle branch block.
Echocardiogram: [**2183-1-8**], preliminary
echocardiogram showed no minimal pericardial effusion, no
evidence of tamponade. Repeat echocardiogram, [**2183-1-10**], no occlusions, limited study, no carotid doppler study
performed. The left atrium is normal in size. Left
ventricular wall thickness was normal. Left ventricular size
cavity size is normal. Overall left ventricular systolic
function is moderately depressed. Overall left ventricular
systolic function is moderately depressed. Resting regional
wall motion abnormalities include septal, anterior akinesis.
Though, the views are limited, it appeared that the inferior
wall was akinetic. There was a small pericardial effusion.
The effusion appears circumferential. There are no
echocardiographic signs or tamponade. Compared to the
previous report of [**2183-1-9**], effusion has not
changed. The ejection fraction appears worse than previously
reported. Previous study is not available for review.
Ejection fraction of 35% to 40%. Cardiac catheterization
[**2183-1-8**]: 1. Left ventriculography revealed an
ejection fraction of 46% with mild global hypokinesis. There
was no mitral regurgitation. 2. Selective coronary
angiography revealed a right dominant system. The left main
coronary artery, left anterior descending and left circumflex
were angiographically normal. The right coronary artery had
a 70% stenosis. The neostented gap was seen on the
previously placed proximal image stents. There was 90%
restenosis placed on the initially placed mid [**Year (4 digits) **]. There
was a 60% restenosis on the distal Cypher [**Year (4 digits) **]. There was
minimal disease of the posterior descending artery,
percutaneous transluminal coronary angioplasty site. 3. At
the end of the procedure right heart catheterization was
performed to rule out tamponade. The right-sided filling
pressures were normal. The preliminary capillary wedge
pressure was 12 mm of mercury. The left ventricular end
diastolic pressure was elevated about 30 mm of mercury.
Cardiac index depressed at 2.2 liters/min meter squared. 4.
Successfully stenting of right coronary artery was performed
with 3 by 5 by 33 mm Cypher drug-eluding [**Year (4 digits) **], complicated
initially by vertebra entrapment, perforation and dissection
of the artery. Final diagnosis: 1. One vessel coronary
artery disease; 2. Moderate systolic and diastolic
ventricular dysfunction; 3. Ventricular right coronary
artery. Hemodynamics: Right atrium 12/9/9, right ventricle
28/10, pulmonary artery 28/16/21, pulmonary capillary wedge
15/13/12, left ventricle 163/30, aorta 163/78, cardiac output
4.4, cardiac index 2.2, SVR 1836, PVR 164. ETT date, [**2182-9-23**], affixed anteroseptal defect, inferior/inferior
septal staining with reperfusion, ejection fraction of 34%.
Laboratory data on [**2183-1-4**], sodium 141, potassium
4.3, chloride 102, bicarbonate 26, BUN 21, creatinine 0.8,
INR 0.9, white blood count 9.3, hematocrit of 36.8, decreased
down to 33 and platelets 276. Peak CKMB 10.
HOSPITAL COURSE: 1. Cardiovascular - The patient was
brought up to the Coronary Care Unit for closer monitoring in
light of the patient's dissection and perforation of the
right coronary artery. The patient was placed on Telemetry
and serial hematocrits were monitored q. 4 hours and q. 6
hours and then q. 12 hours. The patient's hematocrit dropped
from 33 to 31.7 at which point the patient was transfused 1
unit of packed red blood cells with an inappropriate bump and
the patient's hematocrit of 30.7. The patient was then given
a second unit of packed red blood cells with an appropriate
increase to 34.2. The patient's hematocrit subsequently
remained stable and increased to a predischarge hematocrit of
36.7. The patient was started on Aspirin, kept on
Ticlopidine, started on Aspirin, low dose beta blocker and
ACE inhibitor. ACE inhibitor and beta blocker were not
started on the day of admission in Coronary Care Unit until
there was evidence that the patient was hemodynamically
stable. Once, hemodynamic stability was demonstrated, the
patient was started on low dose beta blocker, ACE inhibitor
and titrated up as tolerated. TTE worse than at bedside and
repeated several days after to evaluate for cardiac
tamponade. The patient at no point throughout the stay
showed any indication of pericardial tamponade. The
patient's TTE showed an ejection fraction of 35% to 40%. The
patient was in normal sinus rhythm throughout the entire stay
with episodic episodes of ectopy. The patient ultimately in
the Cardiac Catheterization Laboratory had a Cypher [**Year (4 digits) **]
placed in the right coronary artery. The patient was kept
within the Coronary Unit for one day and subsequently was
transferred to the floor the following day.
2. Hematoma - The patient developed a large right inguinal
hematoma which remained stable, nontender the remainder of
the stay. There was evidence of a small left groin hematoma
as well which did not increase in size. Both hematomas
receded 20 to 30% prior to discharge.
3. Depression - The patient will be restarted on an
outpatient medication regimen on the day of discharge.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSIS:
1. Unstable angina
2. Percutaneous coronary intervention to right coronary
artery
3. Aneurysm of coronary vessel
4. Right coronary artery in-[**Year (4 digits) **] restenosis
5. Right coronary artery perforation
DISCHARGE MEDICATIONS:
1. Aspirin 325 once a day
2. Metformin 1000 mg twice a day
3. Lexapro 20 mg q.h.s.
4. Insulin NPH 30 units twice a day
5. Ticlopidine 250 mg twice a day
6. Insulin, LysPro 10 units, PPN with thinner
7. Zantac 150 mg twice a day
8. Lasix 20 mg once a day
9. Metoprolol tartrate, 50 mg tablet, [**1-31**] tablet p.o. twice
a day
10. Pravachol 40 mg tablet q.h.s.
11. Monopril 20 mg tablet q.h.s.
12. Me
FOLLOW UP:
1. Please follow up with primary care physician, [**Last Name (NamePattern4) **].
[**First Name8 (NamePattern2) 30623**] [**Last Name (NamePattern1) **] in one to two weeks. Call to make an
appointment at [**Telephone/Fax (1) 30837**].
2. Please follow up with Dr. [**Last Name (STitle) **], Cardiology on Monday
[**2-10**], at 9:20 AM, [**Last Name (NamePattern1) 102032**]:
[**Telephone/Fax (1) 5003**].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 53716**]
Dictated By:[**First Name3 (LF) 102033**]
MEDQUIST36
D: [**2183-1-11**] 23:07
T: [**2183-1-12**] 06:08
JOB#: [**Job Number 102034**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3546
} | Medical Text: Admission Date: [**2171-11-27**] Discharge Date: [**2171-12-19**]
Date of Birth: [**2102-9-20**] Sex: M
Service: SURGERY
Allergies:
Lipitor / Augmentin
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
pulseless left leg and black stool
Major Surgical or Invasive Procedure:
Lower extremity Arteriogram
EGD x 2 with endoclipping
OPERATIONS:
1. Ultrasound-guided puncture of right common femoral
artery.
2. Contralateral third-order catheterization of left
external iliac artery.
3. Abdominal aortogram.
4. Serial arteriogram of left lower extremity.
Procedure: Left [**Name (NI) 109913**] PTA BPG with NRGSV
History of Present Illness:
69 yo man with scleroderma with CREST and peripheral vascular
disease, who was initially admitted on [**11-27**] to Vascular surgery
for L foot ischemia and is now being transferred to Medicine
following continued GI bleed. The patient was in his usual
state of health until one week prior to admission, when he began
to experience pain, tingling, and numbness in his left foot with
ambulation. Two days prior to admission his wife observed that
the toes on his left foot had become black at the distal
portions. On the day of admission, he had a bowel movement
producing a small caliber black stool that stuck to the lining
of the toilet. There was no associated rectal pain, abdominal
pain, hemoptysis, or evidence of active bleeding per rectum.
That same day he attended an appointment with his podiatrist,
who referred the patient to [**Hospital1 18**] after observing that his left
foot was cold and pulseless. At the podiatry appointment, the
patient had another bowel movement that was again black colored.
.
In the ED, the patient presented afebrile with the following
vitals: HR 64 BP 90/74 Resp 16 O(2)Sat 97. The patient was
found to be guaiac positive, and his Hct was down to 33 from his
baseline 42. He was admitted to Vascular Surgery for management
of his peripheral vessel disease. On hospital day 2, the
patient patient was briefly transferred to the SICU due to
continued evidence of bleeding and was transfused with 3 units
of RBCs with appropriate Hct bump from 29 to 38. He underwent
EGD to the third part of the duodenum, which revealed a single 5
mm ulcer in the first part of the dudodenum with evidence of
recent bleeding that was treated through placement of endoclips.
A second 1-2 mm ulcer was also found just distal to the treated
lesion but showed no evidence of bleeding. The patient was
begun on heparin anticoagulation at this point given
identification and treatment of likely GI bleed source and the
need to address the likely thromboembolic etiology of his lower
extremity peripheral vascular disease. He was eventually
transferred to the floor, although since hospital day 3 he has
had episodes of hypotension (documentation shows at least one
episode to 63/41), melena, and continuously downtrending Hct to
the most recent nadir of 26.2 today, HD#5. At this point, the
patient was taken off heparin at 1330 PM and was given two units
of RBCs. He was transferred to Medicine, and awaits urgent EGD
scheduled for tomorrow to address his continued GI bleed.
With regard to the patient's vascular disease, serial
arteriogram performed on hospital day 3 demonstrated complete
occlusion of the anterior tibial artery just beyond its origin,
but no intervention was taken. Definitive treatment for his
lower extremity PVD is pending resolution of the patient's GI
bleeding. In addition, chest CTA performed on HD#3 revealed an
incidental finding of multifocal ground-glass patchy opacities
with some nodules and bronchial wall thickening that raised
concern for aspiration/mycobacterial infection, and the patient
was started on a 7 day course of levofloxacin. No fever, night
sweats, foreign travel, or notable sick contacts, although the
patient endorses a 15 lb weight loss over past year and some
recent coughing.
Past Medical History:
- CAD s/p MI, s/p stenting (stents to the RCA, LAD and
circumflex
coronaries.), on ASA and Plavix
- PVD
- scleroderma (sclerodactyly, [**Last Name (un) 8061**])
- hypertension
- gout
- spinal stenosis
- depression
- septic bursitis
- chronic renal insufficiency
- septic bursitis
- depression
- frontotemporal brain injury [**2-26**] trauma
- polyneuropathy
- venous stasis dermatitis
Social History:
Married with one daughter. Wife manages medications. Able to
ambulate slowly, still independent in daily activities and
drives. Former electrician. Social EtOH use, minimal tobacco
use, denies recreational drug use in past.
Family History:
Mother d. age [**Age over 90 **] healthy. Father d. CAD. No GI or
liver disease.
Physical Exam:
Vitals: Tmax 98.3 T 97.9 BP 102/66 (93-110/60-68) HR 64 (60-76)
RR 16 O2Sat 98%/RA
General: Alert, oriented, speaking slowly but comfortably
HEENT: Sclera anicteric, moist mucosa, oropharynx clear
Neck: supple, minimal JVP elevation , no LAD
Lungs: CTAB
CV: Regular rate and rhythm, 3/6 systolic decrescendo murmur
loudest at right upper sternal border radiating to carotids
bilaterally, S2 distinguishable. 3/6 systolic murmur also noted
at apex.
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly, no palpable
abdominal aneurysm
Upper Ext: Radial and ulnar pulses palpable bilaterally.
Sclerodactyly of both hands with derformity. Amputated DIP on
left hand. Hands are pale and cool to touch.
Lower Extr: DP and TPs absent bilaterally. Anterior of distal
left leg cooler to touch compared to right, both are similarly
pale. Distal toes on left foot blackened. Skin graft on R leg.
Pertinent Results:
[**2171-12-16**] 03:40AM BLOOD WBC-11.0 RBC-3.89* Hgb-11.8* Hct-34.2*
MCV-88 MCH-30.4 MCHC-34.6 RDW-16.3* Plt Ct-432
[**2171-12-15**] 11:04AM BLOOD PT-13.5* PTT-26.4 INR(PT)-1.2*
[**2171-12-16**] 03:40AM BLOOD Glucose-105* UreaN-22* Creat-1.3* Na-137
K-4.5 Cl-103 HCO3-25 AnGap-14
[**2171-12-8**] 03:40PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
Brief Hospital Course:
69 yo man with scleroderma with CREST, DM, peripheral vascular
disease, who was initially admitted on [**11-27**] to Vascular surgery
for L foot ischemia but is being transferred to Medicine
following continued GI bleed.
.
ACTIVE ISSUES
.
# GI Bleed:
The patient arrived with a history of one day of suspected
melena and a Hct of 33 down from a baseline of 42. On hospital
day #2 he underwent EGD which revealed a 5 mm ulcer in the first
part of the duodenum with stigmata of bleeding that was
endoclipped for hemostasis. A second small ulcer was visualized
just distal to the treated ulcer but was not bleeding. The
patient was anticoagulated with heparin after the procedure due
to consideration for his peripheral artery disease. During the
next few days his Hct continued to drop, necessitating repeated
RBC transfusions. On HD#4 he was taken off heparin, and on HD#5
repeat EGD was performed. Active bleeding was seen at the same
location as the previously treated duodenal ulcer, and it was
addressed again through placement of five endoclips with epi
injection. Hct was serially trended, heparinization was
stopped, and Plavix was held. The patient's ASA dose was
dropped to 81 mg. His Hct stabilized for >96 hrs prior to his
revascularization procedure on [**12-9**], which was preceded by
same-day EGD documenting no active bleeding.
.
# Lower limb ischemia, L>R:
Serial arteriogram revealed complete occlusion of the anterior
tibial artery just beyond its origin. Revascularization was
delayed in the setting of an acute GI bleed, however. Saphenous
vein bypass from the femoral to anterior tibial artery was
performed on [**12-9**]. No sequelae noted, graft palpable.
Ambulating without difficulty. L foot with ischemic toes and
signs of gangrenous change. Will allow to further demaracate,
return for amputation discussions as outpatient.
.
# Lung opacities and bronchial wall thickening:
Chest CTA for patient's vascular work-up revealed an incidental
finding of multifocal patchy ground-glass opacities, along with
bronchial wall thickening. There was concern for infectious
process involving either aspiration or mycobacterium. The
patient started a 7 day course of levofloxacin empirically
treating for aspiration pneumonia, and work-up for TB was
pursued. On the differential was also early interstitial lung
disease related to patient's systemic scleroderma, although he
is thought to have a more limited form (CREST).
.
INACTIVE ISSUES
.
# Mild aortic stenosis:
Signs were found on physical exam. Pt currently asymptomatic
and ECHO suggests only mild stenosis, so this was monitored with
no considered intervention.
.
#CAD
Patient continued on 81 mg ASA and simvastatin.
#orthostatic hypotension
Likely because of under resuscitation. Per medicine
recommendations, gave patient 2.5L overnight. Responded with
normal pressures. Patient asymptomatic. Medical team and PT
cleared for home with PT. Walker and bedside commode given.
Medications on Admission:
atenolol - 25 mg Tablet
betamethasone dipropionate - 0.05 % Ointment
clopidogrel [Plavix] - 75 mg Tablet
fluoxetine - 40 mg Capsule
gemfibrozil - 600 mg Tablet
isosorbide mononitrate - 30 mg Tablet Sustained Release 24 hr
levothyroxine - 50 mcg Tablet
simvastatin - 20 mg Tablet
soft cervical collar
trazodone - 50 mg Tablet
aspirin - 325 mg Tablet, Delayed Release (E.C.)
niacin - 500 mg Tablet Sustained Release
Discharge Medications:
1. trazodone 50 mg Tablet Sig: half tab Tablet PO HS (at
bedtime) as needed for insomnia.
2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. fluoxetine 20 mg Capsule Sig: Four (4) Capsule PO DAILY
(Daily).
5. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. niacin 500 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO QD ().
7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain : prn for pain. take with colace.
Disp:*20 Tablet(s)* Refills:*0*
9. Outpatient Physical Therapy
Walker for ambulation
10. PT
Commode for bedside
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Primary Diagnoses:
Duodenal ulcer
Peripheral artery disease
Secondary Diagnoses:
Coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It has been a pleasure to care for you at the [**Hospital1 **] Hospital.
You were admitted after your podiatrist noticed that your lower
left leg showed signs of decreased blood circulation. We found
through our testing that this was caused by a blocked blood
vessel in your leg. At the same time we discovered that you had
a bleeding ulcer in your small intestine, which explains the
black stools you had noticed before coming to the hospital. We
performed an endoscopy procedure to stop the bleeding. However,
over the next few days we noticed that you had continued
bleeding, requiring us to transfuse you with blood. On [**12-3**] we
performed another endoscopy procedure that showed that the
original ulcer was bleeding again, and we stopped the bleeding
by applying clips.
Division of Vascular and Endovascular Surgery
Lower Extremity Bypass Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on:
?????? Elevate your leg above the level of your heart (use [**2-27**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? Unless you were told not to bear any weight on operative foot:
?????? You should get up every day, get dressed and walk
?????? You should gradually increase your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over incision,
rinse and pat dry
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 100.5F for 24 hours
?????? Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Followup Instructions:
You will need a follow up CT chest in 3months. Talk to your PCP.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2171-12-31**] 10:15
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6214**], MD Phone:[**Telephone/Fax (1) 3736**]
Date/Time:[**2172-1-14**] 2:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2172-2-27**]
11:00
ICD9 Codes: 5070, 5849, 2851, 3572, 5859, 4241, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3547
} | Medical Text: Admission Date: [**2108-5-7**] Discharge Date: [**2108-5-12**]
Date of Birth: Sex: M
Service: NEUROSURGERY
HISTORY OF PRESENT ILLNESS: This is a 43 year-old white male
with a sudden onset of headache on Friday followed by nausea
and vomiting. It worsened with exertion and the headache
persisted since then. The pain wakes him up at night. He
went to an outside hospital where a CT scan showed blood at
the base of the brain consistent with possible subarachnoid
hemorrhage.
PAST MEDICAL HISTORY: Unremarkable.
MEDICATIONS: None.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Negative alcohol and negative tobacco.
PHYSICAL EXAMINATION: Blood pressure on admission to the
outside hospital was systolic 150. He was awake, alert and
oriented. Speech was fluent and comprehension was intact.
Cranial nerves were intact. Motor and sensory examination
were intact. Physical examination on arrival at the [**Hospital1 1444**], he was again noted to be
neurologically intact and the general physical examination
including the head, eyes, ears, nose and throat, heart, lungs
and abdomen was essentially unremarkable.
LABORATORY STUDIES ON ADMISSION: PTT 30.1, INR 1.2,
hematocrit and chem 7 were within normal limits.
HOSPITAL COURSE: Due to the clinical findings the patient
was admitted to the Neurosurgical Intensive Care Unit. He
underwent an angiogram on the evening of admission and there
was no evidence of source for the bleeding and the patient
tolerated the procedure well. He remained in the
Neurosurgical Intensive Care Unit and was treated with
Nimodipine and subsequently remained in the Neurosurgical
Intensive Care Unit for three days. He was then taken back
to the angiogram suite on the afternoon of the [**2108-5-10**] where he underwent a repeat angiogram, which was
unremarkable. Due to the findings of the two angiograms the
first being on the day of admission and the second being on
the [**2108-5-11**] the patient was subsequently discharged
to home in stable condition on the morning of the first of
[**Month (only) **] with follow up to see Dr. [**Last Name (STitle) 1132**] in the clinic in
approximately three weeks time. The patient's neurological
examination remained normal throughout the hospitalization he
was thus discharged to home in stable and improved condition
with improvement in his headache.
CONDITION ON DISCHARGE: Stable and improved.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 14-133
Dictated By:[**Name8 (MD) 22907**]
MEDQUIST36
D: [**2108-10-13**] 11:04
T: [**2108-10-15**] 05:43
JOB#: [**Job Number 42587**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3548
} | Medical Text: Admission Date: [**2140-12-31**] Discharge Date: [**2141-1-2**]
Service: MEDICINE
Allergies:
Codeine / Morphine
Attending:[**Doctor First Name 1402**]
Chief Complaint:
ICD shock
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a 84 yo male with h/o HTN, CAD s/p stents LAD,
diagonal and OM1, ESRD on HD, and ICD for recurrent polymorphic
ventricular tachycardia, history of probable amiodarone-induced
lung toxicity admitted with firing of his ICD. Symptoms started
at HD where he had nausea and several episodes of vomiting. He
then felt that he was going to be shocked and was shocked 10+
times. He reports that this has happened before when his
electrolytes were off. He was sent to the ED where he was given
calcium gluconate 2 g x1, magnesium 2g x1 and was seen by the EP
service whow started amiodarone drip as well as lidocaine 50 mg
IV x1. Per ED resident, he had 2 further shocks while in the ED,
therefore he was transfer to the CCU. He remained HD stable and
AA0x3.
.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis (he did have a superficial spahenous
clot), 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. He does report 3 [**Last Name (un) 940**] BMs the morning of
admission as well as nausea and vomitting. No abdominal pain.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
.
Past Medical History:
# CV
--CAD: LAD, diagonal, OM1 stent; PCI
--ICD ([**2135**]) [**12-24**] recurrent polymorphic VT
--Pacemaker
--CHF: EF 20-25% ([**4-/2140**] echo)
--HTN
--Hyperlipidemia
--TIA
# Pulm: R pleural effusion ([**4-/2140**]): Thoracentesis x2, cytology
negative, c/b hydropneumothorax, trapped lung
# Renal
--ESRD [**12-24**] HTN
--HD qTRS
# Hematology
--Anemia
--Factor V Leiden (heterozygous): Warfarin goal INR 1.3
--Positive lupus anticoagulant ([**2-/2136**])
--Thrombi: R greater saphenous vein, L varicosities
# GU: Prostate cancer s/p B subcapsular orchiectomy
# Endo: Hypothyroidism
# Psych: Depression
Social History:
# Personal: Lives with daughter
# Employment: Former bar owner in [**Hospital1 3494**]
# Alcohol: Rare
# Tobacco: 20y x 1ppd, quit age 40s. Second-hand smoke x 52y as
bar owner.
# Recreational drugs: Never
Family History:
# M, d 80: Heart failure
# F, d 76: Died in sleep
# Siblings (1 sister, 3 brothers): MI, dementia, heart disease
Physical Exam:
VS: T 98.4, BP 117/49, HR 80, RR 16, 100 O2 % on 2L
Gen: Elderly male in NAD, resp or otherwise. Oriented x3. Mood,
affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: No JVD.
CV: RR, normal S1, S2. No S4, no S3, Harsh murmur at LUSB 2/2 L
A-V HD fistula.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheeze,
rhonchi, but had decreased breath sounds at the right base.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominal
bruits freely reducible lower abdominal hernia.
Ext: No edema, no calf tenderness
Skin: Well healed incision of upper back s/p skin biopsy.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Pertinent Results:
[**2140-12-31**] 05:00PM BLOOD WBC-11.6* RBC-4.01* Hgb-11.7* Hct-34.7*
MCV-87 MCH-29.1 MCHC-33.7 RDW-18.3* Plt Ct-306
[**2140-12-31**] 05:00PM BLOOD Neuts-80* Bands-5 Lymphs-10* Monos-3
Eos-0 Baso-0 Atyps-2* Metas-0 Myelos-0
[**2140-12-31**] 05:00PM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-2+
Macrocy-1+ Microcy-1+ Polychr-1+ Ovalocy-OCCASIONAL Envelop-2+
[**2141-1-2**] 07:10AM BLOOD WBC-4.8 RBC-3.27* Hgb-9.4* Hct-27.9*
MCV-85 MCH-28.8 MCHC-33.8 RDW-18.3* Plt Ct-253
[**2141-1-2**] 07:10AM BLOOD PT-32.3* PTT-39.5* INR(PT)-3.3*
[**2141-1-2**] 07:10AM BLOOD Glucose-70 UreaN-33* Creat-5.1*# Na-142
K-3.9 Cl-95* HCO3-37* AnGap-14
[**2140-12-31**] 05:00PM BLOOD CK(CPK)-41
[**2141-1-2**] 07:10AM BLOOD Calcium-8.5 Phos-5.4* Mg-2.8*
Brief Hospital Course:
84 yo male with h/o CAD, CHF, ESRD on HD and polymorphic VT
presenting after being shocked by ICD likley in the setting of
fluid and elctrolyte shifts.
.
# ICD firing: Polymorphic VT s/p ICD firing. Per primary
nephrologist, patient has been challenging to control in regard
to electrolyte balance. Although he had been titrated to higher
potassium range in order to prevent further episodes. It appears
that viral gastroenteritis and diarrhea further decreased
potassium, down to 3.5 at dialysis per report. Patient was
repleted and controlled with IV amiodarone, which was
discontinued shortly after admisison. Patient has remained
stable and will not require any medication changes.
.
# Coronary artery disease: Hitory of stent to LAD, diagonal and
OM. Last cath on [**2140-5-18**] revealed patent stents. Medical regimen
of aspirin, statin and beta blocker were maintained this
admission.
.
# Chronic systolic heart failure: EF 20-25%. Currently appears
euvolemic after dialysis. Fluid status to be controlled at
dialysis per routine, with special attention to potassium level.
.
# Gastroenteritis: Vomiting and diarrhea. Likely
gastroenteritis, with transient lyphocytosis which is now
resolved. Patient has not had any more emesis and bowel
movements have become less freqent. No risk factor for C. Diff
infection were found. Patient instructed to report to PCP if
symptoms do not improve in the next 48 hours.
.
# ESRD on dialysis: Followed as oupatient by Dr. [**Last Name (STitle) 118**]. Patient
will continue on current Dialysis schedule Tues/thurs/sat.
.
# Factor V leiden heterozygote: therapeutic on coumadin
.
# hypothyroidism: we continued levothyroxine
.
# h/o trapped lung: O2 sats stable, no intervention during
admission.
.
# HTN: well controlled on current regimen, no changes were made.
.
# FEN: renal, cardiac diet
.
# Prophylaxis: Therapeutic on coumadin
.
# Code: Patient remained DNR/DNI during hospitalization,
confrimed with patient and daughter
.
# Communication: Daughter [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 27887**]
Medications on Admission:
Citalopram 20 mg daily
LEVOXYL 200 mcg daily
LISINOPRIL 5 mg daily
Mexiletine 150 mg twice a day
SIMVASTATIN 20 mg daily
TOPROL XL 25 mg daily
TRAZODONE 100 mg at night-time
Discharge Medications:
1. Mexiletine 150 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
2. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID WITH MEALS ().
8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO QHS (once a day
(at bedtime)).
10. Trazodone 50 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
PRIMARY:
Ventricular tachycardia
Viral gastroenteritis
SECONDARY:
Chronic Systolic Heart Failure
End stage renal failure
Discharge Condition:
Hemodynamically stable, without further episodes of ventricular
tachycardia.
Discharge Instructions:
You were admitted to the hospital after you began experiencing
shocks from your defibrillator. We discovered you had developed
a dangerous heart rhythm which was corrected by the shock. We
started a medication to stabilize you while hospitalized; you
will no longer require it after discharge.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1 L
Please keep all previously scheduled appointments, take all
medications as directed (no medications were changed this
hospitalization). If you experience new shocks, or if you
develop chest pain, shortness of breath, nausea, vomiting,
diarrhea, or any other symptom that concerns you, please seek
medical attention.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2141-1-4**] 11:10
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2141-1-25**]
9:00
Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], [**First Name3 (LF) 3947**]. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2141-1-25**] 9:40
ICD9 Codes: 4271, 5856, 4280, 2449, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3549
} | Medical Text: Admission Date: [**2125-4-23**] Discharge Date: [**2125-4-27**]
Date of Birth: [**2068-11-10**] Sex: F
Service: MEDICINE
Allergies:
Azmacort / Clindamycin / Versed / Fentanyl / Morphine / Optiray
300 / Ceftriaxone
Attending:[**First Name3 (LF) 5644**]
Chief Complaint:
transfered from MICU
Major Surgical or Invasive Procedure:
a-line
History of Present Illness:
56 y/o F w/ hx of chronic demyelinating disease, ? of
restrictive/COPD lung disease, adrenal insufficiency, and asthma
nwo being evaluated in the ED for increased shortness of breath
and presumed allergic/?anaphylactic reaction in setting o
fceftriaxone. [**Name (NI) 1094**] husband reports increased fatigue/weakness
over past 2 weeks in setting of URI [**Last Name (un) **] mptoms x 2 weeks. No
fevers, + chills, + mod HA, + soer throat. Progressive
productive cough of yellow-green sputum with increased DOE/SOB
at rest. She usually doesn't use her nebs but over the past [**1-18**]
days has been using it continuously. ? decreased po intake and
abdominal pain (hypogastric) with po's, no urinary symptoms, did
have increased diarrhea. Has several [**Month/Day (3) **] contacts at home
including daughter who works at a daycare.
*
In the ED, she was afebrile, HDS, but hypoxic to 88% on RA,
improved to mid 90s on NC. Labs unremarkable and CXR without
infiltrate, but concerned about pna. She was wheezing, given
nebs, and then given ceftriaxone. Approximately 5 minutes into
ceftriaxone infusion, she became erythematous, difficulty
breathing, ? throat swelling, and hypotensive to 70s. She was
given solumedrol, benadryl, pepcid, and aggressive IVF with
improved SBP's adn the ceftriaxone was discontinued.
Loevofloxacin was given instead.
.
MICU course: The patient respiratory stablized and was on room
air on [**2125-4-25**]. His initial metabolic /resp acidosis, w/
increasing late to 6.3 of unclear etiology. His lactate has
improved to 4.4 on [**4-24**] PM. Her last ABG 7.34/48/87. WBC
normalized from 11.9 to 9.3 and increased to 19 after IV
solumedrol started. Her cultures are pending on transfer. She
was continued on levo for presumed pna.
Past Medical History:
Asthma.
Restrictive lung disease.
Unknown demyelinating syndrome (L leg paresis, bilateral arm
weakness, demyelination on brain MRI, neurogenic bladder)
Adrenal insufficiency.
Osteoporosis.
Hypothyroidism.
History of chest nodules.
Dyslipidemia.
History of K breast papilloma with nipple discharge.
Anxiety.
Labile hypertension.
History of right IJ thrombus in [**2112**].
IgG deficiency.
Anemia.
Status post cholecystectomy in [**2112**].
Dysfunctional uterine bleeding by history.
Atypical pap smears.
Common bile duct stenosis s/p sphincterotomy.
Gastritis and prepyloric ulcers per EGD.
Bilateral hearing loss.
G-tube and self-catheterization
Social History:
The patient states she lives with her husband. Over 50 pack
year smoking hx; quit in [**2109**]. Denies any recent alcohol or IV
drug abuse.
Family History:
Family history is notable for coronary artery disease. Father
had [**Name2 (NI) 499**] cancer, her mother had breast cancer, and her sister
had brain cancer. Works with "special kids" group as coordinator
and volunteer but has not been available for over one month
secondary to frequent and severe ilees
Physical Exam:
Gen: NAD, talkative
HEENT: PERRL
CV: RRR, S1 and s2, 2/6 SEM
Lung:mildly improving wheezing
Abd: LLQ w/ PEG intact, + BS
Ext: WWP, no edema
Skin- intact
Pertinent Results:
..
CTA: no PE, no lung nodule previously noted
CXR ([**4-25**]):?[**Month/Year (2) 25730**] opacity.
Brief Hospital Course:
A/P: 55 y/o F w/hx of demyelinating d/o, restrictive/obstructive
lung disease, adrenal insufficiency, who presented to teh ED
with resp distress and a question of an anaphylactic rxn to
ceftriaxone.
..
1)Allergic/Anaphylactic rxn: timing and rash c/w drug rxn, after
receiving PPI/solumedrol/benadryl was hemodynamically stable.
SHe was continued on combination of PPR/prednisone/benadryl prn
while she was in the floor and she did not have any recurrent
episodes of allergic reaction
..
2)COPD flare: h/o [**Month/Year (2) 25730**] pna, CXR now without infiltrate, exam
nonfocal. Increased sputum productive, known restrictive with
component of COPD, increased O2 requirement but not in distress.
CT chest w/o PE.
-She was continued on levofloxacin and a combination of
nebulizer and prednisone while she was here. SHe did well on
room air as of [**4-27**] and was discharged on [**4-27**] on room air.
..
3) Hypotension: in setting of presumed allergic rxn. \
-She did not have any further episodes of hypotension today
..
4) Demyelinating disaes: rx with benzos. She had a total of 3
episodes of spasm while she was on the floor over the course of
2 days. Her usual baseline is 1 episodes per day. HEr COPD
flare/pneumonia are the likely culprit of her increased
frequency of spasm. She was continued on her muscle relaxant,
clonazepam. Her ativan was increased as well
..
5) lipid- She was continued on lipitor
..
6) nutrition-
She was continued on B12, folate, IVF and was getting nutrition
via PEG tube while in hospital.
..
7). anemia -Her hct was stable at the time of discharge in the
low 30s.
..
9) adrenal insuffiency
SHe was continued on fludrocortisone and continued on slow
prednisone taper (60 qd at the time of discharge) for total of
18 days as outpatient.
..
Discharge Medications:
1. Levothyroxine Sodium 50 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
2. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 6 days.
Disp:*6 Tablet(s)* Refills:*0*
3. Clonazepam 1 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
Disp:*90 Tablet, Chewable(s)* Refills:*2*
5. Lorazepam 1 mg Tablet Sig: Four (4) Tablet PO TID (3 times a
day).
Disp:*360 Tablet(s)* Refills:*2*
6. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
7. Fludrocortisone Acetate 0.1 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
9. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*90 Tablet(s)* Refills:*2*
11. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
Disp:*90 Tablet(s)* Refills:*2*
12. Baclofen 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*180 Tablet(s)* Refills:*2*
13. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
14. Tizanidine HCl 4 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
Disp:*180 Tablet(s)* Refills:*2*
15. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
16. Buspirone HCl 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*90 Tablet(s)* Refills:*2*
17. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q3-4H () as needed for SOB.
18. Prednisone 10 mg Tablet Sig: as directed Tablet PO as
directed for 18 days: pls take 6 tabs for 3 days, 5 tabs for 3
days, 4 tabs for 3 days, 3 tabs for 3 days, 2 tabs for 3 days, 1
tab for 3 days.
Disp:*63 Tablet(s)* Refills:*0*
19. Benadryl 25 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for allergy symptoms.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
COPD
demyelinating nerve disease
Discharge Condition:
stable
Discharge Instructions:
please take your medications
please take your levoquin for 6 more days
please call your doctor if you experience chest pain or
shortness of breath
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 1575**] [**Last Name (NamePattern1) **], MD Where: CC CLINICAL CENTER
NEUROLOGY Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2125-5-10**] 3:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3031**], M.D. Where: [**Hospital6 29**] [**Hospital **] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2125-6-25**] 10:20
ICD9 Codes: 486, 2765, 5849, 2762, 2449, 4019, 2720, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3550
} | Medical Text: Admission Date: [**2193-12-13**] Discharge Date: [**2193-12-18**]
Date of Birth: [**2133-1-31**] Sex: F
Service: SURGERY
Allergies:
Demerol / Morphine / Adhesive Tape
Attending:[**First Name3 (LF) 5547**]
Chief Complaint:
Large and symptomatic parastomal hernia in the left mid-abdomen.
Major Surgical or Invasive Procedure:
Parastomal hernia repair
Bleeding diathesis
Post-op Delerium
History of Present Illness:
This is a 60-year-old female who underwent an abdominoperineal
resection in [**2189-3-7**] for the management of multiple rectal
villous adenomas which were not amenable to local excision. In
[**Month (only) 205**], she was struck by a car and developed a fairly large and
symptomatic parastomal hernia in the left mid-abdomen. She
develops intermittent bowel obstructions that require admission
to the hospital as well as frequent incarcerations of this
parastomal hernia that require manual reduction. As such, this
parastomal hernia has a significant impact on her quality of
life and she desired repair. In addition, it was evident that
she had a small midline ventral hernia just medial to her
parastomal hernia as well. She does have a long history of a
significant bleeding diathesis of unclear nature and has had
fairly significant bleeding after all of her
surgical procedures. As such, she was evaluated by Dr. [**Last Name (STitle) 2805**] of
the hematology service who advised the administration of DDAVP
and Amicar perioperatively.
Past Medical History:
Past Medical History:
1. Bleeding diathesis of unclear nature. She does give a
history of profuse bleeding after any surgical procedure
including her prior total abdominal hysterectomy, bilateral
inguinal hernia repairs and multiple breast biopsies. She
admits
to easy bruising and has had one significant episode of
epistaxis
that required prolonged nasal packing and transfusions. She has
never been given a firm diagnosis as to the origin of the
bleeding problems and apparently all of her clotting factor
levels and bleeding times have been normal.
2. Hypertension.
3. Elevated lipids.
4. Anxiety disorder.
5. Depression.
6. Meniere's disease
Past Surgical History:
1. Status post total abdominal hysterectomy and bilateral
salpingo-oophorectomy.
2. Status post bilateral inguinal hernia repairs.
3. Status post multiple previous benign breast biopsies.
4. Status post bladder suspension for urinary incontinence.
5. Status post abdominoperineal resection for villous adenomas
of the low rectum.
6. Status post laparoscopic cholecystectomy as management for
acute cholecystitis.
7. Status post previous small-bowel obstruction in [**4-/2192**],
which resolved with bowel rest and NG tube suction
Social History:
She lives in [**Location 1468**] and has two children. She
is currently on disability but worked as a phlebotomist in the
past. She has never smoked and does not drink alcohol.
Family History:
Family History: Her mom died of breast cancer. She has a
maternal grandfather who died of rectal cancer after an [**Month (only) **] her
brother has kidney cancer and Waldenstrom macroglobulinemia.
Her
father died of an MI and her son has had a previous deep venous
thrombosis.
Physical Exam:
Gen: pleasant and well-appearing.
HEENT: Sclerae are anicteric. Neck and supraclavicular fossa is
supple without
lymphadenopathy.
Chest: Lungs are clear to auscultation bilaterally.
Heart: regular rate and rhythm.
Abdomen: well-healed midline incision without hernia. There is
a pink rosebud stoma in the left lower quadrant of the abdomen.
There is an easily
reducible and somewhat tender large peristomal hernia containing
loops of small bowel. Her abdomen is otherwise soft and
nontender.
Extremities: show no edema and are warm.
[**2193-5-17**] CT scan of the abdomen and pelvis. There are several
loops of small bowel in a hernia adjacent to the left mid
abdominal stoma without evidence of
bowel obstruction, free air or free fluid.
Pertinent Results:
[**2193-12-13**] 01:43PM BLOOD Hct-30.4*
[**2193-12-15**] 03:44AM BLOOD WBC-13.3* RBC-3.05* Hgb-9.6* Hct-27.9*
MCV-92 MCH-31.6 MCHC-34.5 RDW-12.9 Plt Ct-349
[**2193-12-17**] 06:40AM BLOOD WBC-13.5* RBC-3.19* Hgb-10.0* Hct-29.2*
MCV-92 MCH-31.3 MCHC-34.1 RDW-12.9 Plt Ct-440
[**2193-12-14**] 05:20AM BLOOD Plt Ct-392
[**2193-12-17**] 06:40AM BLOOD Plt Ct-440
[**2193-12-14**] 07:10PM BLOOD Glucose-131* UreaN-11 Creat-0.8 Na-137
K-4.5 Cl-106 HCO3-23 AnGap-13
[**2193-12-17**] 06:40AM BLOOD Glucose-105 UreaN-12 Creat-0.6 Na-142
K-4.2 Cl-107 HCO3-27 AnGap-12
[**2193-12-17**] 06:40AM BLOOD Calcium-9.0 Phos-2.9 Mg-2.1
.
CHEST (PORTABLE AP) [**2193-12-15**] 7:26 AM
IMPRESSION: No pneumothorax after removal of the gastric tube.
Brief Hospital Course:
This is a 60 year old female with a parastomal hernia in the
left mid-abdomen. She developed intermittent bowel obstructions
and incarcerations necessitating manual reduction. She has a
history of a bleeding diathesis of unclear nature. The
hematology service advised the administration of DDAVP and
Amicar perioperatively.
She went to the OR on [**12-13**] for:
1. Exploratory laparotomy.
2. Extensive lysis of adhesions.
3. Repair of parastomal and ventral hernias with underlay
placement of [**Doctor Last Name 4726**]-Tex DualMesh.
She did well post-op and was followed by the hematology group
their recommendations were as follows:
DDAVP at 0.3 mcg/kg IV given q day for 3 days. The basis for
DDAVP action for treating bleeding associated with platelet
abnormalities is unknown, but it usually is effective.
Amicar, 1 g Amicar q 4 hrs iv or po for 3 days, then q 6 hrs PO
for another 3-4 days. This assumes surgery is uncomplicated and
wound healing is normal.
.
Due to the complexity of these meds and frequent monitoring, she
was in the ICU for 2 days. Her HCT remained stable
post-operatively at ~28, she had no signs or symptoms of
bleeding.
Pain: She had a PCA for pain control and did well. She had some
transient post-op delirium, likely due to the PCA, but this
resolved on its own. Once tolerating clear liquids, she was
switched to PO narcotics.
GI/ABD: She was NPO with IVF. She was started on clears on POD 4
and tolerating these. Her ostomy had +gas on POD 4. Her abdomen
was round, and slightly distended. We were able to advance her
diet as she had return of bowel function.
Her incision was C/D/I with staples in place. She wore an
abdominal binder with ambulation.
Medications on Admission:
Atenolol 25", Buspar 10", HCTZ 25', Protonix 40', Simvastatin
80', Xanax 1''', Buproprion 100", Meclizine 25''', Fiorocet 1prn
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
2. Atenolol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
3. BuSpar 10 mg Tablet Sig: One (1) Tablet PO twice a day.
4. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
7. Xanax 1 mg Tablet Sig: One (1) Tablet PO three times a day.
8. Bupropion 100 mg Tablet Sig: One (1) Tablet PO twice a day.
9. Meclizine 25 mg Tablet Sig: One (1) Tablet PO three times a
day.
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*1*
11. AMICAR 1,000 mg Tablet Sig: One (1) Tablet PO every six (6)
hours for 2 doses.
Disp:*2 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Parastomal hernia
Discharge Condition:
Good
Tolerating diet
Pain well controlled
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting, diarrhea
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
.
* Please take any new meds as ordered.
* Continue to ambulate several times per day. Please wear
abdominal binder when out of bed and ambulating.
* No heavy lifting >10 lbs for 6 weeks.
* Continue with ostomy care.
* Continue to eat several, small meals throughout the day.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 1924**] in 2 weeks. Call [**Telephone/Fax (1) 7508**]
to schedule an appointment
Completed by:[**2193-12-18**]
ICD9 Codes: 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3551
} | Medical Text: Admission Date: [**2122-11-11**] Discharge Date: [**2122-11-18**]
Date of Birth: [**2078-2-14**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
sore throat, fever, N/V
Major Surgical or Invasive Procedure:
Central line placement
EGD
History of Present Illness:
44yo Italian- and English-speaking man with h/o EtOH abuse and
withdrawal presented to the ED with complaint of 2d of cough,
sore throat, fever, and N/V. He denied abdominal pain, chest
pain, and hsortness of breath. He was noted to be a very poor
historian in the ED, answering most questions by pointing to his
throat. His VS on presentation were T 101 (rectal), HR 120s, BP
110/70, RR 18, O2sat 100% RA, FSBG 221. Labs showed WBC 16,
lactate 16.7, HCO3 16 with AG 33, and EtOH level 171. ECG showed
sinus tachycardia with no ischemic changes, 1st set of enzymes
negative. Code Sepsis was called and a central line was placed,
initial mVO2 88% per ED resident. He had an episode of VT with
line placement that resolved after pulling the catheter back.
Blood and urine cultures were drawn and he was given empiric
Unasyn and vancomycin. UA was negative for UTI and had 50
ketones. CXR was clear. NG lavage was attempted for his history
of [**Location (un) 2452**] vomitus but the patient was unable to tolerate it with
his irritable throat. He also received Valium 10mg IV x 1 then
5mg IV x 3, MgSO4 2g IV, Anzemet 12.5mg IV, and a banana bag (IV
MVI and thiamine 100mg). After receiving 3L NS, his lactate came
down to 8.8. BP was stable throughout his admission. He was
admitted to the MICU for further management.
.
Currently, he c/o throat pain and nausea. He denies abdominal
pain, shortness of breath, chest pain, fever at home. He is
denying EtOH, states last drink was 2d ago.
Past Medical History:
1. "Gastroenteritis" in '[**15**] diagnosed by EGD/colonscopy when he
presented to OSH ([**Location (un) **], MA) with BRBPR.
2. Benign tremor
3. s/p appy at age 8
4. Alcohol abuse with withdrawals
5. pancreatitis
6. pancreatic cyst vs. pseudocyst
7. depression.
Social History:
used to work in business, divorced with ex-wife and 2 children,
denies other family in this country, +EtOH use, cannot specify
amount, last drink 2d ago per pt although EtOH level 171 on
admission, h/o withdrawal requiring Versed gtt. Denies tobacco
and IVDU.
Family History:
1. Father - deceased from prostate CA
2. Mother - deceased from lymphoma
3. No history of HTN, DM, or liver disease in family.
Physical Exam:
Vitals- T 100.4, HR 137, BP 130/78, RR 16, O2sat 99% 2L NC
General- somnolent but easily arousable, oriented x 3 with some
prompting (?[**3-5**] language barrier), no respiratory distress, no
stridor, no drooling, no abnormal voice
HEENT- PERRL, sclerae anicteric, + petechiae in posterior
pharynx, no pharyngeal exudate or white plaques, uvula midline,
?mild posterior pharyngeal edema
Neck- supple with no signs of meningismus, + tenderness to
palpation of anterior neck bilaterally, no palpable LAD
Pulm- CTAB with good respiratory effort
CV- tachycardic but regular, no murmur/rub/gallop
Abd- + BS throughout, nondistended, nontender to deep palpation,
no palpable hepatosplenomegaly
Rectal- guaiac negative per ED
Extrem- no peripheral edema/cyanosis/clubbing, 2+ DP/PT pulses
b/l
Pertinent Results:
[**2122-11-11**] 01:15AM ASA-NEG ETHANOL-171* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2122-11-11**] 01:15AM ALT(SGPT)-16 AST(SGOT)-31 ALK PHOS-84
AMYLASE-78 TOT BILI-0.7
[**2122-11-11**] 01:15AM LIPASE-35
[**2122-11-11**] 01:15AM GLUCOSE-222* UREA N-12 CREAT-1.2 SODIUM-150*
POTASSIUM-3.6 CHLORIDE-101 TOTAL CO2-16* ANION GAP-37*
[**2122-11-11**] 01:40AM PT-13.6* PTT-24.1 INR(PT)-1.2*
[**2122-11-11**] 01:40AM WBC-16.4*# RBC-4.84# HGB-16.7 HCT-46.3 MCV-96
MCH-34.6* MCHC-36.1* RDW-14.6
[**2122-11-11**] 01:40AM NEUTS-91.8* BANDS-0 LYMPHS-4.9* MONOS-2.7
EOS-0.2 BASOS-0.4
[**2122-11-11**] 01:43AM LACTATE-16.7*
[**2122-11-11**] 01:40AM GLUCOSE-217* UREA N-13 CREAT-1.2 SODIUM-151*
POTASSIUM-3.8 CHLORIDE-102 TOTAL CO2-17* ANION GAP-36*
[**2122-11-11**] 01:40AM ALT(SGPT)-18 AST(SGOT)-32 CK(CPK)-69 ALK
PHOS-80 AMYLASE-75 TOT BILI-0.7
[**2122-11-11**] 01:40AM cTropnT-<0.01
[**2122-11-11**] 03:45AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2122-11-11**] 04:15AM ETHANOL-101*
[**2122-11-11**] 04:15AM CRP-1.7
[**2122-11-11**] 04:15AM CORTISOL-41.8*
[**2122-11-11**] 04:15AM CALCIUM-7.6* PHOSPHATE-3.4 MAGNESIUM-1.7
[**2122-11-11**] 04:15AM GLUCOSE-159* UREA N-11 CREAT-0.9 SODIUM-148*
POTASSIUM-4.0 CHLORIDE-110* TOTAL CO2-18* ANION GAP-24*
[**2122-11-11**] 04:37AM LACTATE-8.8*
.
CT Neck [**11-11**]: FINDINGS: There are small level II and IIb lymph
nodes bilaterally. There is no evidence of lymphadenopathy. The
parapharyngeal fat planes are preserved. There are no abscesses.
No enhancing masses are identified. The lung apices appear
normal. Incidental note is made of a left subclavian central
venous catheter with the tip entering into the superior vena
cava, but it is not included on these films. IMPRESSION: No
abscess or enhancing mass. No lymphadenopathy.
.
CT Head [**11-11**]: FINDINGS: There is no intracranial hemorrhage.
There is no midline shift, mass effect or hydrocephalus.
[**Doctor Last Name **]-white matter differentiation is preserved. There are no
fractures.
.
CXR [**11-11**]: FINDINGS: AP portable radiograph reviewed. The lungs
are grossly clear. The pleura are normal. The heart and
mediastinal contours are stable. The pulmonary vasculature is
normal. There is an acute left 6th rib fracture. IMPRESSION: No
evidence for pneumonia. Left 6th rib fracture.
.
ECG [**11-11**]: Baseline artifact. Sinus tachycardia. There appear to
be modest non-specific ST-T wave changes but baseline artifact
makes assessment difficult. Since the previous tracing of
[**2121-3-28**] there may be no significant change but baseline artifact
makes comparison difficult.
.
CXR [**11-13**]: FINDINGS: Comparison is made to the previous study
from [**2122-11-11**]. There is a left-sided central venous
catheter with the distal tip in the proximal SVC. No
pneumothoraces are seen. No gas seen within the mediastinum to
indicate a significant esophageal injury. Again seen is a
subacute fracture of the left sixth rib posteriorly which is
unchanged and demonstrates some callus. The lungs are clear. No
focal infiltrates or pleural effusions are seen. This finding
has been discussed with clinical staff.
.
ECG [**11-13**]: Sinus rhythm. Probably normal ECG. Since previous
tracing of [**2122-11-11**], sinus tachycardia absent and low amplitude
T waves improved.
.
ECG [**11-13**]: Sinus tachycardia. Normal ECG except for rate. Since
previous tracing of the same date, sinus tachycardia now
present.
.
Esophagus [**11-14**]: 1. Mass with stricture of the distal espophagus
just proximal to the GE junction, suspicious for esophageal
cancer. 2. No evidence of free leakage of contrast in the
mediastinum. The findings were discussed with Dr. [**Last Name (STitle) **]
shortly after the study.
.
ECG [**11-14**]: Sinus rhythm. Normal ECG. Since previous tracing of
[**2122-11-13**], sinus tachycardia absent.
.
Duodenal biopsy [**11-16**]: Duodenal mucosal biopsy: Within normal
limits.
Brief Hospital Course:
Mr. [**Known lastname 33230**] is a 44 year old man with h/o EtOH abuse and
withdrawal, admitted with increased white blood cell count,
increased lactate level, and fever, presumed to be sepsis of
unknown etiology. He was initially admitted to the medical ICU,
and his brief ICU course is below:
.
# Lactic acidosis- His elevated lactate was initially feared to
be secondary to sepsis. However, he did not appear clinically
severe enough to explain a lactate of 16. He was not on any
medications that would be suspected to cause lactic acidosis. It
was also felt to be too high to be attributed simply to
alcoholism. His osmolar gap was 4.9, which would not be
consistent with methanol or ethylene glycol intoxication. With
high mixed venous O2 sat, severe thiamine deficiency was
considered a possible diagnosis. His lactate improved to 8 with
aggressive IVF in the ED. He was given 100mg IV thiamine for 2
days. After 1 day, his lactate had come down to normal. He was
subsequently switched to oral thiamine maintenance. Sepsis
workup as below.
.
# Fever/?sepsis: He was febrile in ED and met criteria for
sepsis with elevated lactate, leukocytosis, and fever. He
endorsed recent history of odynophagia although he was unable to
differentiate between esophageal pain and pharyngeal pain.
Possible sources of his sepsis were thought to include neck
abscess, pharyngitis (viral, Strep, GC), esophagitis, pneumonia.
UA clear, CXR read as clear. He was initially treated with
ceftriaxone and vancomycin. Throat swab was negative for Strep.
CT neck showed no abscess. His urine culture was negative and
his blood cultures were no growth to date. His lactate improved
as above. His antibiotics were discontinued. Two blood culture
bottles drawn [**11-11**] were positive on [**11-16**], later determined to
be propionibacterium acnes, most likely contaminant. He was
hemodynamically stable, afebrile, and discharged without
antibiotics.
.
# Chest pain: He gave a history of 4 days of vomiting prior to
admission. He saw a small amount of blood in vomitus in his last
episode. NG lavage was attempted in the ED but he did not
tolerate it. This small amount of blood was felt likely
secondary to [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-[**Doctor Last Name **] tear in the setting of multiple
episodes of vomiting. His hematocrit was subsequently stable. He
initially endorsed occasional substernal pain with swallowing
pills. On [**11-13**], he began to have more severe chest pain with
swallowing pills. He had a particularly acute episode after
attempting to eat regular diet. During that episode, he appeared
to be in severe pain, and was tachycardic and hypertensive. He
had no ischemic changes evident on his ECG. Cardiac enzymes were
negative. At the peak of the pain, he was unable to swallow his
own saliva and began to drool. His pain was somewhat improved
with morphine. His differential was thought to include
esophagitis secondary to vomiting, esophageal Candidiasis with
palatal petechiae, Boerhaave's. GI was consulted for further
evaluation, as below.
.
# Dysphagia/chest pain: barium swallow performed and showed mass
with stricture of the distal espophagus just proximal to the GE
junction, suspicious for esophageal cancer. GI was consulted,
and the EGD showed esophagitis and gastritis. He was continued
on a PPI twice daily and discharged with follow up in [**Hospital **] clinic.
.
# Altered mental status: Initially very somnolent on arrival to
the MICU. However, arousable and oriented with a little
prompting. No meningismus. CT head negative for acute
intracranial process. As his mental status rapidly improved, his
somnolence was felt to be most likely secondary to Valium
administered in the ED. Resolved by the time of discharge.
.
# EtOH withdrawal: He has a history of severe withdrawals
requiring a Versed drip on one admission and periodic Valium
tapers as an outpatient. He had a positive EtOH level on
admission. He was maintained on a multivitamin, thiamine,
folate, and a q2h CIWA scale with Valium for several days; two
days prior to discharge he was not requiring any valium per the
CIWA scale.
.
# Liver disease. He has previously been seen in Liver clinic,
although no biopsy has yet been performed. His thrombocytopenia
and liver function were stable throughout the admission.
Medications on Admission:
Antabuse
Lamictal
Celexa
Lorazepam
Compazine
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Antabuse 250 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
3. Citalopram 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
4. Lorazepam 2 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
5. Lamictal 25 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Esophagitis, gastritis
Lactic acidosis
Discharge Condition:
Stable, able to tolerate PO, walking, afebrile
Discharge Instructions:
You were admitted with nausea, vomiting, fever, sore throat,
elevated lactic acid levels in the blood, and elevated blood
alcohol levels. You were admitted to the intensive care unit for
close observation. In addition, you had an EGD that showed
gastritis and esophagitis, inflammation of your upper GI tract.
.
Please take all of your medications as prescribed. If you
experience worsening trouble swallowing, difficulty breathing,
worsening nausea or vomiting, chest pain, fever, or other
concerning symptoms, please seek medical attention immediately.
Followup Instructions:
Please follow up in the gastroenterology clinic; the phone
number is [**Telephone/Fax (1) 1983**].
ICD9 Codes: 2762, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3552
} | Medical Text: Admission Date: [**2113-5-20**] Discharge Date: [**2113-5-22**]
Date of Birth: [**2048-4-26**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 23753**]
Chief Complaint:
Hypertension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
65F with HTN, DM2, with hypertensive urgency. Pt states that she
was at an American Heart Association function, and had her blood
pressure checked. It was 190/110, and she was advised to go to
the hospital. She states that she has not been feeling well over
the last few weeks. She has had pain in her neck, particularly
over the L side, as well as in her L arm. Pain comes and goes,
and feels like a dull crampy kind of pain. No numbness/weakness
in L arm. Also feels that her balance has been somewhat off,
like she has been unsteady and needs to focus on where she is
walking. Notes feeling of palpitations in L side of neck. No
recent strain. Had recent SOB, better now. Has had substernal
chest pressure with walking up 15 stairs - feels like a
tightening. No chest pressure upon MICU eval.
.
Pt states she has been taking her BP meds. Her last known BP
check was about 2 months ago, and she remembers it being 140/?.
This was "low" for her, and no medication changes were made. She
has been on her current meds over the last 5 months, and prior
to that she was on lisinopril, which was changed to
losartan/HCTZ because of cough. She states that she does not
feel as well on the losartan/HCTZ.
.
ROS: + fatigue over the last 2 weeks, needing to rest more with
exertion. + blurry vision associated with eye pain, bilateral,
lasts a few hours, has been occurring regularly over the last
2-3 years without significant change in the last week. + episode
of abd pain 1 week ago, in middle of abd, + vomiting x1, no
nausea, no recurrence of sx after that episode. Denies fevers.
.
In the ED, BP was 237/103. No papilledema was noted on exam. EKG
did show TWI in III, but no prior EKG was available for
comparison. Pt rec'd ASA 325mg x1 and was placed on a
nitroprusside drip. She was able to be weaned off, and was given
losartan 50mg po x1. She was stable for about 1 hour, and then
was given hydralazine 25mg po. Her BP then increased to
170s/100s, with headache and blurry vision, and she was given
hydralazine 10mg IV x1. Her blood pressure subsequently climbed
to 196/119 and she was admitted to the MICU.
Past Medical History:
PMH:
DM2 - last A1C 7.5 in [**2-5**] - does not take metformin regularly
HTN > 10 years
[**12-2**] ETT MIBI - 6.5 minutes on [**Doctor First Name **], achieved 65% maximum
predicted heart rate, stopped for fatigue, no abnormalities
noted
[**10-2**] echo: EF >60%, mild LAE
diverticulosis
Social History:
Lives with husband. Denies tobacco (past or present), EtOH, or
IVDU. Has 17 children, all of whom are doing well. Not very
active. Not careful of salt in diet
Family History:
no DM2 or HTN known in her family (? sister - [**Name (NI) **]
Physical Exam:
VS: 97.0 126/72 86 16 100% RA
Gen: well-appearing, NAD
HEENT: PERRL, EOMI, MMM, OP clear
Neck: no JVD
CV: RRR, nl S1/S2, no murmurs
Pulm: CTAB, no wheezes or crackles
Abd: soft, obese, NT/ND, +BS, no masses
Ext: no c/c/e
Neuro: no papilledema noted in ED
Pertinent Results:
[**2113-5-20**] 06:00PM PT-11.9 PTT-25.0 INR(PT)-1.0
[**2113-5-20**] 06:00PM PLT COUNT-252
[**2113-5-20**] 06:00PM NEUTS-45.2* LYMPHS-44.9* MONOS-4.1 EOS-5.5*
BASOS-0.4
[**2113-5-20**] 06:00PM WBC-6.7 RBC-5.68* HGB-14.1 HCT-40.8 MCV-72*
MCH-24.8* MCHC-34.5 RDW-13.8
[**2113-5-20**] 06:00PM CK-MB-3
[**2113-5-20**] 06:00PM cTropnT-<0.01
[**2113-5-20**] 06:00PM GLUCOSE-131* UREA N-16 CREAT-0.7 SODIUM-139
POTASSIUM-4.2 CHLORIDE-102 TOTAL CO2-28 ANION GAP-13
.
EKG: 72bpm, LAD, LAFB, TWI in III, no other ST/T wave changes; +
LVH by aVL >10mm criteria
.
CT head without contrast: no acute process
.
CXR: no acute process
.
Exercise MIBI: Left ventricular cavity size is normal.
Resting and stress perfusion images reveal uniform tracer uptake
throughout the left ventricular myocardium. Gated images reveal
normal wall motion. The calculated left ventricular ejection
fraction is 65%.
Brief Hospital Course:
A/P: 65F with DM2 and HTN with hypertensive urgency.
.
# hypertensive urgency - unclear etiology. Pt has been on stable
meds and claims that she has taken them without difficulty.
Evidence of LVH by EKG to suggest ongoing chronic hypertension.
In the ED, BP was 237/103 and was placed on a nitroprusside
drip. She was able to be weaned off, and was given losartan 50mg
po x1. She was stable for about 1 hour, and then was given
hydralazine 25mg po. Her BP then increased to 170s/100s, with
headache and blurry vision, and she was given hydralazine 10mg
IV x1. Her blood pressure subsequently climbed to 196/119 and
she was admitted to the MICU.
.
During her MICU course she was weaned off nitroprusside and was
started on a regimen of amlodipine 10mg daily, atenolol 100mg po
daily, losartan 50mg daily, hctz 25 mg daily with SBP in 140's
and resolution of chest pain. She ruled out for MI x 3 and was
transferred to the floor for further management. She continued
to do well on the floor with SBP in the 130's; denying any
recent symptoms of pheochromocytoma or [**Location (un) **] disease. In
addition to her medication regimen she was also counceled on a
low-salt diet.
.
With regards to her h/o chest pain when walking up steps she had
an exercise MIBI which was normal. She was sent home with PCP
follow up.
Medications on Admission:
atenolol 100mg daily
losartan/HCTZ 50/12.5mg daily
metformin 500mg daily (does not take this consistently)
folate
Discharge Medications:
1. Losartan-Hydrochlorothiazide 50-12.5 mg Tablet Sig: One (1)
Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
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:*2*
5. Metformin 1000 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
hypertensive urgency
chest pain
Discharge Condition:
good, AFVSS BP 113/57
Discharge Instructions:
You came to the hospital with high blood pressure. It is
important for you to continue to take the medications we have
given you for your blood pressure. We have kept you on your
home medicines and added a new medicine called amlodipine.
.
Also, we performed a stress test which was *****normal****.
.
If you have any chest pain, shortness of breath, loss of
consiousness, sudden weakness or numbness or any other worrisome
symptoms then please seek medical attention.
Followup Instructions:
[**Hospital **] community health center [**Telephone/Fax (1) 4255**]: [**5-31**] at 1pm with
Dr. [**Last Name (STitle) **].
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3553
} | Medical Text: Admission Date: [**2199-4-25**] Discharge Date: [**2199-4-29**]
Date of Birth: [**2123-7-5**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
Endoscopy
History of Present Illness:
75 y/o man with PMH significant for esophageal cancer, GI
bleeding, and hepatocellular carcinoma admitted to the MICU
through the ED for GI bleeding. In pertinent recent history, the
pt was admitted to [**Hospital1 18**] for a probable upper GI bleed from
[**3-14**] to [**3-21**]. His varices could not be banded at that time due
to an esophageal stricture. Pt reports that he had been doing
well at home. On Monday, he came to the hospital and had an
infusion of Procrit. Following this, he felt very tired and
continued to feel more and more fatigued on Tues and Wed. He
also notes that his stool became dark on Tuesday. Pt reports
that he had one soft block stool per day over the next two days.
No BRBPR or hematoemesis. Pt denies abdominal pain, nausea, and
vomiting. He does report that his appetite has been very poor
over the last three days. In further discussion, pt reports that
he has felt mildly lightheaded since Tuesday. No vertigo. He
denies CP and SOB. Had difficulty moving around at home for the
last two days because of his severe fatigue but not because of
SOB. He reports mild pain in his right hip which he attributes
to his arthritis. No LE pain or swelling. No dysuria or
hematuria.
In the ED, the pt's VS were 96.3 91 100/46 20 94% RA. Pt was
started on an octreotide drip. Blood is coming up for
transfusion. GI is planning to see the pt. He will be
transferred to the MICU for further care.
Past Medical History:
1. GI bleeding- Pt was recently admitted to [**Hospital1 18**] from
[**Date range (1) 55482**] with a bleed thought to be due to esophageal
varices. Pt could not be successfully banded due to a esophageal
stricture that limited the passage of the banding device. He
retired MICU observation and a total of 9 units of PRBC.
2. Esophageal cancer- Was diagnosed in 05/[**2197**]. Pt was treated
with radiation and cucurrent cisplatin and continuous 5-Fu. He
underwent treatment from [**2198-6-13**] to [**2198-7-20**].
3. Hepatocellular carcinoma- Was diagnosed in 02/[**2198**]. Pt is s/p
chemoembolization in 03/[**2198**]. Per recent notes from Dr. [**First Name (STitle) **],
it appears that the pt had a good local result but has
progressive pulmonary mets. These may be from his esophageal CA
but as his CEA is also rising it cannot be excluded that they
are from his HCC.
4. Arthritis
5. Seasonal allergies
6. HTN
Social History:
Pt is married and lives with his wife. [**Name (NI) **] is the retired owner
of a fish market. He drank a large amount of ETOH until [**2176**]
when he quit and was sober until [**2189**]. However, he resumed
drinking at that time until quiting again in 01/[**2198**]. Pt smoked
3 to 4 PPD from 30 years before quiting 35 years ago.
Family History:
Pt's grandfather died of an unknown cancer. He has a brother
with "heart disease" and a sister with breast cancer.
Physical Exam:
96.3 91 100/46 20 94% RA
Gen- Alert and oriented. NAD. Resting comfortably on the
strecher.
HEENT- NC AT. PERRL. Mildly dry mucous membranes.
Cardiac- RRR. No m,r,g.
Abdomen- Soft. NT. ND. Positive bowel sounds.
Pulm- Diffuse crackles throughout lower half of lungs
bilaterally.
Extremities- No c/c/e. 2+ DP pulses bilaterally.
Pertinent Results:
[**2199-4-25**] 11:05AM BLOOD WBC-4.2 RBC-2.83* Hgb-8.4* Hct-25.6*
MCV-90 MCH-29.7 MCHC-32.8 RDW-18.1* Plt Ct-191
[**2199-4-25**] 06:49PM BLOOD Hct-29.4*
[**2199-4-25**] 10:36PM BLOOD Hct-28.9*
[**2199-4-25**] 11:05AM BLOOD Neuts-79.7* Lymphs-12.6* Monos-6.1
Eos-1.4 Baso-0.2
[**2199-4-25**] 11:05AM BLOOD Plt Ct-191
[**2199-4-25**] 11:05AM BLOOD PT-13.7* PTT-27.0 INR(PT)-1.2
[**2199-4-25**] 11:05AM BLOOD Glucose-127* UreaN-21* Creat-0.7 Na-140
K-4.0 Cl-106 HCO3-27 AnGap-11
[**2199-4-25**] 11:05AM BLOOD ALT-33 AST-71* AlkPhos-139* Amylase-45
TotBili-1.0
[**2199-4-25**] 11:05AM BLOOD Lipase-25
[**2199-4-25**] 11:05AM BLOOD Albumin-3.2* Calcium-12.2* Phos-3.3
Mg-1.6
CHEST (PORTABLE AP) [**2199-4-25**]:
FINDINGS: Central venous line remains in place. Cardiac and
mediastinal contours are unchanged. Note is made of faint
opacity in the right lower lobe, which may represent aspiration
or aspiration pneumonia. Note is made of multiple small nodular
opacities in bilateral lungs, probably representing metastatic
disease noted on the prior chest CT.
IMPRESSION: Faint opacity in right lower lobe, which may
represent aspiration versus aspiration pneumonia. Multiple
nodular opacities in bilateral lungs, probably representing
metastatic disease noted on prior chest CT in this patient with
HCC.
DISCHARGE LABS:
[**2199-4-29**] 10:00AM BLOOD WBC-3.8* RBC-3.57* Hgb-11.3* Hct-32.6*
MCV-91 MCH-31.6 MCHC-34.6 RDW-18.3* Plt Ct-147*
[**2199-4-29**] 10:00AM BLOOD Glucose-117* UreaN-9 Creat-0.5 Na-134
K-3.9 Cl-102 HCO3-24 AnGap-12
[**2199-4-29**] 10:00AM BLOOD Albumin-3.1* Calcium-10.0 Phos-2.3*
Mg-1.4*
[**2199-4-29**] 10:00AM BLOOD PTH-8*
Brief Hospital Course:
1. GI bleeding- Pt with melanotic stools and a Hct drop from 32
on [**4-22**] to 25.6 on arrival in the ED. Bleeding is most probably
from his know esophageal varices. However, this is very
difficult as they could not be banded in the past secondary to
esophageal strictures. GI was consulted and an EGD was
performed. Varicies in esophagus showed the "red [**Last Name (un) 23199**] sign"
(red streaks). No intervention was made but iv octreotide was
administered for four days and his hct remained stable.
2. Hepatocellular carcinoma- Pt is s/p chemoembolization. His
most recent CT scan from [**4-16**] showed tumor thrombus occluding
the portal vein and nodular implants along the hepatic capsule
along with mesenteric stranding consistent with peritoneal
carcinoma. Pt also has significant increase in size and number
of bilateral pulmonary nodules and a new lytic foci in the left
iliac bone and increased size of lytic foci in the right
sacroiliac joint and the thoracic spine. However, unclear if
these are due to the HCC or esophageal CA. Pt's AFP is
significantly increased at 6654. The last value was 1187 from
[**2199-3-14**].
3. Hypercalcemia- This is a new finding for the pt, it is likely
hypercalcemia of malignancy. The patient was given 3 days of
caclitonin IM. His PTH was low but PTHrp was not sent. The pt
also had hypomagnesemia which may be secondary to the
hypercalcemia. Starting a bisphosphonate may be considered as
an outpatient if his calcium remains elevated.
4. Esophageal carcinoma- Pt was treated for this in [**2197**]. [**Month (only) 116**] be
reason for the pulmonary and bone mets but these are most
probably due to the HCC.
5. HTN- antihypertensive medications were held in the setting of
the acute bleed. They were restarted on discharge.
6. FEN- the patient was initially kept NPO and diet was advanced
as tolerated once his hct stabilized.
7. Proph- Pneumoboots; PPI.
8. Code- Full. Discussed at length with the pt and his daughter
who is his health care proxy. [**Name (NI) **] would wish to be recussitated
but not maintained on life support long term with no meaniful
hope of recovery.
Medications on Admission:
1. Nadolol 40 mg [**Hospital1 **]
2. Thiamine 100 mg daily
3. Folic acid 1 mg daily
4. Albuterol MDI 1-2 puffs Q4-6H PRN wheezing
5. Spironolactone 25 mg daily
6. Isosorbide dinitrate 10 mg [**Hospital1 **]
7. Extra strength tylenol QID PRN
8. Lasix 40 mg daily
9. Ambien 5 mg QHS PRN
10. Protonix 40 mg [**Hospital1 **]
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
4. Magnesium Oxide 250 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
5. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a
day.
6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day.
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
8. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO
twice a day.
9. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
10. Nadolol 40 mg Tablet Sig: One (1) Tablet PO twice a day.
11. Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
GI Bleed
Discharge Condition:
Stable, afebrile, hct was stable for >3 days.
Discharge Instructions:
Please call 911 if you have any bloody vomiting or become
dizzy/lightheaded. Please seek medical attention for
fevers>101.4 or for anything else medically concerning.
Please take your medications as directed.
Followup Instructions:
Please see your oncologist in [**12-16**] weeks for follow-up.
1) Provider: [**Name10 (NameIs) **],[**First Name3 (LF) **] MULTI-SPECIALTY MULTI-SPECIALTY
THORACIC UNIT-CC9 Where: CLINICAL CTR. - 9TH FL. MULTI
Date/Time:[**2199-5-2**] 9:30 Provider: [**Name Initial (NameIs) 4426**] 16 Date/Time:[**2199-5-2**]
10:30
2) Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], RN Where: [**Hospital6 29**]
HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2199-5-2**] 10:30
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3554
} | Medical Text: Admission Date: [**2176-1-10**] Discharge Date: [**2176-1-17**]
Date of Birth: [**2105-12-31**] Sex: F
Service: NEUROSURGERY
Allergies:
Codeine
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Behavioral Changes
Major Surgical or Invasive Procedure:
[**2176-1-12**] Right Frontal Craniotomy for Mass resection
History of Present Illness:
This is a 70 yo female with a medical hisptry significant for
stage IV Left thoracic rhabdomyosarcoma currently receiving
chemotherapy and Left breast cancer. She was transferred from
NWH with a right frontal hemorrhagic brain mass. Per patient's
husband, she had dramatic behavioral changes 2-3 days prior to
admission. She could not remember when her doctors [**Name5 (PTitle) 4314**]
were despite repeat reminders. She could not figure out how to
use the phone. She had
an extremely poor memory. She was subsequently brought to the
ER
at NWH where head CT showed a right frontal brain lesion and she
was
transferred to [**Hospital1 18**] for further management.
Past Medical History:
stage IV L thoracic rhabdomyosarcoma currently receiving
chemotherapy, L breast ca - DCIS s/p lumpectomy.
Social History:
Lives with husband. Worked as a bookeeper in husband's law
practice. Never smoked. Occasionally drinks champagne.
Family History:
parents deceased from heart disease. Brother - colon cancer.
Physical Exam:
On Admission:
Vitals: T 98.4; BP 121/71 ; P 114; RR 20; O2 sat 100%
General: lying in bed NAD
HEENT: NCAT, dry mucous membranes
Neck: supple
Pulmonary: decrease lung sounds on L.
Cardiac: tachycardic, with no m/r/g
Abdomen: soft, nontender, non distended, normal bowel sounds
Extremities: no c/c/e.
Neurological Exam:
Mental status: A & O x3, unable to say MOYB. Fluent speech with
no paraphasic or phonemic errors. Adequate comprehension.
Follows simple and multi-step commands. Registers [**2-28**], recalls
[**12-31**] at 5 min. Repetition intact (no ifs, ands or buts). Able
to
name low and high frequency objects. Some L/R confusion. No
apraxia/neglect. [**Location (un) **]/Writing intact. Clock drawing shows
poor planning with numbers collected on R side of clock face.
Misses a line on L during line bisection.
Cranial Nerves:
I: Not tested
II: PERRL, 4-->2mm with light.
III, IV, VI: EOMI. no nystagmus.
V, VII: facial sensation intact, facial strength
VIII: hearing intact b/l to finger rubbing.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: SCM [**5-1**]
XII: Tongue midline without fasciculations.
Motor: Normal bulk. Normal tone. Subtle R pronator drift.
clumsy
finger tap on L. Orbits L hand upon spinning. Subtle L UMN
weakness 4/5 of LUE.
Sensation: intact to light touch
Reflexes: Bic T Br Pa Ac
Right 1 1 1 1 1
Left 2 2 2 1 2
Toes vigorous withdrawal.
On discharge:
[**1-17**]: alert and oriented to person, place, month, and year.
Strength full in all extremities, no pronator drift, sensation
intact, cranial nerves II-XII grossly intact, pupils equal and
reactive to light bilaterally.
Pertinent Results:
CT Head [**2176-1-10**]:
stable hemorrhagic mass in the right frontal convexity with
stable surrounding edema. there is local mass effect, and sucal
effacement, but no midline shift. no new areas of hemorrhage.
Echo [**2176-1-11**]:
Moderate mitral regurgitation with borderline LV systolic
function. Mild aortic regurgitation. Mild pulmonary artery
systolic hypertension. No pericardial effusion seen. There
appears to be a mass that impinges on the right atrium - this is
probably the mass seen on CXR.
MRI Brain [**2176-1-11**]:
3.1 cm enhancing hemorrhagic mass located in the right posterior
frontal lobe with surrounding edema but no midline shift. No
additional enhancing lesions are identified. Given the patient's
history of prior malignancy, this finding is suspicious for a
solitary metastasis.
CT Head [**2176-1-13**]:
Expected post-surgical changes following a right frontoparietal
craniotomy, with blood products in the resection cavity and
pneumocephalus
overlying bilateral frontal lobes.
MRI Head [**2176-1-13**]:
Small area of restricted diffusion identified adjacent to the
surgical bed, measuring 9 x 7 mm in size, possibly representing
a small
ischemic area. With gadolinium contrast, there is a nodular area
of
enhancement at the medial aspect of the surgical cavity,
measuring
approximately 6 x 10.3 mm in size in the transverse dimension x
5.3 x 12.8 in coronal projection, possibly consistent with a
small residual lesion, followup is recommended. There is no
shift of normally midline structures. Expected post-surgical
changes following right frontoparietal craniotomy.
[**2176-1-16**] 06:37AM BLOOD WBC-4.0 RBC-3.09* Hgb-9.6* Hct-28.3*
MCV-92 MCH-31.1 MCHC-34.0 RDW-15.9* Plt Ct-160
[**2176-1-15**] 03:00AM BLOOD PT-13.6* PTT-51.9* INR(PT)-1.2*
[**2176-1-16**] 06:37AM BLOOD Glucose-105* UreaN-17 Creat-0.5 Na-142
K-3.9 Cl-108 HCO3-27 AnGap-11
[**2176-1-16**] 06:37AM BLOOD Calcium-8.5 Phos-1.8* Mg-1.9
[**2176-1-14**] 02:34AM BLOOD Type-ART pO2-261* pCO2-31* pH-7.52*
calTCO2-26 Base XS-3
Brief Hospital Course:
Ms. [**Known lastname 69844**] was admitted to [**Hospital1 18**] for a right frontal hemorrhagic
brain lesion on [**2176-1-10**]. She underwent repeat CT imaging which
was stable and MRI imaging. Cardiac Echo was performed. This
showed a mass that impinges on the right atrium with preserved
cardiac function. She was on Keppra for seizure prophylaxis. She
was on Steroids. She was scheduled for a surgical decompression
and taken to the OR on [**2176-1-12**] for right frontal craniotomy and
resection with Dr. [**Last Name (STitle) **], and remained intubated overnight in
the ICU. On [**2176-1-3**] she was extubated and on [**2176-1-14**] she was
transferred to the SDU. At that time she was oriented to self
and had a slight left pronator drift. On [**2176-1-15**] her foley was
discontinued, however it needed to be reinserted for urinary
retention.Plans to wean at rehab facility. She was seen and
evaluated by speech and swallow and tolerating an appropriate
diet upon discharge. On [**2176-1-16**] she was found to be
neurologically stable. She was given instruction to follow up in
the Brain [**Hospital 341**] Clinic on [**2176-2-5**] at 4PM.She was seen
by PT/OT who felt she would be an appropriate candidate for
rehabilitation, and discharged on [**2176-1-17**].
Medications on Admission:
Lovenox (prophylaxis - has never had a clot), chemotherapy -
last [**1-2**] next on [**1-11**].
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/T/HA.
3. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4-6HOURS
PRN () as needed for Pain.
7. Levetiracetam 1,000 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for emesis.
11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
12. regular Insulin
Regular insulin sliding scale per nursign hand out
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **]
Discharge Diagnosis:
Right Frontal Brain Lesion
Discharge Condition:
Neurologically Stable
Discharge Instructions:
GENERAL INSTRUCTIONS
WOUND CARE:
?????? You or a family member should inspect your wound every day and
report any of the following problems to your physician.
?????? Keep your incision clean and dry.
?????? You may wash your hair with a mild shampoo 24 hours after your
sutures are removed.
?????? Do NOT apply any lotions, ointments or other products to your
incision.
?????? DO NOT DRIVE until you are seen at the first follow up
appointment.
?????? Do not lift objects over 10 pounds until approved by your
physician.
DIET
Usually no special diet is prescribed after a craniotomy. A
normal well balanced diet is recommended for recovery, and you
should resume any specially prescribed diet you were eating
before your surgery. Be sure however, to remain well hydrated,
and increase your consumption of fiber, as pain medications may
cause constipation.
MEDICATIONS:
?????? Take all of your medications as ordered. You do not have to
take pain medication unless it is needed. It is important that
you are able to cough, breathe deeply, and is comfortable enough
to walk.
?????? Do not use alcohol while taking pain medication.
?????? Medications that may be prescribed include:
-Narcotic pain medication such as Dilaudid (hydromorphone).
-An over the counter stool softener for constipation (Colace or
Docusate). If you become constipated, try products such as
Dulcolax, Milk of Magnesia, first, and then Magnesium Citrate or
Fleets enema if needed). Often times, pain medication and
anesthesia can cause constipation.
?????? You have been discharged on Keppra (Levetiracetam), you
will not require blood work monitoring.
?????? You were on Lovenox prior to your admission, you may safely
resume taking this in 1 month.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc, as this can increase your chances of bleeding.
?????? You are being sent home on steroid medication, make sure you
are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation. Make sure to take your steroid medication with
meals, or a glass of milk.
ACTIVITY:
The first few weeks after you are discharged you may feel tired
or fatigued. This is normal. You should become a little stronger
every day. Activity is the most important measure you can take
to prevent complications and to begin to feel like yourself
again. In general:
?????? Follow the activity instructions given to you by your doctor
and therapist.
?????? Increase your activity slowly; do not do too much because you
are feeling good.
?????? You may resume sexual activity as your tolerance allows.
?????? If you feel light headed or fatigued after increasing
activity, rest, decrease the amount of activity that you do, and
begin building your tolerance to activity more slowly.
?????? DO NOT DRIVE until you speak with your physician.
?????? Do not lift objects over 10 pounds until approved by your
physician.
?????? Avoid any activity that causes you to hold your breath and
push, for example weight lifting, lifting or moving heavy
objects, or straining at stool.
?????? Do your breathing exercises every two hours.
?????? Use your incentive spirometer 10 times every hour, that you
are awake.
WHEN TO CALL YOUR SURGEON:
With any surgery there are risks of complications. Although your
surgery is over, there is the possibility of some of these
complications developing. These complications include:
infection, blood clots, or neurological changes. Call your
Physician Immediately if you Experience:
?????? Confusion, fainting, blacking out, extreme fatigue, memory
loss, or difficulty speaking.
?????? Double, or blurred vision. Loss of vision, either partial or
total.
?????? Hallucinations
?????? Numbness, tingling, or weakness in your extremities or face.
?????? Stiff neck, and/or a fever of 101.5F or more.
?????? Severe sensitivity to light. (Photophobia)
?????? Severe headache or change in headache.
?????? Seizure
?????? Problems controlling your bowels or bladder.
?????? Productive cough with yellow or green sputum.
?????? Swelling, redness, or tenderness in your calf or thigh.
Call 911 or go to the Nearest Emergency Room if you Experience:
?????? Sudden difficulty in breathing.
?????? New onset of seizure or change in seizure, or seizure from
which you wake up confused.
?????? A seizure that lasts more than 5 minutes.
Important Instructions Regarding Emergencies and After-Hour
Calls
?????? If you have what you feel is a true emergency at any time,
please present immediately to your local emergency room, where a
doctor there will evaluate you and contact us if needed. Due to
the complexity of neurosurgical procedures and treatment of
neurosurgical problems, effective advice regarding emergency
situations cannot be given over the telephone.
?????? Should you have a situation which is not life-threatening, but
you feel needs addressing before normal office hours or on the
weekend, please present to the local emergency room, where the
physician there will evaluate you and contact us if needed.
Followup Instructions:
FOLLOW UP APPOINTMENT INSTRUCTIONS
??????Please return to the office in [**7-6**] days (from your date of
surgery) for removal of your staples/sutures and a wound check.
This appointment can be made with the Nurse Practitioner.
Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you
live quite a distance from our office, please make arrangements
for the same, with your PCP.
??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**2-5**] at 4pm. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 5074**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone
number is [**Telephone/Fax (1) 1844**]. Please call if you need to change your
appointment, or require additional directions.
??????You will not need an MRI of the brain with/ or without
gadolinium contrast
Completed by:[**2176-1-17**]
ICD9 Codes: 431 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3555
} | Medical Text: Admission Date: [**2164-9-19**] Discharge Date: [**2164-10-16**]
Date of Birth: [**2087-5-7**] Sex: F
Service: NEUROLOGY
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Headache, visual difficulties
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 77 yo woman who was recently dx'ed with HTN and
started on lisinopril 2 wks ago, who presents after severe R
temporal HA that woke her from sleep at 3AM - HA sharp, constant
and throbbing component, which worsens with coughing. She has
also had nausea (no vomiting), and when she tried to walk felt
unsteady on feet. She took [**First Name3 (LF) **] 81mg x 4 tabs, and called 911 -
she was brought to [**Hospital 1474**] Hosp where card [**Last Name (un) **] were neg, gluc
128, INR 1.0, nl hct/ptt/plt; head CT revealed ICH (we do not
have report here), and she was transferred to [**Hospital1 18**] for further
w/u and care. She denies visual changes, but felt that when her
vision was tested in hospital she realized she couldn't see well
to the left. No c/o recent visual changes, hearing changes,
trouble with speech or swallowing, problems with memory or
language, no dizziness, no weakness, numbness, tingling, or
falls; no head trauma. She had a cold 2 months ago, but no
recent f/c/sob/cp/palp/gi/msk c/o.
ROS:
+ dysuria/burning x days
+ leg swelling, on bumex
+ dry cough since starting lisinopril
+ L shoulder pain "chronic"
Past Medical History:
1. HTN - recent dx, on lisinopril. Has developed dry cough
since starting lisinopril
2. AAA s/p percutaneous stent placement [**2163**]
3. Diverticulitis s/p colostomy/reversal 20 yrs ago
4. s/p hernia repairs x 3
5. s/p Appy as child
6. s/p cataract [**Doctor First Name **] bilat
7. pedal edema
Social History:
Lives alone since husband died; former nursing assistant.
Smokes [**3-3**] cig/day, on/off since age 24. Drinks 6 etoh
beverages/wk (all on weekend). No drugs. Has living will,
daughter [**Name (NI) 7346**] [**Last Name (NamePattern1) 68406**] is [**Name (NI) 68407**] - pt says she is full code,
unless underlying process "irreversible."
Family History:
Mother d. MI age 54, siblings with cad. No strokes or aneurysms
in family.
Physical Exam:
T 98.2 149/117 77 23 97%4L
General appearance: white female, nad
HEENT: moist mucus membranes, clear oropharynx
Neck: supple, no bruits
Heart: regular rate and rhythm, no murmurs
Lungs: clear to auscultation bilaterally
Abdomen: soft, nontender +bs
Extremities: warm, well-perfused
Skull & Spine: Neck movements are full and not painful to
palpation in the paraspinal soft tissues
Mental Status: The patient is alert and attentive, +DOW
backwards, registered three objects at 30 seconds and recalled 2
out of 3 items at 3 minutes plus one with prompt. Good knowledge
for events leading to hospitalization. Language is intact with
no errors. Naming intact; only reads R [**1-2**] of words ("fifty"
for "fifty-fifty"). There is no apraxia or agnosia.
Cranial Nerves: Dense L homonomous hemianopsia, does not spare
macula. The optic discs are very difficult to visualize due to
pupil size/lighting. Eye movements are normal, with no
nystagmus. Pupils react equally to light, both directly and
consensually 3->2. Sensation on the face is intact to light
touch, pin prick. Facial movements are normal and symmetrical.
Hearing is intact to finger rub. The palate elevates in the
midline. The tongue protrudes in the midline and is of normal
appearance.
Motor System: There is pain and giveway weakness of L deltoid;
decreased bulk bilat edb's and very mild toe ext weakness. Mild
weakness of R apb with decr bulk of thenar mm as well.
Elsewhere, normal appearance, tone, and full strength elsewhere
in limbs, including shoulder abductors, and extensors and
flexors of the arms, wrists, fingers, hips, knees, feet and
toes. There is no
tremor, drift, or abnormal movements.
Reflexes: The tendon reflexes are 1+ at [**Hospital1 **], [**Last Name (un) **], tri,
patellar, absent at achilles; symmetric. The plantar reflexes
are flexor. No grasp, nl jaw jerk.
Sensory: Diminished vibration at toes; elsewhere, sensation is
intact to pin prick, light touch, and position sense in all
extremities and trunk.
Coordination: There is no ataxia. The finger/nose test and
finger and foot tapping are performed normally, as are rapid
alternating hand movements.
Gait: could not be assessed
Pertinent Results:
145 111 28 99
-------------<
4.5 26 1.1
Phenytoin: 1.0
MCV 88
WBC 11.0 H/H 13.3/ 37.8 PLT 212
N:77.4 L:16.8 M:4.9 E:0.7 Bas:0.1
PT: 12.1 PTT: 25.3 INR: 1.0
SpecGr 1.009
Leuk Mod
Bld Lg
Nitr Pos
RBC [**11-19**] WBC>50 Bact Many
Imaging:
CT head appears to have large R ICH - area of R occipital
(occip-pariet jxn) intraparenchymal blood with associated IVH in
R lateral vent, small amount of blood in L lat vent, with blood
in 3rd, no blood in 4th. Some edema on R, minimal shift.
EKG is NSR with occ PACs, TW flat in III
MRI: 1. There is no definite increase in size of the large right
parietooccipital hemorrhage compared to the study of twelve
hours previously. There is extensive hemorrhage into the right
lateral ventricle with slightly more extension of blood
breakdown products into the third ventricle and left lateral
ventricle.
2. The mass effect on the right ventricular system and cerebral
hemisphere is stable. There is no shift of normally midline
structures, and the basal cisterns are patent.
3. There are mild microvascular changes elsewhere in the
cerebral white matter without evidence of microhemorrhages to
suggest underlying amyloid angiopathy. No enhancing lesion is
seen. There is focal linear enhancement near the lesion, of
uncertain significance, as discussed in the wet [**Location (un) 1131**].
CT Chest/Abd: 1. 6-mm nodules within the lung parenchyma for
which one year interval followup is recommended to assess for
stability.
2. Indeterminate left adrenal lesion for which further
characterization with either dedicated MRI or CT scan of the
adrenal is recommended.
3. Surgical clips in the left upper abdomen, correlate with
prior history of surgery.
4. Infrarenal intraluminal endograft within the aorta.
Surrounding thrombus and no evidence for endoleak seen. Aorta
measures approximately 4.7 x 4.5 in maximal transverse and AP
dimensions. Recommend correlation with prior CT scans to assess
for interval growth of aneurysm site.
5. No evidence for fluid collection within the abdomen and
pelvis.
EEG: Initially showed focal epileptiform discharges, then
generally encephalopathic. 3rd EEG again showed focal
discharges but less frequent.
Brief Hospital Course:
77 yo woman who was recently dx'ed with HTN and started on
lisinopril 2 wks ago, who presents after severe R temporal HA
that woke her from sleep at 3AM, found on exam to have dense L
homonomous hemianopsia, and on CT appears to have R ICH
occipital lobe with extension into ventricular system (blood in
lateral vents R>>L, and blood in 3rd). She has been evaluated
by neurosurgery, who feels that due to her current exam/clinical
picture, a vent drain may currently pose more risks than
benefits, and she should be monitored conservatively for now, in
the ICU. She also has UTI on labs. With normal coags, proplex
is not indicated.
Rec:
-Admit to neurology ICU/Attg: [**Doctor Last Name **]
-Dilantin load 1g, then start 100mg tid
-Q1h neuro checks
-Goal sbp<140s
-Check AM head CT next (or sooner if acute change in exam)
-AM labs including cbc, coags, lytes, a1c, flp, cardiac enzymes
-Tight ISS
-Temp control (goal <100)
-No antiplatelet or anticoag
-Tylenol for pain
-Treat UTI with ceftriaxone; await cultures
-Full code (discussed with patient); [**Doctor Last Name 68407**] is daughter [**Name (NI) 7346**]
[**Name (NI) 68406**]
-MRI/A to evaluate for underlying vascular lesion, or for
presence of microbleeds to suggest underlying etiology (ie,
amyloid, vs hypertensive)
Went to ICU for several days where she was noted to improve.
Transferred to the floor [**9-21**] and noted to be lethargic with
headache am of [**9-22**]. Stat CT done for concern of new
hemorrhage, but no progression seen. Again on [**9-23**] am patient
noted to be lethargic, and stat head CT showed no changes.
Percocets were d/c'd and thought to be contributing. Left
homonymous hemianopsia improved but still present.
Neuro:Neurologically, had encephalopathic exam for majority of
stay with etiology thought to initially be seizures vs.
infection and then narrowed down to infection. Had EEG which
showed focal spikes and was loaded with dilantin. Subsequent
reads of EEG showed diffuse encephalopathy but no focality. Was
continued on Dilantin and then transitioned to Keppra [**10-3**].
Keppra increased to 1500 [**Hospital1 **] on [**2164-10-10**] after repeat EEG showed
few focal sharp/slow wave discharges.
Patient's mentation and level of function gradually improved
over stay.
CVS: Aspirin held for duration of stay and will be restarted
out patient. Low dose antihypertensives started [**9-24**] with
lisinopril 10mg daily and Metoprolol 12.5mg [**Hospital1 **].
ID: Had low grade fevers off and on [**9-23**] and [**9-24**] with 3 blood
cultures/urine cultures from [**9-22**] [**9-23**] and [**9-24**]. No clear
source seen, bu PNA suspected and started on levo and flagyl.
Continued to have low grade fevers second week. Was pan
cultured several times with no growth. Elevated white count but
no left shift. ID was consulted and recommended withdrawing
antibiotics to see if infection would declare itself.
Antibiotics (levo/flagyl) taken off on [**9-28**] and continued to
have low grade fevers. Cultures were continued almost daily but
there was no growth. Transthoracic echo done to rule out
endocarditis and was negative. Transesophageal echo attempted
twice but failed secondary to poor cooperation from patient.
Serial chest xrays showed no clear infiltrate. There was no
skin breakdown and no diarrhea. A torso CT with contrast was
done to rule out any chest cavity fluid collections. LP
performed on [**10-3**] with findings as listed above. Started
Acyclovir, Vancomycin and Ceftriaxone all at meningitic doses.
Cultures were negative, but fever and white count responded to
ABX so finished a one week course. Acyclovir d/c'd after 6 days
when HSV PCR negative. No clear source of infection found after
multiple cultures/work-up. One urine culture with 10-100K
Enterococcus thought to be contamination, but received high dose
vanc for three days regardless.
RESP: no issues
GI: On PPI. Wasn't taking good PO and was eventually on tube
feeds by NG. Transitioned back to ground PO on [**10-11**] with NG
supplement. Multiple samples sent for CDIFF and negative.
DERM: consulted derm regarding vesicles and bed sore. Sent for
studies and negative for HSV.
Follow up CXR or CT should be done as out-patient for follow up
of 6mm pulmonary nodule.
Medications on Admission:
Bumex (for leg swelling)
[**Month/Year (2) **] 81mg
Lisinopril (unknown dose) - x 2 wks
PRN [**Last Name (LF) **], [**First Name3 (LF) **]
Discharge Medications:
1. Zinc Oxide-Cod Liver Oil 40 % Ointment [**First Name3 (LF) **]: One (1) Appl
Topical PRN (as needed).
Disp:*30 1* Refills:*2*
2. Docusate Sodium 150 mg/15 mL Liquid [**First Name3 (LF) **]: One (1) PO BID (2
times a day).
Disp:*60 tab* Refills:*2*
3. Senna 8.6 mg Tablet [**First Name3 (LF) **]: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
4. Miconazole Nitrate 2 % Powder [**First Name3 (LF) **]: One (1) Appl Topical TID
(3 times a day) as needed.
Disp:*30 1* Refills:*0*
5. Lisinopril 5 mg Tablet [**First Name3 (LF) **]: One (1) Tablet PO DAILY (Daily):
hold for SBP <100.
Disp:*30 Tablet(s)* Refills:*2*
6. Acetaminophen 325 mg Tablet [**First Name3 (LF) **]: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for fever >101.0.
Disp:*30 Tablet(s)* Refills:*0*
7. Thiamine HCl 100 mg Tablet [**First Name3 (LF) **]: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2*
9. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
10. Folic Acid 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Nystatin 100,000 unit/mL Suspension [**Last Name (STitle) **]: Five (5) ML PO TID
(3 times a day) as needed.
Disp:*30 ML(s)* Refills:*0*
12. Insulin Regular Human 100 unit/mL Solution [**Last Name (STitle) **]: One (1)
Injection ASDIR (AS DIRECTED): per regular insulin sliding
scale.
Disp:*1 1* Refills:*2*
13. Levetiracetam 100 mg/mL Solution [**Last Name (STitle) **]: 1500mg PO BID (2
times a day).
Disp:*30 days* Refills:*2*
14. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1)
Injection TID (3 times a day).
Disp:*0 0* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Right Occipital Intracranial Hemorrhage
Discharge Condition:
Good
Discharge Instructions:
Return to the ED or call EMS if you experience any new changes
in your vision or severe headache, nausea or vomitting. Follow
up with your appointments as listed below. You will need to
have a follow up CXR in 6 months to monitor a pulmonary nodule.
After discharge, call [**Telephone/Fax (1) 6713**] to schedule your CXR (it is
currently set for [**2165-3-31**] but you may wish to change the date for
convenience).
Followup Instructions:
Stroke: Dr. [**First Name (STitle) **] [**11-12**] at 4:30pm, [**Hospital Ward Name 23**] 8th, [**Telephone/Fax (1) 1694**].
PCP: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 29983**], [**2163-11-20**] at 9am, fax:
[**Hospital1 68408**], [**Last Name (un) 33487**], MA. [**Telephone/Fax (1) 39942**]
(phone)
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
ICD9 Codes: 431, 5990, 4019, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3556
} | Medical Text: Admission Date: [**2199-9-17**] Discharge Date: [**2199-9-20**]
Date of Birth: [**2124-12-7**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
Thoracic aortic aneurysm
Major Surgical or Invasive Procedure:
[**2199-9-17**]: Stent graft repair of thoracic aortic aneurysm
History of Present Illness:
Mr. [**Known lastname 18995**] is a 74-year-old gentleman with a large descending
thoracic aortic aneurysm, who presented for elective
endovascular repair.
Past Medical History:
PMH: HTN, focal type A dissection, type B aortic dissection,
AAA, seizure d/o, SAH 98 s/p craniotomy/aneurysm repair, PUD,
retinal detachment, Raynauds, GIB
PSH: craniotomy/aneurysm repair, hernia repair
Social History:
Alcohol - none; tobacco - 1ppd x many years
Family History:
noncontributory
Physical Exam:
PE on admission:
Gen: AAOx4, cachectic, NAD
CVS: RRR, no M/R/G
Pulm: Coarse b/l. Chronic cough.
Abd: Scaphoid. Nontender, nondistended.
Ext: no clubbing, cyanosis, or edema
Pulses: DP and PT dopplerable bilaterally
Neuro: CN II-XII grossly intact
PE on discharge:
Gen: AAOx4, cachectic, pleasant and conversant, NAD
CVS: Regular, no M/R/G
Pulm: Course, stable, chronic cough.
Abd: Nontender, nondistended, +BS
Ext: Warm, no clubbing, cyanosis, or edema. Bilateral groin
puncture sites clean, dry, and intact. Soft, without erythema
or evidence of hematoma.
Pulses: DP and PT dopplerable bilaterally
Neuro: CN II-XII grossly intact
Brief Hospital Course:
Mr. [**Known lastname 18995**] was admitted on [**2199-9-17**] for planned repair of his
thoracic aortic aneurysm. After appropriate preparation and
informed consent, he underwent endovascular stent graft repair
of his thoracic aortic aneurysm. He tolerated the procedure
well, and after initial recovery in the PACU, he was admitted to
the cardiovascular ICU for post-operative monitoring, management
of his blood pressure and ICP, and frequent neurologic exams.
Through POD#1, Mr. [**Known lastname 18995**] remained hemodynamically stable and
his neurologic exam continued to be intact. His lumbar drain
was removed on [**9-18**] without complication. His diet was
advanced, and he was able to be out of bed to a chair. His
blood pressure was closely monitored, and kept within the target
range. He was transferred to the vascular surgery floor in good
condition.
On [**9-19**], he was able to ambulate and his arterial line and foley
catheter was removed. He voided without difficulty. His home
medications were resumed, and his fluids heplocked.
On [**9-20**], Mr. [**Known lastname 18995**] was evaluated by the physical therapy team,
who cleared him for home with home physical therapy and a
walker. He was found to be ambulating at baseline, tolerating a
regular diet, taking oral pain medication, and with a stable
neurovascular exam. He was instructed to undergo an abdominal
CT scan and follow up in clinic with Dr. [**Last Name (STitle) 1391**] in one month.
He will receive daily home physical therapy, and will follow up
with his PCP for blood pressure management. He was started on
aspirin, and given prescriptions for oral pain medication. Mr.
[**Known lastname 18995**] and his wife understood and agreed with the plan. He
was discharged home with a walker and home PT in good condition
on [**2199-9-20**].
Medications on Admission:
simvastatin 10', HCTZ 25', labetalol 200'', valproic acid 500'',
lisinopril 40', nicotine patch
Discharge Medications:
1. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. valproic acid 250 mg Capsule Sig: Two (2) Capsule PO Q12H
(every 12 hours).
4. labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
6. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for Pain for 5 days.
Disp:*30 Tablet(s)* Refills:*0*
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation for 10 days.
Disp:*20 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Thoracic aortic aneurysm
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 may resume your usual diet.
Please resume your home medications unless specifically
instructed otherwise.
Please take any new medications as directed.
You may shower, and clean your groin puncture sites with soap
and water. Avoid soaking in the tub or swimming until you are
seen in vascular surgery clinic.
Avoid lifting more than 10 pounds or strenuous activity until
cleared by your surgeon.
No dressing is necessary.
Please keep your follow up appointments!
Followup Instructions:
Please call [**Telephone/Fax (1) 1393**] to schedule a follow up appointment
with Dr. [**Last Name (STitle) 1391**] in clinic in one month.
You will be called to schedule an abdominal CT scan prior to
your scheduled appointment.
Please follow up with your PCP for blood pressure management.
ICD9 Codes: 2859, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3557
} | Medical Text: Admission Date: [**2188-5-27**] Discharge Date: [**2188-5-29**]
Service: SURGERY
Allergies:
Antihistamines
Attending:[**Last Name (NamePattern1) 4659**]
Chief Complaint:
nausea/vomitting, RLQ pain
Major Surgical or Invasive Procedure:
Laparoscopic appendectomy
History of Present Illness:
The patient is an 84-year-old gentleman, who was not feeling
well for approximately 2 days with nausea and vomitting. He has
progressively developed right lower quadrant pain. He denies any
history of [**Last Name (NamePattern1) **].
Past Medical History:
1. CAD s/p inferior MI unknown date and no records here. He
states that he had a stent placed in the past.
2. CVA in the left putamen [**2183**] with ongoing right sided
weakness on coumadin.
3. Hypothyroidism
4. Depression
5. Chronic Back Pain
6. Atrial fibrillation
7. Inguinal hernia x4
Social History:
Lives at home. Born in [**Location (un) 86**]. Italian in origin. No tobacco or
etoh currently.
Family History:
NC
Physical Exam:
PE:
MS/NEURO: A/O
HEENT: PERRLA, EOMI
CVS: RRR
Resp:CTA-B
Abd: some firmness and tenderness in right lower quadrant, with
very subtle guarding and no rebound.
Ext: No. P. Edema
Pertinent Results:
[**2188-5-26**] 05:05PM WBC-12.2* RBC-4.71 HGB-14.0 HCT-41.3 MCV-88
MCH-29.8 MCHC-34.0 RDW-14.4
[**2188-5-26**] 05:05PM PLT COUNT-273
[**2188-5-26**] 05:05PM ALT(SGPT)-11 AST(SGOT)-20 ALK PHOS-117
[**2188-5-26**] 05:05PM UREA N-33* CREAT-1.1 SODIUM-139 POTASSIUM-4.6
CHLORIDE-103 TOTAL CO2-23 ANION GAP-18
[**2188-5-27**] 12:10AM PT-47.1* PTT-35.0 INR(PT)-5.5*
[**2188-5-27**] 06:08PM HGB-10.7* calcHCT-32
[**2188-5-27**] 06:00PM PT-21.8* PTT-32.2 INR(PT)-2.1*
Brief Hospital Course:
In the ED, the patient was found to have an INR=5.5. The
patient was admitted to the SICU preoperatively and given 2 u
FFP and vitamin K. The INR was corrected to 2.7. The patient
was transferred to the OR and was given another 2 u FFP. A
central venous catheter was inserted in the OR. The patient had
a laparoscopic appendectomy with no complications. Due to
respiratory difficulty, the patient was reinutbated in the OR.
The patient was later extubated in the PACU. The evening INR was
2.1. The patient was admitted to the floor from the PACU. On
POD1,the patient had B/L rales and expiratory wheezes. IV fluid
was d/c'ed and the patient was given 20mg IV lasix. CXR was
negative for pleural effusions. A few hours later, the patient
had a clear lung exam and was given a regular diet. He was
encouraged to ambulate. On the night of POD1, the patient had
an episode of nausea and a trigger event was called due to
change of mental status and tachycardia on telemetry.
Housestaff and the attending surgeon were contact[**Name (NI) **]. The
patient had normal cardiac enzymes. The patient stabilized and
had no futher events. On POD2, the patient was tolerating a
regular diet, PT assesed the patient as being able to go home,
and his INR=2.6. The patient was discharged on POD2.
Medications on Admission:
Atenolol 25 mg qd
Enalopril 2.5 mg [**Hospital1 **]
Isosorbid 30 mg qd
Prosac 20 mg qd
Zantac 150 mL [**Hospital1 **]
Synthroid 200 microg qd
Senna 2 tab qhs
colace 200 mg qhs
morphine SR 30 mg [**Hospital1 **]
percocet
Discharge Medications:
1. Enalapril Maleate 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times
a day).
2. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. Levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Senna 8.6 mg Tablet Sig: 2-4 Tablets PO BID (2 times a day).
8. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
9. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
10. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain: Please take colace while taking percocet to
prevent constipation.
Disp:*45 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Acute appendicitis
Discharge Condition:
Good
Discharge Instructions:
Please call doctor [**First Name (Titles) **] [**Last Name (Titles) **] greater than 101, nausea/vomiting,
inability to eat, wound redness/warmth/swelling/foul smelling
drainage, abdominal pain not controlled by pain medications or
any other concerns.
Please resume taking all medications as taken prior to this
surgery and pain medications and stool softener as prescribed.
Please follow-up as directed.
No heavy lifting for 4-6 weeks or until directed otherwise. [**Month (only) 116**]
leave wound open to air, please leave steri-strips intact until
they fall off.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] in 2 weeks at ([**Telephone/Fax (1) 19177**].
Please follow up Dr. [**Last Name (STitle) 58**] at ([**Telephone/Fax (1) 24989**] concerning your
blood INR and restarting coumadin
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **] MD, [**MD Number(3) 4661**]
ICD9 Codes: 412, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3558
} | Medical Text: Admission Date: [**2103-12-20**] Discharge Date: [**2103-12-26**]
Date of Birth: [**2045-7-4**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: This is a 58-year-old woman who
was transferred from [**Hospital3 417**] Hospital for cardiac
catheterization. The patient had a long history of
hypertension, hypercholesterolemia, tobacco abuse, and family
history of coronary artery disease, who was in the usual
state of health until Saturday previous to admission when she
experienced bilateral arm and chest discomfort while carrying
groceries. Her symptoms resolved with rest. The same
symptoms occurred again the same evening with exertion and
then were again relieved with rest. The patient presented to
the outside hospital Emergency Room where she was started on
Aspirin, Lovenox and beta blocker. She ruled out for
myocardial infarction by CPK and troponin and had non
diagnostic EKG changes. She is being transferred to [**Hospital1 1444**] for cardiac catheterization.
Results of the catheterization indicated the patient had
three vessel disease and was a candidate for coronary artery
bypass graft. The patient went to the operating room, was
admitted to go to the operating room on [**2103-12-21**].
Her risk factors: Hypertension, tobacco abuse (one pack per
day times 45 years), family history (father diagnosed with
coronary artery disease in his 50's, patient's mother had
coronary artery disease, patient's brother has coronary
artery disease). Hypercholesterolemia (total cholesterol on
admission 300's several years ago). The patient denies any
history of diabetes.
PAST MEDICAL HISTORY: Status post CVA times two in [**2101**],
arthritis, hypertension, hypercholesterolemia, status post
remote pneumonia, status post remote pleurisy, psoriasis.
PAST SURGICAL HISTORY: Status post tubal ligation.
MEDICATIONS: At home, Aggrenox 250 mg po q day.
ALLERGIES: Sulfa causes rash.
SOCIAL HISTORY: The patient lives alone and works full time
doing secretarial work. She has a son who is mentally
handicapped.
PHYSICAL EXAMINATION: On admission vital signs, heart rate
71, blood pressure 134/75, respiratory rate 20. Neck, no
jugulovenous distension, carotids, no bruit in either right
or left carotid artery. Lungs clear to auscultation
bilaterally. Heart, S1 and S2 appreciated, no murmurs, rubs
or gallops. Abdomen soft, non distended, nontender. There
is ecchymosis in mid abdomen, left of midline, likely
secondary to Lovenox injections. Extremities, no bruit at
the left or right femoral arteries. DP and PT pulses are 2+
bilaterally. There is no pedal edema but there is evidence
of some psoriasis of the lower extremities, right greater
than left.
LABORATORY DATA: Cardiac catheterization performed on
[**2103-12-20**]: Three vessel disease in the right dominant system.
Left main coronary artery with short vessel without
significant lesions. The LAD diffusely diseased proximal
section up to 50% with focal 70% mid segment lesion. D1 was
mildly diseased diffusely. Left circumflex had 80% stenosis
in a large OM1 branch. The right coronary artery was
diffusely diseased in the mid segment with serial 80-90%
stenosis. Limited hemodynamics showed elevated LV and
diastolic pressure (21 mmHg). Left ventriculogram
demonstrates a mild mitral regurgitation and left ventricular
ejection fraction of 58% with normal regional wall motion.
HO[**Last Name (STitle) **] COURSE: The patient was admitted to [**Hospital1 346**] and brought to the operating room on
[**2103-12-21**] by Dr. [**Last Name (Prefixes) **] where she received a coronary
artery bypass graft times three. She had an anastomosis
between the left internal mammary artery and the left
anterior descending artery, saphenous vein graft to RCA,
saphenous vein graft to OM. The patient tolerated the
procedure well and was transported to the cardiac surgery
recovery room. The patient was extubated on arrival in the
cardiac surgery recovery room but was on no drips. The
patient's postoperative course was uncomplicated and she was
extubated on the first postoperative day. On the first
postoperative day her diet was advanced as tolerated and she
was transferred to the patient care floor. On postoperative
day #2 her Foley catheter and chest tubes were discontinued.
By postoperative day #3 she began ambulating with some great
hesitancy. Foley catheter was removed. By postoperative day
#5 she was ambulating at level IV, was tolerating po, was
able to void and felt comfortable to go to rehab.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: Discharged to rehab.
DISCHARGE DIAGNOSIS:
1. Status post coronary artery bypass graft times three on
[**2103-12-21**].
DISCHARGE MEDICATIONS: Toprol 75 mg po bid, Furosemide 20 mg
po bid times one week, potassium chloride 20 mEq po bid while
on Lasix, Colace 100 mg po bid while on Percocet, enteric
coated Aspirin 325 mg po q day, Indocin 25 mg po bid, Sarna
cream applied to affected area prn, Percocet 1-2 tabs po q
4-6 hours prn, Ibuprofen 400 mg po q 6 hours prn, Tylenol 650
mg po q 4-6 hours prn, Ativan 0.5 mg po q 8 hours prn.
FO[**Last Name (STitle) **]P: The patient will follow-up in the wound care
clinic in two weeks. The patient will also follow-up with
Dr. [**Last Name (STitle) **], her primary care physician in three weeks.
The patient will follow-up with Dr. [**Last Name (Prefixes) **] in [**4-8**] weeks.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern4) 4722**]
MEDQUIST36
D: [**2103-12-25**] 16:46
T: [**2103-12-25**] 17:08
JOB#: [**Job Number 18043**]
ICD9 Codes: 4111, 4240, 3051, 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3559
} | Medical Text: Admission Date: [**2133-3-25**] Discharge Date: [**2133-4-3**]
Date of Birth: [**2064-1-5**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Palpitations
Major Surgical or Invasive Procedure:
[**2133-3-26**] Cardiac Catheterization
[**2133-3-27**] Six Vessel Coronary Artery Bypass Grafting(left internal
mammary to ramus, vein grafts to left anterior descending, first
obtuse marginal, second obtuse marginal, acute marginal and
right coronary artery)
History of Present Illness:
69 year old male without medical follow up since childhood
presented to new PCP with new complaint of palpitations on
[**2133-3-12**] - no CP, no SOB. At that time exam was notable for HTN
(SBP to 151), tachycardia (104) and hepatomegaly of uncertain
etiology - lungs clear, no JVD, no peripheral edema. EKG on [**3-14**]
showed sinus at 90 with T-wave inversions in the inferior leads,
possible Q-s in the anteroseptal leads, and LVH with ST
elevations in V1-V5. No delta waves or abnormal intervals. PCP
started ASA and Metoprolol which eliminated the patient's
symptoms. Saw patient again on [**3-14**] and the patient was
hypertensive so the Metoprolol was increased to 100 [**Hospital1 **] and
Simvastatin was added for elevated cholesterol. Patient went for
a stress test on [**3-25**] and was found to have a large fixed defect
in the LAD territory. In ED patient was given ASA and metoprolol
Patient admitted for ROMI and evaluation.
Past Medical History:
Hypertension
Hyperlipidemia
Hepatomegaly
Social History:
Social history is significant for remote tobacco use. There is
no history of alcohol abuse, though the patient reports a couple
of beers per week.
Family History:
There is no clear family history of premature coronary artery
disease or sudden death. The patient reports that his father
died of the effects of alcohol abuse on the heart at age 65.
Physical Exam:
Blood pressure was 149/88 mm Hg while seated. Pulse was 84
beats/min and regular, respiratory rate was 20 breaths/min
saturating at 98% on RA.
Generally the patient was thin and and well groomed. The patient
was oriented to person, place and time. The patient's mood and
affect were not inappropriate.
There was no xanthalesma and conjunctiva were pink with no
pallor or cyanosis of the oral mucosa. The neck was supple with
JVP of 8 cm. The carotid waveform was normal. There was no
thyromegaly. The were no chest wall deformities, scoliosis or
kyphosis. The respirations were not labored and there were no
use of accessory muscles. The lungs were clear to ascultation
bilaterally with normal breath sounds and no adventitial sounds
or rubs.
Palpation of the heart revealed a laterally displaced PMI. There
were no thrills, lifts or palpable S3 or S4. The heart sounds
revealed a 2-3/6 diastolic murmur at the apex that was audible
in the axilla. There were no rubs, clicks or gallops.
The abdominal aorta was not enlarged by palpation. There was no
hepatosplenomegaly or tenderness. The abdomen was soft nontender
and nondistended. The extremities had no pallor, cyanosis,
clubbing or edema. There were no abdominal, femoral or carotid
bruits. Inspection and/or palpation of skin and subcutaneous
tissue showed no stasis dermatitis, ulcers, scars, or xanthomas.
Pulses were 2+ distally.
Pertinent Results:
[**2133-3-26**] Cardiac Catheterization:
RIGHT ATRIUM {a/v/m} 16/13/12
RIGHT VENTRICLE {s/ed} 61/12
PULMONARY ARTERY {s/d/m} 61/28/40
PULMONARY WEDGE {a/v/m} 33/34/35
LEFT VENTRICLE {s/ed} 157/39
AORTA {s/d/m} 157/86/115
CARD. OP/IND FICK {l/mn/m2} 3.03
CARD. OP/IND OTHER {l/mn/m2} 1.82
**RESISTANCES
SYSTEMIC VASC. RESISTANCE 2720
PULMONARY VASC. RESISTANCE 132
1. Coronary angiography of this right dominant system revealed
sever
three vessel coronary artery disease with left main involvment.
The LMCA
had a mid to distal 80% eccentric stenosis. The LAD was heavily
calcified with severe dffuse disease of the first and second
diagonal
branches. The mid LAD is occluded and fills via left to left and
right
to left collaterals. The LCX is also heavily calcified with 70%
proximal
disease, diffuse disease of major OM2 branch and 50% stenosis of
the mid
AV groove CX supplying the OM3 and large LPL branch. The LCx
also
provides collaterals to the large distal RCA system. The RCA has
sever
diffuse disease with a proximal to mid total occlusion.
Competitive flow
in the distal RCA with no antegrade filling of the R-PDA and
RPL, with
collateral filling of the LAD. 2. Resting hemodyanmics revealed
severely elevated right and left sided filling pressures with
RVEDP of 15mmHg and LVEDP of 39 mmHg. There was severe pulmonary
artery systolic hypertension with PASP of 58mmHg. The cardiac
index was moderately reduced at 1.82 l/min/m2. There was
moderate systemic arterial systolic hypertension with SBP of
157mmHg. 3. Left ventriculography was deferred due to severely
elevated LVEDP. 4. Successful placement of a 7.5F 40cc IABP
under fluroscopy with good systolic unloading and diastolic
augmentation.
[**2133-3-26**] Transthoracic ECHO:
Left Atrium - Long Axis Dimension: 2.6 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: 5.1 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: 4.6 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: *1.2 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Inferolateral Thickness: *1.3 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 5.6 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 3.9 cm
Left Ventricle - Fractional Shortening: 0.30 (nl >= 0.29)
Left Ventricle - Ejection Fraction: 20% to 30% (nl >=55%)
Aorta - Valve Level: *4.3 cm (nl <= 3.6 cm)
Aorta - Ascending: *3.5 cm (nl <= 3.4 cm)
Aorta - Arch: 2.3 cm (nl <= 3.0 cm)
Aortic Valve - Peak Velocity: 1.1 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 0.5 m/sec
Mitral Valve - A Wave: 0.8 m/sec
Mitral Valve - E/A Ratio: 0.63
Mitral Valve - E Wave Deceleration Time: 154 msec
TR Gradient (+ RA = PASP): *28 mm Hg (nl <= 25 mm Hg)
INTERPRETATION:
Findings:
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or
pacing wire is seen in the RA and extending into the RV.
LEFT VENTRICLE: Mild symmetric LVH. Top normal/borderline
dilated LV cavity size. Severely depressed LVEF. TDI E/e' >15,
suggesting PCWP>18mmHg. No resting LVOT gradient. No VSD.
RIGHT VENTRICLE: Focal apical hypokinesis of RV free wall.
AORTA: Moderately dilated aortic sinus. Mildly dilated ascending
aorta. Normal aortic arch diameter. No 2D or Doppler evidence of
distal arch coarctation.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No
masses or
vegetations on aortic valve. Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Mild mitral
annular calcification. Mild thickening of mitral valve chordae.
Calcified tips of papillary muscles. No MS. Trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Normal
tricuspid valve
supporting structures. No TS. Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR. Normal main PA. No Doppler evidence for PDA
PERICARDIUM: Small pericardial effusion. Effusion
circumferential. No
echocardiographic signs of tamponade.
Conclusions:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is top
normal/borderline dilated. Overall left ventricular systolic
function is severely depressed (ejection fraction 20-30 percent)
secondary to severe hypokinesis of all but the basal segments of
the left ventricle. There is extensive apical akinesis with
spontaneous echocardiographic contrast indicating stasis of flow
at the apex. Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). There is no
ventricular septal defect. There is focal hypokinesis of the
apical free wall of the right ventricle, but overall right
ventricular contractile function appears well-preserved. The
aortic root is moderately dilated at the sinus level. The
ascending aorta is mildly dilated. The aortic valve leaflets (3)
are mildly thickened. No masses or vegetations are seen on the
aortic valve. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. There is a small
pericardial effusion. The effusion appears circumferential.
There are no echocardiographic signs of
tamponade.
CHEST (PA & LAT) [**2133-4-1**] 6:39 PM
CHEST (PA & LAT)
Reason: evaluate for hemothorax
[**Hospital 93**] MEDICAL CONDITION:
69 year old man with HTN, h/o palpitations, p/w abnormal EKG.
REASON FOR THIS EXAMINATION:
evaluate for hemothorax
HISTORY: 69-year-old male with hypertension, history of
palpitations and abnormal EKG. Evaluate for hemothorax.
Comparison is made to prior radiograph dated [**3-31**] and [**3-28**], [**2132**].
PA AND LATERAL CHEST RADIOGRAPHS
FINDINGS: Stable appearance to left pleural effusions with
slight decrease in right effusion is noted. Probable left lower
lobe compression atelectasis is stable. The remaining lung
appears clear. No change to CABG changes and cardiomegaly. Mild
calcifications are again noted within the thoracic aorta. No
evidence of pneumothorax or pulmonary edema.
IMPRESSION:
1. Stable left effusion with slight decrease in right effusion,
otherwise unchanged.
Please note evaluation for hemothorax can be obtained with
dedicated chest CT examination.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7411**]
[**2133-4-1**] 10:15AM 9.1 3.74* 11.3* 32.3* 86 30.1 34.8 14.3
278
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct
INR(PT)
[**2133-4-3**] 06:30AM 30.4* 3.2
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2133-4-2**] 06:35AM 31.2*
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
[**2133-3-26**] 12:45PM 66.7 28.3 3.6 0.3 1.0
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct
INR(PT)
[**2133-4-3**] 06:30AM 30.4* 3.2*
BASIC COAGULATION (FIBRINOGEN, DD, TT, REPTILASE, BT) Fibrino
[**2133-3-29**] 03:13AM 585*#
Source: Line-arterial
HEMOLYTIC WORKUP Ret Aut
[**2133-3-29**] 03:13AM 1.4
Source: Line-arterial
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2133-4-2**] 06:35AM 104 36* 1.5* 133 4.3 97 29 11
Brief Hospital Course:
Mr. [**Known lastname **] [**Last Name (Titles) 20003**] in for MI based on enzymes. Given his renal
insufficiency, he was pretreated with hydration and Mucomyst
prior to catheterization. Patient was loaded with Clopidogrel
and Heparin. Cardiac catheterization demonstrated 80% left main
lesion and severe three vessel coronary artery disease. Based
on his critical anatomy, an intra-aortic balloon pump was placed
and patient was transferred to Cardiac surgery service under Dr.
[**Last Name (STitle) 914**] for surgical revascularization. In preperation for
surgery, echocardiogram was performed which showed severely
depressed left ventricular function, estimated LVEF of 20-30%.
The right ventricle had focal apical hypokinesis of the free
wall but overall right ventricular contractile function appears
well-preserved. There was only mild aortic insufficiency and
trivial mitral regurgitation. He otherwise remained pain free on
intravenous therapy and was cleared for surgery.
On [**3-27**], Dr. [**Last Name (STitle) 914**] performed coronary artery bypass
grafting. For surgical details, please see seperate dictated
operative note. Following the operation, he was brought to the
CSRU for invasive monitoring. On postoperative day one, patient
awoke neurologically intact and was extubated without incident.
He maintained stable hemodynamics and weaned from inotropic
support without difficulty. His CSRU course was notable for
paroxsymal atrial fibrillation which was treated with
Amiodarone, beta blockade and anticoagulation. ACE inhibitors
were not utilized postoperatively for hypertension given his
renal insufficiency. His creatinine peaked to 1.9 on
postoperative day three. His renal function otherwise remained
relatively stable throughout his hospital stay. He eventually
transferred to the SDU for further care and recovery. He
continued to experience paroxsymal atrial fibrillation. Just
after several doses of Warfarin, his INR increased as high as
6.9. Warfarin was therefore held for several days and Vitamin K
was administered. After several days, his prothrombin time
gradually improved. He otherwise continued to make clinical
improvements and was eventually cleared for discharge on
postoperative day 7. Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] will monitor his
Warfarin as an outpatient. His goal INR should be around 2.0 for
atrial fibrillation. His INR in discharge is 3.2 and he will
receive 1 mg of coumadin today.
Medications on Admission:
Metoprolol 100 [**Hospital1 **]
Simvastatin ? dose.
ASA 325 qd
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
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:*0*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
7. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Amiodarone 400 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
10. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for
7 days.
Disp:*28 Capsule, Sustained Release(s)* Refills:*0*
11. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day: Take
I mg PO on sat. and Sun., then take as directed for INR of [**1-30**].5
.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Coronary Artery Disease - s/p CABG, Recent Myocardial
Infarction, Systolic Congestive Heart Failure, Postop Atrial
Fibrillation, Hypertension, Hyperlipidemia, Renal Insufficiency
Discharge Condition:
Good
Discharge Instructions:
Patient may shower, no baths. No creams, lotions or ointments to
incisions. No driving for at least one month. No lifting more
than 10 lbs for at least 10 weeks from the date of surgery.
Monitor wounds for signs of infection. Please call with any
concerns or questions. Please take Warfarin as directed. Dr.
[**Last Name (STitle) **] will monitor your Warfarin as an outpatient. Warfarin
should be adjusted for goal INR around 2.0.
Followup Instructions:
Dr. [**Last Name (STitle) **] 2-3 weeks, call for appt
Dr. [**Last Name (STitle) 914**] 4-5 weeks, call for appt
Dr. [**Last Name (STitle) **] in [**1-31**] weeks, call for appt
Completed by:[**2133-4-3**]
ICD9 Codes: 4280, 5859, 9971, 412, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3560
} | Medical Text: Admission Date: [**2195-1-5**] Discharge Date: [**2195-1-6**]
Date of Birth: [**2129-3-1**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
65-year-old M with ALS, BiPAP dependent with baseline O2
presenting with lethargy O2, sat in the 50s. Per nursing
facility, pt was found gasping for air and desatted to 50s. He
has secretions at baseline but was unable to spit them out.
Per report, baseline sat 70-80s; noted to be more lethargic
today with sats noted to be in 50s. No witnessed aspiration
event.
In the ED, initial VS: afebrile 119 128/100 84% on bipap.
Lactate 3.8. Received 1L NS. CXR with bibasilar atelectasis
however in setting of desaturation and leukocytosis to 16.4. No
additional obvious source of infection. Given vanc, cefepime,
levo. Sent cultures. VS prior to transfer: BP: 154/99 HR: 109
90s on bipap at home setting .
Past Medical History:
ALS
g-tube
Anxiety
Vitamin D deficiency
Constipation
Chronic Edema
HTN
HL
PVD
Hemorrhoids
right shoulder pain
Social History:
Social History: He lives at [**Location **] Secure Nursing Facility.
- Tobacco: no documented use
- Alcohol: no current use
- Illicits: no documented use
Family History:
non-contributory
Physical Exam:
On admission:
Vitals: T:96.3 BP: 164/120 P: 104 R: 18 O2: 92% bipap
General: alert, well-nourished, labored breathing, currently
nonverbal
HEENT: Sclera anicteric
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: rhonchi and wheezes bilaterally
Abdomen: soft, non-tender, non-distended, bowel sounds present
GU: no foley
Ext: warm, well perfused, 2+ pulses
On discharge:
Vitals: T:98.9 BP: 146/ 97 P: 94 R: 18 O2: 97% bipap
General: alert, well-nourished, breathing comfortably on nasal
bipap, responds appropriately, following commands
HEENT: Sclera anicteric
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: transmitted upper airway sounds
Abdomen: soft, non-tender, non-distended, bowel sounds present
Ext: warm, well perfused, 2+ pulses, no edema
Pertinent Results:
Admission labs:
[**2195-1-5**] 02:45AM BLOOD WBC-16.4* RBC-4.89 Hgb-13.0* Hct-39.6*
MCV-81* MCH-26.5* MCHC-32.8 RDW-14.2 Plt Ct-538*
[**2195-1-5**] 02:45AM BLOOD Neuts-83.4* Lymphs-9.2* Monos-4.8 Eos-1.8
Baso-0.7
[**2195-1-5**] 02:45AM BLOOD Plt Ct-538*
[**2195-1-5**] 02:45AM BLOOD Glucose-200* UreaN-12 Creat-0.3* Na-132*
K-5.9* Cl-90* HCO3-26 AnGap-22*
[**2195-1-5**] 02:45AM BLOOD ALT-20 AST-54* AlkPhos-35* TotBili-0.3
[**2195-1-5**] 09:48AM BLOOD CK(CPK)-29*
[**2195-1-5**] 02:45AM BLOOD Albumin-3.7 Calcium-10.1 Phos-4.9* Mg-1.9
[**2195-1-5**] 02:59AM BLOOD Lactate-3.8*
[**2195-1-5**] 09:53AM BLOOD Lactate-1.2
Discharge labs:
[**2195-1-6**] 03:12AM BLOOD Glucose-159* UreaN-6 Creat-0.2* Na-132*
K-3.5 Cl-91* HCO3-27 AnGap-18
[**2195-1-5**] 01:00PM BLOOD WBC-11.4*# RBC-4.41*# Hgb-12.1*#
Hct-35.9* MCV-81*# MCH-27.4 MCHC-33.6# RDW-14.1 Plt Ct-543*#
Brief Hospital Course:
65-year-old M with ALS, BiPAP dependent with baseline O2
presenting with lethargy, hypoxia, likely [**12-18**] mucous plugging vs
aspiration pneumonitis.
# Acute respiratory failure: Patient reportedly had an acute
hypoxic event that rapidly resolved. Differential diagnosis
includes transient mucuous plugging vs aspiration vs pneumonia.
A nurse from his facility was concerned him having difficulty
swallowing, although there was no documented aspiration event.
His chest xray does not show an obvious infection. He was
started on empiric treatment for HCAP with vancomycin, levaquin,
and ceftriaxone on [**1-5**]. His hypoxemia improved rapidly and
white count decreased. He remained afebrile throughout his stay
with respiratory status consistent with BiPap. Lactate decreased
from 3.8 on admission to 1.2 the following morning. Antibiotics
were DCed on discharge. O2 sat in mid to high 90s on home
setting nasal BiPAP.
OUTPATIENT ISSUES
-- Admission blood cultures are still pending on [**1-6**].
# ALS: Patient is followed by ALS specialist at [**Hospital1 2025**]. Nursing
facility had little information regarding his status and
functional capacity. Per email from [**Hospital1 2025**] ALS providers, they need
to discuss goals of care with pt.
OUTPATIENT ISSUES:
-- Goals of care discussion
# HTN: Antihypertensives were held on admission given concern
for possible sepsis. Patient remained hemodynamically stable
throughout hospitalization.
Plan to restarted anti-hypertensives at rehab.
# Depression: Celexa, ativan, and trazodone were continued while
pt was in house.
# Transitional issues:
Goals of care discussion with ALS care team
Consider speech and swallow study pending goals of care
discussion
Restart antihypertensives
Medications on Admission:
losartan 50 mg daily
HCTZ 25 mg daily
docusate 100 mg [**Hospital1 **]
citalopram 30 mg daily
bismuth subsalicylate 15 ml tid
tamsulosin 0.4 mg qHS
sodium chloride nasal spral [**11-17**] spray TID
ASA 81 mg daily
albuterol nebs q4h PRN SOB
ipratropium nebs q6h PRN sob
lorazepam 1mg PO QID
lorazepam 1mg PO q6H prn
tramadol 50-100mg q6H prn pain
trazodone 100mg PO qHS
trazodone 50mg PO qHS prn insomnia after 100mg dose
Discharge Medications:
losartan 50 mg daily
HCTZ 25 mg daily
docusate 100 mg [**Hospital1 **]
citalopram 30 mg daily
bismuth subsalicylate 15 ml tid
tamsulosin 0.4 mg qHS
sodium chloride nasal spral [**11-17**] spray TID
ASA 81 mg daily
albuterol nebs q4h PRN SOB
ipratropium nebs q6h PRN sob
lorazepam 1mg PO QID
lorazepam 1mg PO q6H prn
tramadol 50-100mg q6H prn pain
trazodone 100mg PO qHS
trazodone 50mg PO qHS prn insomnia after 100mg dose
Discharge Disposition:
Extended Care
Facility:
[**First Name8 (NamePattern2) 3075**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for Living
Discharge Diagnosis:
Hypoxia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Mr. [**Known lastname 27813**],
It was a pleasure taking care of you during your
hospitalization. You were admitted to the intensive care unit
because you had low oxygen levels. We think this is caused by
either excess mucous in your lungs or food going down the wind
pipe. Your oxygenation improved and you will return to [**First Name8 (NamePattern2) 3075**]
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for Living.
Followup Instructions:
Please arrange follow up with your primary care physician and
ALS specialist once you return to [**First Name8 (NamePattern2) 3075**] [**Last Name (NamePattern1) **]
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2195-1-6**]
ICD9 Codes: 4019, 4439 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3561
} | Medical Text: Admission Date: [**2135-1-21**] Discharge Date: [**2135-1-31**]
Date of Birth: [**2085-2-3**] Sex: F
Service: NEUROLOGY
Allergies:
Hurricaine
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
Called by Emergency Department as a Code Stroke for Left-sided
weakness and aphasia
Major Surgical or Invasive Procedure:
IV-tPA
MERCI clot retrieval
History of Present Illness:
NIH Stroke Scale score was 0: 17
1a. Level of Consciousness: 0
1b. LOC Question: 1
1c. LOC Commands: 0
2. Best gaze: 2
3. Visual fields: 2
4. Facial palsy: 2
5a. Motor arm, left: 4
5b. Motor arm, right: 0
6a. Motor leg, left: 4
6b. Motor leg, right: 0
7. Limb Ataxia: 0
8. Sensory: 1
9. Language: 0
10. Dysarthria: 0
11. Extinction and Neglect: 1
HPI:
Ms. [**Known lastname 104742**] is a 49 y/o woman with a PMH significant for
myelodysplastic syndrome, HTN and hypothyroidism, who presents
with left sided weakness. She reportedly went to bed in her
normal state of health at 2300. Her partner heard her thrashing
in bed at 0130 and at that time, he noted her speech to be
slurred and her left side to be weak, though apparently still
able to move. As it seems that the thrashing likely was around
the time of onset of the stroke, we considered 0130 to be the
last known well time. She was initially taken to OSH, where she
had a CT head that was negative for hemorrhage; it was there
determined that she was "out of the tPA window" and she was
transferred to [**Hospital1 18**] for further care.
Full ROS unable to be obtained as patient very agitated and
seemingly confused when providing her own history. However, she
does not appear to have any recent febrile illnesses and there
is
no current chest pain, shortness of breath, palpitations or
abdominal pain.
Past Medical History:
-HTN
-gout
-hypothyroidism
-myelodysplastic syndrome
-alcohol abuse
-lumbar surgery (exact nature of surgery unknown)
Social History:
She was previously employed as a hairdresser,
though says she hasnt worked in 4 years. Not reported by
patient,
but there is apparently a history of alochol abuse.
Family History:
unknown
Physical Exam:
on admission:
Vitals: T: 97 P: 67 BP: 138/49 SaO2: 99% NC
General: Awake, agitated
HEENT: no oral lesions
Neck: Supple
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR, S1S2
Abdomen: soft, +BS
Extremities: warm, well perfused
Neurologic:
-Mental Status: Alert, oriented to person, "hospital", and year
but not month. Naming generally intact, with some errors on low
frequency objects. Left sided neglect.
-Cranial Nerves: PEERL 6-->4 mm b/l. Gaze deviation to right.
Left sided hemianopia. Would not cross midline to commands but
is
able to track acorss midline. Left facial droop. Sensory loss
left face.
Motor: L hemiparesis- no antigravity ability at all on left.
Right sided strength full.
Sensory: Light touch intact at times when testing sensation, but
sometimes she would not realize when someone was holding her
left
arm, indicating a possible sensory componenent. Dimimihed
pinprick on left.
Reflexex: Patellar reflexes 2+ b/l. Biceps reflex 2+ on right,
remaining reflexes 1+. Toe upgoing on left and mute on right.
Coordination: finger-nose intact on right
Pertinent Results:
[**2135-1-21**] 06:20PM TYPE-ART PO2-104 PCO2-33* PH-7.45 TOTAL
CO2-24 BASE XS-0
[**2135-1-21**] 05:02PM TYPE-ART TEMP-37.1 RATES-/25 TIDAL VOL-500
PEEP-5 O2-40 PO2-148* PCO2-30* PH-7.47* TOTAL CO2-22 BASE XS-0
INTUBATED-INTUBATED VENT-SPONTANEOU
[**2135-1-21**] 05:02PM GLUCOSE-82 K+-3.7
[**2135-1-21**] 05:02PM freeCa-1.08*
[**2135-1-21**] 10:44AM TYPE-ART TEMP-35.0 RATES-15/ TIDAL VOL-500
PEEP-5 PO2-139* PCO2-35 PH-7.42 TOTAL CO2-23 BASE XS-0
[**2135-1-21**] 10:44AM GLUCOSE-124*
[**2135-1-21**] 10:44AM freeCa-1.07*
[**2135-1-21**] 08:39AM TYPE-ART PO2-187* PCO2-34* PH-7.44 TOTAL
CO2-24 BASE XS-0 INTUBATED-INTUBATED VENT-CONTROLLED
[**2135-1-21**] 08:39AM HGB-9.5* calcHCT-29
[**2135-1-21**] 07:38AM TYPE-ART PO2-169* PCO2-36 PH-7.44 TOTAL
CO2-25 BASE XS-1 INTUBATED-INTUBATED VENT-CONTROLLED
[**2135-1-21**] 07:38AM GLUCOSE-146* LACTATE-1.5 NA+-135 K+-3.0*
CL--101
[**2135-1-21**] 07:38AM HGB-10.2* calcHCT-31
[**2135-1-21**] 07:38AM freeCa-1.10*
[**2135-1-21**] 04:35AM GLUCOSE-119* UREA N-24* CREAT-1.4* SODIUM-138
POTASSIUM-3.7 CHLORIDE-99 TOTAL CO2-26 ANION GAP-17
[**2135-1-21**] 04:35AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2135-1-21**] 04:35AM URINE HOURS-RANDOM
[**2135-1-21**] 04:35AM WBC-11.3* RBC-4.08* HGB-11.7* HCT-36.2 MCV-89
MCH-28.6 MCHC-32.3 RDW-17.7*
[**2135-1-21**] 04:35AM PLT COUNT-523*
[**2135-1-21**] 04:35AM PT-12.2 PTT-21.3* INR(PT)-1.0
[**2135-1-21**] 04:35AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017
[**2135-1-21**] 04:35AM URINE BLOOD-TR NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2135-1-21**] 04:35AM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0-2
CTA head/neck [**1-21**]:
Occlusion of the right middle cerebral artery near its origin.
Likely retrograde collateral flow present, reconstituting more
distal branches of this vascular distribution. Evolving infarct
within the right basal ganglia region.
CT head [**1-21**]:Hyperdense regions within the head of the right
caudate nucleus and right lentiform nucleus. The findings are of
concern for either hemorrhagic transformation of the infarct,
versus extravascular accumulation of contrast material. A
followup MR study may be of help in differentiating between
these two entities.
rpt CT head [**1-22**]:
1. Evolving right basal ganglia hemorrhage with underlying
infarct with
intraventricular extension of hemorrhage and 3 mm leftward
shift.
2. Persistent moderate left subgaleal hematoma, felt to be due
to
anticoagulants on earlier studies- correlate clinically.
3. Paranasal sinus disease.
rpt CT head [**1-23**]:
1. No new foci of acute intracranial hemorrhage.
2. Expected interval evolution of the known right basal ganglia
hemorrhagic conversion, with interval decreased attenuation of
the hyperdense hemorrhagic foci but increase of peri-hemorrhagic
edema.
3. Essentially unchanged mild leftward shift of normally midline
structures, with persistent effacement of the right frontal
[**Doctor Last Name 534**].
4. Unchanged trace intraventricular hemorrhagic extension at the
right
occipital [**Doctor Last Name 534**] without developing hydrocephalus.
5. Interval decreased soft tissue swelling and hematoma in the
left temporal and frontal region.
6. Paranasal sinus disease as described above.
[**1-26**]: attempted MRI
Incomplete examination due to lack of patient cooperation. Right
basal
ganglia hemorrhage/hematoma is again noted.
Brief Hospital Course:
Initial Assessment:
Ms. [**Known lastname 104742**] is a 49 y/o woman with a PMH significant for
myelodysplastic syndrome, HTN and hypothyroidism, who presents
with sudden onset left sided weakness. On her exam, her NIHSS is
17 and she has a dense left sided hemiparesis as well as right
gaze deviation, left hemianopia and neglect. Her imaging shows
an
occlusion of R MCA near its origin. Her history, exam and
imaging
are consistent with acute embolic stroke in R MCA. The time of
onset was taken to be 0130; the time of her thrashing, and so
when she was seen here, she remained within the window for IV
tPA. The decision was made to proceed with the IV tPA. The plan
at this time is to proceed with tPA infusion and if clinical
exam
remains unchanged in 30 minutes, then plan is to proceed with
angio for IA tPA vs. Merci.
Neuro:
Ms. [**Known lastname 104742**] was admitted to the neurology ICU, attending Dr.
[**Last Name (STitle) **].
There was no improvement with tPA, and she developed hematomas
of the right knee, left scalp, and left clavicular area, so IV
TPA was stopped. The team proceeded with angio and MERCI device
was used. This resulted in opening of inferior division of the
right MCA, but opening of the superior division was
unsuccessful. She was monitored in the ICU and then was
transferred to the step down unit, then to the floor for further
management. She was started on Aspirin 81mg and Lovenox 40mg
daily (given possible MDS/malignancy.) Her CT scans showed
hemorrhagic conversion in the Right striatum and white matter.
An MRI was attempted, but she was unable to tolerate this.
There was no need to attempt repeating this MRI, per Dr. [**First Name (STitle) **]
stroke attending. Imaging otherwise as above.
CVR:
Blood pressure was controlled metoprolol 25mg TID and as needed
hydralazine. Her metoprolol was increased to 50mg TID prior to
discharge. She had an transthoracic echocardiogram which showed
no ASD or LV thrombus. There was normal global and regional
biventricular systolic function. There was mild pulmonary
hypertension. A bubble study was not done. A transesophageal
echocardiogram was attempted, however Ms. [**Known lastname 104742**] developed
methemoglobinemia (level 29) after receiving benzocaine spray.
She received Methylene blue 140mg IV by anesthesia and had rapid
clinical improvement. Her methemoglobinemia level was zero
before returning to the neurology floor. A transthoracic echo
with bubble was later done which showed No atrial septal defect
or patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers. She had lower extremity doppler
studies which were negative for DVT. Hypercoagulable work up is
pending at the time of discharge: antithrombin 3, prothrombin
gene mutation, factor v leiden.
Heme: Due to her myelodysplastic syndrome and bleeding with tPA,
heme-onc was consulted, and they did not believe there were any
restrictions on her stroke management due to her MDS.
Additionally, the team spoke with her outpatient hematologist
who confirmed no need for epo or aranesp while in the hospital.
Her HCT was stable during her hospitalization.
FEN/GI: She was initially NPO. She was followed closely by
speech and language team and was started on NGT feeds. When
able, a regular diet was initiated and advanced. At the time of
discharge she was tolerating a regular diet with nectar-thick
liquids. Her electrolytes were monitored carefully, and
repleted as necessary.
She received Famotidine for GI prophylaxis.
Psych/ETOH: Initially Ms. [**Known lastname 104742**] had significant alcohol
withdrawal. She was on a CIWA scale and received multiple doses
of Ativan in addition to Valium q12. She also received thiamine
and folate. CIWA was discontinued and she had no further
symptoms prior to discharge. She received Trazadone for sleep.
MSK: Ms. [**Known lastname 104742**] had intermittent pain, especially in left
shoulder. She had an XR which showed no evidence of cortical
disruptions suggestive of fracture or AC separation. Pain was
treated with tylenol and oxycodone.
Medications on Admission:
-amlodipine 5mg daily
-omeprazole 20mg daily
-atenolol 50mg daily
-levothyroxine 50mcg daily
-vit B-12 1000mcg daily
-vit B1 100mg [**Hospital1 **]
-folic acid 1mg daily
Discharge Medications:
1. enoxaparin 40 mg/0.4 mL Syringe Sig: Forty (40) MG
Subcutaneous DAILY (Daily).
2. senna 8.8 mg/5 mL Syrup Sig: Five (5) ML PO BID (2 times a
day) as needed for constipation.
3. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) ML 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. aspirin 325 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 for pain.
7. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
8. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
12. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary diagnosis:
-Stroke (Right PCA+MCA-territory infarction)
Secondary diagnoses:
- EtOHism / withdrawal
- chronic LBP
- chronic mild anemia, possible MDS
- methemoglobinemia secondary to benzocaine spray.
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to [**Hospital1 18**] after you had a large stroke. You
initially received TPA in attempt to break up the clot in your
brain, however this did not improve your symptoms and you
developed bruising. You then had a MERCI retrieval which was
able to open up part of your blood vessels. You were started on
medication, Lovenox, and Aspirin, to prevent further clots and
strokes. You were also started on a blood pressure medication.
You had multiple tests including head CT scans, attempted brain
MRI, echocardiograms, and ultrasounds of your legs to determine
the cause of your stroke. Additionally, multiple laboratory
tests were sent which are still pending.
While you were in the hospital you were treated for alcohol
withdrawal. You also developed a reaction to benzocaine spray,
called methemoglobinemia, in which you developed breathing
problems requiring treatment in the ICU.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2135-3-14**] 1:30
The following tests are pending at the time of discharge:
antithrombin 3, factor v leiden, prothrombin gene mutation.
ICD9 Codes: 2859, 4019, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3562
} | Medical Text: Admission Date: [**2155-11-24**] Discharge Date: [**2155-12-6**]
Date of Birth: [**2071-5-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Excedrin Extra Strength / Chlorhexidine
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2155-11-27**]
1. Aortic valve replacement, 21-mm St. [**Hospital 923**] Medical Biocor
tissue valve.
2. Coronary artery bypass grafting x1, with reverse
saphenous vein graft to the distal right coronary
artery.
[**2155-11-26**] - Cardiac Cath
History of Present Illness:
This is an 84 year old male with known aortic stenosis who has
been followed with serial echocardiograms over the last several
years. Echo's have shown
worsening aortic stenosis and he has noticed progressively
worsening dyspnea on exertion. In addition to dyspnea, patient
does admit to worsening fatigue, poor exercise tolerance and [**2-13**]
pillow orthopnea.
Presents today IV heparin prior to cath in am and AVR.
Past Medical History:
Aortic Stenosis s/p Aortic valve replacement
Coronary artery disease s/p coronary artery bypass graft x 1
Past medical history:
- Hyperlipidemia
- Coagulopathy, has been worked up at [**Hospital 3278**] Medical Center in
the
past and is presumably a factor V Leiden deficiency, for which
he
has been on Warfarin
- History of Pulmonary embolus, History of Left Leg DVT
- Left Leg Varicosities
- Cervical spine injury, 5 ruptured discs
- Prostatism
- Osteoarthritis
- Dystonia syndrome
- [**Doctor Last Name 9376**] GI disease
- Apparently he has had very long periods for wearing off of
anesthesia after prior surgical procedures
Social History:
The patient is a retired police officer and also previously
worked as a deacon. Wife passed away 2 yrs. ago. He has 3
children, the eldest of which is a neurosurgeon. The patient
denies EtOH, tobacco, or IVDU.
Family History:
non-contributory
Physical Exam:
Pulse: 87 Resp: 16 O2 sat: 97% room air
B/P Right: 154/91 Left: 164/92
Height: 67" Weight: 185 lbs
General: Elderly male in no acute distress. Obvious dystonia.
Requires walker with ambulation
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x] poor dentition
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [x] grade 4/6 SEM radiating
to
carotid regions
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x] with small ventral hernia
Extremities: Warm [x], well-perfused [x]
Edema: trace bilaterally
Varicosities: Left GSV varicosed. Right GSV appears suitable
Neuro: + Dystonic movements. CN 2-12 grossly intact. Equal
strength bilaterally in upper and lower extremities. No focal
deficits noted.
Pulses:
Femoral Right: 2 Left: 2
DP Right: 1 Left: 1
PT [**Name (NI) 167**]: 1 Left: 1
Radial Right: 2 Left: 2
Carotid Bruit: transmitted murmurs
Pertinent Results:
Cardiac Cath [**2155-11-26**]: 1) Selective angiography of this
right-dominant system demonstrated two-vessel CAD. The LMCA was
normal. The LAD had minimal disease, with a 30% ostial diagonal
1 stenosis. The LCx was normal. The RCA had a 90% ostial
stenosis but was otherwise normal.
2) Limited resting hemodynamics revealed right-sided pressures
at the upper limit of normal, with a mean RA pressure of 7 mmHg,
a mean PA pressure of 17 mmHg, and a mean wedge pressure of 10
mmHg. Central aortic pressure was normal at 131/65 mmHg.
3) Cardiac output by Fick was estimated to be 4.6 l/min (index
of approximately 2.2-2.4 l/min/m2).
Carotid Ultrasound [**2155-11-25**]: 70-79% stenosis in the bilateral
internal carotid artery with prominent heterogeneous plaques.
ECHO [**2155-11-27**]: PRE-CPB: The left atrium is mildly dilated. No
thrombus is seen in the left atrial appendage. 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. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. There are simple atheroma in
the aortic arch. There are complex (mobile) atheroma in the
descending 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). Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen.
POST-CPB: A bioprosthetic valve is seen in the aortic position.
The valve is well-seated with normal leaflet mobility. There are
no paravalvular leaks. There is no AI. The peak gradient across
the aortic valve is 36mmHg, the mean gradient is 18mmHg with CO
of 4.7L/min. The left ventricle chamber size is small,
consistent with hypovolemic state. The LV systolic function
remains, normal with EF>65%. Mitral regurgitation remains mild
and tricuspid regurgitation appears to be mild. The appearance
of the mobile atheroma in the descending aorta is unchanged from
pre-bypass. There is no evidence of aortic dissection.
[**2155-12-6**] 04:30AM BLOOD WBC-10.6 RBC-3.29* Hgb-10.1* Hct-30.6*
MCV-93 MCH-30.8 MCHC-33.1 RDW-14.1 Plt Ct-433
[**2155-12-5**] 05:15AM BLOOD WBC-11.1* RBC-3.22* Hgb-9.9* Hct-29.9*
MCV-93 MCH-30.8 MCHC-33.1 RDW-13.7 Plt Ct-364
[**2155-12-6**] 04:30AM BLOOD PT-30.6* INR(PT)-3.0*
[**2155-12-5**] 05:15AM BLOOD PT-32.2* INR(PT)-3.2*
[**2155-12-4**] 05:01AM BLOOD PT-38.1* PTT-150* INR(PT)-3.9*
[**2155-12-4**] 12:07AM BLOOD PT-34.0* PTT-48.5* INR(PT)-3.4*
[**2155-12-3**] 06:54AM BLOOD PT-27.3* PTT-65.1* INR(PT)-2.6*
[**2155-12-2**] 04:20AM BLOOD PT-22.5* PTT-55.6* INR(PT)-2.1*
[**2155-12-1**] 01:13AM BLOOD PT-18.8* PTT-72.8* INR(PT)-1.7*
[**2155-11-30**] 02:02AM BLOOD PT-16.5* PTT-48.9* INR(PT)-1.5*
[**2155-11-29**] 02:03AM BLOOD PT-15.3* PTT-28.4 INR(PT)-1.3*
[**2155-11-28**] 04:06AM BLOOD PT-15.2* PTT-30.0 INR(PT)-1.3*
[**2155-11-27**] 01:15PM BLOOD PT-16.2* PTT-36.3* INR(PT)-1.4*
[**2155-11-27**] 11:39AM BLOOD PT-16.2* PTT-33.1 INR(PT)-1.4*
[**2155-11-26**] 10:46AM BLOOD PT-17.0* PTT-46.8* INR(PT)-1.5*
[**2155-11-26**] 06:40AM BLOOD PT-14.6* PTT-73.6* INR(PT)-1.3*
[**2155-12-6**] 04:30AM BLOOD UreaN-23* Creat-1.4* Na-134 K-4.7 Cl-101
[**2155-12-5**] 05:15AM BLOOD Glucose-97 UreaN-24* Creat-1.3* Na-135
K-4.1 Cl-99 HCO3-25 AnGap-15
Brief Hospital Course:
Mr. [**Known lastname 18397**] was admitted to the [**Hospital1 18**] on [**2155-11-24**] for surgical
management of his aortic valve disease. He was placed on heparin
as he had been off coumadin for 4 days. A cardiac
catheterization was performed which revealed single vessel
coronary artery disease. The hematology service was consulted
given his Factor V leiden heterzygous mutation. Postoperative
anticoagulatin recommendations were made. The vascular surgery
service was consulted for bilateral 70-79% carotid stenosis on
duplex ultrasoound. Surgery was currently not warranted however
it was recommended that he follow-up with Dr. [**Last Name (STitle) **] in 6 months.
On [**2155-11-27**], Mr. [**Known lastname 18397**] was taken to the operating room where
he underwent coronary artery bypass grafting to one vessel and
an aortic valve replacement using a tissue valve. Please see
operative note for details. Postoperatively he was taken to the
intensive care unit for monitoring. Over the next 24 hours, he
was weaned from pressors, slowly awoke neurologically intact and
was extubated. Hematology was consulted for Factor V Leiden
deficiency and Heparin was started in addition to Coumadin until
INR>2.0. The patient did exhibit some post-operative confusion
initially. Narcotics were discontinued and the patient cleared.
He remained neurologically intact for the remainder of the
hospital course. Chest tubes and pacing wires were pulled per
caridac surgery protocol. He was started on Coumadin [**12-2**]. He
was transferred to the step down unit in stable condition. He
went into a rapid atrial fibrillation on POD 6 and became
hypotensive and developed pulmonary edema. He was transferred
back to the CVICU for cardioversion and Amio drip. He converted
to sinus rhtyhm with 200 J x 1 and remained hemodynaically
stable. He was transferred back to the step down unit in stable
condition. He was put on Tylenol and Ultram for pain. He
remained in Sinus Rhythm. He will be discharged on Amiodarone,
Simvastatin dose was reduced accordingly. He did develop some
serous drainage from the sternal wound. There was no erythema,
and sternum was stable. Leukocytosis ensued and the patient was
started on antibiotics. Additionally, urine culture grew
pseudomonas. Antibiotics were changed to Cipro to cover the
sternal wound and UTI. Sternal drainage had decreased by the
time of discharge. He was discharged to [**Hospital 38**] Rehab for
further physical therapy on POD 9. All follow-up appointments
advised.
Medications on Admission:
Simvastatin 80 mg daily
Niacin 1000 mg daily
Terazosin 2 mg twice daily
Warfarin 5 mg daily (held [**2155-11-25**])
Omeprazole 40 mg [**Hospital1 **]
Multivitamin daily
Claritin 10 mg daily
Oxycodone 5mg prn
Botox injections every three months to neck/arm
Amoxicillin prn for dental procedures
Calcium/Vitamin D daily
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. terazosin 1 mg Capsule Sig: Two (2) Capsule PO BID (2 times a
day).
3. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for
5 days.
4. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO once a day for 5 days.
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
6. Acetaminophen Extra Strength 500 mg Tablet Sig: Two (2)
Tablet PO every six (6) hours: Do not exceed 4grams/24h.
7. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
8. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
9. niacin 1,000 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
10. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400mg [**Hospital1 **] x 1 week, then 400mg daily x 1 week, then
200mg daily.
11. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 7 days. Tablet(s)
12. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
13. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
14. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
15. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
16. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day: MD
to dose daily for goal INR [**2-13**], dx: Factor V Leiden deficiency.
17. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for pruritis.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 4542**] Rehabilitation and Nursing of [**Location (un) 38**]
Discharge Diagnosis:
Aortic Stenosis s/p Aortic valve replacement
Coronary artery disease s/p coronary artery bypass graft x 1
Past medical history:
- Hyperlipidemia
- Coagulopathy, has been worked up at [**Hospital 3278**] Medical Center in
the
past and is presumably a factor V Leiden deficiency, for which
he
has been on Warfarin
- History of Pulmonary embolus, History of Left Leg DVT
- Left Leg Varicosities
- Cervical spine injury, 5 ruptured discs
- Prostatism
- Osteoarthritis
- Dystonia syndrome
- [**Doctor Last Name 9376**] GI disease
- Apparently he has had very long periods for wearing off of
anesthesia after prior surgical procedures
Discharge Condition:
Alert and oriented x3 nonfocal
Deconditioned
Incisional pain managed with Ultram
Incisions:
Sternal - no erythema, minimal serous drainage. sternum stable,
incision intact
Leg Right - healing well, no erythema or drainage.
Edema- trace
Discharge Instructions:
1) Please shower daily including washing incisions gently with
mild soap, no baths or swimming until cleared by surgeon. Look
at your incisions daily for redness or drainage.
2) Please NO lotions, cream, powder, or ointments to incisions.
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart provided.
4) No driving for approximately one month and while taking
narcotics. Driving will be discussed at follow up appointment
with surgeon when you will likely be cleared to drive.
5) No lifting more than 10 pounds for 10 weeks
6) Please call with any questions or concerns [**Telephone/Fax (1) 170**]
*Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] on [**2155-12-31**] at 1:45PM
Cardiologist: Dr. [**Last Name (STitle) **] on [**2155-12-22**] 10:40AM
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 2903**] in [**4-15**] weeks
Follow-up with vascular in 6months, [**2156-5-13**] at 10:00AM, in
relation to carotids - Dr [**Last Name (STitle) **]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication Factor V Leiden
Deficiency
Goal INR [**2-13**]
First draw [**2155-12-7**], then Monday, Wednesday, Friday
Please arrange for Coumadin/INR follow-up prior to discharge
from rehab
Completed by:[**2155-12-6**]
ICD9 Codes: 4241, 5990, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3563
} | Medical Text: Admission Date: [**2133-9-16**] Discharge Date: [**2133-10-5**]
Date of Birth: [**2067-3-14**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
Pt has a persistant and slight growth increase in a spiculated
nodule in the right upper lobe. This was PET positive, with no
evidence for
distant metastatic disease.
He was admitted for bronch, med and right upper lobectomy via
right thoracotomy.
Major Surgical or Invasive Procedure:
right upper lobe lobectomy, chest tube placement, doxycycline
pleurodesis
History of Present Illness:
Mr. [**Known lastname 9464**] is a 66-year-old gentleman with
multiple medical problems including coronary artery disease,
dysrhythmias, and a mixed obstructive and restrictive lung
process. He was seen earlier this summer with an infiltrative
nodule in the right upper lobe, associated with infectious
symptomatology. He was treated aggressively and an interval
followup showed resolution of the pneumonitis, but
persistence and slight growth in a spiculated nodule in the
right upper lobe. This was PET positive, with no evidence for
distant metastatic disease.
Past Medical History:
PMH: CLL dx [**2131**]
Renal Cell carcinoma, followed by serial CT scans, next [**Month (only) **]
[**2132**]
COPD
CAD s/p MIx2, stent
Chronic back pain
Vision impairment
Postoperative neuralgia, responsive to nortriptyline
Bell's palsy giving L facial droop.
Social History:
Lives in [**Location 1456**], MA with girlfriend. Retired police officer,
worked in security / alarm company. Currently retired.
Significant tobacco history, now quit. Rare social alcohol.
Sedentary lifestyle.
Family History:
Brother and sister with lung CA, mother CAD
Physical Exam:
General; well appearing 66 yr old male in NAD.
HEENT: non-focal
COR: RRR S1S2
Lungs: CTA bilat
abd: soft, NT, ND, +BS
Extrem: no c/c/e
Neuro: A+OX3- no focal findings.
Pertinent Results:
[**2133-9-16**] 02:55PM GLUCOSE-125* UREA N-19 CREAT-1.0 SODIUM-141
POTASSIUM-4.4 CHLORIDE-107 TOTAL CO2-24 ANION GAP-14
[**2133-9-16**] 02:55PM CALCIUM-8.2* PHOSPHATE-4.3 MAGNESIUM-1.6
[**2133-9-16**] 02:55PM WBC-22.4*# RBC-4.91 HGB-15.2 HCT-45.3 MCV-92
MCH-30.9 MCHC-33.5 RDW-13.6
CHEST (PA & LAT) [**2133-10-2**] 10:58 AM
CHEST (PA & LAT)
Reason: interval chnage in PTX
[**Hospital 93**] MEDICAL CONDITION:
66 year old man with s/p thorocotomy, 2 right CT's-posterior
tube clamped/ anterior tube to water seal.
REASON FOR THIS EXAMINATION:
interval chnage in PTX
HISTORY: Chest tubes clamped and/or to water seal.
Lateral and two frontal chest radiographs. Since examination 24
hours earlier on previous day, the more posterior of the two
right chest tubes has been removed. The large right pneumothorax
is unchanged in size and appearance with no focal mass and
probably no consolidation in secondarily collapsed lung. Heart
is normal in size with tortuous aorta. Clear left lung without
vascular congestion. No effusions identified. Right subcutaneous
emphysema.
IMPRESSION: Removal right chest tube with otherwise no change.
Specifically, the large right PTX is unchanged.
cardiac echo;
Conclusions:
The left atrium is elongated. Left ventricular wall thicknesses
are normal.
The left ventricular cavity size is normal. Overall left
ventricular systolic
function is mildly depressed. Resting regional wall motion
abnormalities
include inferolateral akinesis/hypokinesis (the apex is not
fully visualized).
Right ventricular chamber size and free wall motion are normal.
The aortic
valve leaflets (3) are mildly thickened. There is no aortic
valve stenosis.
The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation
is seen. The estimated pulmonary artery systolic pressure is
normal. There is
no pericardial effusion.
Compared with the report of the prior study (tape unavailable
for review) of
[**2133-4-7**], regional wall motion is probably similar.
Electronically signed by [**First Name4 (NamePattern1) 553**] [**Last Name (NamePattern1) **], MD on [**2133-9-24**] 17:49.
Brief Hospital Course:
Pt was admitted on [**2133-9-16**] for bronch, med and right upper
obectomy via right thoracotomy.
Operative course was notable for raw parenchyma along the
sharply developed right minor fissure was oversewn with 2
layers of Prolene. 2 right chest tubes were placed and connected
to sxn with continuous air leaks d/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] parenchyma.
Post operative course was complicated by persistant air leaks,
secretions requiring serial bronchs, and afib. These air leaks
were prolonged and pt was unable to tolerate water seal. Chest
tubes were doxycyclined x 3. After approx 2 weeks, pt was able
to [**Last Name (un) 1815**] clamping of one chest tube which was removed and the
remaining chest tube was placed to a hemlick valve with a
continued but slow leak upon discharge.
Pt initially required serial bronch's to clear secretions and
was started on augmentin for PNA.
AFIB: post operative afib was managed with amiodarone and
lopressor. Pt was subsequently admitted to the CCU for severe
bradycardia. Pt's amiodarone and lopressor were d/c'd. His heart
rate stabilized and his afib remained rate controlled without
beta blocker. He was started on anticoagulation -lovenox with
bridge to coumadin. His INR on d/c was 2.1. His primary care,
Dr. [**Last Name (STitle) 7790**] will follow his INR. His lisinopril was resumed as
prior to admission for BP control.
Pain: was initially controlled w/ epidural, transitioned o PCA
then to po percocet w/ good relief.
He was [**Last Name (un) 1815**] reg diet, ambulating w/ walker and remained O2
dependent.
He was d/c'd to home w/ VNA follow up.
Medications on Admission:
xanax, ASa, combivent, lipitor, lisinopril, nortriptyline
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*60 Disk with Device(s)* Refills:*2*
4. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
Disp:*1 puffer* Refills:*2*
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
6. Nicotine 7 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
Disp:*5 Patch 24HR(s)* Refills:*2*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for constipation.
Disp:*30 Capsule(s)* Refills:*0*
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
9. Prilosec 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*
10. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed.
Disp:*100 Tablet(s)* Refills:*0*
11. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) as needed for chest tube prophylaxis.
Disp:*30 Capsule(s)* Refills:*0*
12. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
13. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
right upper lobe lobectomy for lung cancer, persistent air leak,
atrial fibrillation.
Discharge Condition:
stable
right chest tube to hemlick valve
Discharge Instructions:
please resume all your preoperative medications. You can return
to your regular diet. You may shower.
Call Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 46290**] if you have fever, chills, sweats,
nausea, vomiting, shortness of breath, wound redness or drainage
or if your chest tube or valve are no longer functioning. DO NOT
OCCLUDE THE VALVE AT THE END OF THE CHEST TUBE.
Your primary care doctor will monitor your anticoagulation. You
must have your blood drawn on [**10-6**] by the visiting nurse. If
you experience a headache, change in vision or a trauma to your
head you must present to the emergency room immediately. Please
be careful to not injury yourself because you are at high risk
of bleeding due to the anticoagulation.
Followup Instructions:
please follow up with Dr. [**Last Name (STitle) **] on tuesday [**10-13**] at 3:30pm
in the [**Hospital Ward Name 23**] clinical center. Please arrive 45 minutes prior
to your appointment and report to [**Hospital Ward Name 23**] clinical center [**Location (un) **] radiology for a Chest XRAY. Please follow up with your
primary care physician to have your INR checked. The VNa will
check your INR on tuesday [**10-6**].
Completed by:[**2133-10-6**]
ICD9 Codes: 9971, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3564
} | Medical Text: Admission Date: [**2144-2-19**] Discharge Date: [**2144-3-11**]
Date of Birth: [**2144-2-19**] Sex: M
Service: Neonatology
NOTE: This is an interim summary covering the dates between
[**2144-2-19**] and [**2144-3-11**].
HISTORY OF PRESENT ILLNESS: This is a 21-day old male infant
with a corrected gestational age of 34 and 1/7 weeks. The
infant was born at 30 weeks gestation to a 36-year-old
gravida 2, para 0 (to 2) woman.
The pregnancy was previously uncomplicated until the mother
presented with preterm labor. She was treated with
betamethasone and started on terbutaline with a plan to
discharge her home. However, a prolapsed cord was noted.
Thus, the infant was delivered via a STAT cesarean section.
The infant's birth weight was 1620 grams.
Prenatal screens were unremarkable. The infant received
blow-by oxygen and stimulation in the Delivery Room and was
noted to have mild respiratory distress. Apgar scores were 7
at one minute of age and 9 at five minutes of age. The
infant was brought to the Neonatal Intensive Care Unit for
prematurity and respiratory distress.
PHYSICAL EXAMINATION ON PRESENTATION: General physical
examination on admission revealed the infant was a pink,
active, and nondysmorphic. Head, eyes, ears, nose, and
throat examination revealed anterior fontanel was soft. The
palate was intact. Cardiovascular examination revealed a
regular rate and rhythm. Normal first heart sounds and
second heart sounds. Pulses were normal. Chest examination
revealed mild contractions. There was good air entry. There
were clear breath sounds. The abdomen was soft, nontender,
and nondistended. There was a 3-vessel cord. There was no
hepatosplenomegaly. There was normal male external
genitalia. The testes were palpable in canals bilaterally.
There was a patent anus. The hips were normal. Neurologic
examination revealed age appropriate. Tone revealed the
infant was moving all extremities spontaneously. There were
immature reflexes. Appropriate for gestational age.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM:
1. RESPIRATORY ISSUES: The infant was placed on continuous
positive airway pressure without supplemental oxygen.
Initial blood gas was 7.35/53. The infant quickly
transitioned to room air and has done well since then. The
infant did have some apnea of prematurity noted on day of
life three for which he was subsequently started on caffeine.
He did have significant tachycardia on the caffeine, so it
was discontinued at approximately two and a half weeks of
age. Since then, the infant has had no significant apnea
noted.
2. CARDIOVASCULAR ISSUES: The infant has been
hemodynamically stable. He has no murmur.
3. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: The infant was
initially nothing by mouth and given intravenous fluids. He
advanced slowly on enteral feedings, and is currently
receiving Premature Enfamil 24 calories per ounce. The
infant has started to take some feedings orally; however, he
is receiving most of his volume via a gavage tube.
The infant's weight on the day of this dictation is 2.035
kilograms. He has been growing well.
4. GASTROINTESTINAL ISSUES: The infant had a peak bilirubin
of 8.3 on day of life four. He was treated with single
phototherapy which was discontinued on day of life five.
Follow-up bilirubin on day of life six was 6.8. The infant
has no clinical jaundice at this time.
5. HEMATOLOGIC ISSUES: An initial complete blood count
revealed the infant's white blood cell count was 6800, with a
benign differential, his hematocrit was 56.8, and his
platelets were 214,000. The infant has not received any
transfusions. His hematocrit has not been repeated since
birth. The infant has no clinical signs or symptoms of
anemia.
6. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: The infant was
initially started on ampicillin and gentamicin given his
prematurity and respiratory distress. His blood cultures
remained negative, and the antibiotics were discontinued at
48 hours of life.
7. NEUROLOGIC ISSUES: A head ultrasound on day of life
seven was normal. The infant had a repeat ultrasound on day
of life 30. There has been no active neurologic issues
during this period of time.
8. SENSORY ISSUES: The infant will require both audiologic
screening and ophthalmologic examination prior to discharge.
CONDITION AT DISCHARGE: Condition on discharge was stable.
PRIMARY PEDIATRICIAN: The primary pediatrician is unknown at
this time.
MEDICATIONS ON DISCHARGE:
1. Ferrous sulfate.
2. Vitamin E.
DISCHARGE DIAGNOSES:
1. Prematurity.
2. Respiratory distress.
3. Apnea of prematurity.
4. Rule out sepsis.
5. Hyperbilirubinemia.
6. Feeding immaturity.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 36142**], M.D. [**MD Number(1) 36143**]
Dictated By:[**Last Name (NamePattern1) 50798**]
MEDQUIST36
D: [**2144-3-11**] 13:47
T: [**2144-3-11**] 14:54
JOB#: [**Job Number 52975**]
ICD9 Codes: 7742 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3565
} | Medical Text: Admission Date: [**2160-9-5**] Discharge Date: [**2160-9-11**]
Date of Birth: [**2091-3-31**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6029**]
Chief Complaint:
bloody stool and dizziness
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
This is a 69yo M h/o peripheral vascular disease, chronic renal
insufficiency, type II diabetes, recurrent DVT on Coumadin and
diastolic CHF who presented to the ED on [**2160-9-4**] after noting
black tarry stools x 2 days and experiencing an episode of
dizziness in which he fell to the floor in his kitchen. Patient
denies LOC on falling. He did not hit his head, and remembers
event well.
.
On arrival to the ED, VS were T: [**Age over 90 **]F, BP 107/32, HR 58, RR 20,
SaO2 97% RA. Orthostatics were done, demonstrating supine BP
115/80, upright 104/70. Initial labs were significant for hct
16.3 and INR 7.3, with grossly heme+ black stool. He refused NG
lavage. He was given 2U FFP, 10mg Vitamin K SC, 1L NS, and 2U
PRBC. After transfusion, hct had only increased from 16.3 to
17.8. ECG demonstrated NSR at 60bpm, nl axis and intervals, TW
flattening in inferior leads, TWI V6, no ST elevations; no
significant change from prior. CK was 170(6), with troponin of
0.09, which is his baseline in the context of chronic renal
insufficiency. He denied CP or SOB. He denied any new
medications or significant dietary changes, and stated that his
coumadin was last checked 1 week ago. He believes his coumadin
dose may have been increased, but is unsure.
.
In the MICU, FFP and Vitamin K was given for supertherapeutic
INR. EGD revealed multiple non-bleeding 2-5mm shallow ulcers
likely secondary to NSAID used. There was also a single
non-bleeding red lesion in the the proximal body of stomach with
minor erosions at the GE junction. During his MICU stay, blood
pressure was controlled with Hydralazine and Captopril. The
patient experienced some pulmonary congestion in the context of
aggressive fluid replacement and was managed with Lasix. As HCT
had stabilized, patient was transferred to the floor ternoon for
further management.
Past Medical History:
Recurrent BL DVT on Coumadin
Chronic Stasis Dermatitis with leg ulcers
PVD – Right tibial arterial disease on arterial dopplers
HTN
L tib-fib osteomyelitis s/p vanco x 6 weeks in [**11-30**]
Mild diastolic CHF
borderline DMII
Social History:
Former smoker (1pack per month), former light EtOH user (1 pint
per month). Denies drug use. Retired security guard.
Lives alone with daily home health aide. No close family.
Family History:
NC
Physical Exam:
Vitals: T99.6 BP 1156/63 HR 75 RR 18 O2 Sat 94% RA
Appearance: comfortable, in supine in bed, well-kept, NAD
HEENT: NC/AT. Anicteric. Oropharynx clear and without
exudates/erythema.
Neck: Negative LAD. Supple neck. No carotid bruis.
Pulm: Diffuse minimal wheezes BL. No R/W/C.
Cardio: Distinct S1, S2. Slight decrescendo murmur immediately
after S1.
ABD: S/NT. + Distention. + BS.
EXT: Warm, well-perfused. No calf-tenderness. Intact pedal,
radial pulses. Dressing over LLE ulcer is clean, dry and intact.
NEURO: No focal defecits.
Pertinent Results:
[**2160-9-5**] 11:02PM HCT-23.0*
[**2160-9-5**] 08:15PM HCT-23.7*
[**2160-9-5**] 08:15PM PT-16.2* INR(PT)-1.5*
[**2160-9-5**] 04:40PM TYPE-ART TEMP-36.7 PO2-60* PCO2-36 PH-7.42
TOTAL CO2-24 BASE XS-0 INTUBATED-NOT INTUBA
[**2160-9-5**] 04:40PM LACTATE-2.2*
[**2160-9-5**] 04:25PM WBC-9.9 RBC-3.02*# HGB-8.0*# HCT-24.4*
MCV-81* MCH-26.4* MCHC-32.7 RDW-16.6*
[**2160-9-5**] 04:25PM PT-18.3* PTT-27.2 INR(PT)-1.7*
[**2160-9-5**] 02:25PM HCT-21.4*
[**2160-9-5**] 07:53AM WBC-10.2 RBC-2.37* HGB-6.2* HCT-18.8* MCV-79*
MCH-26.0* MCHC-32.8 RDW-17.1*
[**2160-9-5**] 07:53AM PT-23.6* PTT-24.4 INR(PT)-2.4*
[**2160-9-5**] 02:00AM HGB-5.9* HCT-17.8*
[**2160-9-4**] 06:54PM WBC-11.8* RBC-2.03*# HGB-5.0*# HCT-16.3*#
MCV-80* MCH-24.8* MCHC-30.9* RDW-17.9*
[**2160-9-4**] 06:54PM PT-57.4* PTT-32.8 INR(PT)-7.3*
.
EGD: [**2160-9-5**]: multiple non-bleeding 2-5mm shallow ulcers in 1st
and second portion of duodenum. Single non-bleeding red lesion
in proximal body of stomach, and minor erosions at the GE
junction. The gastric lesion was of unclear significance and
would not bleed upon provocation.
Brief Hospital Course:
.
1.GI Bleeding: Given EGD, bleeding likely due to NSAID-induced
duodenal ulcers or gastritis with ulceration at GE junction in
setting of an INR of 7.3 on [**2160-9-4**]. Warfarin was held; patient
was started on a pantoprazole 40 mg [**Hospital1 **]. HCT was monitored
closely and patient was discharged after it had stabilized for
greater than 48 hrs. He did not have a colonoscopy while
in-patient; he will be having one as an out-patient. This was
discussed with his PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **].
.
2. History of multiple DVTs: INR 7.3 ([**9-4**])--> 1.2 ([**9-11**]).
Bilateral LENIs on [**2160-9-5**] were negative for DVT.
Anti-coagulation held initially given GI bleeding. Given h/o
multiple DVT's and concern about potential for clot, warfarin
was restarted prior to discharge. At time of discharge INR was
not yet therapeutic. He will have his INR followed by his PCP as
he usually does.
.
3.HTN: Patient had been hypertensive in MICU despite GI bleed.
He was started on captopril for blood pressure control.
Eventually he was transitioned over to lisinopril and
metoprolol. He will continue to have his blood pressure
monitored by daily home care nurse and his PCP; medications will
be further titrated if necessary.
.
4. L lower extremity leg ulcer: No obvious infection. Evaluated
by podiatry service -daily application of aquacel and dry kerlex
was recommended. Patient will be seen daily by wound care nurse
following discharge.
.
Medications on Admission:
Lopressor 200 mg [**Hospital1 **]
Lasix 40 mg [**Hospital1 **]
nifedipine ER 90 mg qd
coumadin 3 mg qhs
lisinopril 40 mg qd
Iron 325 mg qd
nexium 40 mg qd
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*59 Tablet(s)* Refills:*2*
3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
4. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*80 Tablet(s)* Refills:*2*
5. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Disp:*120 Tablet(s)* Refills:*2*
6. Warfarin 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*0*
7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Disp:*60 Capsule(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
caregroup
Discharge Diagnosis:
1.Upper GI Bleed, likely from duodenal ulcers.
2. HTN
3. Diabetes
Discharge Condition:
Good
Discharge Instructions:
Please follow-up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], at your residence.
Please discuss with him the following issues:
1. Management of your duodenal ulcers
2. Outpatient colonoscopy
3. INR management - you will need to have your INR checked on
Monday [**9-15**]
4. Ongoing blood pressure control - we have restarted you on all
of your usual blood preesure medications - metoprolol and
lisinopril - and we restarted your Lasix as well. We held your
nifedipine while you were here and have not yet restarted it.
Please talk to Dr. [**Last Name (STitle) **] about restarting the nifedipine when
you see him on Monday [**9-15**].
Followup Instructions:
Please follow-up with your PCP as suggested above.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 6035**]
ICD9 Codes: 5789, 2851, 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3566
} | Medical Text: Admission Date: [**2137-8-6**] Discharge Date: [**2137-8-30**]
Date of Birth: [**2100-12-7**] Sex: M
Service: MEDICINE
Allergies:
Dapsone / Bactrim Ds
Attending:[**First Name3 (LF) 13024**]
Chief Complaint:
hypotension, positive blood cultures
Major Surgical or Invasive Procedure:
Central Femoral Line placement, now removed
History of Present Illness:
36 M with end stage HIV/AIDS (last CD4 17), known PML, history
of EtOH abuse; admit from [**Hospital1 **] with hypotension and positive
blood and sputum cultures (from few weeks ago). No notes as to
what BPs were or how usually run. [**Hospital1 **] notes state having
frequent loose stools and urine cloudy. Has L PICC in place. In
discussion with RN supervisor, patient seems to have been sent
in for workup of low grade fevers (not for hypotension); SBP 84
last on [**8-2**] and has since been in 90's to 100s (baseline).
.
Recent admission to [**Hospital3 2005**] in [**2137-6-2**]. Had positive
culture on [**2137-7-12**] for VSE, staph coag neg on [**2137-7-23**], blood cx
negative on [**2137-7-31**], C.diff neg last on [**2137-7-28**]. Amikacin and
vanco ?in recent past.
.
In the ED, T 99.1, HR 90, BP 90/64, R 18, 100% on 40% FiO2 TM.
Received 2 L NS; SBP 92-106. Vanco and Zosyn given. Femoral CVL
in place.
Past Medical History:
- HIV: Diagnosed [**2123**], risk factor MSM. Had been on HAART. Last
CD4 count 17 in 4/[**2137**].
- PML - Diagnosed in [**2137-3-2**]. Found to have +[**Male First Name (un) 2326**] virus on LP
and
non-enhancing lesions consistent with progressive multifocal
eukoencephalopathy
- PCP [**2127**]: pt reports at that time he mostly had severe fatigue
and it was not similar to this presentation. Was on Bactrim
which he is allergic to but had undergone desensitization;
stopped taking bactrim in [**Month (only) **] so currently on no prophylaxis.
- Hx gonorrhea
- anal condylomata s/p laser destruction/biopsy [**3-7**], results
showed only low-grade dysplasia. Has had no follow-up.
- Alcohol abuse: prior withdrawal seizures, pt reports in [**3-7**]
and [**4-7**]. Entered detox [**2137-2-16**]
- hx R shoulder fracture sustained during seizure in setting of
alcohol withdrawal
- Hx oral candidiasis
- Depression
- Anxiety
- Trach and PEG in 6/[**2137**]. Admitted and intubated for
respiratory distress and aspiration pneumonia. Unclear reason
for trach.
Social History:
SF is a homosexual man who in the past has engaged in
unprotected anal intercourse. He recently lived in [**Location 3786**], MA
with his mother and grandmother. His grandmother is in ailing
health and his mother has severe rheumatoid arthritis. He does
not know his father and has no siblings. SF was formerly
employed as a temp worker. He had abused alcohol for last 15
years with periods of sobriety as long as 6 months. He has a
maternal uncle who is an alcoholic. No hx of tobacco or illicit
drug use.
Family History:
Mother with rheumatoid arthritis
Physical Exam:
Vitals: T97.5, P96, BP 108/65, R28, 100% TM at 12LPM.
General: No interaction or apparent awareness of surroundings.
NAD, breathing comfortably on TM.
HEENT: NC/AT. PERRL. Sclera anicteric. MM slightly dry.
Neck: Trached on TM. No adenopathy.
Chest: Poor effort, but appears clear.
Heart: Somewhat diminished, regular, slightly tachy, no murmurs
appreciated.
Abdomen: + BS (hypoactive), soft, ND, ecchymoses from heparin,
at times appears ?tender in epigastrium, no guarding.
Extrem: Slightly cool, hands and feet with mild pitting edema. R
CVL in place.
Neuro: Moves extremities minimally to painful stimuli (?except
RUE). Sensing painful stimuli only, not responsive to voice or
command.
Pertinent Results:
[**2137-8-6**] 04:50PM URINE CA OXAL-FEW
[**2137-8-6**] 04:50PM URINE RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE
EPI-0
[**2137-8-6**] 04:50PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2137-8-6**] 04:50PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2137-8-6**] 04:50PM PT-14.0* PTT-32.7 INR(PT)-1.2*
[**2137-8-6**] 04:50PM PLT SMR-NORMAL PLT COUNT-326
[**2137-8-6**] 04:50PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-NORMAL
[**2137-8-6**] 04:50PM NEUTS-38* BANDS-0 LYMPHS-45* MONOS-10 EOS-6*
BASOS-1 ATYPS-0 METAS-0 MYELOS-0
[**2137-8-6**] 04:50PM HGB-10.6* calcHCT-32
[**2137-8-6**] 04:50PM GLUCOSE-104 LACTATE-1.5 NA+-133* K+-3.9
CL--94*
[**2137-8-6**] 04:50PM ALBUMIN-3.1* CALCIUM-8.6 PHOSPHATE-4.4
MAGNESIUM-2.2
[**2137-8-6**] 04:50PM CK-MB-NotDone
[**2137-8-6**] 04:50PM cTropnT-0.02*
[**2137-8-6**] 04:50PM LIPASE-31
[**2137-8-6**] 04:50PM ALT(SGPT)-42* AST(SGOT)-33 CK(CPK)-23* ALK
PHOS-96 TOT BILI-0.3
[**2137-8-6**] 04:50PM estGFR-Using this
[**2137-8-6**] 04:50PM GLUCOSE-103 UREA N-19 CREAT-0.5 SODIUM-135
POTASSIUM-4.1 CHLORIDE-98 TOTAL CO2-31 ANION GAP-10
[**2137-8-12**] 03:38AM BLOOD WBC-4.3 RBC-2.49* Hgb-9.8* Hct-28.9*
MCV-116* MCH-39.4* MCHC-34.0 RDW-16.3* Plt Ct-263
[**2137-8-7**] 1:06 am SPUTUM Site: INDUCED
**FINAL REPORT [**2137-8-10**]**
GRAM STAIN (Final [**2137-8-7**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2137-8-10**]):
SPARSE GROWTH OROPHARYNGEAL FLORA.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
AMIKACIN-------------- 16 S
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM------------- 8 I
PIPERACILLIN---------- 32 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ =>16 R
[**2137-8-7**] 1:06 am STOOL CONSISTENCY: SOFT Source: Stool.
**FINAL REPORT [**2137-8-8**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2137-8-8**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
[**2137-8-7**] 5:44 am BLOOD CULTURE
Blood Culture, Routine ([**Month/Day/Year **]):
[**2137-8-6**] 4:50 pm URINE Site: CATHETER
**FINAL REPORT [**2137-8-7**]**
URINE CULTURE (Final [**2137-8-7**]): NO GROWTH.
[**2137-8-6**] 4:45 pm BLOOD CULTURE
**FINAL REPORT [**2137-8-12**]**
Blood Culture, Routine (Final [**2137-8-12**]): NO GROWTH.
[**2137-8-10**] 4:07 pm STOOL CONSISTENCY: FORMED Source:
Stool.
**FINAL REPORT [**2137-8-11**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2137-8-11**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
Brief Hospital Course:
Hypotension/fever/?sepsis: Per [**Hospital1 **] his baseline blood
pressure appeared to be mid 90s, had one BP of 84/52 on [**8-2**] but
[**Name8 (MD) **] RN supervisor appears to have been in the 90s since. We
believe he was sent in more for low grade temps (up to 100.8 off
and on); in ED had SBP 90 and has been in the 90's to 100's
since. Has advanced HIV but no recent CD4 count (none since
prior to HAART) so therefore may be at high risk for infection.
Review of records with the patient showed that he had had
blood cx collected [**7-23**] positive for coag negative staph
(susceptible to tetracycline and vanc), as well as a catheter
tip w/ coag negative staph also on [**7-23**]. He also had negative
blood cx x2 on [**2137-7-31**]. He also has a history of E coli and
Pseudomonas in his sputum (sensitive to cefepime and Pip/Taz) on
[**7-17**]. Sputum from [**7-20**] showed moderate Pseudomonas with
intermdiate resistance to Amikacin, and pt had Amikacin levels
from [**7-31**], but no additional data regarding this treatment was
available.
He also has an indwelling PICC, it is unknown how long this
has been in place. After arrival in the MICU, he was started on
Vancomycin and Zosyn. He had two negative C. diff tests [**7-26**]
and [**7-28**], and another was sent here, which was also negative.
Blood, urine, and sputum cultures were also sent. The sputum
showed no microorganisms, and the urine culture had no growth.
Blood cultures [**8-6**] showed no growth. Patient spiked a
temperature to 101.6 on [**2137-8-7**], and was re-cultured (blood cx
still [**Date Range **] [**8-12**]), but has remained afebrile since then.
Chest x-ray showed no evidence of pneumonia or acute disease.
Patient's CD4 was sent and the level was 53. Given improvement
in clinical appearance, further workup, including LP, was not
pursued at this time. Consideration was also given to removing
the PICC as a potential source of infection, but as patient had
no evidence of growth on blood cultures or worsening infection,
this was left in. Pt had a femoral central line placed in the
ED, and this was removed on [**2137-8-9**].
Pt was afebrile for several days, but on [**8-12**]/8, began to
spike recurrent fevers to 103(rectal). Sputum, blood, and urine
cultures were sent on [**8-12**] and showed WBCs and bacteria in urine
but never grew any bacteria. Sputum showed PSA as before. ID was
called for consult regarding whether to get an LP and further
workup for infectious cause of fever however they felt that PSA
was likely a colonization and fever was central in origin not
infections. Serologies for CMV and EBV were negative. Vanco and
Zosyn were d/c'd on [**2137-8-15**].
*** Primary care provider will need to follow up [**Date Range **] blood
cultures ***
Sinus Tachycardia: This is believed to be long standing
(though unclear etiology); records report [**Hospital1 1501**] dosing of 400 mg
metoprolol daily. Of note, an H&P from [**2137-6-14**] reports his dose
as Metoprolol 25 mg [**Hospital1 **]. Pt intially received multiple boluses
of IVF, and had a decrease in his HR, though this would
generally increase back to around 120 bpm. Patient was started
on low dose metoprolol, which was gradually increased to 50 TID
by [**2137-8-9**]. His HR continued to range from 90-120, with SBPs in
the 90s to 100s and the metoprolol was decreased again to 37.5mg
with stable SBPs in 90s and HR 110s.
.
H/o Positive sputum cultures: Pt has history of pseudomonas
and E. coli in sputum with multiple drug resistance. No clear
evidence of pneumonia on CXR, but with significant
immunosuppresion. Sputum intially showed no organisms, and pt
was empirically treated with zosyn/cipro. On [**8-11**], his sputum
sensitivities resulted, and he was changed over to [**Month/Year (2) 21347**]. The
Pseudomonas was sensitive to both Zosyn and [**Last Name (LF) 21347**], [**First Name3 (LF) **] the plan
is to treat for a total of 14 days. Including the 4 days of
Zosyn leaves 10 days of [**First Name3 (LF) 21347**], for a stop date of [**2137-8-20**].
Antibiotics were d/c'd on [**2137-8-15**] as it was felt they were not
indicated in setting of colonization and no infection.
.
PML. Very poor mental status at baseline, does not appear
changed per [**Hospital1 **] reports. Progressive neurologic impairment
as expected. Mental status appeared unchanged per records. A
CT was ordered that showed much progressed PML since [**4-9**]. Had
several discussions with mother regarding goals of care, and she
intially indicated she did not want patient to be intubated or
have chest compressions and then after the results of the CT
decided to not escalate his care further. He was thus kept on
nutrition, fluids, and narcotics only. If necessary she agreed
to also have him get antibiotics.
.
HIV/AIDS: Last CD4 count 17 was prior to HAART; now on HAART x
4 months. Recheck of CD4 was 53. Pt was continued on HAART,
with atovaquone for prophylaxis.
.
Anemia. Macrocytic likely [**2-2**] HAART. No change in last week
per records from [**Hospital1 **]. Stable during hospitalization.
.
History of EtOH abuse. Now at skilled nursing facility, no
concern for withdrawal issues.
.
FEN: Pt was continued on tube feeds with equivalent formula.
PPx: Pt was prophylaxed with HSQ, H2 blocker while an
inpatient
Communication. Mother [**Name (NI) **] is HCP; number is [**Telephone/Fax (1) 94548**].
Code: During this admission, code status was changed to
DNR/DNI after discussions with mother, may need to readdress for
future admissions.
.
At time of transfer off of MICU [**Location (un) **], Mr. [**Known lastname **] is
unresponsive to pain. His pupilary reflexes are deranged. He
requires frequent suctioning, is tachycardic, and at times
febrile, but is stable. All of this seems to be related to
autonomic dysregulation as a consequence of his PML. It is worth
noting that his sputum is colonized by Psuedomonas, but he does
not have a Pseudomonal infection per ID. Indeed, although he has
continued empiric treatment for this colonization/infection, his
fevers are unchanged as are his other vital signs. As stated
above, his course has been a long and complicated decline to his
current state.
=======================Medicine Floor
Team====================================
All medical management initiated in the ICU was continued on the
general medical service. Scopolamine patches were increased to
two q72h and provided good control of secretions. Electrolytes
and white count were stable. Pt was transiently febrile and
started on Linezolid for a positive blood culture, but Abx were
discontinued b/c culture showed likely contaminant. Linezolid
was discontinued and fever resolved on its own.
At the time of tranfer to outside facility, the pt is
unresponsive, but calm and apparently comfortable. His
electrolytes and white count are unremarkable. He has been
afebrile for 5 days.
Medications on Admission:
Albuterol/ipratrop MDI QID
Atovaquone 750 mg daily
Butt balm topical [**Hospital1 **]
Colistin inhaled 150 mg [**Hospital1 **]
E-mycin 0.5% eye ointment TID
HSQ Q8H
Lopinavir/ritonavir 200/50 [**Hospital1 **]
Mefloquine 250 Qsaturday
Metoclopramide 10 mg QID
Metoprolol 100 mg Q6H
Petroleum ophthalmic QID
Promod 2 scoops [**Hospital1 **]
Raltegravir 400 mg Q12H
Scopalamine patch 1.5 mg x2 patches Q72H
Tenofovir 300 mg daily
Thiamine 100 mg daily
Zidovudine/Lamivudine 150/300 mg [**Hospital1 **]
PRN meds: acetaminophen, A/A nebs, Nacl inhalation, loperamide,
zofran, zyprexa 5mg.
O2 by trach collar at 35%
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
Disp:*qs 1 month * Refills:*2*
2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
Disp:*60 Tablet(s)* Refills:*2*
3. Raltegravir 400 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
Disp:*120 neb* Refills:*2*
7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours).
Disp:*120 neb* Refills:*2*
8. Atovaquone 750 mg/5 mL Suspension Sig: Ten (10) mL PO DAILY
(Daily).
Disp:*300 mL* Refills:*2*
9. Lopinavir-Ritonavir 400-100 mg/5 mL Solution Sig: Five (5) ML
PO BID (2 times a day).
Disp:*150 ML(s)* Refills:*2*
10. Lamivudine-Zidovudine 150-300 mg Tablet Sig: One (1) Tablet
PO BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
11. Scopolamine Base 1.5 mg Patch 72 hr Sig: Two (2) Patch 72 hr
Transdermal Q72H (every 72 hours).
Disp:*10 Patch 72 hr(s)* Refills:*2*
12. Erythromycin 5 mg/g Ointment Sig: One (1) ribbion Ophthalmic
TID (3 times a day).
Disp:*90 ribbion* Refills:*2*
13. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for fever.
Disp:*60 Tablet(s)* Refills:*0*
14. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
Disp:*500 ML(s)* Refills:*2*
15. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
Disp:*qs month * Refills:*2*
16. Amitriptyline 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*15 Tablet(s)* Refills:*2*
17. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
18. Morphine 10 mg/0.7 mL Pen Injector Sig: 2-4 mg Intramuscular
q2 prn as needed for before turning pt.
19. Bisacodyl 5 mg Tablet Sig: Two (2) Tablet PO once a day.
20. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO twice
a day.
21. Artificial Tear with Lanolin Ointment Sig: One (1) Appl
Ophthalmic PRN (as needed).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 511**] Sianai at [**Hospital 1263**] Hospital
Discharge Diagnosis:
Acquired Immunodeficiency Syndrome
Progressive Multifocal Leukoencephalopathy
Hypotension
Anemia
Sinus Tachycardia
Pneumonia
Discharge Condition:
Fair. Pt has persistent tachycardia, which is chronic. .
Discharge Instructions:
You were admitted to the hospital for concern about low blood
pressures, fevers, and infection. Your blood pressure responded
to fluid, and you were started on antibiotics for a presumed
infection. While you intially had a few fevers, these did not
recur after [**8-9**]. Cultures of your blood, sputum, and
urine showed no evidence of infection or bacteria by [**2137-8-10**].
Also, your red blood cell count was low, but stable, during this
admission.
If your clinical status deteriorates, your mother should consult
your PCP about whether [**Name Initial (PRE) **] transfer to the hospital would be
appropriate.
Followup Instructions:
Please follow-up with your PCP as necessary.
Completed by:[**2137-8-30**]
ICD9 Codes: 4589, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3567
} | Medical Text: Admission Date: [**2165-5-14**] Discharge Date: [**2165-5-21**]
NOTE: Discharge date is still to be determined.
CHIEF COMPLAINT: New onset renal failure.
male with a history of diabetes, polymyalgia rheumatica (on
chronic steroids times four years), hypertension, benign
prostatic hypertrophy, and hypercholesterolemia who presented
for lower extremity peripheral angiography for bilateral foot
ulcers when he was found to have an elevated [**Year (4 digits) **] urea
nitrogen of 100, creatinine of 2.3, and potassium of 6.6.
approximately four months ago. Due to his worsening [**Year (4 digits) **]
sugar levels, he was started on insulin in [**2164-1-23**].
The patient's foot ulcers continued to develop, and the
patient complained of foot pain predominantly at night and
with pressure of the sores. The patient is unsure how they
developed as he checks his feet every night and applies a
salve two to three times per day. He has applied Neosporin
to his current sores, but noticed they had difficulty
healing. He recently began seeing a podiatrist regarding
foot care.
The patient was referred for a Vascular consultation because
of his continuing foot ulcerations and pain. He was
scheduled for a lower extremity angiography on the day of
admission but was found to have the elevated [**Year (4 digits) **] urea
nitrogen, creatinine, and potassium as above. Therefore, the
procedure was cancelled. An electrocardiogram was done which
showed peaked T waves. The patient was given 10 units of
regular insulin, and 1 amp of D-50, and started on half
normal saline at 100 cc per hour. He was admitted to the
Medicine Service for new onset of renal failure.
The patient denied any oliguria, hematuria, dysuria, flank
pain, or abdominal pain; although, he does complain of
urinary hesitancy which is chronic. His urine has been
clear. He feels that his urine output matches his oral
intake of approximately five cups of fluid per day. He has
had one episode of nephrolithiasis in his 30s. He complains
of fatigue, anorexia, and a 10-pound weight loss over the
past four months, as well as increasing shortness of breath
which has increased to shortness of breath with one flight of
stairs. The patient denies any fevers, chills, recent
infections, chest pain, orthopnea, nausea, vomiting,
diarrhea, bright red [**Year (4 digits) **] per rectum, or melena.
In addition, he complains of a cough which has been worsening
over the past four months. It is productive of purulent
sputum. He denies ever coughing up any [**Year (4 digits) **]. He also
complains of new voice hoarseness which also began during the
same time period.
PAST MEDICAL HISTORY:
1. Type 2 diabetes diagnosed four years ago when he started
steroids. He was originally on Metformin but recently began
insulin in [**2165-1-22**] for worsening [**Year (4 digits) **] sugars. Last
hemoglobin A1c (per patient) was 11.4.
2. Polymyalgia rheumatica diagnosed four years ago.
Symptoms are much improved after starting on steroids.
3. Temporal arteritis.
4. Benign prostatic hypertrophy, status post transurethral
resection of prostate; diagnosed approximately 11 to 15 years
ago. The patient has urinary hesitancy but denies any
urinary retention. Biopsy showed no evidence of prostate
cancer (per patient). Last prostate-specific antigen (per
primary care physician) was 2.6.
5. Hypertension.
6. Hypercholesterolemia.
7. Chronic lower extremity edema with a question of
congestive heart failure.
MEDICATIONS ON ADMISSION:
1. Methylprednisolone 4 mg p.o. q.a.m. and 2 mg p.o. q.h.s.
2. Spironolactone 50 mg p.o. q.d.
3. Metformin 1500 mg p.o. at dinner.
4. Pravastatin 10 mg p.o. q.h.s.
5. Lisinopril 20 mg p.o. q.a.m.
6. Furosemide 80 mg p.o. q.a.m.
7. Tylenol p.o. p.r.n.
8. Humalog 75/25 22 units q.a.m. and 12 units q.p.m.
ALLERGIES: The patient has no known drug allergies.
FAMILY HISTORY: The patient has a twin brother who had type
1 diabetes. The patient's mother and another brother had
type 2 diabetes.
SOCIAL HISTORY: The patient is a former smoker and quit
approximately 50 years ago. He drinks approximately one
glass of wine per day. He denies any illicit drug use. The
patient lives with his wife in [**Name (NI) 7740**], [**State 350**].
The patient was in the Army during World War II; then worked
as a truck driver, and then was a contractor. He has since
retired. He has two children; one daughter who lives in the
area, and one son who lives in [**Name (NI) 108**].
PHYSICAL EXAMINATION ON PRESENTATION: Temperature of 98.1,
[**Name (NI) **] pressure of 140/70, pulse of 95, respiratory rate
of 18, satting 98% on room air. In general, the patient was
a thin, elderly, white male lying in bed in no acute
distress. He had a hoarse voice. Head, eyes, ears, nose,
and throat showed pupils were equal and reactive to light.
Extraocular movements were intact. His sclerae were
anicteric. The oropharynx was moist. There were no
petechiae noted. The neck was supple. There was no cervical
lymphadenopathy. There was no thyromegaly. There was no
elevated jugular venous pressure. The heart had a regular
rate and rhythm with a 2/6 systolic murmur heard most
prominently at the left upper sternal border. The lungs had
faint crackles in the left lower lobe and were otherwise
clear. The back had no costovertebral angle tenderness.
There was slight pitting edema over the middle back. There
was no point tenderness. The abdomen was soft, nontender,
and nondistended. There was no rebound or guarding. No
hepatosplenomegaly. The bowel sounds were normal. The
extremities showed 2+ femoral pulses bilaterally, 1+ dorsalis
pedis pulses bilaterally. There was no lower extremity
edema. The left foot showed a dry crusted ulcer over the
medial aspect of the first metatarsal head and the lateral
posterior heel. The right foot showed a dry crusted ulcer
over the medial aspect of the first metatarsal head and the
medial posterior heel. The skin showed decreased turgor.
Neurologic examination showed cranial nerves II through XII
to be grossly intact. Proprioception was slightly impaired
in the left extremities bilaterally.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories on
admission showed a white [**Name (NI) **] cell count of 11.7, hematocrit
of 30.3, platelets of 269, mean cell volume of 87. Sodium
of 139, potassium of 6.1 (status post insulin and
Kayexalate), chloride of 102, bicarbonate of 18, [**Name (NI) **] urea
nitrogen of 100, creatinine of 2.3, [**Name (NI) **] sugar of 189.
HOSPITAL COURSE: The patient was admitted to the General
Medicine Service for further evaluation and management of his
new onset renal failure. In addition, there was concern over
his recent fatigue, shortness of breath, cough, and new
hoarse voice.
1. RENAL: The patient was felt to be most likely prerenal
given his physical examination findings as well as a bland
urine sediment, negative urinalysis, and FENa of less
than 1%.
He had a renal ultrasound which was normal. He was hydrated
for the first two hospital days, and his creatinine had come
down to 1.3 by the morning of [**5-17**]. He had a magnetic
resonance angiography of the renal arteries done on [**5-19**]
which showed mild right-sided renal artery stenosis. His
Zestril and diuretics were held initially. SPEP and UPEP
were negative.
A coude catheter was placed on the second hospital day in
order to closely monitor the patient's ins-and-outs. A
regular Foley catheter was unable to be placed after three
attempts by the nurses. The patient then developed fevers on
[**5-17**] and was found to have a urinary tract infection.
The coude catheter was therefore removed on [**5-17**], and the
patient was started on renally dosed Levaquin.
During this same time period (on [**5-17**]) when the patient
developed rigors, he also appeared clinically fluid
overloaded on examination with bibasilar crackles which were
increased from the time of admission. He had received 2
units of packed red [**Month (only) **] cells the night prior, and it was
felt that he may have become fluid overloaded in this
setting. His [**Month (only) **] urea nitrogen and creatinine had come
down to 46 and 1.3 at that time. The patient received two
doses of Lasix on that day; each time 40 mg p.o. His
intravenous fluids were also discontinued on [**5-17**]. His
creatinine was then stable on [**5-18**], and he was feeling
better.
On [**5-19**], his creatinine had slightly bumped to 1.5. He
was still on Lasix 40 mg p.o. q.d. He had not restarted his
Aldactone which he was on as an outpatient. Zestril 5 mg was
added on [**5-19**] to see if any element of pump dysfunction
was causing the patient's increasing creatinine. However,
the patient's creatinine stayed at 1.5 the next day while on
the Zestril and Lasix. The Zestril was then discontinued,
and the Lasix 40 mg p.o. q.d. was continued.
On [**5-21**], the patient's creatinine again bumped to 1.8, so
his Lasix was discontinued as well, and he was gently
rehydrated. At the time of this Discharge Summary he was
currently being gently rehydrated, and a repeat creatinine
will be checked tomorrow. In addition, a new FENa will be
calculated, and the urine will again be spun to look at the
sediment.
2. CARDIOVASCULAR: The patient had a question of a history
of congestive heart failure given his lower extremity edema.
He was on significant diuretic doses as an outpatient but did
present with clinical dehydration; so, it was unclear as to
whether he actually required diuretics or not. His primary
care physician was [**Name (NI) 653**] and an echocardiogram had never
been performed on the patient.
Therefore, an echocardiogram was obtained here both to
evaluate him with regard to his fluid management as well as
for possible preoperative evaluation if he is going to
undergo bypass surgery. The findings of the echocardiogram
showed the left atrium to be mildly dilated. There was mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size was normal. The regional left ventricular wall
motion was normal. The left ventricular ejection fraction
was normal at greater than 55%. The aortic loop was mildly
dilated. The aortic valve leaflets were moderately
thickened, and there was trace aortic regurgitation. There
was mild-to-moderate mitral regurgitation.
Although the patient carried a diagnosis of hypertension, he
had no episodes of hypertension while admitted. The highest
[**Name (NI) **] pressure recorded was 140/70 on admission. In fact, on
[**5-17**], the patient developed hypotension into the 80s in
the setting of low [**Month (only) **] sugars as well as hypothermia. He
was rigoring. It was felt he was hypoglycemic initially
secondary to his evening insulin dose. However, later in the
day on [**5-17**], he continued to rigor and also developed a
relative fever of 99.5 which was up from 95 earlier in the
morning. He was cultured and found to have the urinary tract
infection as already described. He was given stress-dose
steroids for one day given concern for possible adrenal
insufficiency in the setting of his chronic steroid use and
new infection. His [**Month (only) **] pressure has been stable and has
been in the 100 to 120 range.
3. INFECTIOUS DISEASE: The patient developed a urinary
tract infection in the setting of catheter placement as
already described. He is currently on day [**6-4**] of Levaquin
renally dosed.
In addition, there were 1/2 [**Month/Year (2) **] cultures which came back
with Staphylococcus aureus. These [**Month/Year (2) **] cultures were drawn
on [**5-16**], prior to the patient's episodes of hypotension
and rigors. It was unclear who ordered these [**Month (only) **] cultures
or if they were even the patient's actual [**Month (only) **] cultures.
There was possible concern for osteomyelitis given that these
[**Month (only) **] cultures grew Staphylococcus aureus, so plain films
were obtained of both feet which showed no evidence of
osteomyelitis.
A magnetic resonance imaging could be considered to fully
evaluate for the possibility of osteomyelitis in the feet;
however, given that his ulcers have been there for
approximately four months, and the plain films showed no
evidence, it was unlikely that the patient does have
osteomyelitis. At the time of this Discharge Summary, the
decision has been to hold off on any further imaging of the
feet.
It should be noted that the urine culture came back positive
for Enterobacter cloacae which was sensitive to Levaquin.
4. PULMONARY: There was concern for possible pulmonary
malignancy given the patient's history of fatigue, sputum,
chronic cough, and new hoarseness. A chest x-ray was
initially obtained which showed fullness in the
aorticopulmonary window. The lung showed emphysema and
scattered linear areas of scarring. There was no obvious
masses on chest x-ray.
On [**5-20**], the patient began coughing up flecks of [**Last Name (LF) **],
[**First Name3 (LF) **] a CT scan was obtained of the chest to more fully evaluate
the possible full aorticopulmonary window. The chest CT
showed no evidence of an aorticopulmonary window mass. There
were several small subcentimeter mediastinal lymph nodes
present in the aorticopulmonary window as well as throughout
the mediastinum. These nodes were nonspecific, but could be
related to a chronic infiltrative lung disease. There was a
subpleural pattern of ground glass and reticular opacities
with some associated traction bronchiectasis and
bronchiolitis which involved all lobes but was most prominent
in the lung bases. These findings were felt to be consistent
with possible usual interstitial pneumonia, nonspecific
interstitial pneumonia, infectious etiology such as
Mycobacterium avium-intracellulare.
At the time of this Discharge Summary, a sputum culture has
been obtained which was showing 1+ gram-positive cocci in
pairs and clusters and 1+ gram-negative rods. The culture
was still pending. In addition, a culture will be obtained
for acid-fast bacillus looking for possible atypical
mycobacteria. A repeat chest was recommended in
approximately three months to document any possible
progression of the lymphadenopathy as well as the reticular
infiltrates.
5. ENDOCRINE: The patient has a history of diabetes and has
been restarted on his Humalog 75/25. This was held during
his episodes of hypoglycemia on [**5-17**]. Since then we have
been titrating his dose and have most recently increased his
morning dose to 22 units, and his bedtime dose is currently
at 8 units. The patient continues to have good morning and
midway [**Month (only) **] sugars with elevated sugars in the 300s after
dinner and in the evening. Some regular insulin given at
dinner time may help these chronically elevated evening
sugars. At this time, this has not yet been instituted.
The patient also may have had some adrenal insufficiency in
the setting of his urinary tract infection as already
described. He was on hydrocortisone for one day and has
since been on only his former Medrol doses.
6. HEMATOLOGY: The patient's hematocrit was 30.3 at the
time of admission, but on the third hospital day it dropped
down to 23.3 in the setting of his hydration. There was no
obvious acute [**Month (only) **] loss. The patient has a history of
gastrointestinal bleeding, and stools were attempted to be
guaiaced. The patient received 2 units on [**5-16**], and his
hematocrit appropriately bumped to 32.5. It has remained
stable around 30 since that time. He most recently had a
rectal examination by Vascular Surgery on the day of this
Discharge Summary, and the vascular surgeon reported the
stool to be guaiac-positive. We are currently watching the
hematocrit q.d. and will transfuse for less than 27. If the
hematocrit again was to drop, the patient will need an
inpatient gastrointestinal workup for possible
gastrointestinal sources of bleeding. Until then, he was
being continued on his iron supplementation. Regardless, he
will need a gastrointestinal workup prior to any vascular
surgery to evaluate his guaiac-positive stool.
7. GASTROINTESTINAL: The patient has a history of
gastrointestinal bleeding and has guaiac-positive stools as
described above. He will get either an inpatient or
outpatient esophagogastroduodenoscopy and colonoscopy to
evaluate his guaiac-positive stool pending stability of his
hematocrit. If his creatinine remains stable, he can have
the workup as an outpatient.
8. FLUIDS/ELECTROLYTES/NUTRITION: The patient's potassium
was elevated on admission but was brought down nicely with
the insulin, D-50, calcium gluconate, and Kayexalate. He has
since had no problems with hyperkalemia.
9. VASCULAR: The patient had noninvasive arterial studies
on [**2165-5-15**]. This examination showed significant
bilateral tibial disease, greatest on the right side compared
to the left. The ankle-brachial index on the right based on
the dorsalis pedis artery was 0.46. The ankle-brachial index
on the left based on the dorsalis pedis artery was 0.51. The
patient is currently undergoing an magnetic resonance
angiography of the lower extremities to further evaluate the
arterial anatomy for possible bypass planning. The patient
will require futher evaluation by the vascular surgery service
for consideration of future lower extremity
bypass.
CONDITION AT TIME OF THIS DICTATION: Condition at the time of
this
Discharge Summary was stable and the patient remains on the
inpatient medical service
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 37086**], M.D.
[**MD Number(1) 37087**]
Dictated By:[**Last Name (NamePattern1) 6859**]
MEDQUIST36
D: [**2165-5-21**] 16:45
T: [**2165-5-21**] 17:10
JOB#: [**Job Number 40289**]
ICD9 Codes: 5849, 4271, 5070 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3568
} | Medical Text: Admission Date: [**2112-1-28**] Discharge Date: [**2112-2-3**]
Date of Birth: [**2063-4-30**] Sex: M
Service: NEUROSURGERY
Allergies:
Vicodin
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
CC:[**CC Contact Info 19114**]
Major Surgical or Invasive Procedure:
NONE INVASIVE
EPLEY MANEUVER
History of Present Illness:
HPI: 48M fell while walking down stairs. Does not recall
slipping but does recall trying to reach for railing but "my arm
would not move." Struck the back of his head. Had severe
dizziness after fall and was unable to stand up. Denies nausea,
vomiting, chest pain, SOB, neck pain, back pain, or any other
injuries.
Patient had a history of an LP for bad headaches 12 years ago
that showed xanthochromia. Workup by neurosurgery including
angiogram never showed source or aneurysm. Grandfather died of
aneurysm at age 82.
Past Medical History:
HIV ?????? well controlled, no history of Ois
HepC - prior history of treatment trial, not tolerant of
medications
IDDM ?????? x 33 years, on insulin pump. A1C 5.6%
Diabetic Nephropathy ?????? has proteinuria, on ACE
Social History:
Lives with wife and children. Wife very supportive.
Family History:
NC
Physical Exam:
PHYSICAL EXAM:
O: T: 97.1 BP: 134/68 HR:84 R 20 99% RA O2Sats
Gen: comfortable, NAD.
HEENT: Pupils: 5 to 2 Bilaterally EOMI
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, Visual fields
are
full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-25**] throughout. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Reflexes: B Pa
Right 2+ 2+
Left 2+ 2+
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
On discharge - pt with non focal neuro exam / pain well
controlled.
Pertinent Results:
RADIOLOGY Final Report
CT HEAD W/O CONTRAST [**2112-2-1**] 5:41 PM
CT HEAD W/O CONTRAST; CT ORBITS, SELLA & IAC W/ & W/
Reason: Please do bilateral temporal bone head ct to rule out
fractu
[**Hospital 93**] MEDICAL CONDITION:
48 year old man with SAH/SDH, vertigo.
REASON FOR THIS EXAMINATION:
Please do bilateral temporal bone head ct to rule out fracture
as well as ? SAH/SDH size, thanks.
CONTRAINDICATIONS for IV CONTRAST: None.
HISTORY: 48-year-old male with subarachnoid hemorrhage/subdural
hemorrhage, now with vertigo. Concern for change in size of
hemorrhage or fracture.
COMPARISON: CTA head, [**2112-1-31**] and [**2112-1-30**]; cerebral
angiogram, [**2112-1-29**]; MRA brain, [**2112-1-29**]; and non-contrast head,
CT [**2112-1-28**].
TECHNIQUE: Non-contrast CT of the head and temporal bones.
FINDINGS: Again demonstrated is the small subdural hematoma
along the superior sagittal sinus near the vertex which is not
appreciably changed. Suspected subdural hematoma of the inferior
left frontal lobe is not well visualized on today's examination.
No new sites of intracranial hemorrhage are identified. There is
no shift of normally midline structures. The ventricular system
is stable in size and configuration. There is no evidence of
acute major vascular territorial infarction. There is mild
mucosal thickening of the ethmoid sinus and moderate right
maxillary sinus mucosal thickening. Opacification of several
bilateral mastoid air cells is noted with small fluid levels in
a few of the air cells. The middle ear cavities are clear. There
is no evidence of temporal bone fracture. No gross abnormality
of the bilateral ossicles or middle ear structures are
identified.
Minimal calcifications of the carotid siphons are noted.
IMPRESSION:
1. No significant change in small subdural hematoma near the
vertex along the superior sagittal sinus.
2. Suspected small subdural hematoma of the inferior frontal
lobe, not well appreciated on today's examination.
3. Opacification of a small number of mastoid air cells, left
greater than right.
4. No evidence of fracture.
5. Paranasal sinus mucosal thickening as described.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: TUE [**2112-2-2**] 8:34 AM
RADIOLOGY Final Report
CT ORBITS, SELLA & IAC W/ & W/O CONTRAST [**2112-2-1**] 5:41 PM
CT HEAD W/O CONTRAST; CT ORBITS, SELLA & IAC W/ & W/
Reason: Please do bilateral temporal bone head ct to rule out
fractu
[**Hospital 93**] MEDICAL CONDITION:
48 year old man with SAH/SDH, vertigo.
REASON FOR THIS EXAMINATION:
Please do bilateral temporal bone head ct to rule out fracture
as well as ? SAH/SDH size, thanks.
CONTRAINDICATIONS for IV CONTRAST: None.
HISTORY: 48-year-old male with subarachnoid hemorrhage/subdural
hemorrhage, now with vertigo. Concern for change in size of
hemorrhage or fracture.
COMPARISON: CTA head, [**2112-1-31**] and [**2112-1-30**]; cerebral
angiogram, [**2112-1-29**]; MRA brain, [**2112-1-29**]; and non-contrast head,
CT [**2112-1-28**].
TECHNIQUE: Non-contrast CT of the head and temporal bones.
FINDINGS: Again demonstrated is the small subdural hematoma
along the superior sagittal sinus near the vertex which is not
appreciably changed. Suspected subdural hematoma of the inferior
left frontal lobe is not well visualized on today's examination.
No new sites of intracranial hemorrhage are identified. There is
no shift of normally midline structures. The ventricular system
is stable in size and configuration. There is no evidence of
acute major vascular territorial infarction. There is mild
mucosal thickening of the ethmoid sinus and moderate right
maxillary sinus mucosal thickening. Opacification of several
bilateral mastoid air cells is noted with small fluid levels in
a few of the air cells. The middle ear cavities are clear. There
is no evidence of temporal bone fracture. No gross abnormality
of the bilateral ossicles or middle ear structures are
identified.
Minimal calcifications of the carotid siphons are noted.
IMPRESSION:
1. No significant change in small subdural hematoma near the
vertex along the superior sagittal sinus.
2. Suspected small subdural hematoma of the inferior frontal
lobe, not well appreciated on today's examination.
3. Opacification of a small number of mastoid air cells, left
greater than right.
4. No evidence of fracture.
5. Paranasal sinus mucosal thickening as described.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: TUE [**2112-2-2**] 8:34 AM
RADIOLOGY Final Report
MRA BRAIN W/O CONTRAST [**2112-1-29**] 9:50 AM
MRA BRAIN W/O CONTRAST; MRA NECK W&W/O CONTRAST
Reason: Please evaluate for aneurysm or other vascular
malformation.
Contrast: MAGNEVIST
[**Hospital 93**] MEDICAL CONDITION:
48 year old man with SAH - likely nontraumatic.
REASON FOR THIS EXAMINATION:
Please evaluate for aneurysm or other vascular malformation.
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 48-year-old with subarachnoid hemorrhage. Please
evaluate for aneurysm or vascular malformation.
There are no prior MRAs available for comparison. Comparison is
made with the CT head from [**2112-1-28**].
TECHNIQUE: Three-dimensional time-of-flight MR arteriography was
performed with rotational reconstructions.
FINDINGS: There is a large PCA on the right, likely a normal
variant. There is a small, triangular 1.5-mm protrusion at the
probable origin of the left ophthalmic artery, close to the area
of recent hemorrhage. However the ophthalmic artery itself is
not seen and thus this cannot definitively be called an
infundibulum. There is a large PCA which is likely a normal
anatomic variant. The remaining intracranial, vertebral and
internal carotid arteries and their major branches appear
normal. There is no evidence of stenosis, occlusion or aneurysm
formation.
IMPRESSION: There is a small protrusion at the expected origin
of the left ophthalmic artery, which does not meet all the
criteria for an infundibulum, as the origin of the ophthalmic
artery is not seen. As a result recommend CTA or cerebral
angiography for further evaluation of the opthalmic artery.
There is a large PCA which is likely a normal variant.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name4 (NamePattern1) 19115**] [**Last Name (NamePattern1) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 7415**]
Approved: SAT [**2112-1-30**] 9:36 PM
RADIOLOGY Final Report
MRA NECK W&W/O CONTRAST [**2112-1-29**] 9:50 AM
MRA BRAIN W/O CONTRAST; MRA NECK W&W/O CONTRAST
Reason: Please evaluate for aneurysm or other vascular
malformation.
Contrast: MAGNEVIST
[**Hospital 93**] MEDICAL CONDITION:
48 year old man with SAH - likely nontraumatic.
REASON FOR THIS EXAMINATION:
Please evaluate for aneurysm or other vascular malformation.
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 48-year-old with subarachnoid hemorrhage. Please
evaluate for aneurysm or vascular malformation.
There are no prior MRAs available for comparison. Comparison is
made with the CT head from [**2112-1-28**].
TECHNIQUE: Three-dimensional time-of-flight MR arteriography was
performed with rotational reconstructions.
FINDINGS: There is a large PCA on the right, likely a normal
variant. There is a small, triangular 1.5-mm protrusion at the
probable origin of the left ophthalmic artery, close to the area
of recent hemorrhage. However the ophthalmic artery itself is
not seen and thus this cannot definitively be called an
infundibulum. There is a large PCA which is likely a normal
anatomic variant. The remaining intracranial, vertebral and
internal carotid arteries and their major branches appear
normal. There is no evidence of stenosis, occlusion or aneurysm
formation.
IMPRESSION: There is a small protrusion at the expected origin
of the left ophthalmic artery, which does not meet all the
criteria for an infundibulum, as the origin of the ophthalmic
artery is not seen. As a result recommend CTA or cerebral
angiography for further evaluation of the opthalmic artery.
There is a large PCA which is likely a normal variant.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name4 (NamePattern1) 19115**] [**Last Name (NamePattern1) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 7415**]
Approved: SAT [**2112-1-30**] 9:36 PM
Cardiology Report ECG Study Date of [**2112-1-28**] 5:50:54 PM
Normal sinus rhythm. Normal tracing. Mild baseline artifact. No
significant
change compared with tracing [**2102-8-17**].
Read by: [**Last Name (LF) **],[**First Name3 (LF) **] S.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
65 162 90 400/408 56 27 51
([**Numeric Identifier 19116**])
RADIOLOGY Preliminary Report
CAROT/CEREB [**Hospital1 **] [**2112-1-29**] 3:44 PM
CAROT/CEREB [**Hospital1 **]
Reason: r/o aneurysm
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
48 year old man with SAH
REASON FOR THIS EXAMINATION:
r/o aneurysm
HISTORY: 48-year-old male patient with subarachnoid hemorrhage
to rule out aneurysm.
TECHNIQUE: Informed consent was obtained from the patient after
explaining the risks, indication and alternative management.
Risks explained included stroke, loss of vision and speech,
temporary or permanent with possible treatment with stent and
coils if needed.
The patient was brought to the interventional neuroradiology
theater and placed on the biplane table in the supine position.
Both groins were prepped and draped in the usual sterile
fashion. A patient timeout was performed by two patient
identifiers. Access to the right common femoral artery was
obtained using a 19-gauge single wall needle, under local
anesthesia using 1% lidocaine mixed with sodium bicarbonate and
with aseptic precautions. Through the needle, a 0.35 [**Last Name (un) 7648**]
wire was introduced and the needle taken out. Over the wire, a 5
French vascular sheath was placed and connected to saline
infusion (mixed with heparin 500 units in 500 cc of saline) with
a continuous drip. Through the sheath, a 4 French Berenstein
catheter was introduced and connected to continuous saline
infusion (with heparin mixture: 1000 units of heparin in 1000 cc
of saline). The following vessels were selectively catheterized
and arteriograms were performed from these locations. After
review of films the catheter and the sheath were withdrawn and
pressure was applied on the groin until hemostasis was obtained.
The procedure was uneventful and the patient tolerated the
procedure well without complications. The patient was sent to
the floor with orders.
The following blood vessels were selectively catheterized and
arteriograms were obtained in the AP and lateral projections.
1. Right internal carotid artery.
2. Left internal carotid artery.
3. Right common carotid artery.
4. Left common carotid artery.
5. Right vertebral artery.
6. Left vertebral artery.
The left posterior communicating artery appears prominent. The
left vertebral artery is seen supplying the anterior spinal
artery. There is no evidence of any aneurysms, AV fistulas, AV
formations, stenosis or occlusions.
IMPRESSION:
Cerebral angiogram of the above-mentioned vessels demonstrated
no evidence of any aneurysm, vascular malformation, stenosis or
occlusion.
The attending, Dr. [**Last Name (STitle) **] was scrubbed and present for the entire
procedure.
DR. [**First Name8 (NamePattern2) 19117**] [**Name (STitle) **]
DR. [**First Name (STitle) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
PreliminaryApproved: TUE [**2112-2-2**] 2:29 PM
Brief Hospital Course:
Pt was admitted to the hospital to the ICU for observation and
close monitoring after slip and fall resulted in Subarachnoid
hemorrhage and subdural hematoma. Pt underwent Angiogram which
was negative for aneurysm. He was started on Nimodipine. Stroke
consult was obtained for intial syncope workup. He was placed on
meclizine for continued complaints of vertigo. He was
transferred to a regular floor and evaluated by the ENT team for
the c/o vertigo. They performed Epley Maneuver from which the
pt has relief of symptoms. They diagnosed him with benign
positional vertigo. He was seen by PT and deemed safe for
discharge with a home safety eval. His dilantin and nimodipine
were stopped as he has never had a sz during this stay nor is
his SAH thought to be aneurysmal. he was d/c'd to home without
pain medication per his request. Follow up and instructions
were discussed.
Medications on Admission:
Medications prior to admission:
Atripla
Crestor
Lipitor
Lisinopril
Insulin
ASA - last dose was one week ago - stopped it because he has a
planned surgery for hernia repair soon.
Discharge Medications:
1. ATRIPLA Oral
2. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Meclizine 12.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
benign positional vertigo
subarachnoid hemorrhage
Discharge Condition:
STABLE
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY
?????? Have a family member check your incision daily for signs of
infection
?????? Take your pain medicine as prescribed
?????? Exercise should be limited to walking; no lifting, straining,
excessive bending
?????? You may wash your hair only after sutures and/or staples have
been removed
?????? You may shower before this time with assistance and use of a
shower cap
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
?????? If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit
- YOUR DILANTIN WAS STOPPED, YOU DID NOT HAVE A SEIZURE.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? New onset of tremors or seizures
?????? Any confusion or change in mental status
?????? Any numbness, tingling, weakness in your extremities
?????? Pain or headache that is continually increasing or not
relieved by pain medication
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
?????? Fever greater than or equal to 101?????? F
AVOID SUDDEN MOVEMENTS OF YOUR HEAD - THIS WILL POSSIBLY REVERSE
THE POSITIVE OUTCOME THAT YOU'VE HAD WITH THE EPLEY MANEUVER.
IF YOU HAVE QUESTIONS REGARDING WHEN THIS ACTIVITY RESTRICTION
IS COMPLETE = PLEASE CALL THE OTOLARYGOLOGY DEPARTMENT FOR DR.
[**First Name (STitle) 3880**].
Followup Instructions:
Dr. [**First Name (STitle) **] / Otoloaryngology as needed [**Telephone/Fax (1) **]
Follow up with your primary care physician within the next 2
weeks
You DO need to follow up in the Neurosurgery Department with Dr.
[**Known firstname **]. PLEASE CALL THE OFFICE FOR AN APPOINTMENT TO BE SEEN IN
4 WEEKS WITH A CAT SCAN OF THE BRAIN TO EVALUATE FOR YOUR
SUBDURAL COLLECTIONS.
TAKE YOUR [**Hospital **]HOSPITAL MEDICATION AS PREVIOUSLY PRECRIBED
AS PER YOUR REQUEST YOU ARE NOT BEING SENT HOME WITH A
PRESCRIPTION FOR NARCOTIC/ PAIN CONTROL.
YOU HAVE THE FOLLOWING APPOINTMENTS ALREADY IN THE SYSTEM
THEY ARE LISTED BELOW FOR YOUR REMINDER
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6400**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2112-3-24**] 9:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6970**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2112-4-26**] 4:00
Completed by:[**2112-2-3**]
ICD9 Codes: 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3569
} | Medical Text: Admission Date: [**2191-2-23**] Discharge Date: [**2191-3-22**]
Date of Birth: [**2151-4-3**] Sex: M
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
Transfer from outside hospital for further management of acute
alcohol-related hepatitis
Major Surgical or Invasive Procedure:
Transcutaneous liver biopsy.
Ultrasound-guided paracentesis.
History of Present Illness:
Mr. [**Known lastname 42306**] is a 39 year old male with a history of ETOH abuse
for the last 6 months who presented to an outside hospital on
[**2191-2-19**] following a week of heavy binge drinking. The patient
reports that he had been drinking at least a half liter of
whiskey daily for the week leading up to admission and had
noticed his skin becoming more jaundiced. He had been eating
little during this time and noticed that he was very weak and
could barely walk which prompted him to call an ambulance which
took him to the OSH.
At the OSH patient received serax for withdrawl at time of
admission. He was initially admitted to the floor but
transferred to the ICU when he was noted to become increasingly
somnolent. Patient's Hct noted to drop from 35 on admission to
26 on [**2-21**] which prompted concern for an active bleed. Patient
was noted to be hypercoaguable with an INR of 4. He was given
Vitamin K on admission and also received FFP prior to an EGD on
[**2-22**] for r/o UGIB. On EGD patient noted to have a duodenal ulcer
with a clear base. He was started on a PPI. Patient also had U/S
with ? portal vein thrombosis. OSH also concerned for SBP though
no paracentesis was performed and it is unclear whether he was
febrile. He was started on ceftriaxone which was switched to
cipro. Patient was transferred to [**Hospital1 18**] for further management
of his liver disease and ? PVT.
Past Medical History:
- EtOH abuse: pt reports heavy drinking x 6 months. Prior to
this he would drink [**1-1**] drinks with dinner. He was in detox at
[**Hospital 8**] hospital for two weeks in [**1-7**]. Per OSH records he has
a hx of DTs.
- ? Acute pancreatitis due to alcohol use
- Hypertension
- IBS
Social History:
Patient is a graduate of [**University/College 80743**]with a degree in
politics. Heavy EtOH use for the past 6 months. No smoking (quit
4 years ago). No history of illicit drug use. Estranged from
wife, has 1 year old son.
Family History:
Father: Alcoholism
[**Name (NI) **] family history of liver disease
Physical Exam:
Vitals: T: 98.4 BP: 105/68 P:104 R: 18 O2: 98% RA
General: Alert, oriented, no acute distress
HEENT: scleral icterus, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops. + small spider [**Doctor Last Name **] on chest.
Abdomen: soft, non-tender, mildly distended and slightly tense,
peripheral dullness ot percussion, bowel sounds present, no
rebound tenderness or guarding, +hepatic enlargement by
percussion. No fluid wave appreciated.
Ext: Warm, well perfused, 2+ pulses, 2+ bilateral edema.
Neuro: +asterixis vs. tremor.
Pertinent Results:
ADMISSION LABS:
CBC:
[**2191-2-23**] 11:00PM BLOOD WBC-6.4 RBC-3.20* Hgb-10.6* Hct-32.3*
MCV-101* MCH-33.0* MCHC-32.7 RDW-17.4* Plt Ct-171
[**2191-2-23**] 11:00PM BLOOD Neuts-63 Bands-1 Lymphs-19 Monos-16*
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-1*
COAGS:
[**2191-2-23**] 11:00PM BLOOD PT-16.5* PTT-42.2* INR(PT)-1.5*
[**2191-2-23**] 11:00PM BLOOD Glucose-130* UreaN-2* Creat-0.8 Na-134
K-4.1 Cl-102 HCO3-22 AnGap-14
LFTs:
[**2191-2-23**] 11:00PM BLOOD ALT-192* AST-372* LD(LDH)-689*
AlkPhos-145* TotBili-24.2*
IRON STUDIES:
[**2191-2-23**] 11:00PM BLOOD calTIBC-137* Ferritn-GREATER TH TRF-105*
DISCHARGE LABS:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2191-3-22**] 05:40AM 10.0 2.75*# 9.3*# 27.2*# 99* 33.7* 34.1
21.4* 417
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2191-3-21**] 05:50AM 88 7 0.4*1 138 3.8 104 26 12
ENZYMES ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili
[**2191-3-21**] 05:50AM 43* 126* 313* 55 12.9*
HEMOLYTIC WORKUP Ret Man Ret Aut
[**2191-3-21**] 05:50AM 8.0*
HEMATOLOGIC Hapto
[**2191-3-21**] 05:50AM 38
MICROBIOLOGIC DATA:
Urine culture [**2-24**]: negative
Blood cultures [**Date range (1) 80744**]: negative x3
Stool C dif [**2-25**]: negative
Urine culture [**3-6**]: negative
Peritoneal fluid culture [**3-7**]: negative
Blood culture [**3-7**]: negative x2
Urine culture [**3-7**] and [**3-9**]: negative
Blood culture [**3-9**]: negative x2
Peritoneal fluid culture [**3-9**]: negative
Blood culture [**3-13**]: negative x2
Stool C dif [**3-9**] and [**3-10**]: negative
Urine culture [**3-14**]: negative
IMAGING STUDIES:
CTA ABDOMEN/PELVIS [**2-24**]:
1. No evidence of venous thrombosis.
2. Organizing fluid collection in the left anterior pararenal
space from subacute pancreatitis, still active within the tail.
3. Mild pancreatic duct dilation in the body and tail is likely
related to
the sequela of pancreatitis, although MRCP after the patient's
symptoms have resolved can be obtained to evaluate .
4. Diffusely fatty liver. No biliary pathology to explain
hyperbilirubinemia.
LIVER CORE BIOPSY [**2-25**]
Liver, core needle biopsy:
1) Severe macrovesicular steatosis with frequent ballooning
degeneration; no definitive [**Doctor First Name 68085**] hyaline is seen.
2) Portal and lobular predominantly neutrophilic infiltrate.
3) Bile duct proliferation with associated neutrophils.
4) Focal portal venous thrombosis with organization.
5) Mild cholestasis.
6) Mild portal fibrosis, no significant sinusoidal fibrosis
(trichrome).
7) Mild iron deposition seen predominantly in Kupffer cells
(iron stain).
MRA/MRV BRAIN [**2-25**]:
FINDINGS: MRA HEAD:
The arteries of anterior and posterior circulation demonstrate
normal flow
signal without stenosis or occlusion. No aneurysm greater than 3
mm in size
is seen.
IMPRESSION: Normal MRA of the head.
MRV OF THE HEAD:
The head MRV demonstrates normal flow in the superior sagittal
and transverse sinuses as well as in the deep venous system.
IMPRESSION: Normal MRV of the head.
MRI ABDOMEN [**3-4**]:
1. Minimal decrease in size of left retroperitoneal hematoma.
2. Decreased signal intensity in the pancreas, which may be due
to
pancreatitis. Suspect a phlegmon adjacent to the tail (not
significantly
changed vs. prior).
3. Fatty liver without evidence of biliary ductal dilatation. No
evidence of gallstones or choledocholithiasis.
CXR [**3-13**]:
The heart size is normal. Mediastinal position, contour and
width are
unremarkable. The lung volumes are significantly better compared
to the prior study with improvement of bibasal atelectasis. The
current study demonstrates what appears to be a new opacity at
the left lower lung in the left infrahilar area that might
represent a focus of aspiration or developing infection.
Attention to this area on the subsequent studies is highly
recommended. No pleural effusion or pneumothorax is
demonstrated.
BILATERAL LOWER EXTREMITY ULTRASOUND [**3-13**]:
Large amount of subcutaneous edema noted bilaterally in the
calves. No evidence of DVT seen in either lower extremity.
Brief Hospital Course:
A 39 year-old man with history of EtOH abuse without known
cirrhosis, who was originally admitted to OSH with likely
alcoholic hepatitis, now transferred for further management.
# Acute Hepatitis
He underwent a liver biopsy shortly after admission. Pathology
was consistent with acute alcoholic hepatitis (see full report
above). There was no evidence of cirrhosis. CTA at admission
showed no portal vein thrombosis. His liver enzymes were
followed daily and bilirubin rose to peak at 38. Prednisone was
started when he did not improve with supportive management.
However, due to the development of fevers and infection,
prednisone was stopped after only three days. As his liver
function worsened, he developed symptoms of hepatic
encephalopathy, abdominal distention, lower extremity swelling,
and diffuse pruritis from hyperbilirubinemia. His encephalopathy
was treated with lactulose and rifaximin, titrated to four bowel
movements per day. Pruritis was treated with ursodiol in
addition to hydroxyzine and sarna lotion as needed. Ascites and
lower extremity edema were treated with paracenteses
(therapeutic and diagnostic), Lasix and spironolactone. With
these interventions, his symptoms were well-controlled. His
liver function has improved significantly, with mental status
having returned to baseline, anasarca now resolved, and pruritis
well-controlled on prn meds. At time of discharge we are
continuing rifaximin for encephalopathy prophylaxis. Lactulose
was stopped due to stomach cramping and diarrhea. He should
continue rifaximin until he follows up with Dr. [**Last Name (STitle) 497**]. He can
continue on hydroxyzine and sarna as needed for pruritis.
# Acute Renal Failure
His renal function worsened in tandem with worsening liver
function. There was no improvement after fluid challenge or
albumin infusion. We started midodrine and octreotide for
treatment of hepatorenal syndrome when his creatinine rose to as
high as 3.0 (from baseline <1.0). Renal function improved and
returned to baseline with this intervention.
# History of EtOH
Upon admission, he was started on thiamine, multivitamin, and
folate. For alcohol withdrawal, we used a CIWA scale with Valium
given every six hours for scores >10. Despite this, he was found
a few days after admission to be non-responsive, with normal
blood pressure and pulse. Given that he was alert and fully
oriented minutes before this event it was felt he could have
been having a seizure. He was given intravenous Ativan and
transferred to the ICU. He underwent MRA/MRV of the head and
head CT that were all normal. He was seen by the neurology team
who agreed that this event could have been an alcohol withdrawl
seizure. He was extubated 12 hours later and transferred back to
the floors within one day. He was continued on Valium prn, and
there were no further withdrawal symptoms. Social work has been
involved in his care from the onset, and has provided him with
multiple options for rehabilitation. He understands the serious
danger of drinking again, and he will begin inpatient alcohol
rehab after this admission.
# Fevers, Leukocytosis, and LLL Infiltrate on CXR
After prednisone was initiated for alcoholic hepatitis, he
developed fevers to 101.7. We therefore stopped the prednisone
and checked urine, blood, and peritoneal fluid for infection.
All of these returned negative. However, he was noted on CXR to
have a new left lower lobe infiltrate. This was treated with a
five day course of levofloxacin. His symptoms and fever resolved
after this treatment. The CXR should be followed up as
outpatient to ensure resolution of the infiltrate.
# Left Leg Cellulitis
As his hepatitis was improving, he was noted to have asymmetric
edema with LLE>RLE. There was concern of DVT versus cellulitis.
Bilateral LE doppler showed no venous clot. Therefore we started
IV nafcillin for empiric treatment of cellulitis. He received
four days of nafcillin, after which the left leg redness and
swelling improved substantially. The nafcillin was then switched
to oral dicloxacillin. He should complete a 7-day course for
left leg cellulitis.
# LLQ Organization/Loculation
This was seen on imaging at admission and felt to be consistent
with a pancreatic pseudocyst. He had acute alcoholic
pancreatitis in [**11-6**]. This collection can be followed as
outpatient.
# Question of SBP
He was started on ceftriaxone which was transitioned to
ciprofloxacin at outside hospital for concern of SBP. Per OSH
records no paracentesis was performed. At [**Hospital1 18**] radiology was
unable to perform a diagnostic paracentesis at admission since
ascitic fluid was not accessible even by U/S guidance. Cipro was
stopped. However, later in the admission, when he spiked a fever
on prednisone, we again pursued ultrasound-guided paracentesis
for diagnostic work-up. At that time, there was sufficient fluid
for drainage. This fluid was negative by cell count analysis and
culture for SBP.
# Diarrhea
He has chronic diarrhea believed due to IBS (he has in the past
declined colonoscopy as outpatient), which may have been
exacerbated during this admission by lactulose. TTG during this
admission was negative for celiac disease. We sent stool samples
for pancreatic elastase and fat studies to evaluate for
pancreatic insufficiency given his history of pancreatitis;
these were both positive. We therefore started him on pancreatic
enzyme supplements to be taken with meals. He should also
continue on pantoprazole twice daily to enhance absorption of
the enzymes. Given that all infectious work-up for diarrhea was
negative, we were comfortable starting loperamide for symptom
treatment.
# Anemia
His hematocrit was low throughout this admission, stabilizing in
the mid 20s. Iron level was 128, with ferritin greater than
[**2181**]. His MCV was elevated, suggestive of anemia from underlying
liver disease. B12 and folate levels were normal. There were no
signs or symptoms of active bleeding. Stool guiaic was negative.
One day prior to discharge, he was transfused 2U PRBCs for
hematocrit of 22 with appropriate bump after the transfusion to
27. Labs were sent for haptoglobin (38), LDH (313) and
reticulocyte count (8.0). These were indicative of an
appropriate marrow response to anemia; the normal haptoglobin
makes hemolysis less likely; furthermore, his LDH is only mildly
elevated and bilirubin has been downtrending, both not
consistent with an active hemolytic process. He will likely need
colonoscopy as outpatient, but we believe his anemia will
continue to improve as his bone marrow responds from this severe
acute illness.
# Duodenal Ulcer
This was noted on EGD from OSH. Per their report there was a
clean ulcer base with no signs of active bleeding. During this
admission we started a PPI, and increased the dosing frequency
to allow for better absorption of pancreatic enzyme supplements.
# FEN
Post-pyloric dobhoff tubes were placed during the admission for
poor oral intake. He pulled these out on two separate occasions,
and because his oral intake was improving when he pulled out the
dobhoff for the second time, we were comfortable supplementing
meals with ensure supplements. At time of discharge, he is
tolerating pos with adequate caloric intake.
His code status is full code.
Medications on Admission:
Metoprolol 50 mg daily
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Loperamide 2 mg Capsule Sig: One (1) Capsule PO DAILY (Daily)
as needed for diarrhea.
Disp:*30 Capsule(s)* Refills:*2*
5. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule,
Delayed Release(E.C.) Sig: Two (2) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
Disp:*60 Cap(s)* Refills:*2*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Pain.
Disp:*30 Tablet(s)* Refills:*0*
8. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*180 Tablet(s)* Refills:*2*
9. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for itching.
Disp:*30 Tablet(s)* Refills:*2*
10. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed.
Disp:*1 qs* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 3244**] Treatment Center - [**Hospital1 1562**]
Discharge Diagnosis:
Primary Diagnoses
Alcoholic hepatitis
Hepatorenal syndrome
Pneumonia
Cellulitis
Alcohol-withdrawal seizure
Discharge Condition:
Vital signs stable. Afebrile. Mentating at baseline.
Discharge Instructions:
You were admitted to the hospital for treatment of alcoholic
hepatitis. A biopsy taken of the liver showed changes consistent
with acute hepatitis. There was no evidence of cirrhosis. If you
continue to drink alcohol, it is very likely that the liver
disease will progress to cirrhosis, which carries with it
increased risk of infection, bleeding from the gastrointestinal
tract, and fluid retention in the abdomen and legs. Cirrhosis is
irreversible. If you stop drinking alcohol altogether, it is
likely that the changes in the liver seen during this admission
will reverse themselves and you will return to your normal state
of health. For this reason, it is very important that you seek
help so that you do not drink alcohol again.
.
This hospital course was complicated by alcohol withdrawal
seizures for which you received Valium, and also by pneumonia
and skin infection for which you were treated with antibiotics.
There was also concern of kidney failure (hepatorenal syndrome),
which reversed after treatment with medicines to increase blood
flow to the kidneys.
.
There have been several changes to your medicines:
1. We added multivitamin, folate and thiamine. Please continue
to take these nutritional supplements.
2. We added pancreatic enzyme supplements to help decrease
diarrhea.
3. We added pantoprazole for gastric acid suppression and
protection against ulcers.
4. We added rifaximin, to be taken three times daily to prevent
mental status change or confusion from the hepatitis.
5. We added Tramadol to be taken up to two times daily as needed
for abdominal pain related to the hepatitis.
6. We added hydoxyzine and sarna lotion, which can be taken as
needed for itch.
.
Please note your follow-up appointments below.
.
Please call your doctor if you develop worsening abdominal pain,
blood in stools, fevers, or other symptoms that are concerning
to you.
Followup Instructions:
Please note the appointments below that have been scheduled for
you:
1. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD Phone: [**Telephone/Fax (1) 2422**] Date/Time:[**2191-4-1**]
8:00
2. [**Name6 (MD) 640**] [**Name8 (MD) **], MD Phone: [**Telephone/Fax (1) 250**] Date/Time:[**2191-4-13**] 3:00
Completed by:[**2191-3-22**]
ICD9 Codes: 486, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3570
} | Medical Text: Admission Date: [**2166-9-23**] Discharge Date: [**2166-10-11**]
Date of Birth: [**2088-11-12**] Sex: M
Service: [**Hospital Unit Name 196**]
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4765**]
Chief Complaint:
CHF
Major Surgical or Invasive Procedure:
Bronchoscopy
History of Present Illness:
This 78 year old male with history of a.flutter, AS, COPD,
tachycardia-induced cardiomyopathy stopped taking his
medications one week ago and presents today with SOB, LE
swelling, ataxia. He also has decreased exercise tolerance,
increased DOE, PND, anorexia. He has had documented heart rates
in the 130-140s for the last 9 months. He was scheduled for
cardiac catheterization to evaluate coronary arteries and aortic
valve next monday with possible a.flutter ablation and possible
AVR. At baseline he can climb about 15 steps before becoming
SOB. No chest pain or syncope.
On arrival to ED heart rate was 170 and BP 94/79 goat 20mg Dilt
IV, 540 mg XR, azithro and CTX, BP dropped to 80/70s and HR
dropped to 130s in regular a.flutter.
Past Medical History:
PMHx:
1. Urinary retention/BPH
2. A.flutter - diagnosed 2 years ago
3. COPD
4. Aortic stenosis
5. tachycardia-induced cardiomyopathy
Social History:
Lives alone in [**Hospital1 392**], 1ppd smoker
Family History:
non-contributory
Physical Exam:
Temp 95.7
BP 86-110/70-76
Pulse 130-170
Resp 20
O2 sat 94% on 3L NC
Gen - Alert, uncomfortable appearing male, short of breath
HEENT - PERRL, extraocular motions intact, anicteric, mucous
membranes moist, poor dentition
Neck - JVP at 15 cm, no cervical lymphadenopathy
Chest - Coarse scattered rhonchi
CV - Normal S1/S2, irregularly irregular, holosystolic murmer
[**3-15**] radiating to carotids (exam limited by coarse upper airway
sounds)
Abd - Soft, nontender, nondistended, with normoactive bowel
sounds, right sided reducible hernia
Back - No costovertebral angle tendernes
Extr - 2+ lower extremity edema. 2+ DP pulses bilaterally
Neuro - Alert and oriented x 3, grossly intact
Skin - No rash
Brief Hospital Course:
Pt expired at end of hospital course.
In the ED Mr. [**Known lastname **] x-ray showed evidence of right sided
pleural effusion with some collapse/consolidation. He refused a
decubitus film at that time. Our plan was to try to tap his
effusion in the morning. Mr. [**Known lastname **] arrived at the floor and was
monitored overnight. He was given Vitamin K to correct his INR
and placed on a Heparin gtt with the plan to send him for a
TEE/flutter ablation in the morning and tap his effusion. He
was found to have a Sat of 83% on 4L NC the morning after
admission. He was placed on 100% non-rebreather and his Sats
improved to high 80s. His ABG on this was pH 7.41, pCO2 52, pO2
50. He was given Diltiazem 90 PO, Nebulizers. He continued to
have low o2 saturations and was transferred to the CCU for
further monitoring.
On sedation for intubation, the patient's BP dropped and he
required levophed to maintain his pressures. He had an TEE that
was negative for clot. He continued to be tachycardic to the
160-180s, and was taken to the EP [**Known lastname **] for ablation +/- pacer
placement on the afternoon of [**9-24**]. Then in the EP [**Last Name (LF) **], [**First Name3 (LF) **]
attempt at cardioversion was attempted which was not successful
in attaining SR. Ablation of the isthmus was performed, with
termination of the A flutter and reversion to A fib. Ibutolide
was given to stop the A fib, with SR in the 70s occuring but
with BP still low and QTc 550msec. Once back in CCU, pt had
reversion to A flutter.
His hospital course in the CCU:
1. CARDIOVASCULAR
A. RHYTHM: the patient initially responded to Amio gtt with
reversion to sinus brady. However, he did not tolerate a
conversion to Amio PO, went back into A fib/flutter but with
rate at around 100bpm which is relatively controlled for this
gentleman who generally has a HR in the 140-160s. The patient
was maintained on Amio gtt thereafter.
B. PUMP: CHF with poor systolic and diastolic function; required
pressors on and off throughout his CCU stay, including levohphed
and dobutamine, which were difficult to wean; the patient has
severe AS but is not a candidate for surgery given his lung CA,
would consider valvuloplasty as last resort. Pt developed
cardiogenic shock and had non-operable end-stage heart disease
with critical AS. He was made DNR and his goals of care were
shifted from a curative strategy to palliation. He passed away
[**2166-10-11**].
C. CORONARIES: unclear disease, unlikely to get cath given his
lung CA
2. PULMONARY: Pt with non-operable stage 3B NSCLC.
3. RENAL: repleted lytes, K and Mg in particular, qd
4. INFECTIOUS DISEASE: PNA, leukocytosis
gave levo/flagyl for post-[**Last Name (un) **] pna, then started on Vanc for
presumed line sepsis
5. HEME: coagulation profile abnormality with INR 1.7, which
responded somewhat to vitamin K; unclear if from shock liver vs
NPO and abx
6. GI: s/p ileus, now tolerating tube feeds; cont tube feeds,
bowel regimen
7. NEURO: intubated/sedation, no acute needs
8. PSYCH: med noncompliance, wanted to leave AMA initially but
agreed to intubation, cath. Will assess capacity when extubated
9. Prophylaxis: anticoagulated, ppi while intubated, bowel
regimen
Medications on Admission:
cialis 10mg po prn
dig 0.125 mg qD
dilt XR 580 mg po qD
flonase
lasix 80mg po qD
ranitidine
Discharge Medications:
expired
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Tachycardia-induced cardiomyopathy
Sick Sinus Syndrome
Severe Aortic Stenosis
Lung cancer, unspecified
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
Completed by:[**2166-11-12**]
ICD9 Codes: 4280, 4241, 2875, 4254, 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3571
} | Medical Text: Admission Date: [**2140-9-6**] Discharge Date: [**2140-9-23**]
Date of Birth: [**2089-3-30**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Encephalopathy
Major Surgical or Invasive Procedure:
[**2140-9-9**] liver transplant
History of Present Illness:
51F with primary biliary cirrhosis, currently on the transplant
list, with MELD 24 at today's admission (recent MELD scores have
been between 23-28). She is brought in now by her boyfriend who
reports that she has been increasingly somnolent over the past
2-3 days. She initially was just "very sleepy," but has slowly
become more confused and difficult to arouse. She has also
complained of abdominal pain and bloating. He believes that she
is taking all of her medications, but is unsure of how her bowel
habits have been. He called EMS who took her to her local ED;
after IVF hydration she was transferred to [**Hospital1 18**] for further
monitoring. History was obtained mostly from the chart and
patient's boyfriend as she was minimally responsive at time of
consult.
ROS: unable to obtain
Past Medical History:
PMH:
- Primary biliary cirrhosis since [**48**] years old
- Cirrhosis complicated by portal hypertension, portal
gastropathy, ascites and hepatic encephalopathy
- History of anemia requiring blood transfusions
- History of thrombocytopenia
- Hemorrhoids
- Anal fissure
-[**2140-9-10**] rectal swab VRE
-Klebsiella UTI [**9-14**]
-R IJ non-occlusive thrombus [**9-14**]
PSH:
- cholecystectomy
- Caesarean section
-[**2140-9-9**] Orthotopic deceased donor liver transplant,
portal vein to portal vein anastomosis, common bile duct to
common bile duct without a T-tube, celiac axis of the donor
to common hepatic artery of the recipient, piggyback.
Social History:
- She is currently unemployed. She was laid off from her job as
an administrative assistant about a year ago.
-Tobacco: 30-pack-year smoking history, she quit smoking about
two years ago.
-ETOH: None
-Illicit drugs: None
Family History:
Mother with pancreatic cancer at age 79
Physical Exam:
99 80 95/54 20 97%
Gen: somnolent, will open eyes to pain. A&Ox1-2, follows
commands intermittently but falls asleep quickly. Jaundiced
HEENT: sclera icteric
CV: RRR
Pulm: CTAB
Abd: soft, distended w/shifting dullness. Mildly TTP throughout
Ext: WWP, 2+ pedal edema bilat
Pertinent Results:
[**2140-9-5**] 9:19 pm URINE
**FINAL REPORT [**2140-9-8**]**
URINE CULTURE (Final [**2140-9-8**]):
KLEBSIELLA PNEUMONIAE. 10,000-100,000 ORGANISMS/ML..
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
[**2140-9-10**] rectal swab VRE
[**2140-9-5**] 06:50PM BLOOD WBC-4.4 RBC-2.50* Hgb-9.3* Hct-26.9*
MCV-108* MCH-37.3* MCHC-34.7 RDW-17.3* Plt Ct-60*
[**2140-9-23**] 05:58AM BLOOD WBC-4.8 RBC-2.87* Hgb-9.1* Hct-27.7*
MCV-97 MCH-31.9 MCHC-33.0 RDW-17.5* Plt Ct-147*
[**2140-9-18**] 06:05AM BLOOD PT-10.8 PTT-28.0 INR(PT)-1.0
[**2140-9-5**] 06:50PM BLOOD PT-16.2* PTT-45.5* INR(PT)-1.5*
[**2140-9-5**] 06:50PM BLOOD Glucose-88 UreaN-37* Creat-1.2* Na-129*
K-4.2 Cl-105 HCO3-16* AnGap-12
[**2140-9-14**] 04:58AM BLOOD Glucose-164* UreaN-111* Creat-4.9* Na-137
K-4.1 Cl-99 HCO3-18* AnGap-24*
[**2140-9-18**] 06:05AM BLOOD Glucose-114* UreaN-45* Creat-1.1 Na-142
K-4.2 Cl-111* HCO3-27 AnGap-8
[**2140-9-23**] 05:58AM BLOOD Glucose-85 UreaN-49* Creat-1.4* Na-139
K-5.2* Cl-106 HCO3-25 AnGap-13
[**2140-9-23**] 05:58AM BLOOD tacroFK-8.3
[**2140-9-5**] 06:50PM BLOOD ALT-168* AST-346* AlkPhos-179*
TotBili-20.3*
[**2140-9-9**] 12:48AM BLOOD ALT-152* AST-295* AlkPhos-156*
TotBili-28.1*
[**2140-9-23**] 05:58AM BLOOD ALT-53* AST-20 AlkPhos-74 TotBili-2.1*
Brief Hospital Course:
51 yo F with h/o primary biliary cirrhosis (listed for liver
transplant)c/b ascities, portal HTN, hepatic encephalopathy
presented with worsening encephalopathy and hypotension. She was
admitted to the SICU and intensive work-up for the etiology of
her poor mentation was begun. Initial labs confirmed she was not
intoxicated. It was noted that she had not taken her lactulose
for a week.
Liver enzymes were elevated. Creatinine had increased to 1.5
from baseline of 1.0. She was treated with IV fluid, colloids
and lactulose as well as rifaximin. Mental status improved and
she was transferred out of the SICU. Urine isolated klebsiella
sensitive to Ceftriaxone. Ceftriaxone was also used to cover
empirically for SBP given abdominal pain. US did not demonstrate
enough ascites to do paracentesis.
On [**2140-9-9**], a liver donor was available and accepted. She
underwent orthotopic deceased donor liver transplant, portal
vein to portal vein anastomosis, common bile duct to common bile
duct without a T-tube, celiac axis of the donor to common
hepatic artery of the recipient, piggyback. Two JP drains were
placed. Please refer to operative note for details. Surgeon was
Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] assisted by Dr. [**First Name4 (NamePattern1) 3742**] [**Last Name (NamePattern1) **]. Postop, she
was sent to the SICU for management. She received blood products
per transplant protocol goals. She was extubated on [**9-10**] and had
decreasing LFTs. Hepatic duplex on [**9-11**] demonstrated patent
veins w/lack of diastolic flow in main HA. Repeat duplex on [**9-11**]
showed patent veins with improved diastolic flow in HA. LFTs
continued to decrease. JP drains were non-bilious.
Urine output gradually decreased. IV fluid boluses were
initially given. Lasix was then given with minimal response.
Nephrology was consulted noting oliguria/[**Last Name (un) **] and recommended
Lasix. CRRT was not indicated.
On [**9-12**], a Dobhoff advanced under fluoroscopy. She was oliguric
with increased creatinine, but no indications for CRRT. Tube
feeds were started. Diet was also started and tolerated.
R arm was noted to be edematous and was larger than the left
arm. A non-occlusive thrombus was noted in the right IJ on
Dopplar. Central line in that location was removed. No
anticoagulation was initiated. The lateral JP was d/c'd on [**9-14**].
She transferred out of the SICU on [**9-15**]. Tube feeds continued as
well as lasix for generalized edema. Lasix was given daily.
Urine output gradually increased as well as urine output.
Creatinine decreased to a low of 1.1.
She was drinking up to 5 nutritional supplements a day as well
as eating small amounts of food. She was had slow return of GI
function and required dulcolax rectal suppositories a few times,
but eventually was able to move her bowels. She disliked the
feeding tube and demonstrated that she could take sufficient
Kcals to meet her nutritional needs. The feeding tube was
subsequently removed on [**9-21**]. Medial JP was d/c'd and site
sutured.
PT worked with her and felt that she was safe for discharge to
home without home PT. She was ambulating independently at time
of discharge. She continued to have a fair amount of RUQ
incision area pain for which she took Oxycodone 5mg (only a
couple times per day). Abdominal incision was intact with
staples without redness or drainage.
Glucoses were elevated and were treated with glargine and
humalog. [**Last Name (un) **] was consulted and adjusted insulin daily.
Insulin 70/30 (pen [**Hospital1 **] )was recommended for home regimen. She
received instruction from the [**Name8 (MD) **] RN educator.
Immunosuppression consisted of tapering steroid protocol,
cellcept which was adjusted to qid for some GI complaints and
Prograf. She did very well with medication teaching. VNA
services were arranged. She was discharged home on lasix 40mg
daily for bilateral leg edema.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Anucort-HC *NF* (hydrocorTISone Acetate) 25 mg Rectal QHS
hold on [**8-24**]
2. Lactulose 30 mL PO TID
titrate to [**3-6**] BMs per day
3. Omeprazole 20 mg PO DAILY
4. Rifaximin 550 mg PO BID
5. Ursodiol 300 mg PO QID
6. Lidocaine Jelly 2% (Urojet) 1 Appl TP PRN anal pain
7. Ferrous Sulfate 325 mg PO DAILY
Discharge Medications:
1. Omeprazole 20 mg PO DAILY
2. FreeStyle Freedom Lite *NF* (blood-glucose meter) 1 meter
Miscellaneous x1
RX *blood-glucose meter [FreeStyle Lite Meter] 1 meter for qid
blood sugar checks Disp #*1 Kit Refills:*0
3. FreeStyle Lite Strips *NF* (blood sugar diagnostic) 1 bottle
Miscellaneous x1
check blood sugars prior to meals and bedtime
RX *blood sugar diagnostic [FreeStyle Lite Strips] 1 four
times a day Disp #*1 Bottle Refills:*3
4. Docusate Sodium (Liquid) 100 mg PO BID
5. Fluconazole 400 mg PO Q24H
6. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth once a day Disp #*14
Tablet Refills:*0
7. Mycophenolate Mofetil 500 mg PO QID
8. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
9. PredniSONE 20 mg PO DAILY
decrease per taper. due to decrease to 17.5mg on [**9-29**]
10. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
11. Tacrolimus 2.5 mg PO Q12H
12. ValGANCIclovir 900 mg PO DAILY
13. 70/30 15 Units Breakfast
70/30 5 Units Dinner
RX *insulin NPH & regular human [Humulin 70/30 Pen] 100 unit/mL
(70-30) take 15 Units before BKFT; 5 Units before DINR; Disp #*1
Not Specified Refills:*3
14. Insulin pen needles
BD nano ultrafine needles for 70/30 insulin pen
for [**Hospital1 **] injections and prn
supply: 1 box
refill: 6
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] area VNA
Discharge Diagnosis:
Hepatic encephalopathy, Primary biliary cirrhosis
Non occlusive thrombus R IJ
VRE + rectal swab
Klebsiella UTI
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call the transplant clinic at [**Telephone/Fax (1) 673**] if you develop
any of the following:
temperature of 101 or greater, chills,
dizziness/lightheadedness, thirst, nausea, vomiting, jaundice,
inability to take any of your medications, increased abdominal
pain or bloating/distension, incision redness/bleeding/drainage,
constipation, or edema worsens or legs are thin (no swelling),
weight loss of 3 pounds
_You will need to have blood drawn twice weekly for labs
monitoring at [**Hospital1 18**] lab, [**Hospital Ward Name **] Office Medical Building [**Location (un) 453**]
(every Monday and Thursday)
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 14955**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2140-9-29**] 1:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 14254**], [**Name12 (NameIs) 1046**] Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2140-9-29**] 3:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 14955**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2140-10-3**] 10:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2140-9-23**]
ICD9 Codes: 5845, 5990, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3572
} | Medical Text: Admission Date: [**2127-1-12**] Discharge Date: [**2127-2-7**]
Date of Birth: [**2082-5-16**] Sex: M
Service: PLASTIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5667**]
Chief Complaint:
Necrotizing fasciitis
Major Surgical or Invasive Procedure:
[**2127-1-12**]:
Incision and drainage of deep neck abscess of the neck with
extensive debridement of the skin and muscle, as well as fascia
of both sides of the neck and the anterior upper chest wall.
[**2127-1-17**]:
1. Left pectoralis myofascial flap.
2. Split-thickness skin grafting measuring an area of 30 cm x 20
cm, meshed at 1.5:1.
History of Present Illness:
44M with HIV (per report, unknown CD4. no HARRT) who had dental
abscess 10 days ago in [**State 4565**]. He underwent L inferior
tooth extraction, and was placed on oral Abx. During the next 2
days, he began feeling L neck swelling, and while on a plane
flight, the neck wound opened and started draining purulence.
He was seen by an OSH in [**State 108**], and the neck abscess continued
to spread, and he started draining copious amounts of fluid. He
was started on IV abx, but was ultimately brought to [**Hospital1 18**] ED by
his father. Today he reports [**6-8**] pain, no fevers or chills.
No difficulty breathing. He was diagnosed with HIV 7 yrs ago and
stopped f/u due to financial reasons. Denies any infections
until now. Also c/o diarrhea for past 4 weeks, and 30 lb weight
loss over past 6 weeks. No night sweats. No dyspnea, cough.
Past Medical History:
-HIV, diagnosed [**2119**], never on ARV, no Hx infections
-Hx hemorrhoids, s/p "day surgery" x 3
Social History:
Up until last week lived in basement of friend's home in LA.
Moved to LA from [**Location (un) 86**] 20 yrs ago. No tobacco, rare ETOH.
Cocaine (nasal) [**2098**]'s. Intermittent methamphetamine (last 1 yr
ago), marijuana recently.
Family History:
NC
Physical Exam:
On admission:
Vitals: 34.6C 75 112/61 18 98%RA
Gen: Alert & oriented x3, in [**6-8**] pain, but breathing and
speaking comfortably
OC: s/p extraction L lower molar
Neck: submental and L neck skin necrotic and open area ~5x6cm -
draining purulence. Portion of straps anteriorly eroded. skin
overlying T2-3 appears necrotic, leathery, erythematous,
blanches
with palpation. fluctuant down to ~T2-3 bilat across chest.
very tender to palpation.
HP/LX: deferred to OR
Pertinent Results:
Labs on admission:
[**2127-1-12**] 10:40AM BLOOD WBC-10.5 RBC-4.00* Hgb-9.3* Hct-29.0*
MCV-73* MCH-23.4* MCHC-32.2 RDW-20.0* Plt Ct-377
[**2127-1-12**] 10:40AM BLOOD Neuts-86.4* Bands-0 Lymphs-6.7* Monos-6.5
Eos-0.3 Baso-0.1 Atyps-0 Metas-0 Myelos-0
[**2127-1-12**] 10:40AM BLOOD PT-17.9* PTT-34.3 INR(PT)-1.6*
[**2127-1-13**] 11:02AM BLOOD WBC-7.3 Lymph-13* Abs [**Last Name (un) **]-949 CD3%-93
Abs CD3-886 CD4%-15 Abs CD4-146* CD8%-76 Abs CD8-724*
CD4/CD8-0.2*
[**2127-1-12**] 10:40AM BLOOD Glucose-58* UreaN-18 Creat-0.4* Na-127*
K-4.0 Cl-97 HCO3-25 AnGap-9
[**2127-1-12**] 10:40AM BLOOD Calcium-7.7* Phos-2.9 Mg-2.0
[**2127-1-12**] 11:09AM BLOOD Lactate-1.8 K-3.8
Imaging:
CT neck/chest with contrast [**2127-1-12**]:
1. Necrotizing fasciitis involving the soft tissues of the
anterior chest
wall, incompletely visualized. No definite
intrathoracic/mediastinal
extension.
2. 5-mm right pulmonary nodule. Followup chest CT in 12 months
is recommended.
Postop CTA head/neck [**2127-1-13**]:
1. No evidence of intracranial hemorrhage. The carotid and
vertebral
arteries and their major branches are patent without evidence of
stenosis or aneurysm formation.
2. Interval surgical drainage of the left cervical abscess with
extensive
post-surgical changes as described above.
3. Sinus disease as described above.
TTE [**2127-1-13**]:
Left ventricular wall thickness, cavity size and regional/global
systolic function appear to be normal (LVEF >55%). 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 structurally normal.
Mild (1+) mitral regurgitation is seen. The pulmonary artery
systolic pressure could not be determined. There is a
trivial/physiologic pericardial effusion.
Brief Hospital Course:
Patient was diagnosed with nectrotizing fascitiis of the neck.
Broad spectrum antibiotics were started in the ED with zosyn,
vancomycin, and gentamycin under ID consultation. He was
immediately taken to the operating room for washout and
debridement. There was gross pus draining from the neck in
multiple areas with soupy muscle visible throughout the open
wound. The open wound measured, in medial to lateral direction
about 8 cm, and in a superior to inferior direction about 6 cm.
Please see Dr.[**Name (NI) 18353**] operative note for details. Patient
tolerated the procedure well and was then transferred to the
TICU intubated. ENT performed daily dressing changes until he
returned to the OR for wound coverage on [**2127-1-17**] by plastics
for left pectoralis myofascial flap and STSG. Please see Dr. [**Name (NI) 73208**] operative note for detailes. Post-operatively, he did
well and was transferred out of the ICU on [**1-21**]. During his
course on the floor he continued to improve. He spiked a fever
a couple days into his stay on the floor and infectious work-up
was significant for likely candidal esophagitis and was started
on a 14d course of fluconazole. A CT scan of his neck to
evaluated for source of infection suggested osteomyelitis of the
left side of the mandible. OMFS was consulted and he was
subsequently taken to the operating room on [**2127-2-3**] where a
debridement of the right and left mandible, placement of rigid
fixation, and extraction of 7 teeth, numbers 18, 21, 22, 23, 24,
25 and 26 was performed. He was subsequently changed from
Augmentin to Zosyn with ID following for likely Osteomyelitis of
the mandible.
His entire postoperative course is outlined below by systems.
.
Neuro: Immediately postoperatively patient was noted to have
anisacoria not noted preoperatively. Neurology was consulted
given the concern for an acute CVA. A CTA of the head and neck
was obtained which was negative for an acute stroke. Neurology
concluded that this was not consistent with a CVA or TIA, and
recommended an opthalmology consult for a formal ophthalmologic
exam. Neuro-optho concluded that his left pupil appears fixed
secondary to synechiae (prior infection). No further treatment
or workup was recommended. Pain was well-controlled with
fentanyl. Versed/fentanyl drips were used for sedation while
intubated. Patient was given ketamine for daily dressing
changes. No episodes of delirium.
Cardiovascular: No active issues. On [**1-13**] (POD1) his pressors
were successfully weaned. His BPs and HR were stable for the
rest of his TICU stay. On [**1-15**] and [**1-18**] he was volume
overloaded on exam and was effectively diuresed with lasix.
Pulmonary: Patient was successfully extubated on [**2127-1-20**] (POD3
s/p wound closure by plastics). No active issues.
.
GI: Diarrhea likely from tube feed regimen. Stool cultures and
O&P were negative. C.diff have consistently been negative.
.
Nutrition: Continous tube feeds (via a dobhoff tube placed
intraoperatively) was started on [**2127-1-13**]. His albumin on
admission was 1.6. He has remained on tube feeds with nutrition
following. At the time of transfer he is currently on a full
liquid diet with continuous tube feeds.
.
Renal: No active issues - UOP adequate, with appropriate GFR.
.
Hematology: On [**2127-1-15**] he was transfused 2uPRBC for a HCT of
19. On [**1-17**] he was again given 2uPRBC before going to the OR
for wound closure by plastics. His HCT remained stable
post-operatively after the plastics closure but did level out in
the low 20's and he was subsequently given 3u PRBC during the
OMFS mandible debridement at which point his HCT has remained
stable at 30.
.
Endocrine: No active issues - his sugars were well-controlled
with a RISS.
.
Infectious Disease: ID was immediately consulted and follows
daily. Patient was immediately started on vanc, zosyn, and
gentamycin. Vanc and gent serum drug levels were closely
monitored, with drug dosing adjusted accordingly. There was no
evidence of active TB (no isolation cautions initiated).
Intraoperative OR cultures from [**2127-1-12**] ultimately grew
polymicrobes, staph aureus, and peptococcus. Staph sensitivies
showed MSSA. Prior wound cultures from an OSH grew
pan-sensitive e. coli and MSSA. Gentamycin was discontinued on
[**2127-1-18**]. Currently, he remains on zosyn for osteomyelitis of
the mandible. Consider stopping vanc once staph aureus
sensitivies return. Serology for toxo, CMV, and syphilis were
negative. He is currently on Zosyn for osteomyelitis of the
mandible, bactrim prophylaxis and fluconcazole for candidal
esophagitis.
Surgical wound: Debrided wound was followed by ENT with daily
dressing changes and packing of the left superior neck dead
space. General and thoracic surgery were consulted for possible
redebridement. All services were in agreement that a repeat
debridement was not indicated. Plastic surgery was consulted
for wound closure management. Patient underwent left pectoralis
myofascial flap and STSG from bilateral thighs on [**2127-1-17**]. His
skin graft sites over his neck were continued with daily
dressing changes with xeroform and kerlex gauze wrapped around
his upper chest and neck. The skin graft site on the R did not
take as well as on the left but it remained clean and has
continued to heal well. The coverage has continued to heal
without infection.
Dispo: Will be transferred to [**Hospital **] rehab
Medications on Admission:
Ibuprofen prn
Immodium prn
Discharge Medications:
1. Senna 8.6 mg Tablet [**Hospital **]: One (1) Tablet PO BID (2 times a
day) as needed.
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
3. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital **]: One (1) ml
Injection TID (3 times a day).
4. Lorazepam 0.5 mg Tablet [**Hospital **]: 1-4 Tablets PO Q4H (every 4
hours) as needed.
5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
6. Zinc Sulfate 220 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO DAILY
(Daily).
7. Ascorbic Acid 90 mg/mL Drops [**Last Name (STitle) **]: Five (5) ml PO DAILY
(Daily).
8. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet [**Last Name (STitle) **]: One (1)
Tablet PO DAILY (Daily) as needed for PCP [**Name Initial (PRE) 1102**].
9. Docusate Sodium 100 mg Capsule [**Name Initial (PRE) **]: One (1) Capsule PO BID (2
times a day).
10. Oxycodone 5 mg Tablet [**Name Initial (PRE) **]: 1-3 Tablets PO Q4H (every 4
hours) as needed for pain.
11. Acetaminophen 500 mg Tablet [**Name Initial (PRE) **]: Two (2) Tablet PO Q6H
(every 6 hours) as needed.
12. Ferrous Sulfate 325 mg (65 mg Iron) Tablet [**Name Initial (PRE) **]: One (1)
Tablet PO TID (3 times a day).
13. Folic Acid 1 mg Tablet [**Name Initial (PRE) **]: One (1) Tablet PO DAILY (Daily).
14. Nystatin 100,000 unit/mL Suspension [**Name Initial (PRE) **]: Five (5) ml PO Q8H
(every 8 hours).
15. Menthol-Cetylpyridinium 3 mg Lozenge [**Name Initial (PRE) **]: One (1) Lozenge
Mucous membrane PRN (as needed).
16. Fluconazole 100 mg Tablet [**Name Initial (PRE) **]: One (1) Tablet PO Q24H (every
24 hours): Started [**2127-1-31**] for 14 day course. Stop date [**2127-2-14**].
17. Chlorhexidine Gluconate 0.12 % Mouthwash [**Month/Day/Year **]: Fifteen (15)
ML Mucous membrane [**Hospital1 **] (2 times a day).
18. Heparin, Porcine (PF) 10 unit/mL Syringe [**Hospital1 **]: Two (2) ML
Intravenous PRN (as needed) as needed for line flush: Heparin
Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
.
19. HYDROmorphone (Dilaudid) 0.25-1.0 mg IV Q3H:PRN
20. Piperacillin-Tazobactam Na 2.25 g IV Q8H
21. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
22. HYDROmorphone (Dilaudid) 0.5-1 mg IV Q3H:PRN pain
23. Alteplase (Catheter Clearance) 1 mg IV PRN catheter
clearance, no more than q8
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
Necrotizing fasciitis
Discharge Condition:
Good, Stable
Discharge Instructions:
Continue daily dressing changes to your neck skin graft sites
with xeroform gauze with kerlex dressing as has been done daily
in the hospital. You should continue to keep your skin graft
donor sites on your legs dry and open to air. Allow the dried
dressing to peel off on its own. You will continue on your tube
feeds and antibiotics. You should continue to ambulate as
tolerated.
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness, swelling or
discharge from incision, chest pain, shortness of breath, or
anything else that is troubling you.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
Followup Instructions:
Follow-up with Dr. [**First Name (STitle) **] in the next week after discharge. Call
his office at ([**Telephone/Fax (1) 9144**] for an appointment
Follow-up with Dr. [**First Name (STitle) **] of OMFS in the next week after
discharge. Call ([**Telephone/Fax (1) 37579**] for an appointment.
Follow-up with the Infectious Disease clinic with Dr. [**Last Name (STitle) 81746**] on
[**2127-2-28**] 11:00. His office number is Phone:[**Telephone/Fax (1) 457**]
ICD9 Codes: 0389 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3573
} | Medical Text: Admission Date: [**2112-5-15**] Discharge Date: [**2112-5-20**]
Date of Birth: [**2037-1-2**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
Sudden onset left sided weakness.
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 75 year old female who presented to an outside
hospital after
developing left sided weakness, a CT of the head revealed a
right intraparanchymal hemorrhage with a holohemespheric right
sided subdural hematoma. She was intubated for airway
protection, paralyzed and transported to [**Hospital1 18**] for care.
Past Medical History:
HTN, Previous ischemic strokes on Coumadin,Renal failure, MI,
Pacemaker placed and recent AV fistula for dialysis.
Social History:
Lives with daughter who helps her with all her ADLs, uses a
rolling walker with seat attachment to mobalize
Family History:
NC
Physical Exam:
On Admission:
PHYSICAL EXAM:
BP:143 / 51 HR:75 R 26 O2Sats 100
Gen: WD/WN, comfortable, NAD.
HEENT: NCNT
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light,2 to 1
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
Motor: Follows commands with the right upper and lower
extremity,
plegic on the left with no response to painful stimuli
Toes downgoing bilaterally
On Discharge:
+ commands in spanish. With interpretor: OR to self, City of
residence, month, year. EO to voice, face symm, PERRL. R full
strength, Left [**5-12**]. + L drift.
Pertinent Results:
[**2112-5-15**] CXR
1. Somewhat low lying endotracheal tube and generously inflated
cuff. Slight retraction of the tube and if feasible decreased
distention of the balloon may be appropriate if clinically
indicated.
2. Nasogastric tube terminating in the stomach, although if
better purchase in the stomach is desired clinically then the
tube could be advanced.
3. Left lower lung opacity, which is nonspecific but could be
seen with
atelectasis and perhaps pleural effusion although pneumonia or
aspiration are difficult to completely exclude. Short-term
followup radiographs may be appropriate to reassess
[**2112-5-15**] CT BRAIN
Overall no significant change in right parietal intraparenchymal
hemorrhage, subdural hematoma and foci of subarachnoid
hemorrhage. No
significant change in 3 mm leftward shift of midline structures.
The presence of an underlying lesion may be evaluated by MRI if
indicated.
[**5-17**] CXR
IMPRESSION: Extubated, significant cardiac enlargement but no
evidence of
pleural effusion, acute pulmonary congestion or acute
infiltrates.
Brief Hospital Course:
Ms. [**Name14 (STitle) **] was received as a transfer from and OSH, intubated for
airway protection during transport, for right SDH and IPH. She
was admitted to the NICU and monitored closely with Q1 hr neuro
checks. Imaging remained stable and she was safely extubated.
She was given a short course of steroids and started on Keppra
for seizure prophylaxis. She was on Coumadin prior to admission
and this was reversed with Pophilnine and VIt K. She required
lopressor IV only once overnight into [**5-17**]. She was chnaged to
Q2 hr neuro checks. SBP was <160. SQH was started. She was
transitioned OOB. She was written for transfer to SDU. PT and OT
ST consults were called and her diet was advanced. They
recommended discharge to rehab. On [**5-18**] and [**5-19**] she remained
stable. On [**5-19**] she was transferred to the floor. Rehab
screening was initiated. She was offered a bed at rehab on [**5-19**]
but since she still received IV hypertensive medication she was
unable to be discharged. The medication was discontinued and she
had no need for the IV medication and was subsequently deemed
fit for discharge to rehab.
Medications on Admission:
calcitrol
cyanocobalamin
ferrous sulfate
lorazepam
metoprolol
pre-natal multivit
nitorglycerin sl
omperazole
lisinopril
norvasc 10 mg daily
hctz
aspirin 81
warfarin
epogen
percocet
lipitor
ibuprofen
Discharge Medications:
1. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
TID (3 times a day).
2. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection [**Hospital1 **] (2 times a day).
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/temp/ha.
8. hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for SBP>160.
9. famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
11. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
12. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
13. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
14. nystatin 100,000 unit/mL Suspension Sig: 500,000 units PO
Q8H (every 8 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
right parietal hemorrhage
right subdural hematoma
left hemiplgia
hypertension
Discharge Condition:
Level of Consciousness: Lethargic but arousable.
Mental Status: Confused - sometimes.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Ms. [**Known lastname **] - you were admitted to the hospital with a right
subdural hematoma and right sided hemorrhage into the brain.
You originally required respiratory support and then were able
to be extubated. General Instructions
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
?????? You have been discharged on Keppra (Levetiracetam) for seizure
prophylaxis, you will not require blood work monitoring.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) 739**], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2112-5-20**]
ICD9 Codes: 412, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3574
} | Medical Text: Admission Date: [**2173-7-20**] Discharge Date: [**2173-8-1**]
Date of Birth: [**2102-6-11**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
OSH transfer who had enlarged 10 mm CBD
present with bloody ascites and likely hepatic artery
pseudoaneurysm with extravasation
Major Surgical or Invasive Procedure:
[**2173-7-20**]: IR coil embolization
History of Present Illness:
71F transferred from OSH for workup of an enlarged 10 mm CBD
present with bloody ascites and likely hepatic artery
pseudoaneurysm with + extravasation. Pt state that she was in
her usual state of health aside from new onset migraines when
yesterday am she
noted the acute onset of severe abdominal pain. The pain
initially began in the lower and middle abdomen with radiation
to
the back [**11-1**]. Currently pain is localized to RUQ, w/ [**2172-3-26**]
pain.
Nausea accompanied the strongest pain, without emesis. She
describes otherwise normal bowel habits, no fevers, chills,
melena, hematochezia or BRBPR. She was initially evaluated at
[**Hospital 1562**] hospital where RUQ US showed 10 mm CBD with trace free
fluid in the abdomen. HCT was 39 but patient was hypotensive to
the 79/55 and given 3 L of fluid. Ct head was performed because
of new migraines. She was given Unasyn and transferred to [**Hospital1 18**]
where she has remained normo to hypertensive 150s but
persistently tachycardic in sinus. She is currently on her
hypotensive 5th liter of fluid, HCT 31.
Past Medical History:
PMH: Hypothyroid, Recurrent UTIs, Insomnia, Hx of EtOH abuse
PSH: Vagotomy, pyloroplasty and hiatal hernia repair elective
([**2122**], elective )Breast lumpectomy for atypical hyperplasia,
Right shoulder
Social History:
32 years sober from AA, No IVDA, former smoker quit in [**2142**]
Family History:
Brother recently at [**Hospital1 18**] for perforated viscus, AZD, Lung ca
in father
Physical Exam:
98.2 120 142/91 20 97% 4L Nasal Cannula
Gen: NAD, A&Ox3, tan female without pallor.
CVS: Tachycardic , no m/r/g/
Pulm: Clear anteriorly
Abd: tender in RUQ and epigastrium with fullness but no discrete
masses, no pulsations noted. Midline well healed scar.
Rectal: No hemorrhoids, guaiac neg
Ext: WWP
Pertinent Results:
Initial labs:
[**2173-7-20**] 02:15AM BLOOD Glucose-159* UreaN-11 Creat-0.7 Na-136
K-4.2 Cl-103 HCO3-18* AnGap-19
[**2173-7-21**] 01:47AM BLOOD Glucose-131* UreaN-16 Creat-0.5 Na-134
K-4.0 Cl-101 HCO3-24 AnGap-13
[**2173-7-20**] 02:15AM BLOOD PT-11.9 PTT-22.7 INR(PT)-1.0
[**2173-7-20**] 02:15AM BLOOD Plt Ct-184
[**2173-7-20**] 02:15AM BLOOD WBC-11.9* RBC-3.22* Hgb-10.4* Hct-31.1*
MCV-97 MCH-32.4* MCHC-33.6 RDW-12.8 Plt Ct-184
[**2173-7-20**] 02:15AM BLOOD ALT-185* AST-163* LD(LDH)-547* AlkPhos-81
TotBili-0.3
[**Hospital **] hospital course labs:
[**2173-7-31**] 06:20AM BLOOD Glucose-87 UreaN-5* Creat-0.4 Na-133
K-4.0 Cl-97 HCO3-28 AnGap-12
[**2173-7-23**] 01:19AM BLOOD WBC-17.1* RBC-3.60* Hgb-11.1* Hct-31.7*
MCV-88 MCH-30.8 MCHC-35.0 RDW-15.2 Plt Ct-177
[**2173-7-31**] 06:20AM BLOOD WBC-10.7 RBC-3.49* Hgb-10.9* Hct-31.3*
MCV-90 MCH-31.1 MCHC-34.7 RDW-14.4 Plt Ct-412
[**2173-7-21**] 02:29PM BLOOD ALT-3494* AST-3962* CK(CPK)-266*
AlkPhos-313* TotBili-1.2
[**2173-7-24**] 11:12PM BLOOD ALT-820* AST-140* AlkPhos-315*
TotBili-2.0*
[**2173-7-31**] 06:20AM BLOOD ALT-140* AST-48* AlkPhos-220* TotBili-1.5
[**2173-7-21**] 01:07PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE IgM HBc-NEGATIVE
Studies:
[**7-20**] RUQ U/S
IMPRESSION:
1. Moderate ascites, with echogenicity which may represent
blood. Correlation with hematocrit values is recommended, and CT
can be considered for further evaluation.
2. The CBD is not dilated and the gallbladder appears normal. No
biliary stone is seen.
[**7-20**] CT Abd pelvis:
IMPRESSION:
1. Large left hepatic arterial pseudoaneurysm, resulting in
compression of
the left portal vein, with active extravasation at the left
inferior aspect. The left hepatic lobe is hypoperfused.
2. Moderate intrapelvic and intra-abdominal hemorrhagic ascites.
3. Diffusely dilated pancreatic duct warrants further evaluation
with MRCP or ERCP following treatment of acute issues.
[**7-27**] CT Abd Pelvis:
IMPRESSION:
1. Increased distribution of ground-glass opacities, now diffuse
in nature. Differential includes pulmonary hemorrhage,
infection or possibly fluid overload. However, given lack of air
bronchograms, pyogenic pneumonia is less likely though a viral
pneumonia is still a consideration. Fluid overload, is less
likely given interval resolution of pleural effusions. Thus the
most likely diagnoses include pulmonary hemorrhage or viral
pneumonia.
2. Distention with increased gallbladder wall edema and
irregularity of the luminal surface of the gallbladder wall is
concerning for potential gangrenous cholecystitis. Recommend
further evaluation with an ultrasound to further assess for any
intraluminal membranes or other evidence of gangrenous
cholecystitis. Given patient's lack of feeding status and
hepatic hypoperfusion, clinical and lab values or HIDA scan
would be of little utility in further diagnosis.
3. Stable hypoperfusion of the entire left hepatic lobe and the
hepatic dome.
4. Bilateral hepatic artery aneurysm coiling without evidence of
residual
flow noted within the aneurysm or in the left hepatic artery.
5. Improved abdominal and pelvic ascites
Brief Hospital Course:
ICU:
[**2173-7-26**] trigerred [**7-26**] @ 17:50 for RR 27
[**2173-7-24**] cont lasix gtt, added acetazolamide
[**2173-7-23**] off dilt, BP improved, a-line d/c'd, duplex - patent
hepatic arteries
[**2173-7-22**] episodes of SBP 200s, responds to dilt, TTE: WNL, CTA -
coils working
[**2173-7-21**] off labetolol gtt, HCT 24->27 s/p 1u pRBC, +1add'l
pRBC, rheum c/s, west 1 c/s
ICU COURSE:
[**7-20**]: She was admitted to the ICU and sent urgently to IR for
coil embolization: 3 aneurysms seen on arteriogram, 2 visible
during IR. Per report "multiple aneurysms,
coiled dominant L HA bilobed aneurysm to stasis, coils & gelfoam
to branch of RHA, 3rd aneurysm not visible end of procedure'. On
return to ICU she was mildly hypertensive (SBP 160) and was
started on a labetolol gtt and hydralazine. She was transfused
2u prbc prior to embolization with increasing hematocrit after
the procedure.
[**7-21**]: Showing signs of stability, further work-up was performed
for question of auto-immune vasculitis. A hepatobiliary surgery
and rheumatology consult were obtained. A renal U/S done was
normal. She showed signs of fluid overload this day,
desaturating to the low 80's with a CXR consistent with
pulmonary edema. She responded well to diuresis with lasix but
required 2 more units PRBC to keep her hct above 28. The
labetolol drip was DC'd in exchange for prn hydralazine. Her
liver enzymes peaked, as expected, this day. They were monitored
daily or twice daily, to ensure they peaked and receded as we
expected.
[**7-22**]: Aggressive diuresis was continued. ECHO showed normal
ventricular function while CTA chest showed no PE but continued
volume overload. CT of the liver showed resolution of the
aneurysms, functioning coils and patent hepatic vein with the
expected hypoperfused left liver segments.
[**7-23**]: Liver duplex showed sucessful embolization of L hepatic
artery and patent R hepatic arterial system. Being >48 hours out
from embolization, subcutaneous heparin was started. Diuresis
continued with good effect (-1650mL/24hr). Liver enzymes
continued to return towards normalcy. Her bilirubin peaked at
2.2 on post-procedure day 4 and then also began to normalize. At
beginning of diuresis 2 days prior, she was positive 8L. Our
target diuresis was 1.0-1.5L/day. Over the following 2 days this
was achieved. She continued to spike fevers nightly while all
cultures and work-up remained negative. We were aware of her
issue with chronic UTI, but urine studies were not consistent
with this being the source. The most likely explanation is an
inflammatory cascade driven by the areas of infarcted liver.
Consistent with this theory, her fevers reduced as LFTs and
bilirubin returned to [**Location 213**].
While in the ICU, she was seen by rheumatology consult, who
recommended vasculitis labs, all of which were negative (ANCA,
anti-Sm, [**Doctor First Name **] & dsDNA). Rheum recommended no steroids at this
time. At the time of transfer to the floor, she was tolerating
regular diet, fevers had resolved, her hematocrit was stable,
ambulating independently.
Floor:
Mrs. [**Known lastname 65014**] was transferred to the floor in stable condition and
she continued to improve clinically. Her bilirubin continued to
remain elevated while her LFTs trended downwards and there was
concern for gallbladder pathology. a RUQ U/S performed on [**7-28**]
showed a heterogenous gallbladder that was concerning for
necrosis. She was evaluated for a perc chole on [**7-29**] but repeat
U/S did not show necrosis. She tolerated a regular diet and was
up and out of bed, with minimal pain. She was set to be
discharged home on [**2173-8-1**].
Medications on Admission:
levothyroxine 112 mcg, nitrofurantoin 50 mg, Vitamin C 1000
mg, Calcium 600 with Vitamin D3 600 mg", Fish Oil, MVI, folic
acid 400 mcg, Vitamin B Complex, Stool Softener 100 mg,
melatonin 300 mcg, magnesium 250 mg, Lunesta Qhs
Discharge Medications:
1. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] VNA [**Hospital3 **]
Discharge Diagnosis:
Left hepatic artery aneurysm with active extravasation
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 abdominal pain. You had
a work-up done at an outside hospital which showed bloody fluid
in your abdomen and hepatic artery pseudoaneurysms and you were
transferred to [**Hospital1 18**]. You were initially admitted to the ICU for
resuscitation and management and underwent IR embolization of
your hepatic artery aneurysms. You were transferred to the floor
on [**2173-7-25**] and continued to improve daily. There was concern for
your gallbladder being infected, since your liver function
studies were elevated, but an ultrasound performed did not show
evidence of that. You were tolerating a regular diet,
ambulating, and pain was well controlled.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. You may take
tramadol or ibuprofen for pain control. Please follow-up with
your PCP.
Followup Instructions:
Please follow-up with the acute care service in 1 month with Dr.
[**Last Name (STitle) **] or Dr. [**Last Name (STitle) 853**] with a CT A/P w/ IV contrast in the arterial
phase performed before your appointment. You can schedule this
appointment and the imaging study by calling the [**Hospital 2536**] clinic:
#[**Telephone/Fax (1) 600**].
ICD9 Codes: 4589, 2851, 2449, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3575
} | Medical Text: Admission Date: [**2105-3-24**] Discharge Date: [**2105-3-27**]
Date of Birth: [**2057-2-17**] Sex: F
Service: [**Last Name (un) **]
TIME OF DEATH: [**2105-3-27**] at 1856.
HISTORY OF PRESENT ILLNESS: Patient is a 48 year-old female
who flu-like symptoms for 1 weeks, 4 to 5 days of right upper
quadrant pain, nausea, vomiting, dark diarrhea, decreased
p.o. intake and was reported by family to be jaundiced. She
had been taking approximately Tylenol #3 Extra Strength and
noted that her urine had been dark. She denies any alcohol or
exposure to rural mushrooms in the last year.
PAST MEDICAL HISTORY: Asthma, heartburn. She denies stroke
or myocardial infarction.
PAST SURGICAL HISTORY: Only tubal ligation.
ALLERGIES: She has no known allergies.
FAMILY HISTORY: Diabetes, hypertension.
PHYSICAL EXAMINATION: At presentation she was afebrile.
Heart was 74, 90/58, 16, 98%. She was jaundiced, alert and
oriented. Scleral icterus. Her lungs were clear. She had
hepatomegaly. The right upper quadrant was tender. Rectal:
Guaiac negative.
A 48 year-old female who had acute hepatitis. Etiology of the
hepatitis was unclear. Supposedly related to Tylenol. She had
an acetaminophen level of 17 at time of presentation. AST was
8,124, ALT was 6,780, alkaline phosphatase was 209 and total
bilirubin was 17.8.
Patient was admitted to the medical service and followed
approximately for 1-1/2 days, given Mucomyst and as her care
progressed and her INR decided to drift up and her liver
function continued to deteriorate patient was taken over by
the transplant surgery service. At this point in time factor
7 was given on multiple occasions. Fresh frozen plasma drip
was started and patient was intubated for airway protection
as she was developing encephalopathy. Additional to that a
neurosurgical consultation was obtained and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 36066**] drain
was placed for ICP monitoring. The ICP initially at
presentation was in the 30s. It was elevated shortly after a
CT scan was found to be normal immediately after placement of
ICP monitoring device. Approximately 6 hours later
neurosurgical attending was again at the bedside evaluating
the drain for elevated ICP in the 48 to 51 range. Pupils were
reactive at that point in time and an attempt was made to
decrease the ICP with blowing off the CO2. The ventilator was
increased for a period of time. She is blowing off the CO2 to
change the ICP. The ICP did not change in response to these
maneuvers. Additional to that her sodium was already 154 and
the decision was undertaken not to give Mannitol at the time.
The patient had equally reactive pupils. She was then taken
to the CT scanner and evaluated again with serial CT scan
imaging of the head and was found to have some measure of
cerebral edema. The patient progressed throughout the course
of the day, worsening, hepatic dysfunction and additional
vasculopathy or cerebral edema progressed. Eventually
discussion was undertaken with family about CMO status. CMO
status was agreed upon by family and patient actually had an
asystolic event shortly thereafter. A family meeting was
undertaken and family agreed to autopsy.
FINAL DIAGNOSES: Hepatic encephalopathy.
Acute hepatic failure.
Coagulopathy.
Brain death.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 3432**]
Dictated By:[**Last Name (NamePattern1) 7823**]
MEDQUIST36
D: [**2105-3-27**] 20:32:25
T: [**2105-3-27**] 21:49:45
Job#: [**Job Number 36067**]
ICD9 Codes: 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3576
} | Medical Text: Admission Date: [**2129-8-18**] Discharge Date: [**2129-8-24**]
Date of Birth: [**2081-2-27**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Amoxicillin / Bactrim
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
shortness of breath, fevers
Major Surgical or Invasive Procedure:
None
History of Present Illness:
48-year-old female with PMH significant for IDDM, chronic
idiopathic pancreatitis, HTN and prior splenic vein thrombosis (
> 10 yrs. ago) who presented to the ED after 3 days of worsening
cough and shortness of breath. She reports having developed
fatigue and sore throat about 5 days ago and then she developed
a cough about 2 days ago with a "brownish" productive sputum.
She also reports having alternating chills and sweats over past
2-3 days as well but she did not take her temperature at home.
She denies recent travels but states several of her
grandchildren had bad colds at a recent family gathering last
week. She denies any known history of CHF, PEs, or MIs in the
past. She denies LE edema but has noticed some mild orthopnea
over past day but never before in the past.
In the ED, initial vital signs were : Temp 98.2F, Tmax 100.4F,
BP 136/70, RR 20, O2 sats were 99% on NRB. She was given IV
750mg Levaquin and IV 1g Vancomycin. Also received IV Zofran x 1
for some nausea complaints. In ED, AP CXR showed bilateral
opacities concerning for ARDS initially but repeat PA & lateral
views notable for diffuse pulmonary edema with underlying patchy
infiltrates concerning for PNA.
Upon arrival to the [**Hospital Unit Name 153**] the patient appeared to be in no acute
distress, she was able to speak in full sentences and did not
appear to be using any accessory muscles to breath. She had temp
98.5F axillary, BP 105/62, HR 89, RR 16-18, and O2 saturation
level of 99% on NRB ( 12L).
REVIEW OF SYSTEMS:
(+) Per HPI, also has intermittent headaches, diffuse muscle
aches, nausea. Chronic right sided and epigastric abdominal pain
is at baseline per patient.
(-) Denies recent weight loss or gain. Denies chest pain or
tightness, palpitations. Denies vomiting, diarrhea, constipation
and last BM yesturday. Denies recent change in bowel or bladder
habits. Denies dysuria. Denies arthralgias.
Past Medical History:
-Chronic pancreatitis biopsy proven, followed by Dr. [**Last Name (STitle) 3315**]
here at [**Hospital1 18**]. On chronic narcotics and enzymes.
-IDDM, secondary to chronic pancreatitis, followed by Dr. [**First Name (STitle) 3636**]
at [**Last Name (un) **]
-Hypertension
-history of splenic vein thrombosis
-Depression
-Mitral regurgitation
-h/o MRSA bacteremia
-Genital herpes
-I & D of LLE abscess [**12/2128**]
-tobacco use
Social History:
Ms. [**Known lastname **] lives in [**Location 686**]. She has 3 children, 5
grandchildren. Former nursing assistant. Long-standing smoker,
smoked 2PPD x 30 years and then 1PPD x last 3 years. No EtOH. No
illicit drug use. She is currently separated from her spouse who
was recently incarcerated.
Family History:
Her father died of pancreatic cancer at age 56. Her mother died
from anesthesia reaction. + h/o breast cancer in family.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals -Temp 98.5F axillary, BP 105/62, HR 89, RR 16-18, and O2
saturation level of 99% on FM( 12L / FiO2 100%).
.
GEN: - Resting comfortably in bed, no acute distress
HEENT: -PERRL, sclera anicteric, MMM, erythematous posterior
oropharynx noted, no exudates noted
NECK: - supple, JVP at 9cm, mildly tender cervical lymph nodes
but no appreciable enlargement
PULM: Bilateral crackles at bases, no wheezes or rhonchi
CVS - RRR, normal S1/S2; loud S2 and otherwise no murmurs, rubs,
or gallops appreciated
ABD: normoactive bowel sounds; soft, mild TTP over right side of
abdomen and epigastric region, non-distended, no rebound or
guarding
EXT- Warm, well perfused, radial and DP pulses 2+; no clubbing,
cyanosis or edema
SKIN - no rashes, warm to the touch
Neuro -CNs [**3-17**] in tact, appropriate 5/5 strength with
upper/lower extremities, no focal sensory deficit, gait
assessment deferred
Pertinent Results:
[**2129-8-24**] 05:30AM BLOOD WBC-8.7 RBC-3.52* Hgb-9.5* Hct-29.3*
MCV-83 MCH-27.0 MCHC-32.3 RDW-16.7* Plt Ct-450*
[**2129-8-20**] 05:09AM BLOOD WBC-9.2 RBC-3.44* Hgb-9.4* Hct-28.9*
MCV-84 MCH-27.2 MCHC-32.4 RDW-16.9* Plt Ct-266
[**2129-8-19**] 01:31PM BLOOD WBC-12.0* RBC-3.71* Hgb-10.1* Hct-30.4*
MCV-82 MCH-27.3 MCHC-33.3 RDW-16.8* Plt Ct-301
[**2129-8-18**] 04:20AM BLOOD WBC-14.6* RBC-3.72* Hgb-10.2* Hct-31.0*
MCV-83 MCH-27.4 MCHC-32.9 RDW-17.4* Plt Ct-244
[**2129-8-17**] 10:20PM BLOOD WBC-14.3* RBC-4.04* Hgb-11.2* Hct-33.9*
MCV-84 MCH-27.7 MCHC-33.0 RDW-16.9* Plt Ct-263
[**2129-8-17**] 10:20PM BLOOD Neuts-85.2* Lymphs-12.4* Monos-2.1
Eos-0.1 Baso-0.1
[**2129-8-19**] 01:31PM BLOOD PT-13.5* PTT-34.0 INR(PT)-1.2*
[**2129-8-19**] 01:31PM BLOOD Fibrino-910*
[**2129-8-19**] 01:31PM BLOOD ESR-105*
[**2129-8-19**] 01:31PM BLOOD Ret Aut-1.5
[**2129-8-24**] 05:30AM BLOOD Glucose-189* UreaN-13 Creat-0.8 Na-138
K-5.0 Cl-102 HCO3-29 AnGap-12
[**2129-8-23**] 05:15AM BLOOD Glucose-60* UreaN-10 Creat-0.8 Na-142
K-4.4 Cl-107 HCO3-28 AnGap-11
[**2129-8-18**] 04:20AM BLOOD Glucose-64* UreaN-22* Creat-1.3* Na-141
K-3.6 Cl-108 HCO3-19* AnGap-18
[**2129-8-17**] 10:20PM BLOOD Glucose-67* UreaN-20 Creat-1.3* Na-140
K-3.3 Cl-108 HCO3-20* AnGap-15
[**2129-8-19**] 05:01AM BLOOD LD(LDH)-784* AlkPhos-83 TotBili-0.2
[**2129-8-18**] 06:52PM BLOOD CK(CPK)-103
[**2129-8-18**] 04:20AM BLOOD ALT-9 AST-42* LD(LDH)-895* CK(CPK)-119
AlkPhos-81 TotBili-0.1
[**2129-8-17**] 10:20PM BLOOD ALT-6 AST-47* LD(LDH)-959* CK(CPK)-85
AlkPhos-87 TotBili-0.1
[**2129-8-18**] 06:52PM BLOOD CK-MB-3 cTropnT-<0.01
[**2129-8-18**] 04:20AM BLOOD CK-MB-4 cTropnT-<0.01
[**2129-8-17**] 10:20PM BLOOD cTropnT-<0.01
[**2129-8-17**] 10:20PM BLOOD CK-MB-NotDone proBNP-4677*
[**2129-8-24**] 05:30AM BLOOD Calcium-8.3* Phos-3.1 Mg-1.8
[**2129-8-19**] 05:01AM BLOOD Calcium-7.1* Phos-1.8* Mg-1.7 Iron-14*
[**2129-8-18**] 04:20AM BLOOD Albumin-2.9* Calcium-7.8* Phos-3.4 Mg-2.0
[**2129-8-19**] 01:31PM BLOOD Hapto-407*
[**2129-8-19**] 05:01AM BLOOD calTIBC-187* Hapto-341* Ferritn-87
TRF-144*
[**2129-8-19**] 01:31PM BLOOD ANCA-NEGATIVE B
[**2129-8-19**] 01:31PM BLOOD [**Doctor First Name **]-POSITIVE * Titer-1:40 [**Last Name (un) **]
[**2129-8-18**] 09:24AM BLOOD HIV Ab-NEGATIVE
[**2129-8-22**] 12:37PM BLOOD Type-ART Temp-36.5 O2 Flow-4 pO2-107*
pCO2-45 pH-7.39 calTCO2-28 Base XS-1 Intubat-NOT INTUBA
Comment-NASAL [**Last Name (un) 154**]
[**2129-8-21**] 01:49PM BLOOD Type-ART Temp-36.4 O2 Flow-4 pO2-68*
pCO2-44 pH-7.40 calTCO2-28 Base XS-1 Intubat-NOT INTUBA
Comment-NASAL [**Last Name (un) 154**]
[**2129-8-19**] 01:52PM BLOOD Type-ART Temp-37.2 Rates-/22 FiO2-95
pO2-64* pCO2-37 pH-7.39 calTCO2-23 Base XS--1 AADO2-576 REQ
O2-95 Intubat-NOT INTUBA
[**2129-8-19**] 07:31AM BLOOD Type-ART pO2-74* pCO2-38 pH-7.38
calTCO2-23 Base XS--1
[**2129-8-18**] 04:07PM BLOOD Type-ART pO2-61* pCO2-37 pH-7.36
calTCO2-22 Base XS--3
[**2129-8-18**] 03:24AM BLOOD Type-ART Temp-37.8 FiO2-99 pO2-98
pCO2-31* pH-7.38 calTCO2-19* Base XS--5 AADO2-594 REQ O2-95
Intubat-NOT INTUBA
[**2129-8-19**] 01:52PM BLOOD Lactate-1.0
[**2129-8-17**] 11:02PM BLOOD Lactate-2.0
[**2129-8-19**] 01:52PM BLOOD freeCa-1.15
[**2129-8-20**] 01:00PM BLOOD MYCOPLASMA PNEUMONIAE ANTIBODY IGM-PND
[**2129-8-20**] 01:00PM BLOOD MYCOPLASMA PNEUMONIAE ANTIBODY, IGG-PND
[**2129-8-20**] 12:54PM BLOOD CHLAMYDOPHILA PNEUMONIAE ANTIBODIES
(IGG,IGA,IGM)-PND
[**2129-8-17**] 11:25PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.019
[**2129-8-17**] 11:25PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2129-8-17**] 11:25PM URINE RBC-0 WBC-[**4-7**] Bacteri-MOD Yeast-NONE
Epi-21-50
[**2129-8-17**] 02:28PM URINE Hours-RANDOM Creat-129 Na-LESS THAN
[**2129-8-17**] 02:28PM URINE Osmolal-459
**FINAL REPORT [**2129-8-19**]**
Legionella Urinary Antigen (Final [**2129-8-19**]):
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
[**2129-8-18**] 9:24 am SPUTUM Site: INDUCED Source: Induced.
**FINAL REPORT [**2129-8-18**]**
GRAM STAIN (Final [**2129-8-18**]):
<10 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final [**2129-8-18**]):
TEST CANCELLED, PATIENT CREDITED.
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
[**2129-8-18**]): NEGATIVE for Pneumocystis jirovecii
(carinii)..
[**2129-8-18**] 8:02 am Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal swab.
**FINAL REPORT [**2129-8-20**]**
Respiratory Viral Culture (Final [**2129-8-20**]):
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Rapid Respiratory Viral Antigen Test (Final [**2129-8-18**]):
Respiratory viral antigens not detected
[**2129-8-20**] 3:49 pm SPUTUM Site: INDUCED Source: Induced.
**FINAL REPORT [**2129-8-21**]**
GRAM STAIN (Final [**2129-8-20**]):
<10 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
[**2129-8-21**]): NEGATIVE for Pneumocystis jirovecii
(carinii)..
ECG Study Date of [**2129-8-17**] 10:09:50 PM
Sinus rhythm. Left ventricular hypertrophy. Diffuse non-specific
ST-T wave
changes. Compared to the previous tracing of [**2128-12-4**] the rate
has increased. Non-specific ST-T wave changes are more
prominent. There are new T wave inversions in leads I, aVL with
ST segment flattening in lead V6. Clinical correlation is
suggested.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
93 152 84 344/401 24 50 171
CHEST (PA & LAT) Study Date of [**2129-8-17**] 11:51 PM
IMPRESSION: Findings are consistent with pulmonary edema with
overlying
airspace disease such as infection (likely hemorrhage). Consider
diuresis and repeating radiograph.
Portable TTE (Complete) Done [**2129-8-18**] at 12:27:46 PM
Conclusions
The left atrium is mildly dilated. The estimated right atrial
pressure is 0-10mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). The estimated cardiac index is high
(>4.0L/min/m2). Tissue Doppler imaging suggests an increased
left ventricular filling pressure (PCWP>18mmHg). Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic stenosis. Trace aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. Mild
(1+) mitral regurgitation is seen. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Mild pulmonary artery systolic hypertension. Mild mitral
regurgitation.
Compared with the prior study (images reviewed) of [**2127-7-21**], the
findings are similar
CT CHEST W/O CONTRAST Study Date of [**2129-8-18**] 3:03 PM
IMPRESSION:
1. Extensive parenchymal abnormalities seen as areas of ground
glass, some
degree of septal thickening and more solid areas of
consolidation.
Differential diagnosis would include widespread infection,
severe
hypersensitivity reaction, ARDS and unlikely pulmonary edema.
Correlation
with bronchoscopy may be suggested. Sparing of lingula in full
part of right middle lobe is noted.
2. Thyroid enlargement, correlation with thyroid ultrasound is
recommended.
3. Left intramuscular fat-containing lesion most likely within
the left
deltoid muscle that giving its septation may represent either
septated lipoma or liposarcoma( much less likely) and should be
further followed.
BILAT LOWER EXT VEINS PORT Study Date of [**2129-8-18**] 3:58 PM
IMPRESSION:
1. No DVT in either the right or left lower extremity.
2. Borderline enlarge right inguinal lymph node, minimally
enlarged since
exam from one year prior. Recommend clinical correlation.
CT CHEST W/O CONTRAST Study Date of [**2129-8-23**] 9:22 AM
IMPRESSION: Marked interval improvement in overall lung aeration
compared to CT from five days prior. Persistent diffuse
pulmonary abnormality, now
primarily upper lobe in distribution, right greater than left.
The
differential diagnosis remains nonspecific and clinical
correlation is
recommended. Improving mediastinal adenopathy.
UNILAT UP EXT VEINS US RIGHT Study Date of [**2129-8-23**] 1:58 PM
IMPRESSION: Occlusive thrombus around the distal portion of the
basilic vein surrounding the PICC line. No other thrombosis
identified in right upper extremity including no deep venous
thrombosis.
Brief Hospital Course:
1. Hypoxia, Probable Pneumonia vs. Probable Interstitial Lung
Disease:
Patient admitted to the [**Hospital Unit Name 153**], on [**8-17**], w/ productive sputum,
fevers , leukocytosis, cough and marked shortness of breath with
desaturations to the 70s range on room air are all concerning
for PNA. CXR showed bilateral edema and cephalization. [**8-18**] CT
Chest showed extensive parenchymal abnormalities seen as areas
of ground glass, some degree of septal thickening and more solid
areas of consolidation. She was started on Vancomycin,
Levofloxacin and Aztreonam on [**8-18**]. Sputum Cx were
non-diagnostic as they were contaminated by oral flora, PCP (-),
respiratory virus serologies (-), urine legionella antigen (-).
Serologies for atypicals (mycoplasma, chlamydia) are pending, as
are autoimmune labs (Anti-neutrophil Cytoplasmic Antibody;
Anti-GBM; Anti-Nuclear Antibody Screen). Her O2 sats continued
to improve and she transitioned from NRB to 4L NC on [**8-21**]. She
has been afebrile throughout admission. Repeat Chest CT after
arriving on the floor showed interval improvement. Pulmonary
consultation was obtained, and the patient will follow up in
pulmonary clinic. She was changed to levofloxacin on discharge.
Smoking Cessation was advised, although the patient was not
interested.
2. Leukocytosis
- Patient presented w/ elevated WBC to 14.3 with left shift.
Likely secondary to PNA in setting of aforementioned symptoms of
cough, fevers, productive sputum and dyspnea. Cx results as
above. WBC trended down to normal by time of discharge.
3. Acute Diastolic CHF
EKG with prominent LVH. Longstanding HTN makes diastolic
dysfunction quite likely. Last TTE in [**2127**] showed LVEF >55% but
may have worsened systolic function and/or additional diastolic
CHF since that time. She had an elevated BNP in 4k range which
supports CHF exacerbation which was likely triggered by new PNA.
TTE done on [**8-18**] results are pending.
4. Type 2 Diabetes Uncontrolled:
Her ICU course has been complicated by both hypoglcemia and
hyperglycemia. She has a home insulin regimen of humalog and
Lantus. On ICU discharge, she was at 32 units of Lantus.
5. Chronic pancreatitis
Per multiple OMR GI notes she is noted to have idiopathic
chronic pancreatitis of unclear etiology after mutiple studies.
She is seen by Dr. [**Last Name (STitle) 3315**]. At current time her chronic
abdominal pain is near usual baseline and she has normal lipase
level. Enzyme replacement was as her home regimen.
6. Benign Hypertension
Patient initially had BPs in the 100s/50s w/o BP medication.
Once she was started on treatment for her PNA, her BP went up to
the 110s-120s/60s-70s. Her BP continue to trend up to SBP
180-190s, lisinopril was re-started on [**8-21**] and amlodipine on
[**8-22**].
7. Anemia of Chronic Disease
Chronic in nature. Her normal Hct range is 30-33. Hct was 29 on
[**8-22**].
8. Depression
Slightly flattened affect on exam. She denied any current
suicidal ideation/homicidal ideation. Per OMR notes, long
history of depressive symptoms. Stable at current time.
Medications on Admission:
Amlodipine 10 mg PO daily
Amylase-Lipase-Protease ( VIOKASE 16) - 935 mg (60,000
unit-[**Unit Number **],000
unit-[**Unit Number **],000 unit) Tablet - 2 Tablet PO with meals
Atenolol-50 mg PO qdaily
Fentanyl-75 mcg/hour Patch 72 hr, apply 2 patchs q3days
Insulin [**Unit Number 7452**] - 40 units QHS
Insulin Lispro (Humalog)/ SSI PRN four times a day
Lisinopril - 40 mg PO qdaily
Omeprazole - 20 mg qdaily
Oxycodone-Acetominophen- 5 mg/325 mg Tablet - [**Hospital1 **] PRN
Prochlorperazine- 10 mg tablet - Q-6 hrs PRN for nausea
Colace -100 mg Capsule - [**Hospital1 **]
Discharge Medications:
1. Amylase-Lipase-Protease 48,000-16,000- 48,000 unit Capsule,
Delayed Release(E.C.) Sig: Two (2) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
2. Fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
4. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
6. Insulin [**Hospital1 7452**] 100 unit/mL Solution Sig: Forty (40) units
Subcutaneous at bedtime.
7. Insulin Lispro 100 unit/mL Insulin Pen Sig: ASDIR Sliding
Scale Subcutaneous ASDIR.
8. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
11. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO twice a day
as needed for pain.
12. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
every six (6) hours as needed for nausea.
Discharge Disposition:
Home
Discharge Diagnosis:
Hypoxia
Probable Pneumonia
Probable Interstitial Lung Disease
Acute Diastolic CHF
Chronic Pancreatitis
Upper Extremity Line Thrombus
Discharge Condition:
Good
Discharge Instructions:
Return to the hospital with difficulty breathing,
nausea/vomitting, fever/chills, coughing up blood or chest pain.
You are being discharged on antibiotics, levofloxacin, which can
make your tendons weak while taking it. Do not engage in heavy
phsyical activity such as sports. Continue taking this even if
you feel better.
Followup Instructions:
Follow up in pulmonary clinic Dr. [**First Name8 (NamePattern2) 8982**] [**Last Name (NamePattern1) 7273**] [**2129-10-5**] at
4:00pm. Prior to this appointment go to Spirometry at [**Location (un) 8661**] 7
on [**2129-10-5**] at 3:30
ICD9 Codes: 486, 4280, 4240, 311, 4019, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3577
} | Medical Text: Admission Date: [**2162-8-9**] Discharge Date: [**2162-8-13**]
Date of Birth: [**2110-9-29**] Sex: F
Service: MEDICINE
Allergies:
Heparin (Porcine) / Erythromycin Base
Attending:[**First Name3 (LF) 12084**]
Chief Complaint:
fever to 103.0 at home, RLE pain, and chills.
Major Surgical or Invasive Procedure:
none
History of Present Illness:
[**Known firstname **] [**Known lastname 101760**] is a 51-year-old woman with history of ESRD s/p
renal transplant [**2151**], PVD, CAD who presented to the Emergency
Department this morning with complaints of fever to 103.0 at
home, RLE pain, and chills. Reports she was in her USOH until 5
Am this morning - had to urinate, but due to limited mobility
from osteoarthritis, used a bedpain with assistance from
husband. [**Name (NI) 4906**] noted patient to be extremely warm and took
patient's temperature, found it to be 103.0. Patient also began
to complain of right foot pain, swelling, and redness, which she
had not experienced prior to this morning (may have had some
heel pain 2 days PTA, but unclear if this is new or old).
Reports chronic LE issues secodnary to [**Name (NI) 1106**] insufficiency,
but pain and erythema are new. Patient also reports growth on
Left 4th digit that was being managed as outpatient. Was
productive of pus ~ 1 week ago, which was swabbed and drained by
PCP [**Last Name (NamePattern4) **] [**8-6**]. Wound swab grew coagulase positive staph and
Enterobacter cloacae. No further pus drainage, differential
according to OMR note was blister drainage vs. gout vs. local
pus collection. She denied any subsequent pus drainage from the
finger.
.
On review, patient denied chest pain, shortness of breath,
nausea, vomiting, abdominal pain, diarrhea, constipation, or
diaphoresis. Skin changes as per HPI.
.
In the ED, initial VS were T 102.8; HR 52; BP 93/32; RR 18; O2
94% RA. Patient received doppler of RLE which did not reveal
DVT. BP was recorded as upper 80s systolic. Lactate was 1.7, she
was started on Vancomycin and Ceftazidime for presumed sepsis
from RLE. CXR without infiltrate. Patient refused central line
as she did not think it was warranted. She was admitted to the
MICU for further care.
.
Of note, patient reports that her Allopurinol was recently
increased to 100 [**Hospital1 **] due to her gout issues.
Past Medical History:
# SLE
# End stage renal disease s/p transplant [**2158**] now with chronic
allograft nephropathy
# Dilated cardiomyopathy, EF 35%
# Peripheral [**Year (4 digits) 1106**] disease, s/p right first toe amputation,
s/p
# Bilateral femoral popliteal bypass.
# Osteoarthritis, s/p left total hip replacement.
# s/p multiple AV fistula revisions
# s/p colectomy with end ileostomy secondary to perforated
ischemic transverse colon
# Coronary artery disease, s/p perioperative myocardial
infarction
# History of MRSA wound infection
# Positive Hepatitis C
# Hemachromatosis from mult transfusions
# Anemia of Chronic Inflammation
# Hyperparathyroidism s/p parathyroidectomy 10 yrs ago
# Avascular necrosis of hips
Social History:
Denies tobacco, Etoh, drugs. On disability.
Family History:
No history of CAD or malignancy. + h/o DM in her mother.
Physical Exam:
VS: T 97.8; BP 101/78; HR 76; RR 14; O2 98% 1.5L NC
GEN: Lovely middle-aged woman in NAD
HEENT: PERRL. EOMI. Wears glasses. MMM. Op clear
CV: III/VI systolic murmur LUSB
LUNGS: CTA B/L
ABD: colostomy bag on RLQ without erythema or drainage. soft.
well-healed prior surgical scars. NT/ND.
EXT: RLE with dolor, calor, rubor. Non-palpable pulses. 1st
digit s/p amputation. Exquisitely tender to touch. No crepitus.
LLE with swelling. Non-tender, warm. Hand: 4th digit on left
hand with crusted lesion on distal aspect of palmar side - no
pus, erythema, or other signs of active infection
NEURO: AO x 3. No asterixis. No focal deficits except decreased
LE ROM [**2-19**] pain.
Pertinent Results:
[**2162-8-9**] 11:10PM URINE HOURS-RANDOM UREA N-527 CREAT-158
SODIUM-21
[**2162-8-9**] 11:10PM URINE OSMOLAL-250
[**2162-8-9**] 11:10PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020
[**2162-8-9**] 11:10PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-TR
[**2162-8-9**] 11:10PM URINE RBC-[**3-22**]* WBC-[**6-27**]* BACTERIA-MOD
YEAST-NONE EPI-0-2 RENAL EPI-0-2
[**2162-8-9**] 11:10PM URINE HYALINE-0-2
[**2162-8-9**] 12:18PM TYPE-[**Last Name (un) **] COMMENTS-GREEN
[**2162-8-9**] 12:18PM LACTATE-1.5
[**2162-8-9**] 11:55AM WBC-12.0*# RBC-3.65* HGB-10.2* HCT-30.8*
MCV-85 MCH-28.1 MCHC-33.2 RDW-15.5
[**2162-8-9**] 11:55AM NEUTS-87* BANDS-1 LYMPHS-6* MONOS-6 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2162-8-9**] 11:55AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-OCCASIONAL
[**2162-8-9**] 11:55AM PLT SMR-LOW PLT COUNT-148*
.
RLE duplex ([**2162-8-9**]): IMPRESSION: No evidence of DVT involving
the right lower extremity.
.
RIGHT FOOT, THREE VIEWS. ([**2162-8-9**]):
The patient is status post amputation of the first ray at the
base of the
first proximal phalanx. The amputation borders are relatively
well
corticated. On today's exam, there is more pronounced focal
osteopenia along the plantar medial aspect of the distal 1st
metatarsal -- if this corresponds to a site of ulceration, then
this could represent early osteomyelitis. No cortical
interruption or periosteal new bone formation is identified at
this site or elsewhere in the foot. There is diffuse osteopenia
and dense [**Month/Day/Year 1106**] calcification. There is some increased
density in the middle phalanx of the second digit, unchanged
compared with [**2162-3-18**]. No acute fracture and no dislocation is
identified.
.
AP Chest ([**2162-8-9**]):
FINDINGS: Portable AP view of the chest is obtained and
compared with prior study from [**2162-3-18**]. The heart is enlarged.
Linear right basilar atelectasis is noted. No large pleural
effusions are present. There is no evidence of CHF. The
mediastinal contour is unremarkable. Aortic knob calcification
is present. There is no pneumothorax. Osteopenia is noted in
the visualized osseous structures.
IMPRESSION: Cardiomegaly, with right basilar atelectasis. No
CHF.
.
LEFT FOURTH FINGER PERFORMED ON [**8-10**]:
AP, lateral and oblique films were obtained.
As seen on the study from [**2158-5-10**], there are extremely
extensive
[**Year (4 digits) 1106**] calcifications and demineralization of the bony
structures. Amorphous soft tissue calcifications are seen at the
level of the middle and distal phalanges. There is distal soft
tissue thinning. The findings are consistent with the history
of SLE. No finding is seen that suggests osteomyelitis.
IMPRESSION: As seen on the study from [**2158-5-10**], there is
profound osteopenia with extensive [**Month/Day/Year 1106**] calcifications.
There are more extensive amorphous fourth finger soft tissue
calcifications than on the prior study.
.
AP chest ([**2162-8-10**]): FINDINGS: AP single view of the chest
obtained with patient in sitting upright position is analyzed in
direct comparison with a similar preceding study of [**2162-8-9**]. Marked cardiomegaly including evidence of left atrial
enlargement is present as before. There is some upper zone
redistribution pattern, but no conclusive evidence for
interstitial or alveolar edema is noted. Linear atelectasis
exists bilaterally but the lateral pleural sinuses remain free.
No pneumothorax is present. When direct comparison of the lung
fields is made with the previous examination, there is slightly
more increased perivascular haze and also the heart size appears
to have increased slightly. No new discrete parenchymal
infiltrates are identified.
IMPRESSION: Further progression of cardiomegaly and now some
mild congestion. No evidence of pulmonary edema as yet.
.
Brief Hospital Course:
In the MICU pt abx regiment was changed to vanc and meropenem
due to the hx of (MSSA and) enterobacter. Was also followed by
the renal service due to ARF with a creatinine bump to 2.4, was
managed with gentle fluid rehydration with return of systolic bp
into 130s. Had cotrosyn stim test to test for adrenal
insufficiency as a cause of hypotension; was normal.
Hypotension possibly related to patient being on BB with
worsening renal failure but may also have been due to sepsis
although blood culutures did not grow out positive. Also,
lactate was normal making ischemia due unlikely as a cause. Pt
swelling, pain and redness with great improvement; pt was
therefore transferred to the floor on CC7.
.
Pt continued to improve on the floor; her renal function quickly
returned to [**Location 4222**] with a creatinine of 1.8; she remained
afebrile for the remainder of the stay. A source of infection
was never clearly identified. Bladder and respiratory
infections were thought very unlikely given normal studies. Pt
had no GI sx's. ID thought source of fever was most likely the
L 4th finger with a gout lesion that was superinfected. Since
cultures of this had grown out enterobacter and MSSA (although a
hx of MRSA) vanc and meropenem was continued. Cellulitis of the
R leg was thought possible although less likely as a cause of
fever. Later in the stay pt was refusing PICC placement and was
demanding to go home. Pt had expressed discontent with numerous
thing during the hospitalization up to this point, one of them
being the experience with the plastic surgery team during their
visit (recommended soaking the finger qid for 15 minutes in warm
water and taking off ring). Despite numerous conversations with
the intern, the resident, the attending, the transplent team,
the entire ID team, pt clearly stated she would leave that day
and do so without a PICC.
.
The following is a summary of the contants of the conversation
held with patient prior to discharge: We have decreased your
gabapentin dose to 300 daily, decreased your cellcept to 500
twice a day (since so far out and ID thought this may help with
fighting infection). We have also changed your calcitriol to 0.5
mcg twice a day, your Sodium bicarbonate to 650mg three times a
day, and decreased your metoprolol to 12.5 mg twice a day.We
have recommended that you have a PICC line placed for IV
antibiotics, however you have refused. Instead, we have
developed an alternative plan as below. You should also start
taking your linezolid on the evening of sunday [**8-15**] until you
are out of pills. Start your ciprofloxacin tonight and continue
until you are out of pills. You need to understand that this is
not the optimal therapy as you may not absorb the linezolid as
well as an IV antibiotic. In addition, linezolid can cause
decreaased platelets, for which you are already at high risk.
You will need to have MWF blood counts to monitor your platelets
with your VNA until one week after you finish your linezolid
dosing. They will send the results to Dr. [**Last Name (STitle) **] for review. We
also strongly recommend that you schedule an MRI for your finger
to make sure there is no osteomyelitis as well as an
echocardiagram to make sure you do not have endocarditis. Please
schedule these tests on Monday.
.
When patient left on [**8-13**] she was urinating on own, was off
supplemental oxygen, afebrile and eating and drinking on her
own.
Medications on Admission:
1. Allopurinol 100mg PO BID (recently increased)
2. Cellcept 1g PO BID
3. Prednisone 10mg PO qd
4. Protonix 40mg PO qd
5. Calcitriol 0.25mcg PO TID
6. NaHCO3 [**2105**] [**Hospital1 **]
7. Metoprolol 25 PO BID
8. Cyclosporine 25mg PO BID
9. Folic Acid 4mg PO qd
10. Bactrim 1 pill 3x/week
11. Fentanyl Patch 50mcg/hr q72h
12. Neurontin 600 PO TID
13. MVI s iron qd
Discharge Medications:
1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
3. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
4. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO 3X/WEEK (MO,WE,FR).
6. Cyclosporine Modified 25 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours).
7. Sodium Bicarbonate 650 mg Tablet Sig: One (1) Tablet PO three
times a day.
Disp:*90 Tablet(s)* Refills:*0*
8. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
Disp:*30 Tablet(s)* Refills:*0*
9. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*0*
10. Folic Acid 1 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
11. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
12. Linezolid 600 mg Tablet Sig: One (1) Tablet PO twice a day.
13. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q24H
(every 24 hours).
Disp:*30 Capsule(s)* Refills:*0*
14. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
15. Epoetin Alfa 4,000 unit/mL Solution Sig: 4000 (4000) units
Injection QMOWEFR (Monday -Wednesday-Friday).
16. Calcitriol 0.25 mcg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
Disp:*60 Capsule(s)* Refills:*0*
17. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
18. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO twice a
day for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
19. Outpatient Lab Work
CBC qMWF. Call results to Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 250**]
Discharge Disposition:
Home With Service
Facility:
Caregroup VNA
Discharge Diagnosis:
RLE cellulitis
Acute Renal Failure
Gout
s/p transplant
Discharge Condition:
stable
Discharge Instructions:
Please seek medical attention IMMEDIATELY should you develop
fevers, chills, confusion, dizziness, increased leg pain,
shortness of breath or any other concerning symptoms.
We have decreased your gabapentin dose to 300 daily, decreased
your cellcept to 500 twice a day. We have also changed your
calcitriol to 0.5 mcg twice a day, your Soudium bicarbonate to
650mg three times a day, and decreased your metoprolol to 12.5
mg twice a day.
We have recommended that you have a PICC line placed for IV
antibiotics, however you have refused. Instead, we have
developed an alternative plan as below.
You should also start taking your linezolid on the evening of
sunday [**8-15**] until you are out of pills. Start your
ciprofloxacin tonight and continue until you are out of pills.
You need to understand that this is not the optimal therapy as
you may not absorb the linezolid as well as an IV antibiotic.
In addition, linezolid can cause decreaased platelets, for which
you are already at high risk. You will need to have MWF blood
counts to monitor your platelets with your VNA until one week
after you finish your linezolid dosing. They will send the
results to Dr. [**Last Name (STitle) **] for review.
Followup Instructions:
Please call [**Telephone/Fax (1) 250**] tommorrow morning to arrange for an
appoinitment with Dr. [**Last Name (STitle) **]. She should follow your CBCs
checked by your VNA as well as to follow up your ECHO and MRI
results.
.
Please make appointments to obtain an ECHO and and MRI performed
by early next week. We have provided you with information on
how to arrange these
Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2162-9-14**] 3:00
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7145**] ORTHOPEDIC PRIVATE PRACTICE
Date/Time:[**2162-9-15**] 12:30
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7145**] ORTHOPEDIC PRIVATE PRACTICE
Date/Time:[**2162-12-29**] 2:30
ICD9 Codes: 0389, 5849, 4254, 4439, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3578
} | Medical Text: Admission Date: [**2103-9-21**] Discharge Date: [**2103-10-5**]
Date of Birth: [**2016-10-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Chest pain, transfered after cardiac cath showed 3VD
Major Surgical or Invasive Procedure:
[**2103-9-25**] Coronary artery bypass grafting x5 with left internal
mammary artery to the left anterior descending artery and
reverse saphenous vein graft to the posterior left ventricular
branch artery and second diagonal artery and sequential reverse
saphenous vein graft to the obtuse marginal artery and the first
diagonal artery.
History of Present Illness:
86 year old spanish speaking man w PMH HTN, HLD, known 2 vessel
CAD from [**2101**], s/p PPM for AV block, admitted on [**2103-9-20**] with
chest pain while walking. He had stable angina before but it got
worse before admission. Ruled in for MI with a troponin peak of
0.095, NSTEMI diagnosed. No further symptoms since admission.
Cathed today at OSH via right radial where he was found to have
3VD with two lesions in the LAD (mid and distal),Cx and RCA
occluded. EF of 50% seen on ventriculogram. Receiving plavix
600mg load at OSH. The patient was transferred for PCI of LAD,
evaluation at [**Hospital1 18**] determined that surgical evaluation for CABG
would be the best option given 3VD.
Past Medical History:
- Coronary Artery Disease
- PPM for AV block in [**2101-8-26**] at [**Last Name (LF) **], [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] Dual
Chamber Model # 5820 Serial # [**Numeric Identifier 111967**]
Social History:
From [**Country 26231**], moved here 4 years ago, married.
Denies alcohol, tobacco, and drug use.
Family History:
Five siblings died. Doesn't know reason.
Physical Exam:
ADMISSION EXAM:
VS- T 97 BP 141-152/64-100 HR 58-62 RR 16 O2sat 97%
GEN: NAD, friendly
[**Name (NI) 4459**]: MMM
NECK: no elevation in JVP
CV: RRR S1S2 no MGR
RESP: CTABL no crackles or wheezes
ABD: + BS soft NTND
EXT: no edema, + pulses
Discharge exam:
VS 98.5 77 124/67 18 100% RA
Gen: NAD
Neuro: A&O x3, MAE. nonfocal exam
Pulm: CTA-bilat
CV: RRR(paced), sternum stable incision CDI
Abdm: soft, NT/ND/+BS
Ext: warm, well perfused. No CCE
Pertinent Results:
Admission labs:
[**2103-9-27**] 05:35AM BLOOD WBC-12.6* RBC-2.85* Hgb-8.9* Hct-26.5*
MCV-93 MCH-31.3 MCHC-33.6 RDW-13.9 Plt Ct-101*
[**2103-9-26**] 12:07PM BLOOD Hct-29.3*
[**2103-9-26**] 01:27AM BLOOD WBC-12.5* RBC-3.76* Hgb-11.7* Hct-34.5*
MCV-92 MCH-31.2 MCHC-34.0 RDW-13.7 Plt Ct-112*
[**2103-9-27**] 05:35AM BLOOD Glucose-216* UreaN-27* Creat-1.2 Na-137
K-5.4* Cl-104 HCO3-24 AnGap-14
[**2103-9-26**] 12:00PM BLOOD Na-134 K-4.4 Cl-104
[**2103-9-26**] 01:27AM BLOOD Glucose-92 UreaN-15 Creat-1.0 Na-136
K-4.1 Cl-106 HCO3-20* AnGap-14
[**2103-9-25**] 01:13PM BLOOD UreaN-17 Creat-0.7 Na-138 K-4.2 Cl-112*
HCO3-23 AnGap-7*
Discharge Labs:
[**2103-10-4**] 05:55AM BLOOD WBC-11.6* RBC-2.74* Hgb-8.3* Hct-25.9*
MCV-95 MCH-30.4 MCHC-32.2 RDW-15.7* Plt Ct-324
[**2103-10-4**] 05:55AM BLOOD Plt Ct-324
[**2103-10-4**] 05:55AM BLOOD Glucose-61* UreaN-18 Creat-1.0 Na-136
K-4.7 Cl-102 HCO3-28 AnGap-11
[**2103-10-4**] 05:55AM BLOOD Calcium-8.2* Phos-2.9 Mg-2.3
Radiology Report CHEST (PA & LAT) Study Date of [**2103-10-2**] 9:31 AM
Final Report: The patient had recent sternotomy for CABG.
Mediastinal and cardiac contours are top normal with left-sided
pectoral pacemaker in adequate position. Left mid lung
atelectatic band is minimal. Left lower lobe is better aerated.
The residual pleural effusion is minimal bigger on the left
side. There is no pneumothorax.
CONCLUSION: The patient had recent sternotomy for CABG. The
lungs are better aerated. Residual pleural effusion is minimal,
bigger on the left side.
.
Carotid U/S [**2103-10-2**]: Less than 40% stenosis of the bilateral
extracranial internal carotid arteries.
Brief Hospital Course:
86 year old spanish speaking man w PMH HTN, HLD, known 2 vessel
CAD from [**2101**], s/p PPM for AV block [**2101-8-4**], admitted on
[**2103-9-20**] with chest pain while walking. Ruled in for NSTEMI at
OSH, got cardiac cath which showed 3VD, transferred here for
surgical intervention. The patient's troponins were trending
down after NSTEMI. PCI was not felt to be appropriate in the
case of 3VD, so the patient was scheduled for CABG after Plavix
wash out (had received Plavix load at OSH). The patient was
brought to the Operating Room on [**2103-9-25**] where the patient
underwent coronary artery bypass grafting x5 with left internal
mammary artery to the left anterior descending artery and
reverse saphenous vein graft to the posterior left ventricular
branch artery and second diagonal artery and sequential reverse
saphenous vein graft to the obtuse marginal artery and the first
diagonal artery with Dr. [**Last Name (STitle) **]. Please see operative note for
surgical details. Overall the patient tolerated the procedure
well and post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. He remained
hemodynamically stable in the immediate post-op period, his
anesthesia was reversed and he was extubated. POD 1 found the
patient alert and oriented and breathing comfortably. The
patient was neurologically intact and hemodynamically stable, he
weaned from vasopressor support and Beta blockers were
initiated. The patient was started on diuretics and gently
diuresed toward the preoperative weight. Additionally the
patient was transferred to the telemetry floor for further
recovery. Chest tubes and pacing wires were discontinued per
cardiac surgery protocol without complication. EP initially
interrogated PPM and increased rate to 80 for blood pressure
support, they reinterrogated the PPM prior to discharge and he
will need a follow up with Dr. [**Last Name (STitle) **] at [**Last Name (STitle) **] in 1 month. Foley
needed to be reinserted on POD 2 due to failure to void. He did
have some hematuria with the reinsertion. This was removed prior
to discharge and patient voided successfully and without
hematuria. On POD 3 he developed a distended abdomen, nausea and
vomiting. A KUB showed and stool in bowel, he was made NPO, NGT
was inserted and he was given multiple bowel medications.
LFT's/Amylase/Lipase were within normal limits. NGT was removed
2 days later and diet was advanced. The patient had multiple
bowel movements, abdominal distention decreased and he was
tolerating a full oral diet. [**Last Name (un) **] was consulted as the patient
had no history of diabetes (preop HGBA1C 7.3), and required
insulin post-operatively. He was started on oral agents, Lantus
was stopped, and the diabetes educator instructed him on
checking blood sugars and oral medications via interpreter. He
will need diabetes follow up with his PCP. [**Name10 (NameIs) **] patient was
evaluated by the physical therapy service for assistance with
strength and mobility. By the time of discharge on POD 10 the
patient was ambulating with assistance, the wound was healing
well and pain was controlled with Tylenol. The patient was
discharged home with multi cultural VNA in good condition with
appropriate follow up instructions.
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from OSH
records, pt will bring list tomorrow.
1. Simvastatin 20 mg PO DAILY
2. Tamsulosin 0.4 mg PO DAILY
3. Metoprolol Tartrate 50 mg PO DAILY
4. Losartan Potassium 50 mg PO DAILY
5. Hydrochlorothiazide 12.5 mg PO DAILY
6. Finasteride 5 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN pain
RX *acetaminophen 650 mg 1 (One) tablet(s) by mouth every four
(4) hours Disp #*120 Tablet Refills:*0
2. Aspirin EC 81 mg PO DAILY
RX *aspirin 81 mg 1 (One) tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*2
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 (One) tablet(s) by mouth twice a
day Disp #*60 Tablet Refills:*1
4. Simvastatin 20 mg PO DAILY
RX *simvastatin 20 mg 1 (One) tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*2
5. Ranitidine 150 mg PO BID Duration: 1 Months
RX *ranitidine HCl 150 mg 1 (One) tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
6. Potassium Chloride 20 mEq PO BID Duration: 1 Weeks
RX *potassium chloride 20 mEq 1 (One) by mouth twice a day Disp
#*14 Tablet Refills:*0
7. MetFORMIN (Glucophage) 500 mg PO BID
RX *metformin 500 mg 1 (One) tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*2
8. Finasteride 5 mg PO DAILY
RX *finasteride 5 mg 1 (One) tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*2
9. Metoprolol Tartrate 25 mg PO BID
RX *metoprolol tartrate 25 mg 1 (One) tablet(s) by mouth twice a
day Disp #*60 Tablet Refills:*2
10. Tamsulosin 0.4 mg PO DAILY
RX *tamsulosin 0.4 mg 1 (One) capsule(s) by mouth once a day
Disp #*30 Capsule Refills:*2
11. Furosemide 20 mg PO Q12H Duration: 1 Weeks
RX *furosemide 20 mg 1 (One) tablet(s) by mouth twice a day Disp
#*14 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
Multicultural VNA
Discharge Diagnosis:
- Coronary Artery Disease s/p Coronary artery bypass graft x 5
Past medical history:
- PPM for AV block in [**2101-8-26**] at [**Last Name (LF) **], [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] Dual
Chamber Model # 5820 Serial # [**Numeric Identifier 111967**]
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with Tylenol
Sternal Incision - healing well, no erythema or drainage
Lower extremity: Left saph site clean/dry/intact
Edema: trace bilateral lower extremity edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for one month or while taking narcotics. Driving will
be discussed at follow up appointment with surgeon.
No lifting more than 10 pounds for 10 weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Surgeon Dr. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 170**] Date/Time: [**2103-10-25**] 1:00
[**Hospital **] Medical Office Building , [**Doctor First Name **]., [**Hospital Unit Name **]
Wound check Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2103-10-11**] 11:00
[**Hospital **] Medical Office Building , [**Doctor First Name **]., [**Hospital Unit Name **]
Cardiologist Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] B. [**Telephone/Fax (1) 37284**], [**2103-10-23**] at
2:00p
Electrophysiologist: Dr. [**Last Name (STitle) **] [**Name (STitle) **] at [**Hospital3 **] for PPM
interrogation in 1 month - left message with office to call
patient with appointment [**Telephone/Fax (1) 3342**]
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) **],[**Last Name (un) **] [**Doctor Last Name **] [**Telephone/Fax (1) 80120**] in [**5-10**]
weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2103-10-5**]
ICD9 Codes: 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3579
} | Medical Text: Admission Date: [**2123-12-25**] Discharge Date: [**2124-1-14**]
Date of Birth: [**2070-11-30**] Sex: F
Service: Cardiothoracic
HISTORY OF PRESENT ILLNESS: The patient is a 53-year-old
woman who had onset of severe thoracic pain two days prior to
admission while she was away in [**State 531**]. She returned home
to [**Location (un) 86**] from [**State 531**] due to the chest pain associated with
nausea and vomiting. Since that time the nausea and vomiting
had subsided; however, the patient chest pain remained
constant over the past 48 hours.
On examination in the Emergency Room the patient was found to
profoundly bradycardic and diaphoretic. Her
electrocardiogram revealed 30-degree AV block with a rate in
the 40s, and a systolic blood pressure of 110. At that time
she was brought to the cardiac catheterization laboratory for
cardiac catheterization and temporary pacemaker placement.
Please see the catheterization report for full details.
PAST MEDICAL HISTORY: (Past medical history is significant
for)
1. Coronary artery disease.
2. Type 2 diabetes mellitus.
3. Hypertension.
4. Cholesterol.
MEDICATIONS ON ADMISSION: Medications prior to admission
included atenolol, Zestril, aspirin, and Glucophage.
LABORATORY DATA ON PRESENTATION: Laboratory work on
admission revealed a white blood cell count of 22.8,
hematocrit 38, platelets 376. Sodium 131, potassium 4.4,
chloride 93, bicarbonate 22, blood urea nitrogen 18,
creatinine 1.1, glucose of 520. PT was 13.8, PTT was 24.5,
INR of 1.3.
PHYSICAL EXAMINATION ON PRESENTATION: The patient's
physical examination prior to admission in the Emergency Room
revealed a heavy-set woman. Neurologically, alert and
oriented. Head, ears, nose, eyes and throat revealed pupils
were equally round and reactive to light. Extraocular
movements were intact. Neck was supple. No lymphadenopathy.
No obvious jugular venous distention. No bruits. Lungs had
diminished breath sounds anteriorly bilaterally. Heart
sounds revealed a regular rate and rhythm with a positive
rub. No murmur. Abdomen was soft, midline laparoscopy scar.
Extremities revealed no obvious peripheral vascular disease,
positive pedal pulses.
RADIOLOGY/IMAGING: The patient's catheterization showed left
anterior descending artery with a shifting plaque into the
circumflex with no refill down the left anterior descending
artery or the circumflex, proximal ostial 80% to 90% lesion.
HOSPITAL COURSE: The patient remained hypotensive in
cardiogenic shock while in the catheterization laboratory.
An intra-aortic balloon pump was placed, and Cardiac Surgery
was consulted.
Post catheterization, the patient was brought emergently to
the operating room for coronary artery bypass graft. Please
see the Operative Note for full details.
In summary, the patient underwent coronary artery bypass
graft times two with a vein graft to the left anterior
descending artery and a vein graft to the first obtuse
marginal. At the time of transfer the patient remained in
cardiogenic shock. She had an arterial line, a Swan-Ganz
catheter, and intra-aortic balloon pump, ventricular pacing
wires times two, and atrial pacing wires. She also had two
mediastinal chest tubes and a right pleural chest tube. At
the time of transfer, her mean arterial pressure was 84.
Central venous pressure was 19. She was AV paced with an
intra-aortic balloon pump at 1:1. She was transferred with
propofol at 30 mcg/kg per minute, Milrinone at 0.25 mcg/kg
per minute, amiodarone at 1 mcg/kg per minute, Neo-Synephrine
at 1.5 mcg/kg per minute, dopamine at 10 mcg/kg per minute,
and insulin at 1 unit per hour.
On postoperative day one the patient was kept sedated in an
effort to allow her to rest throughout the day. She remained
fully ventilated and the balloon pump remained at 1:1.
On the morning of postoperative day two the patient was
weaned from her sedation. Following the weaning of sedation
she was weaned from the ventilator and successfully
extubated. Later on that morning her intra-aortic balloon
pump was weaned and ultimately discontinued. In addition,
the patient's Milrinone was weaned to off. The patient
remained in the Intensive Care Unit on postoperative days
three and four to monitor her respiratory and cardiopulmonary
status. Over the course of those two days the patient
remained hemodynamically stable.
However, on postoperative day four her cardiac index took a
dip and she was restarted on her Milrinone. In addition, her
respiratory status seemed to be taking a turn for the worse.
Her respiratory rate increased. She was producing large
amounts of sputum and becoming increasingly hypoxic despite
increasing oxygen support. A chest x-ray at that time showed
bilateral patchy infiltrates. On the afternoon on
postoperative day four the patient was intubated by
Anesthesia.
Over the next several days the patient remained intubated
requiring full ventilatory support. She was empirically
started on vancomycin and Levaquin. Her chest x-ray during
that time showed acute respiratory distress syndrome versus
bilateral lower lobe infiltrates. Infectious Disease was
consulted and the patient was begun on vancomycin,
levofloxacin, and clindamycin which were ultimately changed
to vancomycin and ceftazidime. Sputum from her previous
culture grew out methicillin-susceptible Staphylococcus
aureus.
On postoperative day 10 through postoperative day 13 the
patient showed vast gains in her pulmonary status, and on
postoperative day 13 she was weaned from the ventilator and
successfully extubated. She remained in the Intensive Care
Unit for two additional postoperative days to monitor her
pulmonary status. On postoperative day 15 she was
transferred to the floor for continued postoperative care and
cardiac rehabilitation.
Following extubation the patient had a speech and swallow
consultation as well as [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Clinic consultation. On
further recommendations of Speech and Swallow, she was
initially begun on clear liquids and advanced slowly to soft
solids and then to a full regular diet.
Once on the floor, with the assistance of nursing and
physical therapy, the patient's activity level was increased
on a daily basis. She remained hemodynamically stable. Her
respiratory status continued to improve. She was weaned from
her oxygen.
On postoperative day 16 she was brought to the
Electrophysiology laboratory for electrophysiology studies.
At that time she was found to not have inducible ventricular
tachycardia, and therefore no automatic internal
cardioverter-defibrillator was placed. She continued to work
with nursing and physical therapy over the next several days.
On postoperative day 20, it was deemed that she was stable
and ready for discharge to home.
CONDITION AT DISCHARGE: At the time of discharge, the
patient was stable.
DISCHARGE DIAGNOSES:
1. Coronary artery disease, status post percutaneous
transluminal coronary angioplasty, status post coronary
artery bypass graft times two with saphenous vein graft to
left anterior descending artery and saphenous vein graft to
first obtuse marginal.
2. Type 1 diabetes mellitus.
3. Hypertension.
4. Hypercholesterolemia.
MEDICATIONS ON DISCHARGE:
1. Aspirin 325 mg p.o. q.d.
2. Glucophage 500 mg p.o. t.i.d.
3. Zestril 2.5 mg p.o. q.d.
4. Amiodarone 400 mg p.o. q.d.
5. NPH insulin 42 units q.a.m. and 8 units q.p.m.
6. Regular insulin sliding-scale.
PHYSICAL EXAMINATION AT TIME OF DISCHARGE: Vital signs were
temperature 98.8, heart rate 84, sinus rhythm, blood pressure
100/60, respiratory rate 18, oxygen saturation 95% on room
air. Weight preoperatively was 66.2 kg, at discharge was
66.1 kg. Physical examination revealed alert and oriented
times three, conversant. Moved all extremities. Breath
sounds were clear to auscultation bilaterally. Heart sounds
revealed a regular rate and rhythm, first heart sound and
second heart sound. Sternum was stable. Incision was open
to air, clean and dry. The abdomen was soft, nontender, and
nondistended, normal active bowel sounds. Extremities were
warm and well perfused. No clubbing, cyanosis or edema.
Right lower extremity incision was healing well, open to air,
clean and dry.
LABORATORY DATA ON DISCHARGE: Hematocrit 34.6, glucose 4.8,
blood urea nitrogen 19, creatinine 0.8.
DISCHARGE FOLLOWUP: The patient was to have follow up with
Dr. [**Last Name (STitle) 1537**] in one month. She was also to have follow up with
Dr. [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) **] of Cardiology on [**3-2**]. She was to
return to the [**Hospital 409**] Clinic in two weeks for follow-up wound
checks.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Name8 (MD) 415**]
MEDQUIST36
D: [**2124-1-17**] 11:24
T: [**2124-1-18**] 16:04
JOB#: [**Job Number 16970**]
ICD9 Codes: 4280, 5185, 486, 2762 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3580
} | Medical Text: Admission Date: [**2167-9-19**] Discharge Date: [**2167-11-4**]
Service: MICU, GREEN
CHIEF COMPLAINT: The patient is an 80-year-old with recent
complicated hospitalization on the Neurosurgical Service for
fall complicated by subdural hematoma who presented with
decreased mental status with apparent seizure activity.
male with history of diabetes, coronary artery disease,
pacemaker, transient ischemic attacks, status post prolonged
hospitalization at [**Hospital6 256**] from
[**9-19**] through [**10-27**] on the Neurosurgical/SICU
Service for falling down stairs resulting in facial trauma
and right moderate subdural hematoma. His course was
complicated by prolonged intubation and failure to wean
and aspiration, initially followed by recurrent pneumonia,
atelectasis, left lower lobe collapse, congestive heart
failure, and fluid overload, and depressed mental status. He
underwent tracheostomy on [**10-3**] complicated by tracheal
bleeding, pneumothorax, and asystolic arrest. His course was
also complicated by recurrent atrial fibrillation well controlled
by Diltiazem, persistent guaiac positive stools, but GI declined
work-up, renal insufficiency with creatinine range from 2.1-2.9.
He was discharged to rehabilitation on [**2167-10-23**]. His
course at rehabilitation was notable for recent fevers with work-
up reportedly with gram-negative rods in urine and sputum. He
was started on Ciprofloxacin and subsequently Ceftazidine. He
was initially lethargic with thyroid studies showing increased
TSH of 76 and decreased T4 at 2.0. He was begun on Synthroid
0.025 mg per day. Also of note, Diltiazem was changed to Digoxin
for unclear reasons.
From a respiratory standpoint, he started to wean slowly and
most recently on pressure support or 15, PEEP of 5, FIO2 30%
breathing <30 BPM, and tidal volume of >5 cc/kg . Reportedly ABG
seven days ago was pH of 7.41, pCO2 42, pO2 106. He had been
receiving aggressive diuresis with Lasix 100 mg q.12 hours
which slowly increased his bicarb from 28 on transfer on
[**10-28**], to 234 on [**11-2**]. Apparently his mental
status improved somewhat. On [**11-2**] he was alert and
responsive. He was smiling and shaking hands with people.
OF NOTE HE WAS MADE DNR TODAY.
At 2 a.m. he was noted to have what appeared to be a tonic clonic
seizure. He eyes rolled to the back of his head. He turned red.
His body appeared rigid, and he appeared to have a upper
extremity greater than lower extremity, right greater than left
tonic clonic jerking movements. Vitals signs with a blood
pressure of 132/49, heart rate 80, respirations 20, oxygen
saturation 100%. This appeared to last about 15 min per the
nurse but 5 min per the respiratory therapist taking care of him.
Subsequently this all resolved except for continued right arm
shaking for about 10 min. He received Ativan 1 mg IV push.
He was bagged and suctioned. Temperature was 100.2??????.
Ten minutes after this, he was placed on vent settings for 10
min. Subsequent ABG was with a pH of 7.59, pCO2 36, pO2 94.
He remained unresponsive and was transferred to [**Hospital6 1760**].
On transfer he remained unresponsive. Vitals signs were
100.2??????, 70s, 152/71, 100%. Chest x-ray and head CT
unchanged. Vent settings on transfer were SIMB 600 x 10,
FIO2 60%, pressure support 5 PEEP, ABG 7.49, pCO2 49, pO2 82.
Vent was changed to PAP 10/5, FIO2 30%. Neurology was
consulted, and the patient was admitted to MICU.
PHYSICAL EXAMINATION: General: Not following commands. He
seemed to direct eyes toward voice. The patient was in no
acute distress. Vital signs: 97.4??????, 140/62, heart rate 76,
respirations 20, oxygen saturation 90%. HEENT: There was a
1-2 cm laceration over the right parietal scalp, [**2-3**]
ulceration lesion on the left chin with granulation tissue,
exudate. Pupils equal, round and reactive to light.
Oropharynx clear. Dry mucous membranes. Increased jugular
venous distention. No lymphadenopathy. Status post trach.
Trach site clean, dry and intact. Lungs: Coarse breath
sounds with rales. Left lung base irregularly irregular.
Heart: No murmurs, regurgitation. Abdomen: Positive bowel
sounds. Soft, nontender, nondistended. Status post PEG tube
PEG site clean, dry and intact with no erythema.
Extremities: There was 2+ edema in the extremities. There
was a right PICC line in place. Scattered petechia. Eyes
opened spontaneously. He directed eyes to voice but did not
follow commands. Pupils reactive and equal but somewhat
sluggish. Unable to test other cranial nerves. Tone
increased throughout. Withdraws to pain. Moves all four
extremities. Toes upgoing bilaterally.
LABORATORY DATA: Sodium 143, potassium 3.6, chloride 100,
bicarb 34, BUN 109, creatinine 2.9, glucose 136; white count
10.1, hematocrit 28.8, glucose 230; calcium 8.2, magnesium
2.1, phosphate 2.5; INR 1.5; TSH 75.8; T1 927, T4 2.8 on
[**10-29**]; digoxin level pending; urinalysis greater than
50 white blood cells, no yeast, rare bacteria; urine culture,
blood culture, and sputum culture pending.
Chest x-ray showed infiltrate at left base consistent with
pneumonia vs atelectasis, small left pleural effusion,
right base atelectasis and distinct vascular margins which
could represent component of interstitial edema.
Head CT showed moderate size right subdural measuring 1.6 cm,
slightly increased from last CT. No evidence of acute
hemorrhage.
ASSESSMENT AND PLAN: This is an 80-year-old male with a
history of diabetes, coronary artery disease, transient
ischemic attacks, recent prolonged hospitalization, for
subdural hematoma status post fall, complicated by failure to
wean, who presented with depressed mental status post seizure
at [**Hospital6 85**].
1. Neurological: He appeared to have had a seizure and was
postictal upon presentation. Predisposition likely underlying
subdural hematoma and possible cerebrovascular disease. Unclear
what might have precipitated this event overnight. The patient
had a low-grade fever, recently diagnosed hypothyroidism begun on
Synthroid, which all may be potential contributors. Head CT
showed no new bleed or midline shift.
Neurology recommended Fosphenytoin load of 1.2 mg IV with
subsequent 300 mg once a day 12 hours afterloading dose.
This was subsequently changed to Dilantin 300 mg once a day.
EEG was obtained with no evidence for active seizure
activity.
2. Respiratory status: history of failure to wean, with
multifactorial etiology, initial massive nasal bleeding,
aspiration, recurrent pneumonia, congestive heart failure, and
fluid overload, pneumothorax requiring chest tube, s/p trach
placement, and intermittent atalectasis.
At this time, he appeared to have a left lower lobe
infiltrate. Reportedly sputum was with gram-negative rods. He
has been aggressively diuresed with Lasix with increasing bicarb
and metabolic alkalosis.
Sputum cultures at [**Hospital1 **] showed Pseudomonas and other gram
positive organisms, and urine culture showed Klebsiella. The
patient was continued on Ceftazidine and Ciprofloxacin.
Ceftazidine dose was 1 g q.d. and Ciprofloxacin was 200 mg q.12
hours. Infectious Disease was consulted and agreed with
antibiotic dosing. Chest PT was continued and suctioning.
With regard to metabolic alkalosis and congestive heart
failure, the plan was to hold Lasix for now, replete
chloride. With regard to ventilation, the patient was
oxygenating well with baseline FIO2 of 30%. Recommended
changing back to baseline CPAP setting of 15 and 5.
Infectious disease: The patient had a low-grade fever with
apparent pneumonia. He was continued on Ceftazidine and
Ciprofloxacin.
Cardiovascular: He had a history of rapid atrial
fibrillation. Digoxin was held and levels were checked.
Diltiazem was changed to Digoxin. The patient was also well
controlled on beta-blocker and calcium channel blocker.
Currently holding Aspirin anticoagulation given recent
subdural bleed.
Endocrine: Diabetes was followed with fingerstick glucose
and placed on regular Insulin sliding scale.
Hypothyroidism: The patient was continued on Levothyroxine
at 0.025 mg per day.
Chronic renal failure: Likely secondary to diabetes. Lasix
was held through this hospitalization. Will continue to
follow BUN and creatinine.
Hematology: The patient was repleted with Vitamin K.
Continue to follow PT and PTT.
GI: Chronic guaiac positive stools. Continue with Protonix.
Continue to check stools. Follow serial hematocrit.
FEN: Total body fluid overloaded but intravascularly
depleted. Holding Lasix for now and restarting tube feeds at
30 cc/hr.
Lines: Right PICC line, tracheostomy, PEG tube, Foley
catheter.
CODE STATUS: DNR CONFIRMED BY DAUGHTER.
DISCHARGE STATUS: Fair.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DIAGNOSIS: Seizure.
DR.[**Last Name (STitle) 2437**],[**First Name3 (LF) **] 12-664
Dictated By:[**Name8 (MD) 4575**]
MEDQUIST36
D: [**2167-11-4**] 07:56
T: [**2167-11-4**] 07:47
JOB#: [**Job Number 34928**]
ICD9 Codes: 5990, 2760 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3581
} | Medical Text: Unit No: [**Unit Number 56078**]
Admission Date: [**2118-3-19**]
Discharge Date: [**2118-3-22**]
Date of Birth: [**2050-3-23**]
Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: This is a 67-year-old male
without a history of significant cardiac disease, who was
transferred from [**Hospital6 5016**] for emergent cardiac
catheterization. Reportedly, the patient had stuttering
chest pain for 1-2 weeks, and on morning of transfer, he had
severe substernal chest pain and was found to have anterior
ST elevations. He was started on heparin and had ventricular
fibrillation. The patient was cardioverted to normal sinus
rhythm. Following this, the patient again had ventricular
fibrillation arrest and was again shocked successfully.
MEDICATIONS ON ADMISSION: Aspirin 81 mg 1 p.o. q.d.
SOCIAL HISTORY: He is married, 50-pack-year history of
smoking, occasional ETOH, otherwise social history
noncontributory.
FAMILY HISTORY: Noncontributory.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION ON ADMISSION: Temperature 37.2 degrees,
heart rate 58, respiratory rate 10, blood pressure 118/68.
Generally, the patient is sedated, in no acute distress.
Heart has regular rate and rhythm with no murmurs, clicks or
gallops. The lungs are clear to auscultation bilaterally.
Abdomen is soft, nontender, nondistended with no
hepatosplenomegaly. Extremities are free of any clubbing,
cyanosis or edema. Plus 1 dorsalis pedis palpated
bilaterally.
LABORATORY DATA: EKG, significant for normal sinus rhythm at
60, normal axis, normal intervals, loss of R wave progression
in the precordial leads. Bedside echocardiogram revealed an
EF of 30-40 percent, no MR, severe anterolateral inferior
wall motion abnormalities. Cardiac on [**2118-3-18**] revealed LAD
mid 70 percent status post stent, RCA 67 percent stenosis x2,
circumflex with 70-80 percent ostial lesion, LVEDP 40
percent, otherwise CK 171, MB 3.6, troponin 0.01. Sodium
145, potassium 3.8, chloride 106, bicarbonate 23, BUN 17,
creatinine 1.0, and glucose 130. White count 11.4,
hematocrit 47.0, and platelet count is 276.
HOSPITAL COURSE: Coronary artery disease: The patient was
maintained on aspirin, Plavix, heparin, and initially on
nitroglycerin gtt. The nitroglycerin gtt was eventually
weaned, and the patient was stabilized on beta-blocker as
well as ACE inhibitor for pump. The patient's
echocardiogram, official report, revealed normal LMCA, LAD
with mid segment occlusion with evidence of thrombus, left
circumflex nondominant vessel with ostial 70 percent lesion,
RCA dominant vessel with anterior takeoff.
Interventional Details: Change for 7-French, AD guiding
catheter after cooling in cool MI to a PT [**Name (NI) 9165**] wire
crossed without difficulty. Predilation was with 2.0 x 15 mm
Open Sail stenting was with KA 3.5 x 15 mm Hepacoat to 14
atm. Final residual was 0 percent with no reflow distally.
After several rounds of Nipride, the flow was TIMI 2 plus.
The patient was continued on aspirin, Plavix, Lipitor,
heparin, and Coumadin until INR therapeutic. He was also
maintained on beta-blocker as well as an ACE inhibitor. The
patient during his hospitalization had complaints of groin
pain at catheterization site. A lower extremity ultrasound
was negative for aneurysm or fistula.
The patient had elevated LFTs which were felt secondary to
his Lipitor. There was improvement in LFTs by the time of
discharge.
FEN: The patient was maintained on cardiac diet.
Electrolytes were repleted. The patient was a full code,
communication was with his wife.
DISCHARGE DIAGNOSIS: History of myocardial infarction status
post stent to left anterior descending.
RECOMMENDED FOLLOWUP: The patient is to set a followup with
his primary care physician [**Name Initial (PRE) 176**] 10 days of discharge. At
that time, he should have his coagulation studies as well as
electrolytes and LFTs checked. The patient is also to have
his coagulation studies checked on [**2118-3-24**] at the [**Hospital3 6265**] Laboratory. The results of this will be
communicated to Dr. [**First Name (STitle) **] at [**Telephone/Fax (1) 13254**]. The patient is
to see Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 284**] on [**2118-4-25**] at 12:30 p.m. The
patient on [**2118-4-20**] at 2 p.m. also has an echocardiogram at
seventh floor [**Hospital Ward Name 23**] Center. On [**2118-4-20**] at 3 p.m., the
patient is also to go to the Holter lab for Holter monitor
placement.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg 1 p.o. q.d.
2. Plavix 75 mg 1 p.o. q.d.
3. Atorvastatin 40 mg 1 p.o. q.d.
4. Oxycodone-acetaminophen 5-325 mg tablets, 1-2 tablets q.4-
6h. as needed for pain, for 3 days.
5. Pantoprazole 40 mg 1 p.o. q.d.
6. Metoprolol tartrate 50 mg, to be taken 0.5 tablet 1 p.o.
b.i.d.
7. Lisinopril 5 mg 1 p.o. q.d.
8. Coumadin 5 mg 1 p.o. q.h.s.
Outpatient laboratory work again, INR, PT/PTT, liver function
tests, and chem-10 to be performed on [**2118-3-24**] and to be
called in to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 13254**].
[**First Name8 (NamePattern2) **] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], MD
[**MD Number(2) 15194**]
Dictated By:[**Last Name (NamePattern1) 18827**]
MEDQUIST36
D: [**2118-6-16**] 13:32:54
T: [**2118-6-16**] 17:50:44
Job#: [**Job Number **]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3582
} | Medical Text: Admission Date: [**2204-11-14**] Discharge Date: [**2204-11-19**]
Date of Birth: [**2154-5-25**] Sex: M
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 3853**]
Chief Complaint:
"lethargy."
Major Surgical or Invasive Procedure:
intubation/extubation
History of Present Illness:
Patient is a 50 M with a past history of diabetes, chronic lower
leg pain, COPD, obesity-related hypoventilation syndrome, past
history of respiratory failure, chronic pain on opiates, DMII
who presents with decreasing and fluctuating mental status per
his mother. [**Name (NI) **] is also complaining of leg pain and weakness
that is similar to prior. He has been feeling somewhat more
short of breath particularly with exertion. He is using his
albuterol and ipratroprium inhalers slightly more than baseline.
He also states that he has had some non-productive cough, chills
but no fevers. His mother controls his medications, and she is
fairly certain that he has not overdosed on his pills.
In the ED, his initial VS were 97.5 116 146/81 8 100% ra. He
then triggered for hypoxia to 88% on RA. His exam was
significant for lethargy, moving all extremities but not
compliant with full neuro exam [**12-20**] drowsiness. He had wheezing
on pulmonary exam. His ABG showed pCO2 63. Lactate 1.4. Tox
screen was positive for benzos. His EKG showed sinus 116, NANI,
no STE. CXR showed LLL infiltrate and he was given levoquin. He
was also given solumedrol and azithro for COPD flare. Vitals
prior to transfer: P 94, 140/82, O2 sat 93% on 4 L via biPAP
.
On arrival to the MICU, patient was requesting food.
Past Medical History:
- Type 2 DM has been followed at [**Last Name (un) **] (last A1c 8.0 [**2204-10-8**])
- OSA on CPAP at home
- Hepatits C - s/p aborted course of interferon
- Major depressive disorder, ? of schizophrenia and bipolar
disorder
- Hypertension
- Bilateral avascular necrosis of femoral heads s/p hip
replacements in '[**79**] and '[**85**]
- s/p L1/L2 kyphoplasty after fall [**6-25**]
- s/p left distal radius fracture after fall [**6-25**]
- Bilateral lower extremity edema, thought to be secondary to
venous stasis
- DJD of his back
- Osteoporosis
- Morbid Obesity
- Schatski's ring
Social History:
On disability, lives with his mother, attends a day program.
- Tobacco: Smokes [**12-21**] ppd for > 10yrs
- Alcohol: no EtoH for 15 years
- Illicits: Stopped IVDA in [**2186**] after 3 years of use, did take
cocaine with heroine. Has not used since then.
Family History:
father with DM and CAD
Physical Exam:
Vitals: T: 97.2 BP: 160/72 P: 106 R: 17 O2: 94% on 2L NC
General: Obese, AAOx3, closes eyes during interview but easily
arousable
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: diminished breath sounds throughout, no wheezes, rales,
ronchi
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present, no organomegaly
Ext: hypertrophic toenails
Neuro: CNII-XII intact, moving all extremities, 3/5 strength in
LE limited by pain, sensation intact throughout
Discharge PE:
General: Obese, flat affect, in NAD
HEENT: CN 2-12 grossly intact, MMM
CV: distant HS, RRR, no RMG
Lungs: CTAB, no WRR, distant BS
Abdomen: obese, soft, NTND, bowel sounds present
Extremities: decreased strength in hip flexion and extension [**1-21**]
and knee extension/flexion 4+/5 and ankle plantar flexion and
extension 4+/5, sensation in grossly intact
Pertinent Results:
Admission:
[**2204-11-14**] 11:30AM BLOOD WBC-4.5 RBC-3.88* Hgb-12.1* Hct-37.1*
MCV-96 MCH-31.2 MCHC-32.7 RDW-13.9 Plt Ct-127*
[**2204-11-14**] 11:30AM BLOOD Neuts-69.1 Lymphs-21.7 Monos-6.6 Eos-2.1
Baso-0.4
[**2204-11-14**] 11:30AM BLOOD Glucose-161* UreaN-33* Creat-1.0 Na-135
K-4.9 Cl-99 HCO3-29 AnGap-12
[**2204-11-14**] 11:30AM BLOOD Calcium-9.0 Phos-4.4 Mg-1.5*
[**2204-11-14**] 01:09PM BLOOD Type-ART pO2-109* pCO2-59* pH-7.34*
calTCO2-33* Base XS-4 Comment-GREEN TOP
[**2204-11-14**] 11:48AM BLOOD Glucose-150* Lactate-1.4
Discharge:
[**2204-11-17**] 06:10AM BLOOD WBC-5.5 RBC-3.86* Hgb-11.9* Hct-35.2*
MCV-91 MCH-30.9 MCHC-33.9 RDW-13.9 Plt Ct-139*
[**2204-11-19**] 06:00AM BLOOD Glucose-327* UreaN-23* Creat-0.9 Na-134
K-4.4 Cl-93* HCO3-32 AnGap-13
[**2204-11-19**] 06:00AM BLOOD Calcium-9.6 Phos-4.1 Mg-1.6
CXR [**2204-11-14**]
IMPRESSION: Mild pulmonary edema. Repeat imaging after diuresis
is
recommended to evaluate for concomitant pneumonia.
ECHO [**2204-11-15**]
IMPRESSION: Suboptimal image quality. Normal global and regional
biventricular function. Mildly dilated aortic arch. Mild
pulmonary artery hypertension.
Brief Hospital Course:
50M with h/o OSA, COPD and chronic pain on narcotics, who was
admitted with hypercarbic respiratory failure.
#. AMS: Patient presented with increased lethargy for week. He
was oriented on arrival to the MICU but was falling asleep
intermittently during the interview. Patient had been taking
seroquel 600 mg po qHS and xanax 4 mg po BID, oxycontin SR 100
mg po TID, oxycodone IR 10 mg po q3-4h which are likely
contributing to his AMS. He has not been taking risperdal. Held
all pysch meds while lethargic discontinued seroquel. Decreased
xanax dose and continue lower dose seroquel once more awake.
Treated medical comorbities as below. His AMS improved and he
was transferred to the floor. His AMS was thought to be
multifactorial. His BiPAP settings were adjusted, psych was
consulted and adjusted his medications to seroquel 300mg PO
daily, risperidone 3mg Daily and diazepam 1mg PO QID. Pain was
also consulted and we were able to lower his pain regiment to
oxycontin 40mg PO Q8H and oxycodone 10mg PO Q6H:PRN and Topomax
25mg PO Daily. We discussed with the patient and his mother the
fine balance needed between symptom control and maintaining his
normal mental state and respiratory integrity. He will follow
up with psych in the outpatient setting for eventual weaning off
of the seroquel and diazepam.
.
#Shortness of breath: likely multifactorial - obesity
hypoventilation, pulmonary HTN from OSA, COPD exacerbation, in
the setting of taking multiple sedating medications. Patient was
originally admitted to the ICU for respiratory failure requiring
BiPAP in the ED. On arrival to the MICU, he was on 2 L NC and
while minimal shortness of breath and wheezing. He also also
evidence of pulmonary edema on CXR but no sign of pna.Continued
prednisone 60 mg po daily and azithromycin 250 mg po daily . He
was intubated for brief period of time and successfully
extubated. Continued home BIPAP at night and albuterol and
ipratroprium nebs. Home BiPAP settings are Nasal CPAP with PSV,
inspiratory pressure 18cm/H20, expiratory pressure 10 cm/H20,
supplemental oxygen 2-6 L/min to maintain SpO2 to >92%. He was
diuresed 6.4L and was satting well at his goal O2 of 88-92% on
RA at the time of transfer to the floor. He remained stable on
the floor.
.
# Chronic pain: He has severe, debilitating chronic pain [**12-20**]
bilateral hip avascular necrosis. His home narcotics and benzos
were tapered and he was transferred to the floor with CIWA
protocol. Psychiatry consulted and recommended continuation of
xanax during taper period with ativan for CIWA. Pain service
was also consulted and recommended new regimen of standing
oxycontin 40mg PO Q8H with oxycodone 10mg Q6H:PRN as well as
Topomax 25mg Daily. On this new regiment, we were able to
achieve his baseline pain of [**2-26**]. He was discharged on this
new regiment.
.
# schizophrenia: pt denied AH/VH. psych was consulted and
recommended starting risperidal alongside seroquel and slowly
tapering seroquel, because of its sedative effects. He will
also continue diazepam 1mg QID for now with plan to taper off of
benzodiazepines in the future.
.
# Diabetes: Patient was continued on home insulin 70/30 [**Hospital1 **]
regiment with a sliding scale that was higher than normal
because he was on steroids during his stay for possible COPD
exacerbation. His sugars were high while on the steroids, but
manageable with his ISS. His metformin and glyburide were
restarted at the time of discharge.
.
# Hypertension: continued home metoprolol, lisinopril, and
losartan, hctz, amlodipine with holding parameters
===================================
TRANSITION OF CARE:
-Patient's BiPAP settings are: Nasal CPAP w/PSV (BIPAP)
----Inspiratory pressure: 18 cm/h2O
----Expiratory pressure: 10 cm/h2O
----Supplemental oxygen: 2-6 L/min to maintain SpO2 to >92
- patient needs follow up with psychiatry
Medications on Admission:
-buspirone 15 mg PO BID
-glipizide ER 10 PO twice a day.
-metformin 850 mg PO three times a day with meals.
-lisinopril 40 mg PO once a day.
-metoprolol succinate 100 mg PO DAILY
- quetiapine 600 mg PO QHS
- oxycodone ER 80 mg TID
- oxycodone 10 mg PO q3-4h
- losartan-hydrochlorothiazide 100-12.5 mg PO once a day
- alprazolam 2 mg PO QID prn (takes 4 mg qAM and qPM)
- albuterol sulfate 90 mcg 2 Puffs Q6H prn SOB/ wheezing.
- ipratropium bromide 17 mcg 2 Puffs Q6H prn SOB/ wheezing.
- risperidone 1 mg PO qAM and 2 mg Tablet PO HS (NOT TAKING)
- multivitamin PO once a day. (not taking)
- insulin NPH & regular human 100 unit/mL (70-30)- 40 units [**Hospital1 **]
- Vitamin D 50,000 units PO once a week (not taking)
- Amlodipine 5 mg po daily
- Tamzepam 30 mg po qHS
- Atorvastatin 40 mg po daily
Discharge Medications:
1. buspirone 15 mg Tablet Sig: as directed Tablet PO twice a
day: Please take one pill (15mg) in AM, and two pills (30mg) in
PM .
Disp:*90 Tablet(s)* Refills:*2*
2. glipizide 10 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet
Extended Rel 24 hr PO twice a day.
3. metformin 850 mg Tablet Sig: One (1) Tablet PO three times a
day: with meals.
4. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
6. quetiapine 300 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO HS (at bedtime).
7. losartan-hydrochlorothiazide 100-25 mg Tablet Sig: One (1)
Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every six (6) hours as needed for shortness
of breath or wheezing.
9. Outpatient Physical Therapy
Patient has difficulty ambulating [**12-20**] pain, would benefit from
outpatient PT.
10. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Transdermal
once a day.
Disp:*30 * Refills:*2*
11. ipratropium bromide 0.02 % Solution Sig: Two (2) puffs
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
12. risperidone 1 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
Disp:*90 Tablet(s)* Refills:*2*
13. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. oxycodone 40 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO Q8H (every 8 hours).
Disp:*90 Tablet Extended Release 12 hr(s)* Refills:*0*
16. oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours) as needed for pain.
17. topiramate 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
18. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
19. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
20. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*2*
21. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
dose PO DAILY (Daily).
Disp:*1 bottle* Refills:*2*
22. insulin NPH & regular human 100 unit/mL (70-30) Suspension
Sig: Forty (40) units Subcutaneous twice a day.
23. alprazolam 1 mg Tablet Sig: One (1) Tablet PO four times a
day.
Disp:*120 Tablet(s)* Refills:*0*
24. quetiapine 100 mg Tablet Sig: 1-2 Tablets PO at bedtime as
needed for insomnia.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Health Systems
Discharge Diagnosis:
obesity hypoventilation syndrome
narcotic/benzo overdose
COPD exacerbation
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 14323**],
It was a pleasure participating in your care at [**Hospital1 771**]. You came to the hospital because you
were confused. Your oxygen levels were found to be low so you
were admitted to the ICU. You are on many medications that can
reduce your respiratory drive, or urge to breathe. Notably,
narcotics (oxycontin and oxycodone) and benzodiazepines (xanax)
can do this, so these medications were reduced for your safety.
You were also given medications to treat a possible COPD
exacerbation and reduce extra fluid in your lungs.
Please attend the follow-up appointment listed below with your
primary care doctor to help determine a pain management regimen
that does not cause as many respiratory side effects. You should
also follow up with your psychiatrist to figure out how to best
treat your anxiety.
We made the following changes to your medications:
1. INCREASED buspirone (Buspar) to 15mg in the AM, and 30mg in
the PM
2. DECREASED quetiapine (Seroquel) to 300mg before bedtime, plus
an extra 100-200mg if needed for insomnia
3. DECREASED oxycontin to 40mg by mouth three times daily
4. DECREASED oxycodone to 10mg by mouth every 6 hours as needed
for breakthrough pain
5. DECREASED alprazolam (Xanax) to 1 mg by mouth four times
daily
6. CHANGED risperidone (Risperdal) to 3mg by mouth at bedtime
7. INCREASED losartan-hydrochlorothiazide to 100-25mg by mouth
once daily
8. STOPPED temazepam (Restoril)
9. STARTED docusate (Colace) 100mg by mouth twice daily
10. STARTED senna 1 tab by mouth twice daily
11. STARTED polyethylene glycol (Miralax) 17 gram/dose powder by
mouth daily
Followup Instructions:
Please call your psychiatrist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 27181**]) to
schedule a follow-up appointment as soon as possible (within the
next 1-2 days).
Please call [**Hospital 6549**] Medical Care (1-[**Telephone/Fax (1) 27182**]): this
company will help to optimize your home BiPAP settings and make
sure they are correct.
Department: [**State **] SQUARE, PRIMARY CARE DOCTOR
When: TUESDAY [**2204-11-27**] at 11:20 AM
With: [**First Name11 (Name Pattern1) 2946**] [**Last Name (NamePattern4) 6564**], MD [**Telephone/Fax (1) 2205**]
Building: [**State **] ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: On Street Parking
ICD9 Codes: 2761, 2762, 3051, 4019, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3583
} | Medical Text: Admission Date: [**2138-1-15**] Discharge Date: [**2138-1-24**]
Service: MEDICINE
Allergies:
Aspirin / Iodine / Carafate / Tagamet / Mylanta
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Left Internal Jugular Vein Catheterization
PICC line placement
History of Present Illness:
Mrs. [**Known lastname 75980**] is an 85 year old female with a history of CAD,
atrial fibrillation and congestive heart failure who was
transferred from [**Hospital **] hospital with fevers, cough and
vomiting. The patient has recently been in and out of the
hospital four times over the past six weeks for urinary tract
infections and aspiration events now s/p PEG placement two weeks
ago. She currently presents from rehab with feves, cough and
congestion x 2 days and vomiting x 1 day. She was also noted to
have tachypnea and dizziness at her rehab.
Per the MICU admission note on presentation to [**Hospital **]
hospital she was noted to be afebrile, tachycardic to the low
100s with stable blood pressrue. She later spiked a fever to
102.4 and developed an oxygen requirement. Her labs were
notable for a sodium of 125, WBC count of 17.3 with 34% bands.
CXR at [**Hospital1 **] showed no focal infiltrates but was suggestive
of mild CHF. She was treated with ceftriaxone and azithromycin
for possible pneumonia. She received 500 cc IVF with increased
tachypnea and was subsequently given nitropaste for possible CHF
exacerbation. She was transferred to [**Hospital1 18**] for further
management.
In the [**Hospital1 18**] emergency room her initial vital signs were T; 99.3
HF: 130 (atril fibrillation), BP: 90/50 O2: 98% on RA. Initial
labs were notable for leukocytosis and bandemia (WBC count of
23.1 with 9% bands), BNP of 4181, initial lactate of 3.1 which
improved to 2.1 with gentle hydration. She had a negative UA.
Her CXR showed some questionable interstitial edema with no
focal infiltrates. She had blood cultures sent. She received
vancomycin in additio to the previously received ceftriaxone and
azithromycin. She alos received 2L of normal saline with
improvement in her blood pressure. She was transferred to the
ICU for further management.
While in the ICU her hemodynamics improved. Her antibiotics
were changed to vancomycin, cefepime and azithromycin. She had
left IJ central line placed for IV access. She had a negative
DFA. She had a sputum culture which was polymicrobial and
cultures are pending. Urine culture was negative. Blood
cultures were drawn and were negative to date. She was
transiently hypotensive the afternoon of MICU transfer in the
setting of receiving her home dose of diltaizem. Her blood
pressure quickly improved with 250 NS bolus. She is transferred
to the floor for further management.
On review of systems she denies fevers, chills, lightheadedness,
dizziness, chest pain, dyspnea, nausea, vomtiing, abdominal
pain, diarrhea, constipation, dysuria, hematuria, leg pain or
swelling. She does report fatigue. All other review of systems
negative in detail.
Past Medical History:
-CAD (per pt no h/o MI)
-CHF (per pt's son, due to "irregular HR")
-HTN
-Atrial Fibrillation on coumadin
-Catarcts
-Asthma
-G tube placed 2 weeks ago for recurrent aspiration event
-recent recurrent UTI
-dementia
Social History:
Lives at home w/ son and daughter-in-law, but as per HPI, recent
numerous hospitalizations so presents from rehab (per report,
came from ?[**Location (un) **] country manor nursing home). Never smoked.
Family History:
n/c
Physical Exam:
Vitals - T 96.1, HR 104, BP 91/47, RR 20, O2 98% on 3L NC
Gen - awake, alert, conversive, oriented to person, [**2137**],
hospital
HEENT - PERRL, EOMI, oropharynx clear, MMM
Neck - JVP approx 8-10 cm, no bruits
Heart: soft heart sounds, irregularly irregular, no appreciable
murmurs, rubs, gallops
Lungs - scattered crackles throughout, no wheezes or ronchi
Abd - soft, NT/ND, G tube in place, site without erythema or
purulence
Ext - WWP, 2+ pulses, trace edema bilaterally
Pertinent Results:
Hematology:
[**2138-1-15**] 05:28PM WBC-23.1* RBC-3.42* HGB-10.5* HCT-32.1*
MCV-94 MCH-30.8 MCHC-32.8 RDW-16.4*
[**2138-1-15**] 05:28PM NEUTS-78* BANDS-9* LYMPHS-4* MONOS-6 EOS-0
BASOS-0 ATYPS-0 METAS-2* MYELOS-1*
[**2138-1-15**] 05:28PM HYPOCHROM-NORMAL ANISOCYT-1+
POIKILOCY-OCCASIONAL MACROCYT-1+ MICROCYT-OCCASIONAL
POLYCHROM-1+ OVALOCYT-OCCASIONAL
[**2138-1-15**] 05:28PM PLT SMR-VERY HIGH PLT COUNT-873*
[**2138-1-24**] 06:05AM WBC-20.4* RBC-3.34*# HGB-10.1*# HCT-30.5*#
MCV-91 MCH-30.1 MCHC-33.0 RDW-16.3* PLT-388
[**2138-1-23**] 05:54AM NEUTS-71* BANDS-1 LYMPHS-9* MONOS-3 EOS-12*
BASOS-0 ATYPS-0 2* METAS-2* MYELOS-1*
Chemistries:
[**2138-1-15**] 05:28PM BLOOD Glucose-123* UreaN-32* Creat-1.0 Na-132*
K-5.3* Cl-96 HCO3-21* AnGap-20
[**2138-1-15**] 05:28PM BLOOD Calcium-9.3 Phos-4.5 Mg-1.8
[**2138-1-18**] 05:00AM BLOOD Calcium-8.0* Phos-1.5* Mg-1.5*
[**2138-1-23**] 05:54AM BLOOD Calcium-8.5 Phos-3.0 Mg-1.7
Cardiac Enzymes:
[**2138-1-15**] 05:28PM BLOOD CK-MB-NotDone proBNP-4181*
[**2138-1-15**] 05:28PM BLOOD cTropnT-0.02*
[**2138-1-15**] 05:28PM BLOOD CK(CPK)-26
[**2138-1-15**] 11:00PM BLOOD CK-MB-NotDone
[**2138-1-15**] 11:00PM BLOOD CK(CPK)-24*
[**2138-1-16**] 07:09AM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2138-1-16**] 07:09AM BLOOD CK(CPK)-23*
Other Laboratories:
[**2138-1-22**] 05:43AM BLOOD calTIBC-177* VitB12-1337* Folate-19.3
Ferritn-442* TRF-136*
[**2138-1-18**] 05:00AM BLOOD Osmolal-271*
[**2138-1-15**] 05:40PM BLOOD Glucose-113* Lactate-3.1* Na-131* K-4.9
Cl-98*
[**2138-1-15**] 08:03PM BLOOD Lactate-2.0
[**2138-1-16**] 12:06AM BLOOD Lactate-1.3
[**2138-1-16**] 07:16AM BLOOD Lactate-0.9
[**2138-1-24**] 06:05AM BLOOD Vacomycin-26.6
Urinalysis:
[**2138-1-15**] 05:28PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.014
BLOOD-MOD NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG
BILIRUBIN-NEG UROBILNGN-0.2 PH-9.0* LEUK-TR RBC-0-2 WBC-[**2-5**]
BACTERIA-MOD YEAST-NONE EPI-0 3PHOSPHAT-MOD
[**2138-1-18**] 01:05PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.011
Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR RBC-0-2 WBC-[**5-13**]*
Bacteri-OCC Yeast-FEW Epi-0
[**2138-1-18**] 01:05PM URINE Hours-RANDOM Creat-25 Na-108
[**2138-1-18**] 01:05PM URINE Osmolal-404
EKG [**2138-1-15**]: Sinus tachycardia. Borderline low limb lead
voltage. No previous tracing available for comparison.
Imaging:
CXR [**2138-1-15**]: Some pulmonary vascular congestion and blurring
with nterstitial edema. No overt edema or pleural effusion. No
focal consolidation.
Microbiology:
Blood cultures from [**2138-1-15**] x 2 - negative final
Blood cultures from [**2138-1-20**] x 2 - no growth to date at time of
discharge
Urine cultures from [**2138-1-15**] - negative
Urine culture from [**2138-1-18**] - yeast
DFA for Inflenza A/B [**2138-1-15**] - negative
Stool for Clostridium Difficile [**2138-1-18**], [**2138-1-19**], [**2138-1-20**] and
[**2138-1-22**] - negative
[**2138-1-16**] 3:04 am SPUTUM Source: Expectorated.
**FINAL REPORT [**2138-1-19**]**
GRAM STAIN (Final [**2138-1-16**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE ROD(S).
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): YEAST(S).
1+ (<1 per 1000X FIELD): GRAM NEGATIVE DIPLOCOCCI.
RESPIRATORY CULTURE (Final [**2138-1-19**]):
MODERATE GROWTH OROPHARYNGEAL FLORA.
PROTEUS MIRABILIS. MODERATE GROWTH. PRESUMPTIVE
IDENTIFICATION.
STAPH AUREUS COAG +. MODERATE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
| STAPH AUREUS COAG +
| |
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- 8 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ <=1 S
CIPROFLOXACIN--------- =>4 R
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ 4 S <=0.5 S
LEVOFLOXACIN---------- =>8 R
MEROPENEM-------------<=0.25 S
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
PIPERACILLIN---------- 8 S
PIPERACILLIN/TAZO----- <=4 S
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TOBRAMYCIN------------ 2 S
TRIMETHOPRIM/SULFA---- =>16 R <=0.5 S
VANCOMYCIN------------ <=1 S
Brief Hospital Course:
Mrs. [**Known lastname 75980**] is an 85 year old female with a history of CAD,
atrial fibrillation and recent recurrent hospitalizations for
urinary tract infections and aspiration pneumonia who presents
with fever, tachypnea, hypoxia and hypotension.
Fevers/Leukocytosis, likely due to septicemia, NOS, and
bacterial/aspiration pneumonia: The patient presented with
fevers to 102 degrees with a leukocytosis and bandemia. She
also had an elevated lactate on presentation to 3.1 with mild
hypotension in the setting of rapid atrial fibrillation. Her
only localizing symptoms were tachypnea and mild oxygen
requirement. A broad infectious workup was performed including
blood cultures, urine cultures, sputum cultures and c. difficile
toxin. On admission her UA was trace positive with a urine pH
of 9.0. Blood and urine cultures, however, were negative. She
had a negative DFA. She had four negative C. diff toxin assays.
She had a CXR which showed no focal consolidations. She had a
sputum culture which grew proteus and MRSA. On admission to
this hospital her antibiotic coverage was switched to
vancomycin, cefepime and azithromycin to cover hospital acquired
pneumonia as well as urinary pathogens. This was subsequently
changed to vancomycin and ceftriaxone given sensitivities of
organisms. Her mild hypotension and elevated lactate quickly
improved with fluid boluses. Her fevers quickly resolved. Her
leukocytosis however, persisted. On admission her WBC count was
23.1 with 78% neutrophils and 9% bands. After initiation of
broad spectrum antibiotics her WBC count decreased only slightly
despite improvement in her symptoms and resolution of her
fevers. Initially her differential was left shifted but prior
to discharge this had transitioned to a 12% eosinophilia with
rare myelocytes and metamyelocytes. It was thought that her
persistent leukocytosis was secondary to her antibiotics. She
has plans to complete a 14 day course of antibiotics with
vancomycin and ceftriaxone for her proteus and MRSA in the
sputum. Her vancomycin is being dosed by level. On discharge
her level was 26.6. Her vancomycin trough should be checked
daily and she should be given 1 gram of vancomycin when her
trough falls to below 20. Her CBC and differential should be
rechecked one week after completion of therapy to ensure
improvement in her leukocytosis. If she continues to have
immature cells in her peripheral blood differential or a
persistent leukocytosis, hematology consultation should be
considered as an outpatient.
Anemia: On admission the patient's hematocrit was 32.1 but this
decreased rapidly to 26.2 after gentle fluid hydration. For the
remainder of her hospitalization her hematocrit was stable
between 23 and 26. During this hosptilization her folate and
B12 were checked and were normal. Her iron was measured at 33
with a ferritin 442 consistent with anemia of inflammation.
Prior to discharge she was transfused one unit of PRBCs. Her
hematocrit should also be checked in one week to ensure
stability.
Hyponatremia: On presentation to the OSH the patient's serum
sodium was 125. With gentle fluid hydration this improved to 132
on arrival to this hospital. Studies performed on presentation
here revealed a serum osmolality of 271 with a urine osmolality
404 which was inappropriately elevated consistent with SIADH,
likely due to pulmonary process. She was continued on her
standard tube feeds. Her sodium remained between 130 and 134.
No further interventions were made.
Congestive Heart Failure: Per report the patient has a history
of congestive heart failure. There are no echocardiograms in
our system and it is unclear whether her heart failure is
systolic vs. diastolic. On presentation her initial CXR showed
mild pulmonary edema and her BNP was elevated in the 4000s. Her
oxygenation saturation on arrival here was 98% on RA. Initially
her home CHF regimen was held out of concern for hypotension and
possible sepsis. Her blood pressures remained in the 100s
systolic during her hospitalization and on discharge she was
tolerating metoprolol 12.5 mg [**Hospital1 **] but her home aldactone was not
able to be restarted. Her aldactone should be restarted as an
outpatient once her acute illness has resolved.
Coronary Artery Disease: Again, this is per patient history.
Her EKG on presentation had no changes concerning for ischemia.
She had three sets of negative cardiac enzymes. She was
continued on her home doses of lipitor and plavix. She was also
started on metoprolol 12.5 mg bBID.
Atrial Fibrillation: On arrival to this hospital the patient
was in atrial fibrillation with rapid ventricular response.
This was in the setting of acute infection. Previously she was
taking diltiazem for rate control. Given her history of heart
failure and coronary artery disease she was transitioned to
metoprolol 12.5 mg [**Hospital1 **] for rate control. She tolerated this
medication well. For the majority of her hospitalization she
was in sinus rhythm. She was continued on coumadin for
anticoagulation.
Nutrition: The patient had a PEG tube placed two weeks ago for
tube feeds given frequent aspiration events over the past six
months. On hospital day three the patient was noted to have
decreased potassium, magnesium and phosphorous concerning for
refeeding syndrome. The rate of her tube feeds was decreased
and her electrolytes were repleted aggressively. Her
electrolyte abnormalities quickly resolved. She was placed back
on her full rate of tube feeds which she subsequently tolerated
well.
Prophylaxis: she was continued on coumadin for her atrial
fibrillation was well as DVT prophylaxis.
Access: She currently has a single lumen PICC in place for IV
antibiotics.
FEN: Tube feeds at 55 cc/hr, NPO, aspiration precautions
Code Status: DNR/DNI confirmed with patient and patient's son
[**Name (NI) **] who is her health care proxy.
Communication: [**Name (NI) **] son who is pt's HCP, [**Name (NI) **], ([**Telephone/Fax (1) 77832**]
Medications on Admission:
Cardizem 120 mg TID
Plavix 75 mg Daily
Aldactone 50 mg Daily
Prevacid 15 mg Daily
Calcium Carbonate 1,000 mg TID
Albuterol 90 mcg INH QID
Lexapro 10 mg Daily
Lipitor 20 mg Daily
Coumadin 4 mg 2 times/week
Coumadin 2 mg 5 times/week
Discharge Medications:
1. Clopidogrel 75 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO DAILY
(Daily).
2. Calcium Carbonate 500 mg Tablet, Chewable [**Telephone/Fax (1) **]: Two (2)
Tablet, Chewable PO TID (3 times a day).
3. Albuterol 90 mcg/Actuation Aerosol [**Telephone/Fax (1) **]: Two (2) Puff
Inhalation Q4H (every 4 hours) as needed.
4. Escitalopram 10 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO DAILY
(Daily).
5. Atorvastatin 10 mg Tablet [**Telephone/Fax (1) **]: Two (2) Tablet PO DAILY
(Daily).
6. Metoprolol Tartrate 25 mg Tablet [**Telephone/Fax (1) **]: 0.5 Tablet PO BID (2
times a day).
7. Warfarin 2 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO DAILY16 (Once
Daily at 16).
8. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN
10ml NS followed by 1ml of 100 units/ml heparin (100 units
heparin) each lumen QD and PRN. Inspect site every shift
9. Ceftriaxone-Dextrose (Iso-osm) 1 gram/50 mL Piggyback [**Telephone/Fax (1) **]:
One (1) Intravenous Q24H (every 24 hours).
10. Prevacid 15 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day.
11. Vancomycin 1,000 mg Recon Soln [**Last Name (STitle) **]: One (1) Intravenous
dosed by level for 6 days: Vancomycin level should be checked
[**2138-1-25**]. Dose should be given if trough < 20. Subsequently
should be dosed by level for trough 15-20. .
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary:
Pneumonia
Secondary:
Hypertension
Coronary Artery Disease
Chronic Congestive Heart Failure (ejection fraction unknown)
Asthma
Dementia
Atrial Fibrillation
Discharge Condition:
Stable. Breathing comfortably on room air. Requiring
significant assistance for ambulation.
Discharge Instructions:
You were seen and evaluated for your fevers and cough. You were
thought to have a pneumonia. You were treated with antibiotics.
You were found to have a high white blood cell count. Although
your symptoms improved your white blood cell count did not.
This should be rechecked after you complete your antibiotics for
your pneumonia.
Please take all your medications as prescribed. The following
changes have been made to your medication regimen.
1. Please take ceftriaxone 1 gram IV every 24 hours for 6 more
days
2. Please take vancomycin 1 gram for six more days. Dose will
need to be adjusted by level for target trough of 15-20.
Vancomycin level should be checked on [**2138-1-25**] and dosed as
appropriate.
3. Please take coumadin 2 mg daily instead of alternating with 4
mg. INR should be rechecked on [**2138-1-25**] and coumadin dosing
should be adjusted for a target INR between [**1-5**].
4. Please stop taking Cardizem
5. Please stop taking Aldactone. This medication should be
restarted as an outpatient once the patient has improved
clinically.
6. Please take metoprolol 12.5 mg two times per NGT a day
Please keep all your follow up appointments.
Please seek immediate medical attention if you experience any
fevers > 101 degrees, chest pain, trouble breathing, worsening
cough, significant diarrhea, or any other concerning symptoms.
Followup Instructions:
Please follow up with your primary care physician [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 37063**]
within one week of discharge from rehab. His office phone
number is [**Telephone/Fax (1) 37064**].
Patient should have repeat CBC with differential one week after
completion of antibiotic therapy to assure resolution of her
leukocytosis and eosinophilia.
ICD9 Codes: 5070, 0389, 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3584
} | Medical Text: Admission Date: [**2150-7-18**] Discharge Date: [**2150-7-22**]
Date of Birth: [**2079-6-20**] Sex: M
Service: NEUROLOGY
Allergies:
Dilantin / Bactrim / hydrochlorothiazide / lisinopril
Attending:[**First Name3 (LF) 20506**]
Chief Complaint:
Seizure
Major Surgical or Invasive Procedure:
Intubation ([**2150-7-18**])
Lumbar puncture
History of Present Illness:
History of Present Illness:
Mr. [**Known lastname 6013**] is a 71 yo male with a history of a benigh
pituitary tumor s/p resection ~ 7 years ago with reoccurance of
growth s/p XRT, in addition to history of DM, HTN, HL, OSA on
CPAP here after new onset seizure witnessed by his wife 4 hours
prior to presenting to [**Hospital1 18**]. The history is obtained from the
wife as the patient does not remember anything pertaining to the
event. The wife reports that the patient was in his usual state
of health and went to bed the night before presenting to the
hospital. Around midnight, she heard her husband make a noise
that sounded like gagging and found her husband looking as
though he was not breathing. His lips were blue. She took off
his CPAP machine as she figured it must have been
disfunctioning. Shortly thereafter he began to exhibit
seizure-like activity that lasted for a minute and is presumed
to be a generalized tonic-clonic seizure based on description.
She reports that the patient has not had seizure previously.
He had no infectious symptoms the day prior. The patient was
taken by EMS to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], where he was nonverbal and was not
following commands. Per records, he presented with a nasal
trumpet airway and was assisted with bag valve respiration in a
postictal state that was not improving. He reportedly had no
localization of pain or spontaneous eye opening. He did not
arrest but was intubated given altered mental status. He
initially had several laboratory abnormalities including
elevated CK, CK-MB, LFTs, amylase, and lipase. His inital ABG
after intubation showed: pH 6.7, PCO2 54, PO2 239. HCO3 was
6.7. After less than an hour, he was transferred to [**Hospital1 18**] for
further management. He was not given IV bicarbonate. He was
given 100mg IV keppra (due to an allergy to dilantin, which was
previously used for seizure prophylaxis after his pituitary
tumor resection). He was given ativan, propofol, and
succinylcholine. A CBC and chemistries were pending at the time
of transfer.
On arrival to the [**Hospital1 18**], his initial vitals in the ED were: 50,
140/106, 93%, but his BP dropped to 60/30's within 10 minutes of
arrival. The patient was started on Norepinephrine IV gtt. A
head CT was performed and negative for intracranial processes.
He was empirically started on ceftriaxone and vancomycin for
possible community-acquired meningitis. He was also started on
acyclovir for possible HSV encephalitis. The patient was also
started on Norepinephrine IV gtt for hypotension, and he had a
femoral central line and OGT placed.
He was transferred to the MICU for further management. Lumbar
puncture was attempted [**Last Name (LF) 112154**], [**First Name3 (LF) **] interventional
radiology did a flouro-guided LP. The patient did well in the
MICU and was successfully extubated. He was then transferred to
Neurology.
Past Medical History:
1) Pituitary adenoma s/p resection ~ 7 years ago with
reoccurance of growth s/p XRT
2) panhypopituitarism
3) Diabetes Mellitus
4) HTN
5) HL
6) OSA on CPAP
Social History:
He lives with his wife in [**Name2 (NI) 479**] [**Last Name (LF) **], [**Name (NI) 108**]. He smoked for 30
pack years and stopped 30 years ago. He rarely drinks and denies
drug use. He receives his medical care at West [**Name (NI) **] VA (fax
[**Telephone/Fax (1) 112155**]). He has 2 PCPs- Dr. [**Last Name (STitle) 23225**] at the VA( located in
[**Last Name (LF) **], [**First Name3 (LF) 108**]) and a new PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Name (STitle) 112156**] ([**Telephone/Fax (1) 112157**]).
He obtains his medications at [**Company 4916**] (phone [**Telephone/Fax (1) 112158**]).
Family History:
Mother with CVA
Father with dementia
Physical Exam:
ADMIT EXAM:
Vitals: HR: 50, BP 140/106 (but his BP dropped to 60/30's within
10 minutes of arrival), 02 Sat 93%, RR: Vent
General: sedated on vent, not responding to commands. in NAD
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley, R femoral triple lumen central line.
Ext: pulses in all extremities
Neurology consult exam on admission:
BP 115/64 HR 76 overbreathing vent w/ A/C 20/450/6/100%; sedated
w/midazolam gtt
- Head: NC/AT, no conjunctival pallor or icterus
- Cardiovascular: RRR, no M/R/G
- Respiratory: Nonlabored, clear to auscultaton with transmitted
vent sounds anteriorly
- Abdomen: obese but nondistended, normal bowel sounds, no
tenderness/rigidity/guarding
- Extremities: Warm, no cyanosis/clubbing/edema, palpable
dorsalis pedis pulses.
- Skin: No rashes or lesions
Neurologic Examination:
- Mental Status: intubated. Opens eyes to tapping on shoulder.
Follows simple commands like squeezing hands, opening & closing
eyes.
Cranial Nerves: [II] PERRL 3->2 brisk. [III, IV, VI] EOM intact
horizontally, no nystagmus. [V] Corneals intact [VII] No facial
asymmetry. [IX, X] Cough present
Motor: Normal bulk and tone. No tonic-clonic motions observed,
rare spontaneous motions. Able to withdraw to pain in all
extremities.
Sensory Responds to pain in all extremities and midline
Reflexes
L 2 2 2 2 2
R 2 2 2 2 2
DISCHARGE EXAM:
NAD, comfortable
Alert, oriented, conversing appropriately
Neurological exam nonfocal except for right eye peripheral field
defect (old per patient)
Pertinent Results:
IMAGING:
MRI [**2150-7-18**]-
FINDINGS:
There is a focal area of altered signal intensity in the left
frontal lobe,
with T1 hypo and T2 hyperintense appearance in the center
surrounded by
hypointense signal and negative susceptibility within, likely
related to old
blood products. There is no abnormal enhancement noted within
except for
minimal rim enhancement.
No foci of abnormal enhancement are noted elsewhere to suggest a
mass lesion.
There are a few small foci of slightly increased DWI signal in
the right
parietal lobe (series 1402, image 20, 22), which are too small
to be
accurately characterized and may represent tiny infarcts.
However, these are
not well seen on the ADC sequence.
A few small scattered FLAIR-hyperintense foci are noted,
non-specific in
appearance. There is increased signal intensity, diffusely to a
mild extent
in the mastoid air cells on both sides. There is moderate
mucosal thickening
with fluid in the ethmoid air cells and sphenoid sinuses. The
portal mucosal
thickening and retention cysts are noted in the maxillary
sinuses on both
sides.
The patient is status post surgery, in the sella.
Areas of increased T1 signal are noted, in the floor of the
sella as well as
in the suprasellar location and anterior to the sella likely
related to the
prior procedure/fat packing.
On the post-contrast images, there is a slightly heterogeneously
enhancing
pituitary gland with enlargement noted. There is possible mild
extension of
the tumor into the cavernous sinus on the right side. However,
study is
somewhat limited due to the orientation of the images.
The infundibulum is not well seen. Part of the optic chiasm is
seen.
IMPRESSION:
1. Focal area of altered signal intensity in the left frontal
lobe with very
minimal peripheral enhancement and extensive foci of negative
susceptibility
within, likely relates to an area of prior blood products. No
abnormal
vessels noted adjacent. Correlate with history for prior
trauma.
2. Two small foci of increased DWI signal in right parietal
lobe-
acute-subacute tiny infarcts- attention on f/u.
2. Pan-paranasal sinus disease involving the ethmoid and
sphenoid sinuses
predominantly and mild in the mastoid air cells on both sides.
3. Post-surgical changes in the sella, along with an enlarged
pituitary
gland, with slight heterogeneous enhancement. This may
represent
residual/recurrent adenoma.
Comparison with prior studies can be helpful to assess interval
change.
Otherwise, consider followup in a few weeks/months to assess
stability/progression. There is possible mild extension of the
tumor into the
cavernous sinus on the right side. However, study is somewhat
limited due to
the orientation of the images.
EEG [**2150-7-18**] -
FINDINGS: CONTINUOUS EEG RECORDING: Began at 18:05 on the
evening of [**7-18**] and continued until 7 the next morning.
Again, it showed a very low voltage, relatively rapid background
of about [**11-27**] Hz, with some anterior
predominance. There was a In the recording from 20:30 until
22:30 the first evening. Otherwise, the background remained the
same through the end of the recording.
SLEEP: No normal waking or sleep patterns were evident.
CARDIAC MONITORING: showed a generally regular rhythm with an
occasional PVC.
SPIKE DETECTION PROGRAMS: Showed muscle and other artifact, but
there were no clearly epileptiform features.
SEIZURE DETECTION PROGRAMS: Showed no electrographic seizures.
PUSH BUTTON ACTIVATIONS: There were none.
IMPRESSION: This telemetry captured no pushbutton activations.
It showed a low voltage faster pattern, uniform in all head
regions, throughout recording. This suggests medication effect.
There were no areas of focal slowing, and there were no
epileptiform features or electrographic seizures.
ECG [**2150-7-18**] -
Sinus rhythm. Right bundle-branch block. Slight ST segment and T
wave
abnormalities of unknown significance.
ECHO [**2150-7-18**] -
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.5 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *5.9 cm <= 5.2 cm
Right Atrium - Four Chamber Length: *6.3 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.3 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 2.8 cm
Left Ventricle - Fractional Shortening: 0.35 >= 0.29
Left Ventricle - Ejection Fraction: >= 55% >= 55%
Left Ventricle - Stroke Volume: 87 ml/beat
Left Ventricle - Cardiac Output: 6.98 L/min
Left Ventricle - Cardiac Index: 2.93 >= 2.0 L/min/M2
Left Ventricle - Lateral Peak E': 0.10 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': *0.08 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': 8 < 15
Aorta - Sinus Level: 3.6 cm <= 3.6 cm
Aorta - Ascending: *3.6 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.4 m/sec <= 2.0 m/sec
Aortic Valve - LVOT VTI: 21
Aortic Valve - LVOT diam: 2.3 cm
Mitral Valve - E Wave: 0.7 m/sec
Mitral Valve - A Wave: 0.5 m/sec
Mitral Valve - E/A ratio: 1.40
Mitral Valve - E Wave deceleration time: 228 ms 140-250 ms
TR Gradient (+ RA = PASP): 22 mm Hg <= 25 mm Hg
Findings
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. No ASD
or PFO by 2D, color Doppler or saline contrast with maneuvers.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
regional/global systolic function (LVEF>55%). No resting LVOT
gradient.
RIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic
function.
AORTA: Normal aortic diameter at the sinus level. Mildly dilated
ascending aorta.
AORTIC VALVE: No AS. Mild (1+) AR.
MITRAL VALVE: Normal mitral valve leaflets. Mild mitral annular
calcification. Trivial MR. [Due to acoustic shadowing, the
severity of MR may be significantly UNDERestimated.]
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
Normal PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
PERICARDIUM: No pericardial effusion. There is an anterior space
which most likely represents a fat pad, though a loculated
anterior pericardial effusion cannot be excluded.
GENERAL COMMENTS: Contrast study was performed with 1 iv
injection of 8 ccs of agitated normal saline at rest. Suboptimal
image quality - poor echo windows. Suboptimal image quality -
body habitus. Suboptimal image quality - ventilator.
Conclusions
The left atrium is mildly dilated. The right atrium is
moderately dilated. No atrial septal defect or patent foramen
ovale is seen by 2D, color Doppler or saline contrast with
maneuvers. There is mild symmetric left ventricular hypertrophy
with normal cavity size and regional/global systolic function
(LVEF>55%). The right ventricular cavity is mildly dilated with
normal free wall contractility. The ascending aorta is mildly
dilated. There is no aortic valve stenosis. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. Trivial mitral regurgitation is seen. [Due
to acoustic shadowing, the severity of mitral regurgitation may
be significantly UNDERestimated.] The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
There is an anterior space which most likely represents a
prominent fat pad.
IMPRESSION: Normal global and regional biventricular systolic
function. Mild aortic regurgitation. No ASD or PFO seen. Limited
study.
HEAD CT [**2150-7-18**] -
No acute intracranial hemorrhage, large vascular territory
infarct, shift of midline structures or mass effect is present.
The ventricles and sulci are normal in size and configuration.
The patient is status post a right
craniotomy. High-density lining the left frontal [**Doctor Last Name 352**] matter
likely
represents cortical laminar necrosis. Visible paranasal sinuses
and mastoid air cells show diffuse polypoidal mucosal thickening
in both maxillary sinuses and within the ethmoidal air cells and
frontal sinus . A moderate amount of fluid is noted in the
sphenoid air cells.
CXR [**2150-7-19**] -
Slightly rotated positioning. Compared with [**2150-7-18**] at 5:35
a.m., the
cardiomediastinal silhouette is stable. There is more
pronounced focal
opacity in the right midzone, in the perihilar area. This may
reflect the
presence of atelectasis, but an early infiltrate is in the
differential.
There is upper zone redistribution, but I doubt overt CHF.
There is minimal
atelectasis at the left base peripherally, with increased
retrocardiac
density, consistent with left lower lobe collapse and/or
consolidation.
Suspect small amount of fluid at the right costophrenic angle,
unchanged.
IMPRESSION:
1) More pronounced focal opacity in the right perihilar region
-- ?
atelectasis or early pneumonic infiltrate. Otherwise, no
significant change.
MICRO/PATH:
CRYPTOCOCCAL ANTIGEN (Final [**2150-7-18**]):
CRYPTOCOCCAL ANTIGEN NOT DETECTED.
TOXOPLASMOSIS -
ADMIT LABS:
[**2150-7-18**] 02:56AM BLOOD WBC-15.4* RBC-3.53* Hgb-11.5* Hct-34.2*
MCV-97 MCH-32.5* MCHC-33.5 RDW-12.7 Plt Ct-296
[**2150-7-18**] 09:26AM BLOOD PT-10.5 PTT-23.8* INR(PT)-1.0
[**2150-7-18**] 08:23AM BLOOD Plt Ct-323
[**2150-7-18**] 08:23AM BLOOD Glucose-182* UreaN-23* Creat-1.5* Na-138
K-3.3 Cl-108 HCO3-22 AnGap-11
[**2150-7-18**] 08:23AM BLOOD ALT-46* AST-61* LD(LDH)-262*
CK(CPK)-[**2076**]* AlkPhos-28* TotBili-0.1
[**2150-7-18**] 08:23AM BLOOD CK-MB-18* MB Indx-0.9 cTropnT-0.06*
[**2150-7-18**] 08:23AM BLOOD Albumin-3.9 Calcium-7.2* Phos-3.5 Mg-2.2
[**2150-7-18**] 08:23AM BLOOD Free T4-0.56*
[**2150-7-18**] 08:23AM BLOOD TSH-0.34
[**2150-7-18**] 02:56AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2150-7-18**] 02:58AM BLOOD Type-[**Last Name (un) **] pO2-89 pCO2-43 pH-7.18*
calTCO2-17* Base XS--11 Comment-GREEN TOP
[**2150-7-18**] 02:58AM BLOOD Glucose-179* Lactate-6.7* Na-136 K-4.5
Cl-106
RELEVENT LABS:
[**2150-7-18**] 08:23AM BLOOD WBC-11.6* RBC-3.91* Hgb-12.4* Hct-37.2*
MCV-95 MCH-31.7 MCHC-33.3 RDW-13.0 Plt Ct-323
[**2150-7-19**] 03:51AM BLOOD WBC-7.5 RBC-3.41* Hgb-10.8* Hct-32.7*
MCV-96 MCH-31.7 MCHC-33.1 RDW-13.0 Plt Ct-240
[**2150-7-19**] 03:51AM BLOOD PT-12.5 PTT-25.3 INR(PT)-1.2*
[**2150-7-19**] 03:51AM BLOOD Plt Ct-240
[**2150-7-18**] 04:54PM BLOOD Glucose-144* UreaN-22* Creat-1.4* Na-139
K-4.2 Cl-109* HCO3-21* AnGap-13
[**2150-7-19**] 03:51AM BLOOD Glucose-131* UreaN-20 Creat-1.3* Na-139
K-4.4 Cl-109* HCO3-21* AnGap-13
[**2150-7-19**] 03:51AM BLOOD ALT-38 AST-67* LD(LDH)-242 CK(CPK)-2874*
AlkPhos-27* TotBili-0.2
[**2150-7-19**] 03:51AM BLOOD Lipase-20
[**2150-7-18**] 04:54PM BLOOD cTropnT-0.02*
[**2150-7-19**] 03:51AM BLOOD Calcium-8.1* Phos-3.6 Mg-2.0
[**2150-7-18**] 07:00AM BLOOD Type-ART Temp-36.3 Rates-28/ Tidal V-450
PEEP-28 FiO2-100 pO2-169* pCO2-40 pH-7.30* calTCO2-20* Base
XS--5 Intubat-INTUBATED
[**2150-7-18**] 08:56AM BLOOD Lactate-1.6
Cardiac nuclear pharmacologic stress perfusion:
SUMMARY FROM THE EXERCISE LAB:
For pharmacologic coronary vasodilatation 0.4 mg of regadenoson
(0.08 mg/ml) was
infused intravenously over 20 seconds followed by a saline
flush. He had
atypical symptoms with the infusion with an uninterpretable ECG.
IMAGING METHOD:
Resting perfusion images were obtained with Tc-[**Age over 90 **]m sestamibi.
Tracer was
injected approximately 45 minutes prior to obtaining the resting
images.
Following resting images and 20 seconds following intravenous
regadenoson,
approximately three times the resting dose of Tc-[**Age over 90 **]m sestamibi
was administered
intravenously. Stress images were obtained approximately 30
minutes following
tracer injection.
Imaging protocol: Gated SPECT.
This study was interpreted using the 17-segment myocardial
perfusion model.
INTERPRETATION:
The image quality is adequate but limited due to soft tissue
attenuation.
Left ventricular cavity size is normal.
Rest and stress perfusion images reveal uniform tracer uptake
throughout the
left ventricular myocardium.
Gated images reveal normal wall motion.
The calculated left ventricular ejection fraction is 68% with an
EDV of 87 ml.
IMPRESSION:
1. Normal myocardial perfusion.
2. Normal left ventricular cavity size and systolic function.
Brief Hospital Course:
# Neurologic:
The description from the patient's wife, who witnessed the
event, and the elevated creatine kinase seem consistent with
seizure activity. A head CT and a head MRI were both done and
showed no acute intracranial processes. The flouro-guided lumbar
puncture showed 1 WBC and slightly elevated protein. A 24 hour
electroencephalogram showed global slowing consistant with alpha
coma. This was likely post-ictal in etiology. He has been placed
on levetiracetam 750mg [**Hospital1 **] for seizure prophylaxis. Since
transfer to Neurology, he has been found to be fully oriented on
each exam. He has had no focal neurological defects except R
temporal visual field cut in R eye, described as a chronic
problem per patient.
He will begin to see a Neurologist. In 2 months he should have a
repeat MRI to determine whether or not his sellar mass remains
stable.
# Respiratory:
Initial respiratory difficulty presumably was a result of
altered mental status during post-ictal phase. He initially had
a lactic acidosis and consistent ABG abnormalities, likely as a
result of seizing. He was easily extubated following resolution
of the post-ictal phase. He had no further respiratory distress
during the admission.
# Cardiovascular:
Initial lab abnormalities included elevated cardiac enzymes.
Also EKG showed RBBB and inferolateral ST depression of 1mm in
limb leads and 2mm in lateral precordial leads.
On initial presentation he was hypotensive so he received
pressor support and anti-hypertensive medications were held.
Thereafter he received home medication, amlodipine.
Given the EKG changes and CKMB elevation on admission, it was
decided that during his admission he should have a
pharmacological stress test with nuclear imaging. This was
normal.
Throughout this admission he slept with CPAP to continue his
treatment for OSA. It has been recommended that he see a sleep
specialist in order to reassess his current CPAP machine
settings as he and his wife state that the patient hasn't seen a
sleep specialist in 16 years.
# Endocrine:
He has panhypopituitarism as a result of his trans-sphenoidal
pituitary resection. A stress dose of steroids was given in the
MICU. Throughout his admission he was continued on thyroid
hormone replacement, DDAVP, and prednisone. He should follow up
with an endocrinologist to discuss his regimen, including
whether he needs stress-dose steroids for illness and other
emergency situations.
# Renal:
Renal failure on initial presentation presumably due to
prolonged hypoperfusion due to seizure activity. His creatinine
was trended and decreased during his stay, thus suggesting
prerenal failure as the etiology. Medications were renally dosed
and nephrotoxins were avoided.
# FEN/GI:
He was given omeprazole daily. He had no difficulties eating,
drinking, or taking medications by mouth throughout this
admission.
# Musculoskeletal:
He was seen and evaluated by the physical therapy team. He has
an appropriate level of mobility and will just need follow up
for his L shoulder pain, thought to be a rotator cuff injury. It
is recommended that he have outpatient Orthopedics follow-up as
well as outpatient PT for his L shoulder injury.
# DISPO:
He will return home with 24-hour assistance from wife; no other
in-home services are deemed necessary at this time.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Family/Caregiver.
1. Prednisone 7.5 mg PO DAILY
2. Levothyroxine Sodium 150 mcg PO DAILY
3. Alendronate Sodium 70 mg PO QFRI
4. Desmopressin Nasal 4 sprays NAS [**Hospital1 **]
**Refrigerate**
5. Amlodipine 10 mg PO DAILY
hold for SBP<100
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
hold for SBP<100
2. Desmopressin Nasal 4 sprays NAS [**Hospital1 **]
**Refrigerate**
3. Levothyroxine Sodium 150 mcg PO DAILY
4. PredniSONE 7.5 mg PO DAILY
5. LeVETiracetam 750 mg PO BID
6. Alendronate Sodium 70 mg PO QFRI
Discharge Disposition:
Home
Discharge Diagnosis:
Seizure
Panhypopituitarism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted after having a first generalized seizure. Most
likely, this was caused by post-surgical changes in your brain
from your pituitary surgery. After being stabilized and
intubated at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Hospital, you were transferred to our
ICU. In the ICU, several diagnostic studies were obtained,
including head imaging and a lumbar puncture (spinal tap). Once
you were extubated, you were transferred to the general
neurology floor. You were monitored with continuous EEG, and
there were no concerning findings on this. Because you initially
had some EKG changes, we also performed a nuclear stress study
of your heart, which was normal.
Because you had a seizure, we started you on an antiepileptic
medication called levetiracetam (Keppra), please continue taking
this at 750 mg twice daily.
You should not drive for 6 months after your last seizure. You
should also avoid placing yourself in potentially dangerous
situations such as climbing up ladders, swimming without
supervision etc.
You will need to follow up with a neurologist to manage your
seizure medications. Also, a follow-up brain MRI should be
obtained in [**1-16**] months to make sure that the changes seen in
your brain are stable.
You should follow up with an endocrinologist to manage your
panypopituitarism, that is: the absence of the hormones produced
by the pituitary gland. Specifically, you should discuss whether
you should get a home prescription for stress dose steroids in
case of an illness.
You should also follow up with your sleep clinic to assess
whether your home CPAP machine is optimally calibrated, because
uncontrolled sleep apnea can lead to fatigue during the day and
occasionally makes seizures more likely.
You should follow up with occupational therapy and perhaps an
orthopedic surgeon for your rotator cuff injury. We will give
you a script for occupational therapy.
Followup Instructions:
You should see a neurologist within 1 month from discharge.
You should have a repeat MRI 2 months after discharge.
You should get an endocrinologist to follow up with your regimen
of pituitary hormone replacement.
You should see a sleep specialist in order to reassess your
current CPAP settings.
You should have outpatient physical therapy for your L shoulder
injury.
In addition, you may see an orthopedic surgeon for assessment of
your L shoulder injury.
Completed by:[**2150-7-22**]
ICD9 Codes: 2762, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3585
} | Medical Text: Admission Date: [**2144-8-5**] Discharge Date: [**2144-8-23**]
Date of Birth: [**2080-10-11**] Sex: M
Service: Surgery
HISTORY OF PRESENT ILLNESS: The patient is a 63 year old man
with a history of squamous cell carcinoma of the bladder who
presented with chronic pain and fistula drainage status post
cystectomy and prostatectomy in [**2142-11-15**].
The patient was in his usual state of health until [**2142**], when
he was diagnosed with a T4N0MX squamous cell carcinoma of the
bladder. He underwent cystectomy and prostatectomy and has
suffered multiple wound dehiscences and a chronically
draining fistula since that time. The patient reportedly was
doing well until five to six weeks prior to admission, when
his wound reopened and began to drain yellow fluid. He also
began to experience progressively worsening pelvic pain
radiating to his testicles, perineal area and inner thighs.
This pain was relieved with Demerol. The patient also
reports fevers, chills, loss of appetite and a three to five
pound weight loss over the past six weeks. The patient was
initially admitted to the urology service for further workup.
PAST MEDICAL HISTORY:
1. Coronary artery disease, myocardial infarction, status
post angioplasty.
2. Diabetes mellitus.
3. Hypertension.
4. Questionable prostate cancer.
PAST SURGICAL HISTORY:
1. Exploratory laparotomy for perforated bowel.
2. Cystectomy.
MEDICATIONS ON ADMISSION: Atenolol 25 mg p.o.q.d., Demerol
dose unknown, ciprofloxacin dose unknown Zocor 80 mg
p.o.q.d., Cozaar 50 mg p.o.q.d., insulin NPH 25 units b.i.d.
ALLERGIES: Ativan (reaction unknown).
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: On physical examination, the patient
had a temperature of 99.2, heart rate 67, respiratory rate
18, blood pressure 110/75 and oxygen saturation 99% in room
air. General: Awake, alert and oriented times three, in no
acute distress. Head, eyes, ears, nose and throat:
Normocephalic, atraumatic, pupils equal, round, and reactive
to light and accommodation, extraocular movements intact,
moist mucous membranes. Neck: Supple, no jugular venous
distention, no lymphadenopathy. Cardiovascular: Regular
rate and rhythm, no murmur, rub or gallop. Lungs: Clear to
auscultation bilaterally. Abdomen: Soft, suprapubic
tenderness, midline incision with draining sinus lower
portion of incision, ostomy on right draining clear yellow
urine. Genitourinary: Normal uncircumcised phallus, testes
descended bilaterally, nontender, no masses. Extremities:
Warm and well perfused, no cyanosis, clubbing or edema.
Neurologic: Nonfocal.
LABORATORY DATA: Sodium 126, potassium 6, chloride 98,
bicarbonate 16, BUN 36, creatinine 1.3, hematocrit 37.4,
prothrombin time 14.4, INR 1.4, alkaline phosphatase 150,
amylase 30, testosterone 67, free testosterone pending.
HOSPITAL COURSE: The [**Hospital 228**] hospital course and remainder
of this discharge summary will be dictated as an addendum
later this evening.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**], M.D. [**MD Number(1) 521**]
Dictated By:[**Last Name (NamePattern1) 2512**]
MEDQUIST36
D: [**2144-8-23**] 12:04
T: [**2144-8-23**] 06:40
JOB#: [**Job Number 34644**]
ICD9 Codes: 2767, 4019, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3586
} | Medical Text: Admission Date: [**2116-12-24**] Discharge Date: [**2116-12-28**]
Date of Birth: [**2050-11-14**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Morphine / Penicillins / Darvon / Macrobid
Attending:[**Doctor First Name 1402**]
Chief Complaint:
presyncopal episodes
Major Surgical or Invasive Procedure:
EP ablation
History of Present Illness:
66yof w/ pmh CAD s/p CABG '[**85**], AAA repair, DM, PVD s/p bilat
AKA, hypoithyroid, hyperlipidemia, CHF, dizziness, chroinic
wounds (healed pressure ulcer on back, red cuts under breasts,
old healing abd wound), presents to OSH [**12-20**] w/ presyncopal
episodes and hypotension that had been on and off for three
days. She was managed on the floor but tx to CCU [**12-21**] for per
report sustained VT w/ BP 50/. She was intubated and shocked
x5. She was started on Procainamide gtt at 3mg/min, Neo gtt and
propofol gtt. Per report, while pt intubated and sedated, her
she had no VT. Her last shock was [**12-21**].She was weaned from
sedation and extubated [**12-22**] and her VT re-occurred. Since then,
she has been in NS/SB 48-52 and has recurrent VT (5-10 beat
runs) w/ BP 80-90/.
She reported presyncopal attacks for 3 days prior to [**Last Name (un) **]
presentation to the OSH. During these episodes, she felt dizzy
and had reduction in her vision. No associated chest pain, [**Doctor Last Name **]
or palpitations. No history of diarrhoea, vomiting or reduced
intake. There had been no recent change in her home medications.
In addition, she reprots that her caregiver noticed dark stool
on day 2 of symptoms, unclear whether melanotic. Denies any
BRBPR, no nausea/vomiting/abdominal pain.
Transferred to [**Hospital1 18**] for possible EP ablation of the focus of
her presumed Vtach. On arrival at [**Hospital1 18**] CCU, ECG in sinus
revealed RBBB, LAFB, left atrial abnormality. ECG from OSH([**Hospital1 34**])
showed NSVT negative in II, III, F, positive in 1, L, transition
at V3/V4 in setting of SVT possible AT at 260.
Past Medical History:
- CAD s/p MI [**2085**], s/p CABGx3
- h/o AAA repair in [**2104**] at [**Hospital1 112**]
- HTN
- Hyperlipidemia
- Hypothyroidism
- CHF (EF 30-35%)
- PVD s/p B AKA [**12-31**] infection of total knee prostheses, with
left side revision [**2112**] and known DVT (on coumadin).
- ventral hernia (incisional)
- s/p cholecystectomy ([**2084**])
- depression
- precautions (MRSA - [**12-6**], VRE - leg [**1-6**], ESBL - urine klebs
[**10-6**])
Social History:
She lives at with a personal care attendant, is able to
dress/feed herself, but needs a [**Doctor Last Name 2598**] lift to move around. 1.5
ppd tobacco. Denies etoh, ivdu. Sister [**Name (NI) **] (HCP) lives in
[**Name (NI) 8447**] ([**Telephone/Fax (1) 97139**].
Family History:
Father: hx HTN, angina
Physical Exam:
ON ADMISSION:
Tcurrent: 36.3 ??????C (97.3 ??????F)
HR: 100 (72 - 100) bpm
BP: 91/61(66) {87/43(55) - 96/69(73)} mmHg
RR: 14 (14 - 24) insp/min
SpO2: 91%
Heart rhythm: SR (Sinus Rhythm)
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with no elevation of JVP
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. Irregularly irregular cardiac impulse, normal S1, S2. No
murmurs or added heart sounds. No thrills, lifts.
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 abdominial bruits.
EXTREMITIES: Bilateral AKA. No femoral bruits. Mild edema on the
lower limb stumps bilaterally.
SKIN: Healing scars on her back, active lesions beneath her
breasts.
PULSES:
Right: Carotid 2+ Femoral 2+
Left: Carotid 2+ Femoral 2+
Pertinent Results:
CXR [**2116-12-25**]
Sinus rhythm with ventricular premature beats. Right
bundle-branch block. Left anterior fascicular block.
Anterolateral lead ST-T wave abnormalities are primary and are
non-specific. Since the previous tracing of [**2114-4-1**] ventricular
ectopy is present. Otherwise, there is no significant change.
.
- CXR at OSH showed no evidence of pulmonary congestion.
.
- ECG: ECG in sinus revealed RBBB, LAFB, left atrial
abnormality. ECG from OSH([**Hospital1 34**]) showed NSVT negative in II, III,
F, positive in 1, L, transition at V3/V4 in setting of SVT
possible AT at 260.
.
- ECHO: [**2116-12-21**] at [**Hospital6 33**]. Full report in chart.
Of note, EF 10-15%. Severe diffuse hypokinesis. Akinesis and
aneursymal deformity of apical walls. Mild mitral
regurgitation, trace tricuspid regurgitation, PASP estimated at
13mmHg + RA pressure.
.
CT ABD/PELVIS [**2116-12-26**]
1. Diffuse thinning of anterior abdominal musculature with
diffuse bulge of abdomen. Fat containing umbilical hernia.
Multiple gas-filled loops of bowel including the transverse
colon, finding which can be seen in bedbound patients. No bowel
obstruction.
2. Diffusely abnormal abdominal aorta with long-segment fusiform
aneurysm (5 cm), as previously described. Size is similar to
that seen on [**2114-4-1**], however now with increased mural thrombus,
effectively resulting in decreased size of true lumen. Also now
occluded right common iliac artery, with reconstitution of flow
seen at right common femoral artery.
3. Cardiomegaly with left ventricular enlargement and left
ventricular
aneurysm.
4. Possible 3-mm right lower lobe nodule, incompletely imaged.
[**First Name8 (NamePattern2) **]
[**Last Name (un) 8773**] criteria, if the patient is at high risk for
intrathoracic
malignancy, follow-up CT would be recommended in 1 year.
Otherwise, no
further imaging would be recommended.
5. Multiple renal hypodensities, too small to characterize.
.
TTE [**2116-12-25**]
Poor image quality. The left atrium is mildly 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 mildly dilated.
There is severe regional left ventricular systolic dysfunction
with akinesis of the distal 2/3rds of the ventricle. A left
ventricular mass/thrombus cannot be excluded (not seen but poor
visualization of the apex cannot exclude). There is no
ventricular septal defect. The diameters of aorta at the sinus,
ascending and arch levels are normal. The mitral valve leaflets
are mildly thickened. Mild to moderate ([**11-30**]+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is no pericardial effusion. EF 20-25%.
Compared with the prior study (images reviewed) of [**2114-4-4**], no
clear change (given LV dysfunciton persists, Takotsubo CM is no
longer on the differential). If indicated, a repeat study with
echo contrast OR a cardiac MRI may better assess LV/RV function
and exclude apical thrombus.
Brief Hospital Course:
66F with CAD s/p CABG [**2085**], HL, PAD s/p B/L AKA in [**2112**] & AAA
endovascular repair [**2104**], hypothyroid, 1 PPD [**Last Name (LF) 1818**], [**First Name3 (LF) **] 30-35%
per [**Hospital1 34**] echo [**2114**], obesity, decub ulcer, ventral hernia with
ulceration p/w VT storm to [**Hospital1 34**] now transferred to [**Hospital1 18**] for
possible VT ablation by Dr. [**Last Name (STitle) 13177**].
.
#Arrhythmia: SVT with RBBB with intervals of VTach (runs of
between 3 and 18 each time). At least two ectobic sites, one in
the atria causing the SVT and one causing the VT. Probable
causes previous MI, hyper/hypotension, elytes. Pt denies any
CP/SOB/orthopnea. TSH was normal at 1.8. ECG from [**Hospital1 34**] showed
NSVT negative in II, III, F, positive in 1, L, transition at
V3/V4 in setting of SVT possible AT at 260.
ECG on arrival to [**Hospital1 18**] in sinus showed RBBB, LAFB, left atrial
abnormality
Pt was started on procainamide gtt at 3, VT initially reduced
but then flared up and gtt was increased to 4, and then DCd
prior to ablation. CCU attending ?????? 60 minutes critical care. Pt
continued to have runs of VT and was taken for ablation. EP lab
transseptal approach to ablate focus in LV, however found
several other foci of VT as well as AT. Given multiple foci not
all of which successfully ablated, decision to treat with
antiarrythmics. Pt also had a competing atrial tachycardia.
Given procainamide 950mg IV bolus which converted to sinus
(although sinus rhythm difficult to tell from VT - mainly by
rate - VT rate was 130, sinus in 90s) and then transitioned to
amiodarone with procainamide DCd. Pt was monitored but continued
having occasional runs of VT, and plan was to place permanent
pacer. Progressive second degree heart block throughout day
after the procedure with HR transiently dropping to 30s although
BP stable. Resited RIJ to left cordis/ trauma line and placed
temp transvenous pacer. However, she developed septic picture
and permanent hardware was not able to be placed in that setting
(see sepsis, below). Patient had sedation weaned and did not
regain consciousness. In the setting of increasing leukocytosis,
worsening renal failure, anasarca, and acute wound dehiscence at
her groin puncture sites extending deep into the groin tissue,
patient was transitioned to comfort measures only per the wishes
of her family on the morning of [**2116-12-28**]. At 1827 on [**12-28**],
patient expired peacefully of cardiac arrest, with family at
bedside.
.
# Hypotension: Patient's SBP during course of illness ranged
from low of 50s to 90. In the unit the MAPS have been btw 55-70
with SBP of 77-94 and DBP of 48-60. Probable causes are
cardiogenic(previous MI with non-contractile myocardium, SVT/VT,
valvular dxs), hypovolemia, anemia, sepsis, hypothyroidism,
non-compliance to medication). Pt was started on levophed but in
setting of VT/arrythmia with increased ectopy this was changed
to neosynephrine.
.
# CHF: Ptn with previous hx of CAD/MI and CABG.On Ace inh and BB
at home. Probable causes for decompensation include arrythmias,
hypovolemia, anemia. Repeat echo shows decline in EF: [**Month (only) **]/12 -
10-15%, from 30-35% in [**2114**]. Diuresis was attempted with lasix
but was minimally successful. Diuretics then held in setting of
hypotension. ACEI and Bblocker also held in setting of
hypotension.
.
# [**Last Name (un) **]: Creatinine 0.8 on [**2116-12-21**], went up to 1.8 on [**2116-12-27**].
Renal assisted in examination of urine sediment and no casts
were seen. Cytology consistent with pre-renal picture (shrunken
RBCs) but no signs of ATN. FeNa was 0.13%.
.
# Sepsis - WBC to 23 on [**2116-12-27**]. Pt still with phenylephrine
pressor requirement, fevers, and intermittently tachycardic. UA
was dirty and there was evidence of skin breakdown around the
areas where pt had vascular access. PT also had history of MRSA
colonization, and was started empirically on vanc/cefepime. -
central line in RIJ was changed over a wire. New line was placed
in LIJ and catheter tip of RIJ was sent for culture. Urine
culture showed no growth. Blood cultures pending at time of
expiration.
.
# Anemia: Normocytic normochromic anemia. Probably 2/2 blood
loss (dark stool reported), hemolysis or anemia of chronic
illness. Hct down at 31 from 38 five days earlier.
.
# Supratherapeutic INR - pt had INR of 2.5 on presentation (on
warfarin for h/o DVT) which peaked at 4.5 on [**2116-12-26**] even though
coumadin was held after INR was supratherapeutic at 3.5.
.
# Sacral, chest, abdominal, groin wounds: Chronic wounds. Groin
wounds developed secondary to femoral catheterization. Pain
controlled with methadone.
Medications on Admission:
- Levothyroxine 50mcg/d
- Plavix 75mg/d
- Lisinopril 5mg/d
- Imdur 30mg [**Hospital1 **]
- Pravachol 20mg/d
- Coumadin
- Methadone 20mg/d
- Ativan PRN
- Hydroxyzine PRN
Discharge Medications:
expired.
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
ICD9 Codes: 4271, 0389, 5849, 4019, 2724, 2449, 4280, 311, 3051, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3587
} | Medical Text: Admission Date: [**2149-11-10**] Discharge Date: [**2149-11-17**]
Date of Birth: [**2096-10-22**] Sex: F
Service: MEDICINE
Allergies:
Ativan
Attending:[**First Name3 (LF) 3151**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
CENTRAL VENOUS LINE PLACEMENT
History of Present Illness:
For a full admission note, please see MICU Green note. In brief,
this is a 53 year old woman with PMH significant for T1-T2
paraplegia s/p MVC, recurrent UTI/PNA, chronically on 2L of
oxygen at home, and anxiety who presented to hospital with
shortness of breath and fevers.
.
Caretaker noted her to be breathing faster than normal prior to
admission. She also reports recent dysphagia, concerning for
aspiration pneumonia. At home does intermittently straight-cath,
however she is unable to discern signs/sx of UTI. Per care
taker, she was seen by Dr [**Last Name (STitle) 665**] several weeks again found to
have +UA however no definite culture data so not treated.
.
In the ED she was found to have temp of 100.7 with O2 sat at 84%
on 2L (baseline in low 90s) and SBP in 90s. Her WBC count was
elevated and UA found to be positive. She got 2 L of fluid and
was transferred to the MICU. Of note, she had a PICC line on
admission.
.
While in the MICU, she started treatment for UTI with vanc and
[**Last Name (un) 2830**] given hx of [**Last Name (un) 40097**]. She had a CXR that could not exclude
pneumonia. She was also on levaquin for 3 days for legionella
coverage but this was stopped on [**11-11**] when found to be
negative. She has been getting chest PT and nebs and also
reports some cough. Sputum culture growing coagulase positive
staph and gram negative rods.
She had 1 positive blood cx for coag negative staph and PICC
line was pulled.
.
Prior to transfer to the floor her blood pressure was in low
100s, she was mentating well and had no active complaints.
Past Medical History:
#T1 to T2 paraplegia status post a motor vehicle accident.
#Recurrent pneumonia (followed by pulm - Last [**2149-4-9**])
- Per pulm, recurrent pneumonia likely from pulmonary toilet
issues secondary to neuromuscular disease with improvement with
consistent and aggressive bronchopulmonary therapy.
- Prior sputum cultures + for MRSA, pan-sensitive Klebsiella,
and Pseudomonas.
#Recurrent UTIs in the setting of urinary retention requiring
straight catheterization
#COPD
#Hx Pres syndrome
#hepatitis C
#anxiety
#DVT in [**2142**] -IVC filter placed in [**2142**]
#Pulmonary nodules
#Hypothyroidism
#Chronic pain
#Chronic gastritis
#Anemia of chronic disease
#S/p PEA arrest during hospitalization in [**2147-10-3**]
Social History:
Lives at home with husband and 2 adolescent children.
- Tobacco: 35-pack-years, quit several months ago, relapsed
recently.
- Alcohol: Denies.
- Illicits: Denies.
Family History:
Mother passed away with lung disease.
Physical Exam:
Physical Exam on Arrival to the MICU
VS: Tmax: 37.1 ??????C (98.7 ??????F)
Tcurrent: 36 ??????C (96.8 ??????F)
HR: 65 (62 - 80) bpm
BP: 83/47(55) {83/45(55) - 93/74(77)} mmHg
RR: 17 (12 - 23) insp/min
SpO2: 99%
General: Alert, oriented, agitated
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, mildly distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Discharge exam
VS 96.9 117/72 79 20 97% 2L
General: Alert, oriented
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP difficult to assess, no LAD
Lungs: few bibasilar crackles. good aeration
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, bowel sounds present, no rebound
tenderness or guarding
GU: + foley, no suprapubic tenderness
Ext: warm, well perfused, 1+ LE edema halfway up shins. 2+ DP
pulses
Pertinent Results:
[**2149-11-10**] 10:50AM BLOOD WBC-11.7*# RBC-3.51* Hgb-9.6* Hct-30.5*
MCV-87 MCH-27.2 MCHC-31.4 RDW-14.8 Plt Ct-192
[**2149-11-10**] 10:50AM BLOOD Neuts-92.8* Lymphs-5.0* Monos-1.3*
Eos-0.6 Baso-0.3
[**2149-11-10**] 10:50AM BLOOD Glucose-141* UreaN-9 Creat-0.4 Na-140
K-4.2 Cl-100 HCO3-32 AnGap-12
[**2149-11-11**] 03:35AM BLOOD Calcium-8.3* Phos-2.9 Mg-1.8
[**2149-11-10**] 11:02AM BLOOD Lactate-2.3*
[**2149-11-11**] 03:52AM BLOOD Type-[**Last Name (un) **] pO2-74* pCO2-75* pH-7.26*
calTCO2-35* Base XS-3 Comment-GREEN TOP
[**2149-11-11**] 03:52AM BLOOD Lactate-1.3
[**2149-11-11**] 07:51AM BLOOD Type-[**Last Name (un) **] pO2-47* pCO2-87* pH-7.24*
calTCO2-39* Base XS-6
[**2149-11-11**] 12:18PM BLOOD Type-[**Last Name (un) **] pO2-96 pCO2-73* pH-7.28*
calTCO2-36* Base XS-4 Comment-GREEN TOP
[**2149-11-11**] 07:51AM BLOOD Lactate-0.8
.
micro:
**FINAL REPORT [**2149-11-12**]**
URINE CULTURE (Final [**2149-11-12**]):
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMIKACIN-------------- =>64 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- 8 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 256 R
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- =>16 R
**FINAL REPORT [**2149-11-13**]**
GRAM STAIN (Final [**2149-11-10**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final [**2149-11-13**]):
Commensal Respiratory Flora Absent.
STAPH AUREUS COAG +. MODERATE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
KLEBSIELLA PNEUMONIAE. SPARSE GROWTH.
Piperacillin/tazobactam sensitivity testing available
on request.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
| KLEBSIELLA PNEUMONIAE
| |
AMIKACIN-------------- =>64 R
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- 8 R
CIPROFLOXACIN--------- =>4 R
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S =>16 R
LEVOFLOXACIN---------- =>8 R
MEROPENEM------------- <=0.25 S
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- <=0.5 S 2 S
VANCOMYCIN------------ 1 S
CXR [**2149-11-10**]
CHEST, AP AND LATERAL: Patient was unable to raise her arms for
the lateral view, on which bilateral humeral fixation plates and
screws obscure evaluation. Left internal jugular catheter has
been removed. Right PICC again terminates in the mid SVC. There
is no pneumothorax. The lungs are overinflated. Moderate
cardiomegaly persists, with vascular congestion and small
bilateral pleural effusions. Lower lobe opacities
persist, left greater than right. There are old healed
bilateral rib fractures, with associated chest wall deformity.
IMPRESSION:
1. Chronic obstructive airways disease.
2. Congestive heart failure.
3. Bilateral lower lobe opacities may be secondary to #2, but
superimposed
pneumonia is not excluded.
ECHO
The left atrium is elongated. The right atrium is moderately
dilated. Left ventricular wall thickness, cavity size, and
global systolic function are normal (LVEF>55%). Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Right ventricular chamber size and
free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. There is no aortic
valve stenosis. No aortic regurgitation is seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. There is mild
pulmonary artery systolic hypertension. There is a very small
pericardial effusion.
IMPRESSION: Suboptimal study. Normal global biventricular
systolic function. Mild pulmonary hypertension. Very small
pericardial effusion.
.
video swallow study
Penetration and aspiration with thin liquids. Chin tuck helps to
limit aspiration with thin liquids. Penetration with
nectar-thick liquids. For details, please refer to speech and
swallow division note in OMR.
.
discharge labs
[**2149-11-17**] 05:50AM BLOOD WBC-4.9 RBC-3.12* Hgb-8.3* Hct-27.2*
MCV-87 MCH-26.5* MCHC-30.4* RDW-14.6 Plt Ct-216
[**2149-11-17**] 05:50AM BLOOD Glucose-81 UreaN-5* Creat-0.2* Na-145
K-4.0 Cl-102 HCO3-40* AnGap-7*
[**2149-11-17**] 05:50AM BLOOD Calcium-8.8 Phos-3.5 Mg-2.0
Brief Hospital Course:
53F T1-T2 paraplegia s/p MVC, recurrent UTI/PNA, and anxiety who
is presented with SOB and fever initially admitted to the MICU
found to have UTI and pneumonia which improved with antibiotic
treatment.
.
# UTI - Urine cx showed multi-drug resistant klebsiella (only
sensitive to meropenem and cefepime). Patient started on
meropenem. PICC line placement was unsuccessful and tunneled
line was placed. Patient discharged with plans to complete total
10 day course of antibiotics.
.
# pneumonia - Patient presented with SOB, fever, and increased
O2 requirement. CXR showed R pleural effusion and could not
exclude pneumonia. Also given dysphagia concern for aspiration.
Pleural effusion thought to be parapneumonic vs [**3-5**] to heart
failure (CXR also showed enlarged heart). Echo was done and
showed normal EF.
Component of SOB/hypoxia also thought to be secondary to
hypoventilation from underlying paraplegia. Sputum cultures grew
MRSA and klebsiella. Patient was treated with vancomycin,
meropenum, levofloxacin, nebulizers and chest PT while in the
MICU. Levofloxacin was discontinued prior to transfer to the
floor after urine legionella was found to be negative. Given
difficult access, a tunneled line was eventually placed after
failed PICC attempts. Patient clinically improved and oxygen
requirement returned to baseline 2L. Patient was discharged with
plans to complete total 10 day course of IV antibiotics.
.
# Hypotension. Patient initially presented with SBP in the 90s.
She was given 3L in the ED. BP remained stable in the MICU and
on the floor after fluid resuscitation.
.
# Dysphagia. - followed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 572**] as outpatient. Symptoms
are thought to be related to dysphagia for solid foods, although
there is some question whether there may be over spill into the
larynx as well. Previous endoscopy demonstrated some mild
changes in the esophagus, but no obvious stricture; it is
possible in the interim she has developed a stricture as pt with
h/o tracheostomy. Also note of possible esophageal mass on [**9-11**]
CT, although very small in size. S&S recommended regular diet
with thin liquid and video swallow study. Video swallow study
was completed which showed penetration and aspiration with thin
liquids. Chin tuck helped to limit aspiration with thin liquids.
Also showed penetration with nectar-thick liquids.
Recommendations included thin liquids and moist solids, pills
with puree, and aspiration precautions. Patient has plans to
follow up with outpatient gastroenterologist for further
evaluation and treatment.
.
# Depression/Anxiety - continued clonazepam, citalopram,
trazodone
.
# Hypothyroid - continued levothyroxine
.
# chronic pain - continued baclofen, lyrica, methadone,
lidocaine patches. Also was given oxycodone prn.
.
transitional issues
- complete antibiotics as prescribed
- tunneled line will need to be removed after completion of
treatment
- HCO3 will need to be rechecked as was slightly elevated upon
discharge
- patient was full code on this admission
Medications on Admission:
ALBUTEROL SULFATE - 2.5 mg/3 mL (0.083 %) Solution for
Nebulization - one vial inh 4-6 hours prn
BACLOFEN - 10 mg Tablet - 2 (Two) Tablet(s) by mouth in the
morning; 1 (One) tablet at 4 pm and 2 (Two) tablets at bedtime
CITALOPRAM - 20 mg Tablet - 2 Tablet(s) by mouth once a day
CLONAZEPAM [KLONOPIN] - 0.5 mg Tablet - 2 Tablet(s) by mouth (1
mg) three times a day
ESTRADIOL [ESTRACE] - 0.01 % Cream - apply to exterrnal gyn area
twice a week
IPRATROPIUM-ALBUTEROL [COMBIVENT] - 18 mcg-103 mcg (90
mcg)/Actuation Aerosol - 2 puffs three times a day
LEVOTHYROXINE - 112 mcg Tablet - 1 (One) Tablet(s) by mouth once
a day
LIDOCAINE - 5 % (700 mg/patch) Adhesive Patch, Medicated - apply
four patches to the affected areas once a day 12 hours off and
12
hours on - No Substitution
LIDOCAINE HCL - 5 % Ointment - Apply externally to affected area
once a day as needed for burning
METHADONE - 5 mg Tablet - 1 Tablet(s) by mouth three times daily
for pain
METHENAMINE HIPPURATE - 1 gram Tablet - 1 Tablet(s) by mouth
twice a day take with Vitamin C 500
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - one
Capsule(s) by mouth twice a day
OXYBUTYNIN CHLORIDE - 5 mg Tablet - 2 Tablet(s) by mouth in the
AM, one in the afternoon, and 2 in the evening
OXYCODONE - 5 mg Tablet - 1 Tablet(s) by mouth three times a day
as needed for pain
PREGABALIN [LYRICA] - 100 mg Capsule - 1 Capsule(s) by mouth
three times a day
SIMVASTATIN - 10 mg Tablet - 1 Tablet(s) by mouth daily
SUCRALFATE - (post d/c med) (On Hold from [**2148-8-27**] to
[**2148-9-3**] for while taking levaquin) - 1 gram Tablet - 1
Tablet(s) by mouth four times a day
TRAZODONE - 100 mg Tablet - 1 Tablet(s) by mouth at bedtime
.
Medications - OTC
CALCIUM CARBONATE [CALCIUM 500] - (Prescribed by Other
Provider)
(On Hold from [**2148-8-27**] to [**2148-9-3**] for while taking
levaquin)
- 500 mg (1,250 mg) Tablet - 1 Tablet(s) by mouth twice daily pt
unsure if 500mg or 600mg
CATHETER [FOLEY CATHETER] - 14 Fr [**Year (4 digits) 12106**] - Use for urinary
control/self catheterizaion as needed Dx: Neurogenic bladder,
paraplegia (1 month supply)
FACIAL-BODY WIPES [BABY WIPES] - [**Name2 (NI) 12106**] - USE AS DIRECTED PRN
NEBULIZER - Kit - for use in home qd. dx: pneumonia
NICOTINE - (Prescribed by Other Provider) (Not Taking as
Prescribed) - 21 mg/24 hour Patch 24 hr - apply 1 patch daily as
directed
POLYETHYLENE GLYCOL 3350 [MIRALAX] - (Not Taking as Prescribed:
not on medication list provided by patient [**2146-6-15**]) - 17 gram
(100 %) Powder in Packet - one pack by mouth once a day
SURGICAL LUBRICANT JELLY [SURGILUBE] - Gel - as needed for
straight cath
Discharge Medications:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Month/Day/Year **]: One (1) vial Inhalation Q6H (every 6 hours) as
needed for SOB.
2. baclofen 10 mg Tablet [**Month/Day/Year **]: Two (2) Tablet PO BID (2 times a
day).
3. citalopram 20 mg Tablet [**Month/Day/Year **]: Two (2) Tablet PO DAILY (Daily).
4. clonazepam 0.5 mg Tablet [**Month/Day/Year **]: Two (2) Tablet PO three times a
day.
5. vancomycin in D5W 1 gram/200 mL Piggyback [**Month/Day/Year **]: One (1) gram
Intravenous Q 12H (Every 12 Hours) for 5 days: continue until
[**2149-11-21**]. .
Disp:*10 gram* Refills:*0*
6. meropenem 1 gram Recon Soln [**Month/Day/Year **]: One (1) Recon Soln
Intravenous Q8H (every 8 hours) for 5 days: continue through
[**2149-11-21**].
Disp:*QS Recon Soln(s)* Refills:*0*
7. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Month/Day/Year **]:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): apply
four patches to the affected areas once a day 12 hours off and
12 hours on - No Substitution
.
8. levothyroxine 112 mcg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY
(Daily).
9. Combivent 18-103 mcg/Actuation Aerosol Inhalation
10. methadone 5 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO TID (3 times a
day).
11. oxycodone 5 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO three times a
day as needed for pain.
12. omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Month/Day/Year **]: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
13. pregabalin 100 mg Capsule [**Month/Day/Year **]: One (1) Capsule PO TID (3
times a day).
14. simvastatin 10 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY
(Daily).
15. trazodone 100 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO at bedtime.
16. Outpatient Lab Work
Please check CBC, Chem 7, Vancomycin trough level on [**2149-11-18**]
and fax results to Dr.[**Last Name (STitle) 665**] FAX#:[**Telephone/Fax (1) 78619**].
17. Outpatient Lab Work
Please check CBC, Chem 7, on [**2149-11-22**] and fax results to
Dr.[**Last Name (STitle) 665**] FAX#:[**Telephone/Fax (1) 78619**].
18. estradiol 0.01 % (0.1 mg/g) Cream [**Telephone/Fax (1) **]: as directed mg
Vaginal twice weekly: apply to external gyn area twice a week
.
19. lidocaine 5 % Cream [**Telephone/Fax (1) **]: as directed cream Topical once a
day as needed for pain: Apply externally to affected area
once a day as needed for burning
.
20. methenamine hippurate 1 gram Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO
twice a day: take with Vitamin C 500
.
21. oxybutynin chloride 5 mg Tablet [**Telephone/Fax (1) **]: as directed Tablet PO
as directed: 2 Tablet(s) by mouth in the
AM, one in the afternoon, and 2 in the evening
.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
1)Pneumonia
2)Urinary Tract Infection
Discharge Condition:
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Discharge Instructions:
Dear Ms. [**Known lastname **],
You were admitted to our hospital with a concern for a urinary
tract infection and pneumonia. We had trouble obtaining
intravenous access to administer antibiotics, and finally
established it. You will need to have the catheter in for
administration of intravenous antibiotics for a total of 5 more
days. After that you will need to have the catheter removed.
Please keep the catheter site dry and intact.
The following changes were made to your medication regimen:
START Vancomycin
START Meropenem
Followup Instructions:
Department: DIGESTIVE DISEASE CENTER
When: WEDNESDAY [**2149-11-19**] at 1 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],MD [**Telephone/Fax (1) 463**]
Building: [**First Name8 (NamePattern2) **] [**Hospital Ward Name 1950**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3202**]
Campus: EAST Best Parking: Main Garage
Department: ENDO SUITES
When: WEDNESDAY [**2149-11-19**] at 1 PM
Department: [**Hospital3 249**]
When: WEDNESDAY [**2149-11-26**] at 9:00 AM
With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 1114**], M.D. [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2149-11-17**]
ICD9 Codes: 5990, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3588
} | Medical Text: Admission Date: [**2199-1-30**] Discharge Date: [**2199-2-1**]
Date of Birth: [**2166-2-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
lithium overdose
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pt is a 32 y/o male with history of bipolar disorder who
presented to the ED after a suicide attempt with OD of 20
thorazine, 30 Lithium and 6 clonadine at 7 am. Pt reports that
he has depressed recently after the death of his father and
boyfriend in [**Name (NI) **]. His father died of Lung Cancer, and he
reports that his boyfriend died after an accidental overdose
when they "were fooling around with his dad's morphine." Pt was
sexually active with boyfriend, and had an HIV test which was
negative >1 year ago. He is a resident at [**Hospital **] Hospital in
their outpatient dorm, where he has been recieving treatment for
Bipolar Disorder and substance abuse (alcohol and crack cocaine,
last used 40 days prior) under the care of Dr. [**Last Name (STitle) **]. He
reports that "today was a good day" until the evening when "the
voices told him to take his pills." At 7 PM he took all of his
meds in an attempt to kill himself. He left a suicide note,
which stated, "[**Month (only) **]-[**3-8**]. To Whom it [**Month (only) 116**] Concern: It is 7 PM and
I have just taken my own life with 20 thorazine, 30 Lithium, 6
Clonidine."
.
In the ED VS were Temp: BP: / HR: RR: O2sat. Serum tox screen
positive for tricyclics, and Urine tox screen was negative. All
other labs and UA were WNL except, slight elevation of AST to
43. EKG was NSR, with nml QT and QRS. NG tube was placed and
100 gm activated charcol was administered. Serial ekgs (last
22:45) showed no changes. Lithium levels were checked q 4 hr
(last one at 11:52 PM was 2.1, up from 1.6 @ 8:40 PM). Pt was
given NS boluses at 200 cc/hr.
Past Medical History:
Bipolar Disorder
Hypertension
Asthma
Social History:
No smoking
History of ETOH abuse, 40 days sober
Crack Cocaine abuse, 40 days sober
Family History:
Father Died [**Name (NI) **] Cancer
Mother Bipolar Disorder
Grandmother Depression
Physical Exam:
VS: Temp: 96.4 BP: 139/63 HR:91 RR:19 O2sat 97% RA
GEN: Middle aged obese man, sleeping in hospital bed with NG
tube in place.
HEENT: PERRL, EOMI, anicteric, dry MM, Charcoal on teeth,
NECK: 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: obese, nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e, warm, good pulses
SKIN: no rashes/no jaundice
NEURO: AAOx3. Cn II-XII intact. no nystagmus. 5/5 strength
throughout. No tremor. no asterisix. No pronator drift. No
clonus. 1+DTR's-patellar and biceps equal bil.
Pertinent Results:
[**2199-2-1**] 08:12AM BLOOD WBC-5.7 RBC-4.11* Hgb-12.5* Hct-37.4*
MCV-91 MCH-30.5 MCHC-33.5 RDW-13.1 Plt Ct-220
[**2199-1-30**] 08:40PM BLOOD Neuts-50.8 Lymphs-34.6 Monos-7.0 Eos-6.6*
Baso-1.0
[**2199-2-1**] 08:12AM BLOOD Plt Ct-220
[**2199-2-1**] 08:12AM BLOOD PT-12.4 PTT-23.2 INR(PT)-1.0
[**2199-2-1**] 08:12AM BLOOD Glucose-92 UreaN-9 Creat-0.9 Na-140 K-3.6
Cl-108 HCO3-25 AnGap-11
[**2199-2-1**] 08:12AM BLOOD ALT-40 AST-28 LD(LDH)-133 AlkPhos-43
TotBili-0.5
[**2199-2-1**] 08:12AM BLOOD Calcium-8.8 Phos-3.4
[**2199-2-1**] 08:12AM BLOOD Lithium-0.9
[**2199-1-31**] 02:31PM BLOOD Lithium-1.3
[**2199-1-31**] 08:04AM BLOOD Lithium-1.7*
[**2199-1-31**] 02:35AM BLOOD Lithium-2.2*
[**2199-1-30**] 11:52PM BLOOD Lithium-2.1*
[**2199-1-30**] 08:40PM BLOOD Lithium-1.6*
[**2199-1-30**] 08:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-POS
Brief Hospital Course:
A/P: 32 y/o male with history of bipolar disorder who overdosed
on lithium, thorazine, and clonidine in a suisice attempt.
.
# Overdose: In the [**Name (NI) **] pt recieved activated charcoal, NS
hydration, serial ekgs (which were normal) and serial lithium
levels (rising from 1.6 to 2.1 and then trending down to 0.9).
Tox screen noted Tricyclic positive, but according to Toxicology
Service Thorazine can often cause a positive tricyclic result.
He was given continuous bowel irrigation with 1-2 L of golytely
per hour until stools were clear and also NS hydration at 200
cc/hr. was also on 1:1 24-hour sitter.
.
# Bipolar Disorder: Pt has diagnosis of Bipolar disorder,
possibly with psychotic features considering fact that he was
hearing voices. By his report he recently started meds for
bipolar disorder. Per Psychiatry recommendation, psychiatric
meds were held during the hospitalization due to high serum drug
levels after overdose. Psychiatry recommended psychiatric
admission once medically stable and medically cleared. Social
Work was also consulted to assist in discharge planning.
.
# HTN: Pt has a hisory of hypertension on clonidine and
atenelol at home. antihypertensives were held in light of
overdose with multiple clonidine tablets.
meds weren't restarted as BP was normal
.
# Asthma: Lung exam was clear, and pt without any respiratory
complaints.
.
# F/E/N: IVF. NS @ 200cc/hr, Replete lytes PRN. Regular Diet.
.
# PPx: sq Heparin, no bowel reg while on golytely, no ppi needed
.
# Access: Peripheral IV
.
# Dispo: ICU pending further workup and treatment
.
# Code Status: Full
Medications on Admission:
Thorazine 100 mg QHS
Atenelol 75 mg daily
Albuterol prn
Clonidine 0.1 mg QAM
Cogentin 0.5 mg [**Hospital1 **]
Lithium 30 mg QAM and 600 mg QHS
Celexa 20 mg QD
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
lithium overdose
Discharge Condition:
stable
Discharge Instructions:
Please take all medications as prescribed
.
If you have chest pain, shortness of breath, dizziness,
palpitations, nausea, vomitting, diarrhea, suicidal or homicidal
thoughts, depression, anxiety please call the doctor at the
facility
Followup Instructions:
please make a follow up appointment with your psychiatrist Dr.
[**Last Name (STitle) **] within 2 weeks of discharge
.
please make a follow up appointment with your primary care
provider [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] within 2 weeks of discharge
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
Completed by:[**2199-2-1**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3589
} | Medical Text: Admission Date: [**2125-7-10**] Discharge Date: [**2125-7-15**]
Date of Birth: [**2061-4-27**] Sex: F
Service: MEDICINE
Allergies:
Lisinopril
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
Bradycardia and Hypotension
Major Surgical or Invasive Procedure:
Mechanical Ventilation
Cardiac catheterization
History of Present Illness:
64 year old female with cardiac history of type 2 DM on insulin,
hypertension and dyslipidemia presents to the ED with two week
history of generalized weakness and poor po intake. She reports
having had nausea and vomiting for three days last week with
subsequent improvement over the week. She had similar episode
of nausea/vomiting yesterday which led her daughters to bring
her to the the [**Name (NI) **] today. She reports no sick contacts, eating
outside, fever, chills, change in bowel movement, chest pain,
shortness of breath or dysuria.
.
In the ED, she was noted to have bradycardia in 50s, hypotensive
to 69/54 and finger stick of 123. Labs significant for acute
kidney injury with creatinine of 3.3 (baseline of 1.1) and
hematocrit of 25.5 (basline in mid 30s). She was given glucagon
5 mg bolus x 1 without change in her rate or blood pressure.
She was subsequently transferred to CCU for further evaluation
and management.
.
In the CCU, she reported no complaints. She was given IV
atropine 1 mg x 1 which improved her heart rate and blood
pressure. She was started on dopamine gtt at 5 mcg/kg/min which
improved her heart rate but did not improve her blood pressure.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: Clean coronaries on Cath
at [**Hospital1 336**] in [**2117**]
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY: Osteopenia; Gastritis in setting
of NSAID use and extrinsic restrictive lung disease
Social History:
She lives alone. Her daughter lives on the [**Location (un) 1773**] above
her with her husband and children. She works for the city of
[**Location (un) 86**] as an assistant city order. She has quit smoking
recently and denies any alcohol use. Notes her diet is okay.
She is working on eating more sugarless products and working on
exercise.
Family History:
Mother and grandfather had diabetes. One uncle had cancer in
the leg. Another aunt with throat cancer. Another aunt with
breast cancer. Her grandfather had an MI at an older age as
well. She does not know her dad well.
Physical Exam:
On admission:
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Dry mucosal
membranes. NECK: Supple with flat JVP. Left IJ in place
CARDIAC: rRR. No murmurs or gallops appreciated
LUNGS: Poor inspiratory effort. CTAB otherwise
ABDOMEN: Soft, NTND.
EXTREMITIES: No edema. No rash
Neuro: CN 2-12 intact.
On discharge:
Vitals: BP:150-170s/80s HR: 65-90 RR: 18 O2: 98%RA
Gen: alert, sitting in bed, NAD
HEENT: supple, no JVD
CV: regular, no M/R/G, distant
RESP: clear lung fields
ABD: soft, NT, ND, obese, +BS
EXTR: No lower extremity edema
NEURO: A/O, speech clear, no focal defects
Pertinent Results:
Labs/Results
.
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2125-7-14**] 07:30 5.5 3.62* 7.9* 25.3* 70* 21.9* 31.3 18.5*
345
[**2125-7-13**] 04:11 6.9 3.36* 7.4* 23.7* 70* 22.0* 31.3 18.6*
323
[**2125-7-12**] 05:41 7.6 3.60* 8.1* 25.5* 71* 22.5* 31.7 19.1*
352
[**2125-7-11**] 03:37 11.5* 3.63* 7.9* 26.3* 72* 21.8* 30.2* 18.2*
337
[**2125-7-10**] 21:10 6.8 3.53* 8.1* 25.5* 72* 23.1* 31.9 18.3*
339
[**2125-4-19**] 12:35 6.9 4.69 10.6* 34.4* 73* 22.7* 31.0 18.6*
271
[**2125-2-27**] 10:00 6.9 4.83 10.7* 34.3* 71* 22.2* 31.3 17.9*
320
[**2124-11-7**] 12:30 4.5 5.22 11.8* 38.2 73* 22.6* 30.9* 17.2*
323
[**2124-2-10**] 09:55 5.9 4.84 10.8* 34.7* 72* 22.3* 31.1 16.9*
439
.
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2125-7-14**] 07:30 120*1 25* 0.9 141 3.9 109* 21* 15
[**2125-7-13**] 19:10 1.1 141 3.4 109*
[**2125-7-13**] 04:11 771 40* 1.3* 142 3.6 111* 20* 15
[**2125-7-12**] 13:20 1.8* 141 4.0 111*
[**2125-7-12**] 05:41 125*1 53* 2.0* 137 4.4 109* 17* 15
[**2125-7-11**] 17:30 222*1 60* 2.6* 135 4.6 110* 16* 14
[**2125-7-11**] 03:37 119*1 64* 3.5* 138 4.3 109* 16* 17
[**2125-7-10**] 21:10 57*1 67* 3.3* 138 4.2 110* 20* 12
.
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2125-7-11**] 03:37 155 41
[**2125-7-10**] 21:10 23 19 139 81 0.1
.
CPK ISOENZYMES CK-MB cTropnT
[**2125-7-11**] 03:37 2 <0.01
.
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
Cholest
[**2125-7-14**] 07:30 8.6 2.6* 2.1
[**2125-7-13**] 19:10 1.6
[**2125-7-13**] 04:11 6.0* 8.5 3.9 1.9 9*
[**2125-7-12**] 13:20 2.0
[**2125-7-12**] 05:41 8.5 3.9 2.0
[**2125-7-11**] 17:30 8.1* 5.5* 2.2
[**2125-7-11**] 03:37 7.5* 5.7* 2.1
.
HEMATOLOGIC calTIBC Folate Hapto Ferritn TRF
[**2125-7-13**] 04:11 246* 282* 189*
[**2125-7-11**] 03:37 143
.
PITUITARY TSH
[**2125-7-11**] 03:37 2.1
OTHER ENDOCRINE Cortsol
[**2125-7-11**] 03:37 35.2
.
WHOLE BLOOD, MISCELLANEOUS CHEMISTRY Lactate
[**2125-7-12**] 05:47 0.8
[**2125-7-12**] 03:24 0.9
[**2125-7-11**] 23:59 0.7
[**2125-7-11**] 03:42 0.9
.
CXR:
UPRIGHT AP VIEW OF THE CHEST: Low lung volumes are noted. This
accentuates
the size of the cardiac silhouette which is likely mildly
enlarged. The
mediastinal and hilar contours are likely within normal limits.
The lungs are clear without focal consolidation. No pleural
effusion, pneumothorax, or pulmonary vascular congestion is
present. No acute osseous findings are seen.
IMPRESSION: Low lung volumes with mild cardiomegaly. No
evidence for
pneumonia.
.
TTE:
There is mild symmetric left ventricular hypertrophy with normal
cavity size. Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Left ventricular
systolic function is hyperdynamic (EF>75%). Doppler parameters
are indeterminate for left ventricular diastolic function. There
is a mild resting left ventricular outflow tract obstruction.
The right ventricular cavity is dilated with depressed free wall
contractility. The aortic valve leaflets (3) are mildly
thickened. 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 leaflets are
not well seen. No mitral regurgitation is seen. There is no
pericardial effusion.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with hyperdynamic left ventricular
function. Right ventricular dilation and dysfunction.
.
CARDIAC CATHETERIZATION
1. Moderate pulmonary hypertension (PAS 50-55 Mean 30)
2. Preserved cardiac output
3. Elevated right and left sided filling pressures without
hemodynamic evidence supporting constriction.
4. No evidence of valvular stenosis.
5. No angiographically-apparent CAD.
.
Brief Hospital Course:
64F DMII on insulin, HTN and HL admitted with junctional rhythm,
hypotension and acute kidney injury in the setting of likely
beta-blocker toxicity. Pt had an episode of acute respiratory
distress during admission requiring intubation.
.
ACTIVE ISSUES
# Junctional rhythm: The patient presented to the ED with HR in
the 50s and BP of 69/54. EKG showed junctional rhythm. She was
given glucagon 5 mg IV x 1 out of concern for beta-blocker
toxicity. In the CCU, 1 mg atropine was administered with good
response and improvement in HR. She was started on an
epinephrine gtt with improvement in HR, dripp was d/c'ed on
[**7-11**]. ECHO [**7-11**] revealed mild symmetric left ventricular
hypertrophy with hyperdynamic left ventricular function and
right ventricular dilation and dysfunction.
.
# Hypotension: Likely mixed cardiogenic and hypovolemic. She
received ~ 3L of IVF in the ED and additional 1L on presentation
to the CCU. Epinephrine gtt was started with improvement in BP
so d/c'ed on [**7-11**]. AM Cortisol and TSH were normal. TTE showed
hyperdynamic LV function, dilated and depressed contractility of
the RV. Following BP normalization the pt became hypertensive
(see below).
.
# CMP: Pt underwent cardiac cath [**7-12**] as part of work-up for
admission with junctional rhythm, hypotension and abnormal ECHO
with RV dilation. Cath revealed moderate pulmonary hypertension
and elevated right and left sided filling pressures without
hemodynamic evidence supporting constriction. DDx included
restrictive process vs dCHF and pulmonary HTN. No evidence of
valvular stenosis or angiographically-apparent CAD was noted.
Thus, the pt was not placed on ASA. Pt to f/u with Dr. [**Last Name (STitle) **]
within the next two weeks. Also, the pt was instructed to
reschedule pulm f/u as she missed her appointment with pulm
while in-patient.
.
# [**Last Name (un) **]: Cr was 3.3, up from baseline of 1.1 in [**Month (only) 956**]. K was
4.2, BUN 67. Likely prerenal from volume depletion given history
of nausea/vomiting x 1 week. Cr stabilized over the course of
the hospitalization. Appropriate medications were renally dosed.
[**Last Name (un) **] was discontinued during hospitalization with plans for
further discussion as outpatient for restarting given pt with hx
of DMII.
.
# Acute Hypoxemic Respiratory Failure: Likely due to a
combination of flash pulmonary edema and anxiety. In the
afternoon of [**7-11**], pt became acutely dyspneic and tachypneic.
She had bilateral diffuse crackles and CXR showing diffuse
bilateral infiltrates. She was given morphine 2mg IV x2, Lasix
40mg IV x1 and started on a nitro gtt. Pt was also placed on
CPAP however had difficulty tolerating and began to tire with an
ABG 7.23/42/89/18/-9. Anesthesia attempted intubation but had
initial difficulty and pt desatted, briefly became hypotensive
to the 60s, and had junctional rhythm in the 20s. She was given
atropine x1 with increase of HR to 110s and SBP to the 160s. Pt
was successfully intubated. After aggressive diuresis (out 3L),
pt was successfully extubated in the PM of [**7-12**] with no further
episodes of distress. The pt will be calling to schedule f/u up
with pulm in 2 weeks time.
.
# Hypertension: After d/c of epi gtt, pt's BPs elevated to the
160s. After starting pt on 25mg HCTZ (home dose), 10mg
Amlodipine, metoprolol 25 mg po BID, and aggressive diuresis,
BPs improved although still elevated. Losartan was held to
simplify home regimen and decrease risk of future incidence of
renal failure in setting of vomitting and diarrhea.
.
# Microcytic anemia: Hct was 25.5 on admission. Iron studies
consistent with AOCD. EGD in [**2124**] showed gastritis which could
represent mixed iron deficiency and AOCD. Guiaic negative in
the ED. Retic count was depressed at 1.6%. Hemolysis labs were
negative. Hct remained stable.
**The etiology of the patients AOCD remained unclear at the time
of discharge and should be further pursed as an outpatient**
.
CHRONIC ISSUES:
# Type 2 DM: Blood sugars were initially low normal. Her sugars
were well-controlled on an insulin sliding scale. Home dose of
NPH was held due to episode of hypoglycemia (BG=59). Pt
discharged on [**Last Name (un) **] humalin regimen.
.
# HLD: Continued simvastatin 20 mg po qdaily
.
# Depression: Continued on sertraline 150mg po daily.
Desipramine 100 mg was held during hospitalization but resumed
on discharge.
.
# Chronic back pain: Percocet 1-2 tabs po q6 prn pain while in
house. Pt continued on Oxycontin 10mg [**Hospital1 **] on d/c. (Pt on
contract).
.
TRANSITIONAL ISSUES:
Full Code. Pt was given phone numbers for cardiology and
pulmonary and must call to make f/u appointments. A medication
list (and actual bottles) were reviewed with pt and her daughter
prior to discharge. Pt will have visiting nursing care for
medication management post hospitalization.
Medications on Admission:
Albuterol prn
Atenolol 100 mg po qdaily
Desipramime 100 mg po qdaily
Vitamin D2 50,000 units po qweekly
Fluticasone 50 mcg 2 puff daily
Gabapentin 300 mg po qdaily
Losartan 100 mg po qdaily
Metformin 500 mg po qdaily
Oxycontin 10 mg po BID
Sertraline 150 mg po qdaily
Simvastatin 20 mg po qdaily
Triamterene/HCTZ 37.5/25 mg po qdaily
NPH 54 units qam and 60 units qpm
Discharge Medications:
1. triamterene-hydrochlorothiazid 37.5-25 mg Tablet Sig: One (1)
Tablet PO once a day.
2. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. sertraline 50 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
4. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for Wheeze.
5. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. Insulin
Humalog Insulin
55 units every morning
60 units every evening
7. desipramine 100 mg Tablet Sig: One (1) Tablet PO once a day.
8. metformin 500 mg Tablet Sig: One (1) Tablet PO once a day.
9. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
10. Guaifenesin DM Oral
11. iron 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO once
a day.
12. gabapentin 100 mg Capsule Sig: Three (3) Capsule PO three
times a day.
13. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
14. OxyContin 10 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO twice a day.
15. metoprolol tartrate 25 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Disp:*120 Tablet(s)* Refills:*2*
16. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary Diagnoses
-Junctional rhythm induced by beta-blocker toxicity
-Acute Hypoxemic Respiratory Failure
-Acute kidney injury due to volume depletion
-Microcytic anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure caring for you at the [**Hospital1 827**]. Your blood pressure and heart rate were low
because you had too much atenolol (a beta-blocker) in your
system in the setting of decreased blood flow to your kidney
potentially caused by another medication (valsartan or
losartan). You subsequently had trouble breathing and needed to
to be intubated. You had a cardiac catheterization which showed
no evidence of coronary artery disease.
.
We made the following changes to your medications:
1) Stop taking atenolol and instead start taking metoprolol
tartrate 50mg by mouth twice a day to better control your blood
pressure.
2) Stop taking Losartan and Valsartan
3) Start taking Amlodipine 10 mg by mouth once daily to help
control your blood pressure.
.
**Your follow-up information is listed below.
Followup Instructions:
- Please call Dr. [**Last Name (STitle) **] (Cardiology) ([**Telephone/Fax (1) 2037**] for a
follow-up appointment in 2 weeks time.
- Please call for a pulmonology appointment ([**Telephone/Fax (1) 513**] in
the next two weeks.
Department: PODIATRY
When: FRIDAY [**2125-7-27**] at 2:20 PM
With: [**First Name11 (Name Pattern1) 3210**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], DPM [**Telephone/Fax (1) 543**]
Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: [**Hospital **] HEALTH CENTER
When: TUESDAY [**2125-7-31**] at 9:00 AM
With: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 3819**], MD, MPH [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 5849, 4280, 4589, 4019, 2724, 311, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3590
} | Medical Text: Admission Date: [**2137-5-1**] Discharge Date: [**2137-5-6**]
Date of Birth: [**2077-10-14**] Sex: M
Service: MEDICINE
Allergies:
Bactrim / Augmentin / Phenobarbital / Morphine
Attending:[**First Name3 (LF) 4654**]
Chief Complaint:
ETOH Withdrawl/SOB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
58M h/o COPD, HCV, polysubstance abuse admitted to ICU for
hypoglycemia, EtOH intoxication, and possible seizure. The
patient was originally brought in by EMS for acute intoxication
and some possible suicidal ideation. He also notes progressive
worsening SOB over the last 3 weeks. Denies cough, fever,
chills, chest pain, abdominal pain, N/V/D. Initial EtOH level
was 294 at 1:45am. At approximately 4:30am, the nursing staff
witnessed several tonic-clonic events lasting approximately 30
seconds each, with a total of 3. These event resolved on their
own. After the 3rd one, he might of been somewhat post ictal and
confused per the ED staff.
.
Initial vital signs in the ED were 97.6 102 109/69 18 93 ra. He
was also felt to be wheezy on exam so he was given nebs, IV
methyprednisilone, and azithromycin for a COPD flare. He was
given 2mg IV ativan after the third event to possibly prevent
further seizures. Given possible alcohol withdrawal seizures he
was admitted to the ICU.
Past Medical History:
1. COPD- last flare requiring hospitalization in [**2135-6-24**].
Never intubated. Attributes to smoking and [**Doctor Last Name **] [**Location (un) **]
2. Allergic rhinitis
3. HCV- status unknown
4. PTSD/depression since age 20 when he returned from the
[**Country 3992**] war (requiring many hospitalizations at the VA)
5. Polysubstance abuse: drinks etoh and smokes crack - last used
[**Month (only) **] of this year
6. Right total knee replacement
7. Right carotid AV fistula
8. Multiple blood transfusion
Social History:
Smokes less than 1/2ppd tobacco. Hx heavy ETOH (vodka 1 pint)
states that does not drink frequently now, less than once a
week. Also with h/o crack cocaine use states that he last used
used in [**Month (only) **]. Denies IVDA. Per OMR, reports that his parents
were substance abusers and that his mother was physically
abusive. Pt is divorced. Moved to [**Location (un) 86**] from [**Location (un) 7349**] one year ago
to take care of his mother. After she passed away a few months
ago, he moved into a transitional houseing vet house in [**Location (un) **] [**Telephone/Fax (1) 102166**]. He is on SSDI for PTSD but he would
like to find work. Sees social worker/therapist at [**Hospital **] clinic in
[**Location (un) 5503**] named [**Name (NI) 24592**] [**Name (NI) **].
Family History:
Patient believes his mother may have had bipolar. Siblings with
panic attacks.
Physical Exam:
VS: Temp: 99.0 BP: 107/63 HR: 98 RR: 20 O2sat: 96 RA
.
Gen: resting in bed watching TV, no distress
HEENT: PERRL, EOMI. No scleral icterus.
Neck: Supple, no LAD, no JVP elevation.
Lungs: diffuse wheezes
CV: RRR, no murmurs, rubs, gallops.
Abdomen: soft, NT, ND, NABS
Extremities: warm and well perfused, no cyanosis, clubbing,
edema.
Neurological: alert and oriented X 3, CN II-XII intact. Muscle
strength is full throughout. Diminshed ROM in L hand due and LUE
to history of arm injury Sensation to light touch is intact
throughout. There is no pronator drift.
Skin: No rashes or ulcers.
Psychiatric: Appropriate.
Pertinent Results:
[**2137-5-1**] 02:15PM URINE HOURS-RANDOM
[**2137-5-1**] 02:15PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-POS amphetmn-NEG mthdone-NEG
[**2137-5-1**] 12:00PM CALCIUM-8.2* PHOSPHATE-3.2 MAGNESIUM-1.8
[**2137-5-1**] 12:00PM CALCIUM-8.2* PHOSPHATE-3.2 MAGNESIUM-1.8
[**2137-5-1**] 12:00PM WBC-4.5 RBC-3.93* HGB-12.5* HCT-35.8* MCV-91
MCH-31.7 MCHC-34.8 RDW-14.3
[**2137-5-1**] 12:00PM PLT COUNT-343
[**2137-5-1**] 01:52AM LACTATE-3.2*
[**2137-5-1**] 01:45AM GLUCOSE-82 UREA N-25* CREAT-1.1 SODIUM-146*
POTASSIUM-3.7 CHLORIDE-106 TOTAL CO2-23 ANION GAP-21*
[**2137-5-1**] 01:45AM estGFR-Using this
[**2137-5-1**] 01:45AM CALCIUM-9.1 PHOSPHATE-3.6 MAGNESIUM-2.1
[**2137-5-1**] 01:45AM ASA-NEG ETHANOL-294* ACETMNPHN-NEG
bnzodzpn-POS barbitrt-NEG tricyclic-NEG
[**2137-5-1**] 01:45AM WBC-8.0 RBC-4.46* HGB-14.3 HCT-40.3 MCV-91
MCH-32.1* MCHC-35.5* RDW-14.8
[**2137-5-1**] 01:45AM NEUTS-53.0 LYMPHS-37.0 MONOS-5.6 EOS-3.6
BASOS-0.8
[**2137-5-1**] 01:45AM PLT COUNT-433#
[**2137-5-2**] 04:21AM BLOOD calTIBC-244* VitB12-438 Hapto-168
Ferritn-72 TRF-188*
[**2137-5-1**] 01:45AM BLOOD ASA-NEG Ethanol-294* Acetmnp-NEG
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
<br>
[**2137-5-3**] CT Head:
FINDINGS:
The previously detailed posterior fossa hyperdensity is now seen
to be choroid
calcification. There is no intracranial hemorrhage, edema, mass
effect or
vascular territorial infarction. Hypodensity at the
posteromedial aspect of
the left occipital lobe (2:14) is consistent with
encephalomalacia, likely a
sequela of old infarction. Ventricles and sulci are large in
size and normal
in caliber consistent with parenchymal volume loss.
Periventricular white
matter hypodensity is bilateral and likely the sequela of
chronic
microvascular infarction.
The cranial soft tissues are normal. Mastoid air cells are clear
and
paranasal sinuses are unchanged, with persistent mild mucosal
thickening at
the maxillary sinuses and anterior ethmoidal air cells as well
as frontal
ethmoidal recesses.
IMPRESSION:
1. No acute intracranial process.
2. Encephalomalacia at the left occipital lobe, the sequela of
an old
infarction as well as parenchymal volume loss.
3. Unchanged mild mucosal thickening in the paranasal sinuses.
<br>
Initial CXR:
FRONTAL AND LATERAL VIEW, CHEST: There is diffuse prominence of
interstitial
markings, which is slightly more marked than prior study,
particularly in the
lower lobes. There is no focal consolidation, pleural effusion,
or
pneumothorax. Right apical pleural thickening is noted. There is
no evidence
of pulmonary edema. Aortic contour is little bit prominent at
the site of the
ascending aorta. Heart size is normal. Hilar contours are
unremarkable.
Degenerative changes are noted in the vertebral column.
IMPRESSION: Progressive interstitial process, slightly more
marked in the
lower lobes. No focal pneumonia.
Brief Hospital Course:
58 year old man with COPD, chronic HCV infection, polysubstance
abuse including alcohol abuse and related seizures who was
admitted to the ICU for hypoglycemia, alcohol intoxication, and
alcohol intoxication seizure. He also complained of progressive
worsening shortness of breath over the last 3 weeks with out
cough, fever, chills, or chest pain. He had unremarkable CXR. He
was treated for alcohol intoxication and acute COPD exacerbation
and transferred to the floor. He expressed wishes for inpatient
detoxification and therefore social work was consulted; however
initially with limitations for placement given holiday weekend.
He was noted to have acute normocytic anemia with out evidence
of external bleeding. He had recent normal colonoscopy by the [**Hospital **]
hospital. He was never told he had cirrhosis or esophageal
varices; but he does not recall previous EGD or GI bleeding. He
has telangiectasias but no other stigmata of chronic liver
disease. He required no Ativan or other benzodiazepines as he
had no withdrawal symptoms. Despite depression, he had no
suicidal ideation. Pt treated for COPD - sx stable on day of
d/c with pt to complete steroid taper (finished azithro course
on day of d/c) - d/c to shelter as below while awaiting bed at
Hope Found for detox.
<br>
# COPD/Chronic Bronchitis with acute exacerbation - ambulating
with good o2 sats and stable sx.
-finish steroid taper (completed azithro course as above)
<br>
# Etoh Withdrawal/Abuse/Dependency - ciwa stable - S.W.
consulted - screened for detox facilities. CIWA had been 0.
-cont thiamine/folate
-d/c to shelter in [**Hospital1 1559**] - Hope Found arranged for detox -
pt needs to call qdaily for when bed becomes available - pt,
s.w. all in align and agreeable with plan
<br>
# Anemia - Hct controlled - NOT Fe Def, f/u as outpt
<br>
# HCV - outpt follow-up.
<br>
# Depression - cont Sertraline
<br>
Proph - hep
Code - Full
<br>
Dispo - d/c to shelter as above with plan to await bed at Hope
Found for etoh detox
Medications on Admission:
Trazodone 150 mg PO HS
Sertraline 150 mg PO DAILY
Spiriva 1 puff [**Hospital1 **]
Albuterol Two (2) Puff Q4H (every 4 hours) as needed.
Discharge Medications:
1. Sertraline 50 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day for
8 days: ****Please take as the following - starting tomorrow
([**2137-5-7**]) take 4 tabs every morning for next 2 days, then take 3
tabs every morning for next 2 days, then take 2 tabs every
morning for next 2 days, then take 1 tab every morning for next
2 days and then stop.
Disp:*20 Tablet(s)* Refills:*0*
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
7. Trazodone 50 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime) as needed for insomnia.
8. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation
every 4-6 hours as needed for shortness of breath or wheezing.
9. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) Inhalation twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
# COPD Exacerbation
# Alcohol Dependency
# Anemia
# Depression
Discharge Condition:
stable, ambulating well - o2 sats 94% on RA
Discharge Instructions:
Your diagnosis as below - please continue the prednisone,
lowering the dose slowly as prescribed. Slowly increase your
ambulation every day as you slowly continue to improve your lung
function - if your symptoms start worsening, start developing
new fever/chills - please call your provider.
<br>
Please abstain completely from alcohol and any other
medications/drugs that are not prescribed to you. As note you
will also be expected to have a clean tox screen prior to
admission to the alcohol detox center.
<br>
Please call the center - Hope Found at the [**Hospital **] Hospital ,
every morning/day as you will be discharged to [**Hospital1 1559**] Shelter
for ensure your best chance to get bed as soon as it becomes
available. The number is [**Telephone/Fax (1) 102167**] - to talk with
the In-Take Facilitator - Mr. [**First Name (Titles) **] [**Last Name (Titles) **].
Followup Instructions:
****As above - please call the Hope Found daily to check when a
bed will be made available.
<br>
***Please call and arrange a follow-up appointment with your
PCP: [**Name10 (NameIs) 90404**],[**First Name3 (LF) **] J. [**Telephone/Fax (1) 51001**] to be ween in the next [**3-27**]
week.
[**First Name8 (NamePattern2) **] [**Name8 (MD) 474**] MD [**MD Number(2) 4658**]
Completed by:[**2137-5-6**]
ICD9 Codes: 2762, 2859, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3591
} | Medical Text: Admission Date: [**2172-11-13**] Discharge Date: [**2172-11-27**]
Date of Birth: [**2117-8-11**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
transfer for intracranial hemorrhage
Major Surgical or Invasive Procedure:
Intubation
ventricular drain placement
Right IJ placement
MRI
angiography
History of Present Illness:
55 yo woman with a history of hepatitis C and cirrhosis,
bactermia, osteomyelitis and epidural abscess who presented from
OSH after identifying an intracranial hemorrhage. Per the
family
she uses methamphetamines. She was shopping on [**2172-11-12**] late at
night, at felt "disoriented" and weak on the right. She made it
home and beeped her [**Doctor Last Name 534**]. Her mother and husband, who were at
home, helped her get inside. She was noted to be agitated,
talking, but not making sense and had right arm and leg
weakness.
She went to sleep. Her mother called 911 on AM of admission when
she was brought to an OSH. Head CT there showed a large left
parieto- occipital hemorrhage. She was given 1g dilantin for
seizure prophylaxis and transfered here for further management.
At [**Hospital1 18**] she was admitted to the neuro ICU service for q 1hour
neuro checks. She initially was awake and oriented, became
obtunded, thus intubated, started on mannitol, hyperventilated,
and vent drain placed [**11-14**]. She was slow to improve but
eventually sedation was weaned and she was extubated on [**2172-11-24**].
Ventricular drain was also removed on [**2172-11-24**].
Regarding the etiology of the bleed, angiography was performed
on
[**2172-11-14**] and showed only unrelated frontal lobe venous anomaly
but no clear cause of her bleed. It is likely the
methamphetamine use (as per history obtained later by family) is
the culprit of the bleed. She needs an MRI in a few weeks
though
to r/o masses. CT torso was obtained to r/o masses and was
unrevealing (see labs and studies). BP was controlled with PO
metoprolol. Serial CTs showed improving blood resorption.
Glucose control via insulin drip while in the ICU.
She was covered with cefazolin while drain was in place and for
3
doses after drain was removed. She developed a UTI with fever
and was treated with 6 days of levofloxacin.
She was given nutrition via tube feeds.
Keppra was started upon arrival for seizure prophylaxis, but
several days into her admission she was noted to have increased
gaze preference to the left, thus dilantin was started and
keppra
was weaned to off. 2 EEGs did not show epileptiform activities.
The patient currently complains of some mild trouble breathing
but is doing well otherwise. She is confused and unable to
relate a coherant story.
Past Medical History:
1. Hepatitis C chronic, biopsied in [**2170-1-19**] with B
stage four cirrhosis with inflammation. s/p pegylated interferon
and ribavirin. Ribavirin and interferon was stopped secondary to
anemia.
2. Esophagogastroduodenoscopy on [**12-24**] evaluated no varices.
3. Anemia.
4. MICU admission [**7-24**] for bacteremia with mental status
changes, requiring intubation.
5. Osteomyelitis and epidural abscess s/p laminectomy and
drainage of L4/5 [**2170**], also with osteo of 5th metatarsal s/p
surgery also in [**2170**] at time of laminectomy.
6. Tachycardia and frequent PVCs with normal EF, CTA neg for PE
in [**7-24**]
7. Cholelithiasis
8. Multilobar pneumonia after intubation [**7-24**]
Social History:
nurse at a nursing home, acquired HCV via needle stick at
work, + h/o heavy etoh use, + h/o amphetamine use per family
Family History:
per previous d/c summ, patient is adopted
Physical Exam:
T 98.8 BP 137/87 HR88 RR18 O2 Sat 92%
Gen: On ED stretcher, c/o HA
Neck: supple, +pain on passive fexion,
Back: +lumbar lami scar, no
CV: RRR, Nl S1 and S2, 2/6 SEM
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender, +hepatomegaly (non-tender)
ext: no edema
Neurologic examination:
Mental status: Awake and alert, cooperative with exam, Oriented
to person, place, and date. She is inattentive, cannot say [**Doctor Last Name 1841**]
backwards. Speech is fluent with impaired comprehension and
intact repetition; naming impaired - makes many semantic
paraphasic errors. No dysarthria. [**Location (un) **] intact. Unable to do
calculations. + left-right confusion. No evidence of apraxia
or
neglect.
Cranial Nerves:
I: not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally. Appears to have a mild right field cut (worse
inferiorly than superiorly), but she does not cooperate well
with
exam.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V: Sensation "different" on left.
VII: Mild righ NLF flattening.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palate elevation symmetrical
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations, intact movements
Motor:
Normal bulk bilaterally. Tone Increased on right UE and LE. No
observed myoclonus or tremor
[**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IP H Q DF PF TE TF
R 0 0 0 0 0 0 0 0 0 0 0 0 1 1
L 5 5 5 5 5 5 5 5 5 5 5 5 5 5
Sensation: Decreased to light touch, pinprick on right.
Difficult
to evaluate vibration and proprioception due to inattension.
Reflexes:
B T Br Pa Ach
Right 2 2 2 0 1
Left 2 2 2 0 1
Toes were upgoing on right, downgoing on left
Coordination: normal on finger-nose-finger with left hand.
Pertinent Results:
WBC 9.8 (peaked at 16 on [**11-19**])
Hct 37 (nadired at 34 on [**11-23**]
MCV 94
Plt 209
INR 1.1
PTT 36.9 (previous PTTs were normal)
UA [**11-19**]: sm LE, mod bld, tr prot, [**10-10**] WBC, 0 epis, [**1-23**] RBCs
CSF ([**11-19**] after drain) 2 WBC, 305 rbcs, prot 27, gluc 81
CSF ([**11-23**] prior to drain removed) 30 WBCs, 1140 RBCs
Na 142, K 4.0, Cl 109, bicarb 25, BUN 19, Cr 0.6, gluc 126
CK 239, 266 ([**2172-11-13**]) with MB 3, trop <0.01 x 2
Cal 9.1, phos 3.1, mag 2.1
HBA1c 5.4
TG 56 HDL 57 LDL 97 Chol 163
Dilantin 10.2 on [**2172-11-23**]
Stox neg [**2172-11-13**]
ABG [**2172-11-25**]: 7.43/38/82
Micro:
Blood Cx: [**11-14**] NG, [**11-19**] NG, [**11-23**] pending
Urine Cx: [**11-15**] GNR, [**11-19**] contam, [**11-23**] contam
CSF Cx: [**11-19**] NG, [**11-23**] NG
Sputum Cx: [**11-19**] & [**11-23**] sparse OP flora
Cath tip Cx: [**11-19**] NG
NCHCT's:
[**11-13**] at 7:30pm: 1. Moderate-to-large intraparenchymal
hemorrhage within left parietal lobe. 2. Surrounding edema and
sulcal effacement.
[**11-13**] at 11:30pm - no significant change
[**11-6**]: There is no gross change in the left parietal
intracerebral hemorrhage. 3. There has been mild interval
decrease in size of the right frontal subdural hematoma compared
to [**2172-11-14**].
[**11-21**]: 1. No change in the size of the intraparenchymal left
parietal hemorrhage. 2. Slightly more mass effect in the left
cerebral hemisphere with slightly more shift of the midline
structures and more effacement of the suprasellar
cistern.
[**11-24**]: The extent of the hyperdense component of the large left
parietal lobe hemorrhage has reduced since the prior study of
[**11-21**], consistent with partial resorption of the high
density
components. Both studies show what is likely a small right
frontal subdural hematoma, hyperdense relative to
spinal fluid and therefore likely relatively acute in age. The
most superior portion of the hemorrhage is the thickest and
causes slight impression on the adjacent frontal lobe gyri.
The left parietal lobe hemorrhage has an extensive zone of
surrounding edema within the white matter, essentially unaltered
in extent but causing considerable compression of the adjacent
left lateral ventricle. There is a few mm rightward shift of the
septum pellucidum and likely the 3rd ventricle as well. No other
interval changes are appreciated.
Angiogram on [**11-14**]: 1. No evidence of definite dilated arterial
structure, nidus, or dilated veins to indicated arterial venous
malformation. However, it should be noted that CT Angiography is
not sensitive for subtle arterial venous malformation,or changes
from vasculitis, which can be detected with conventional
angiography. 2. No aneurysm is identified. 3. A small somewhat
dilated venous structure in the left frontal lobe could be
secondary to a developmental venous anomaly. 4. It should be
noted that the volume-rendered images are not available for
interpretation. If new findings are seen on those images when
they are available, an addendum will be given to this report.
5. MRI would be helpful for further evaluation.
CXR [**11-13**]: no CP dz
[**2171-11-25**]: report pending, possibly some effusion on the left ?
MRI brain with gad on [**11-14**]: 1. No change in the large left
parietal hemorrhage and its mass effect. 2. There is increased
vascularity noted in the left temporal region. A conventional
angiogram is recommended for further evaluation to exclude an
underlying vascular malformation. 3. No change in the size of
the right frontal subdural hematoma.
CT torso on [**11-18**]: 1) Diffuse patchy nodular or pulmonary
opacities greater posteriorly. This appearance may be due to
infection, aspiration, or inflammatory changes.
2) Right IJ CVL tip in right atrium.
3) Nodular appearance of liver consistent with patient's history
of cirrhosis. Two low attenuation right hepatic foci are
unchanged in appearance and may represent cysts.
4) Cholelithiasis without evidence of cholecystitis.
5) Bilateral nonobstructing renal stones.
6) Likely pancreatic cysts.
EEG on
[**11-15**]: This is an abnormal portable EEG due to the presence of
a
slow and disorganized background rhythm in the [**1-23**] Hz delta and
theta frequency ranges. In addition there is moderate to high
amplitude generalized delta frequency slowing, often with a
triphasic morphology. These findings suggest deep midline
subcoritcal dysfunction and are consistent with an
encephalopathy. No clear lateralizing or epileptiform
abnormalities were seen. Sinus tachycardia was noted on
the cardiac monitor.
[**11-19**]: IMPRESSION: Markedly abnormal portable EEG due to the
prominant focal delta slowing seen over much of the left
hemisphere with some sharp components but no overtly
epileptiform
abnormalities, and due to the bursts of generalized slowing and
surpression and slowing of the background. The first abnormality
suggests a focal structural lesion in the left hemisphere. This
had sharp features but no overtly epileptiform abnormalities.
This does not rule out the possibility of seizures at other
times. The other abnormalities indicate a widespread
encephalopathy. Medications, metabolic disturbances and
infection
are among many possible causes.
Brief Hospital Course:
55 yo woman with large left parietal-occipital lobe hemorrhage
likely secondary to drug use although other causes must be ruled
out. ** PLEASE HPI FOR COMPLETE ICU COURSE INCLUDING WORKUP
THUS FAR **
On exam upon discharge, is awake, alert, oriented to self only,
thinks she's in [**State **], +repeats, + follows commands, + fluent,
realizes she has had a stroke and her right side does not work
well. No neglect, but does have right visual field cut, right
hemiplegia.
NEURO - lobar bleed, likely secondary to amphetamines,
angiography negative, CT torso and MRI showed no metastases.
Mannitol d/c'd. On dilantin for sz prophylaxis although plan is
to wean this over the next 5 days, 2 EEGs without frank
epileptiform activity.
- BP control with PO lopressor
- multipodus boot for RLE
- vent drain d/c'd and extubated on [**11-24**]
CONFUSION - likely secondary to pneumonia, bleed, possibly from
methamphetamine withdrawl causing prolonged intubation.
- levo x 10 days for aspiration pna (to finish [**2172-11-29**]). Also
has atelectasis and needs inspiration spirometer use qD.
ID:
- finished course of cefazolin for vent drain
BP control:
- metoprolol 25 TID
HYPERGLYCEMIA (likely from tube feeds which have now been
stopped): RISS
FEN:
- PPI, thiamine/folate/MVI
- passed video swallow, ground food + thin liquids
PPx: PPI, SC heparin, IS, OOB
Dispo: seen by PT/OT, needs rehab.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
2. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection, 5000 units Injection TID (3 times a day).
Disp:*90 injection, 5000 units* Refills:*2*
3. Clonidine HCl 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch
Weekly Transdermal QTHUR (every Thursday).
Disp:*4 Patch Weekly(s)* Refills:*2*
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*60 Tablet(s)* Refills:*0*
6. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO TID
(3 times a day).
Disp:*450 ML(s)* Refills:*2*
7. Quetiapine Fumarate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
8. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
9. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Phenytoin Sodium Extended 30 mg Capsule Sig: Per taper
schedule, below Capsule PO once a day for 5 days: [**2172-11-28**]: 3
capsules
[**2172-11-29**]: 2 capsules
[**2172-11-29**]: 2 capsules
[**2172-11-30**]: 1 capsule
[**2172-12-1**]: 1 capsule
[**2172-12-2**]: none.
Disp:*9 Capsule(s)* Refills:*0*
13. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed.
Disp:*30 Capsule(s)* Refills:*0*
15. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
16. Insulin Regular Human 100 unit/mL Solution Sig: per sliding
scale Units, regular insulin Injection QACHS: For BG 151-200: 2
Units
201-250: 4 Units
251-300: 6 Units
301-350: 8 Units
351-400: 10 Units
>= 401: 12 Units and [**Name8 (MD) 138**] MD.
.
Disp:*QS Units, regular insulin* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Left parieto-occipital hemmorhagic stroke
Discharge Condition:
Stable
Discharge Instructions:
PT/OT
Take all meds. Attend all followup appointments. Return to the
ED if you experience worsening weakness or unresponsiveness.
Followup Instructions:
With acute rehabilitation facility, and with Dr. [**First Name4 (NamePattern1) 40095**] [**Last Name (NamePattern1) **] in
the [**Hospital 4038**] Clinic at the [**Hospital3 **] Hospital:
[**2-2**], 3 PM, [**Location (un) 858**], [**Hospital Ward Name 23**] Building.
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
ICD9 Codes: 5070, 5990, 5715 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3592
} | Medical Text: Admission Date: [**2146-1-14**] Discharge Date: [**2146-1-19**]
Service: CCU
HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname 131**] is an 80-year-old
woman who was in her usual state of health until
approximately six weeks prior to admission when she fell and
sustained a nose fracture. She then spent two weeks in a
rehabilitation facility, went home for one week, and was then
readmitted to an outside hospital Intensive Care Unit with a
NSTEMI on [**2145-12-30**]. At this time, the patient was felt to be
too debilitated to undergo cardiac catheterization, and she
was therefore transferred to rehabilitation on medical
management.
After recovering, her PCP made arrangements for her transfer
to the [**Hospital1 69**] for cardiac
catheterization. Of note, on [**2145-12-30**], her electrocardiogram
demonstrated T-wave inversions in leads V2 through V4, and
the patient was given enoxaparin, aspirin, and a beta
blocker.
On the day of admission, the patient underwent cardiac
catheterization. This study demonstrated very mild anterior
hypokinesis, no mitral regurgitation, and a left ventricular
ejection fraction of approximately 65%. Her coronary
vasculature was found to be right dominant. She has a normal
LMCA. There was a 90-95% elongated stenosis in the mid
portion of her left anterior descending artery involving the
take-off of a moderate sized first diagonal branch. There
was 80-90% stenosis of the distal vessel. There is also 90%
stenosis of the ostium of D1. There was 60-70% stenosis
proximally in the LCX followed by a 50-60% stenosis.
Stenoses 30-40% were also seen in the OM. Stenoses 50% were
seen in the mid portion of the right coronary artery.
The left anterior descending artery was successfully stented,
and the first diagonal branch was rescued by wire. Late in
the case, thrombus was noted in the left anterior descending
artery stent. Eptifibide was then started, and then the
stent was redilated with a 3 mm balloon. Shortly thereafter,
the patient developed hematemesis necessitating
discontinuation of the eptifibide.
Also of note, the patient developed hypotension several times
during the procedure, each time quickly responding to
Dopamine. At the end of the case, a right heart
catheterization demonstrated a low resting right and left
heart filling pressures and low cardiac index, suggesting
hypovolemia. There was no equalization of pressures. An
echocardiogram demonstrated a tiny pericardial with no
tamponade physiology. There was hypokinesis of the lateral
wall with left ventricular ejection fraction of 45%. The
patient was then transferred to the CCU in stable condition
for further monitoring.
PAST MEDICAL HISTORY:
1. Multiple prior falls with the most recent fall in [**2145**]
while on lorazepam and Zolpidem.
2. Subdural hematoma in [**2141**].
3. Right sided cerebrovascular accident complicated by upper
and lower extremity spasticity and hemiparesis.
4. Hypertension.
5. Baseline confusion.
6. Hypercholesterolemia.
ALLERGIES: No known drug allergies.
MEDICATIONS ON TRANSFER TO THE CCU:
1. EC-ASA 81 mg po q day.
2. Atorvastatin 10 mg po q day.
3. Metoprolol 50 mg po tid.
4. Citalopram 10 mg po q day.
5. Clonazepam 1 mg po q day.
6. MVI one cap po q day.
SOCIAL HISTORY: The patient lives with her daughter in a
house with stairs. Of note, the patient lives on the [**Location (un) 13453**] of this house. The patient denies any history of
tobacco, alcohol, or drug abuse.
PHYSICAL EXAMINATION: On initial physical examination, the
patient's temperature was 99.0 degrees, blood pressure
112/56, heart rate 97, respiratory rate 15, oxygen saturation
is 98% on 3 liters nasal cannula, and her weight was 124
pounds. On Telemetry the patient was found to be in normal
sinus rhythm with a rare PVC. In general, the patient was
lying in bed and confused, although she was in no acute
distress. Her heart was a regular, rate, and rhythm, there
was a 3/6 systolic murmur at the left upper sternal border
without rubs or gallops. She had bibasilar crackles on the
left greater than on the right, and no wheezes. Her abdomen
was soft, nontender, and nondistended and there were
normoactive bowel sounds. She had left femoral sheaths
present without evidence of hematoma. There was trace
bilateral lower extremity pitting edema. Patient was moving
all extremities without difficulty. She was alert and
oriented to the hospital.
Initial laboratory evaluation: The patient's white blood
cells 13.4, hematocrit 24, platelets 405. Initial serum
chemistries were remarkable for a bicarbonate of 19, but
otherwise unremarkable. Initial CK was 165.
Initial electrocardiogram demonstrated ectopic atrial
activity with a rate in the 80s. There was evidence of early
R-wave progression, and biphasic T waves were noted in leads
V2 and V3.
HOSPITAL COURSE BY SYSTEMS:
1. Cardiovascular: Quickly following her arrival to the CCU,
the patient was weaned off Neo-Synephrine; this medication
had been started in the Catheterization Laboratory given her
hypotension. Her postprocedural hypotension was most likely
secondary to a combination of a vagal reaction and
hypovolemia. She was transfused a total of 4 units of packed
red blood cells with a good hemodynamic response. She
subsequently remained hemodynamically stable throughout the
remainder of her admission.
In terms of her coronary artery disease, the patient
underwent PTCA and stenting of the left anterior descending
artery complicated by transient D1 occlusion (restored with
wire) and left anterior descending artery stent thrombosis.
The patient was transiently started on Heparin and
Epidifibitide with resolution of the thrombosis, although she
subsequently developed gastrointestinal bleed. Her Heparin
and eptifibitide were therefore discontinued. She was
maintained on aspirin and Plavix throughout her
hospitalization, although the Heparin and eptifibitide were
not restarted. She was subsequently stabilized on a beta
blocker and atorvastatin.
An echocardiogram was performed on [**2146-1-17**]. This study
demonstrated overall normal left ventricular systolic
function with an ejection fraction of greater than 55%. No
A-V stenosis was seen. Trace AR was seen. There was also
evidence of trivial MR. There was no evidence of pericardial
effusion. The patient was subsequently discharged on a
stable medical regimen as noted below.
Gastrointestinal: As noted above, the patient developed
significant hematemesis, hypotension, and hypovolemia in the
context of anticoagulation during her cardiac
catheterization. The patient subsequently received a total
of 4 units of packed red blood cells with an appropriate
increase in her hematocrit. An abdominal CT scan was done on
[**2146-1-14**] in order to evaluate for a possible retroperitoneal
hematoma; this study was negative. She was initially started
on an intravenous proton-pump inhibitor given her likely
upper gastrointestinal bleed, and was subsequently
transitioned to an oral proton-pump inhibitor prior to
discharge.
At the time of discharge, she was hemodynamically stable, her
hematocrit had been stable for over 48 hours, and she had no
evidence of active gastrointestinal bleeding.
Neurology: The patient has baseline dementia and cognitive
impairment. She was continued on risperidone as needed for
agitation, as well as clonazepam 0.5 mg po bid. She was
given acetaminophen as needed for her chronic right lower
extremity pain.
DISPOSITION: Prior to her discharge, the patient was
evaluated by the Department of Physical Therapy. The
physical therapist felt that the patient was currently
functioning below her baseline, and therefore, a stay at a
rehabilitation facility was recommended to maximize
independence with functional mobility prior to returning
home.
DISCHARGE CONDITION: Stable.
DISCHARGE PLACEMENT: To rehabilitation facility.
DISCHARGE DIAGNOSES:
1. Recent NSTEMI ([**2145-12-30**]).
2. Coronary artery disease status post PTCA and stenting of
the left anterior descending artery.
3. Upper gastrointestinal bleeding.
4. Baseline dementia.
5. Acute blood loss anemia status post cardiac
catheterization.
6. Hypotension secondary to hypovolemia status post cardiac
catheterization.
7. CT scan to rule out peritoneal bleed that was negative.
DISCHARGE MEDICATIONS:
1. EC-ASA 325 mg po q day.
2. Clopidogrel 75 mg po q day x6 months.
3. Atorvastatin 20 mg po q day.
4. Metoprolol 50 mg po bid.
5. Pantoprazole 40 mg po q day.
6. Clonazepam 0.5 mg po bid.
6. MVI one cap po q day.
7. Citalopram 10 mg po q day.
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7169**]
Dictated By:[**Name8 (MD) 2507**]
MEDQUIST36
D: [**2146-1-18**] 03:37
T: [**2146-1-18**] 04:11
JOB#: [**Job Number 45964**]
ICD9 Codes: 2765, 2851, 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3593
} | Medical Text: Admission Date: [**2107-10-4**] Discharge Date: [**2107-10-8**]
Date of Birth: [**2068-12-14**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
Right Ventricular Outflow Tract Ablation
History of Present Illness:
Ms. [**Known lastname **] is a 38 yo F with history of chronic hepatitis B who
is presenting with increasing syncopal episodes over the last
three weeks. The patient reports that she had first syncopal
episodes about a year ago; she had a normal EKG and stress test
at the time; her symptoms otherwise resolved. However, over the
last three weeks, she has noted having increasing syncopal
episodes. The patient reports that she will have a "funny"
feeling in her heart and then within seconds will pass out, LOC,
lasting anywhere from 15-30 seconds. Denies any presyncopal
symptoms; no flushing, n/v, diaphoresis. After walking up, she
reports that her heart is racing, "pounding out of chest." She
also reports generalized weakness after episode. Denies any
confusion, tremors, confusion upon awakening, no stool/urinary
incontinence, no tongue biting. Over the last three weeks, the
patient reports that these episodes have been getting more
frequent (up to 6-7 times/day) and she thinks that they have
been lasting longer than normal. Also reports that the longer
she is blacked out for, the more intense her heart palpitations
and heart racing she feels. No association with standing
up/positional change. Episodes occur when walking or when
sitting.
.
EKG showing RSR prime in V2, with STE in V2, V3. Frequent PVCs
on tele with NSVT; tele on the floor with greater than 10
PVCs/minute. Pt had symptomatic NSVT and was transferred to CCU
with 60 second run of VT. Could not get 12 lead, but given IV
metoprolol 2.5 mg
.
Denies any recent fevers/chills, no n/v/d, no blood in stools,
no changes in bowel movements, no urinary symptoms, no joint
pain, no changes in vision, no headaches, denies any pleuritic
chest pain. She does reports recent "chest cold" with a
productive cough of green sputum.
.
Cardiac review of systems negative as per above.
Past Medical History:
1. CARDIAC RISK FACTORS: -Diabetes, -Dyslipidemia, -Hypertension
2. CARDIAC HISTORY:
- CABG:
- PERCUTANEOUS CORONARY INTERVENTIONS:
- PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
- Chronic Hepatitis B
Social History:
Pt lives with her husband and two young children. Was born in
[**Country 3992**], and came to the US in [**2088**]. Used to work as a
researcher for pharmaceutical company; now stays at home with
children. Denies any alcohol, smoking, or drug use.
Family History:
Mother with bladder cancer, and father with liver cancer.
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: 97.6 85 109/56 28 99 on RA
GENERAL: pleasant young woman, NAD, sitting up comfortably in
bed, alert and talkative
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple, no JVP appreciated
CARDIAC: RRR, normal S1, S2, no murmurs/rubs/gallops
appreciated
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
Neuro: CN 2-12 grossly intact, normal muscle strength and
sensation throughout
.
DISCHARGE PHYSICAL EXAM:
VS: 98.2 77 112/63 14 100 on RA
GENERAL: ple2sant young woman, NAD, sitting up comfortably in
bed, alert and talkative
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple, no JVP appreciated
CARDIAC: RRR, normal S1, S2, no murmurs/rubs/gallops
appreciated
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
Neuro: CN 2-12 grossly intact, normal muscle strength and
sensation throughout
Pertinent Results:
ADMISSION LABS:
.
[**2107-10-4**] 06:15PM BLOOD WBC-8.8 RBC-4.44 Hgb-13.1 Hct-39.1
MCV-88# MCH-29.6# MCHC-33.6 RDW-13.1 Plt Ct-231
[**2107-10-4**] 06:15PM BLOOD Neuts-76.9* Lymphs-18.7 Monos-3.1 Eos-1.0
Baso-0.4
[**2107-10-4**] 06:15PM BLOOD Plt Ct-231
[**2107-10-4**] 06:15PM BLOOD Glucose-88 UreaN-15 Creat-0.6 Na-140
K-3.6 Cl-106 HCO3-26 AnGap-12
[**2107-10-4**] 06:15PM BLOOD Calcium-9.0 Phos-3.5 Mg-2.3
[**2107-10-4**] 06:30PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.014
[**2107-10-4**] 06:30PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG
[**2107-10-4**] 06:30PM URINE RBC-1 WBC-17* Bacteri-NONE Yeast-NONE
Epi-3
[**2107-10-4**] 06:30PM URINE UCG-NEGATIVE
.
PERTINENT LABS:
.
[**2107-10-5**] 06:00AM BLOOD TSH-3.3
[**2107-10-4**] 06:30PM URINE UCG-NEGATIVE
.
DISCHARGE LABS:
.
[**2107-10-8**] 05:58AM BLOOD WBC-6.6 RBC-3.98* Hgb-11.6* Hct-35.2*
MCV-88 MCH-29.1 MCHC-33.0 RDW-12.8 Plt Ct-205
[**2107-10-8**] 05:58AM BLOOD Glucose-87 UreaN-12 Creat-0.5 Na-140
K-3.9 Cl-106 HCO3-27 AnGap-11
[**2107-10-8**] 05:58AM BLOOD Calcium-8.6 Phos-3.9 Mg-1.9
.
MICRO/PATH:
.
MRSA Screen: Negative
.
IMAGING/STUDIES:
.
CXR PA/LAT [**10-4**]:
IMPRESSION: No acute cardiopulmonary process.
.
TTE 11/
IMPRESSION: No structural cardiac cause of syncope identified.
Preserved global and regional biventricular systolic function.
No resting VOT obstruction. Mild to moderate mitral
regurgitation with borderline elevation of pulmonary artery
systolic pressure.
Brief Hospital Course:
Ms. [**Known lastname **] is a 38 yo F with history of chronic hepatitis B who
is presenting with increasing syncopal episodes over the last
three weeks, transferred to CCU after 60 seconds of VT and
possibility of Brugada syndrome. However, found to have no
structural heart abnormalities on ECHO.
.
# syncope/ recurrent idiopathic VT: The patient's ECHO did not
show any evidence of structural heart disease, making Brugada
syndrome unlikely. EP study was performed and the patient is
now status post right ventricular outflow tract ablation. Prior
to the study, beta blockers were held. She was monitored on
tele and her lytes wer repleted aggressively. The patient had
intermittent, self resolving, limited runs of VT while in the
CCU. However, post ablation, her heart rhythm normalized. Post
procedure ECHO was normal, without any evidence of pericardial
effusion. The patient was set up with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts monitor
upon discharge, and she was instructed to follow up with Dr.
[**Last Name (STitle) **].
.
# cough: Pt reports having a cough productive of green sputum.
Denies any fevers, likely bronchitis. A CXR was done showing no
acute infiltrate; no antibiotics were started.
.
# hepatitis B: chronic, not on any medications
.
# dirty UA: The patient was found to have dirty UA with large
leuks and 17 WBC. However, because she was completely
asymptomatic, no treatment was initiated.
.
Transitional Issues:
- The patient is to follow with Dr. [**Last Name (STitle) **] as an out patient re:
[**Doctor Last Name **] of hearts monitoring, which she was discharged with.
Medications on Admission:
none.
Discharge Medications:
none.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
Ventricular Tachycardia status-post Right Ventricular Outflow
Tract Ablation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname **]--
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted with an intermittent abnormal
heart rhythm called Ventricular Tachycardia. You underwent a
study that identified the area in your heart that was causing
the abnormal heart rhythm. You underwent an ablation procedure
and your heart rhythm returned to [**Location 213**]. You are now ready for
discharge.
.
We have set you up for [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts heart monitor to help
monitor your heart.
Followup Instructions:
Please call [**Telephone/Fax (1) 3342**] to schedule a follow-up appointment
with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Completed by:[**2107-10-10**]
ICD9 Codes: 4271 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3594
} | Medical Text: Admission Date: [**2131-4-23**] Discharge Date: [**2131-5-3**]
Date of Birth: [**2054-4-15**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
intubation
central line placement
Cardiac catheterization with no intervention
History of Present Illness:
77 YO gentleman with history of multiple TIAs s/p recetn CEA on
[**4-20**] brought into ED by ambulace for hypoxemia and respiratory
failure. Dr. [**Known lastname **] underwent CEA on [**4-20**] and by accounts had an
uneventful post operative course. By report he developed SOB
yesterday that progressivly worsened overnight. This morning he
was unable to get out of bed secondary to weakness. EMS was
called and by their report he was found supine and purple in
bed. They placed on 15l NRB and O2 Sats only came up to 90%. On
arrival to the ED his VS were notable for RR of 40 and sats in
the 90'2 on 15L. He was awake and alert on arrival with a
relativly clear mental status. He was only able to speak in one
or two word sentences. A CXR demonstrated new onset pulmonary
edema. He has no known pulmonary or cardiac history. He had no
reports of fevers, post op or pre-hospital. He denied cough to
ED staff.
.
In the ED he was initially placed on BiPap and had improvement
in his oxygenation. He was given a sublingual NTG and became
hypotensive, this precluded him receiving nitro GTT. He did not
receive IVF. He was noted to have several apneic episodes while
on BiPAP and was intubated due to respiratory fatigue. The
intubation was complicated by difficult to visualize airways and
he suffered a laceration of his lips. By report there was NO
blood in the ETT.
.
He is currently on FiO2 100 %/Peep 5/Rate 17/TV 600. Sedated on
fentanyl and versed. On 6mcg of dopa with BP 113/68. He has had
minimal UOP. Total UOP 100.
.
His labs are significant for a troponin of 1.13, leukocyotsis
21.6, Anion gap acidosis, Cr of 2.5 (baseline 0.9) and an
elevated lactate (6--->3 with intubation).
Past Medical History:
-h/o stroke in [**2118**], treated at [**Hospital1 2025**], L MCA territory
-BPH with secondary hematuria
-cystic pancreatic mass, following q2years
Social History:
Works at the Mind Body Institute he founded and teaches at HMS.
No tobacco, EtOH, illicits. Lives with wife, he provides care
for his wife and administers her medications.
Family History:
Brother had MI in 40s, sister has carotid stenosis.
Physical Exam:
ED Admission exam:
Temp: 98.2 HR: 109 BP: 108/77 Resp: 33 O(2)Sat: 91 Low
Constitutional: O2 sat 90% NRB FM; pulse 70s
HEENT: Pupils equal, round and reactive to light,
Extraocular muscles intact, Normocephalic, atraumatic
no wheezing; left neck with ecchymosis; no bruit; no puls
mass; JVD on right 5 cm
Chest: bilateral insp rales [**12-25**] way up
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds; no m/r/g
Abdominal: Normal
Extr/Back: Normal
Skin: ecchymosis left neck but no other rashes
Physical Exam on Discharge:
VS: 98.2/98.2 67-72 RR 18-20 BP: 125-152/74-76 O2 sat 92-97% RA
I/O: 8 hour 84/425
24 hour 1130/[**2103**]
TELE: SR, HR 70's
Weight: refused for 2 days
GEN: NAD, sitting comfortably in chair
HEENT: MMM, no conjunctival erythema or scleral icterus
NECK: no JVD; ecchymosis over left CEA site but no fluctuance or
mass
CV: Regular, S1 and S2, no murmur
PULM: lungs CTA throughout
ABDOMEN: nondistended, (+)bowel sounds, nontender
EXTREM: 2+ DP and PT pulses bilaterally, no edema, warm feet
NEURO: alert, oriented x3, answers all questions appropriately
Pertinent Results:
Admission Labs:
[**2131-4-23**] 01:30PM BLOOD WBC-21.6* RBC-4.35* Hgb-13.7* Hct-43.1
MCV-99* MCH-31.4 MCHC-31.7 RDW-13.4 Plt Ct-265
[**2131-4-23**] 01:30PM BLOOD Neuts-90.1* Lymphs-4.9* Monos-4.0 Eos-0.8
Baso-0.3
[**2131-4-23**] 01:30PM BLOOD Glucose-279* UreaN-47* Creat-2.5*# Na-135
K-4.9 Cl-94* HCO3-23 AnGap-23*
[**2131-4-23**] 05:31PM BLOOD ALT-41* AST-152* CK(CPK)-912* AlkPhos-88
TotBili-0.7
Relevant Labs:
[**2131-4-22**] 08:05AM BLOOD proBNP-8203*
[**2131-4-23**] 01:30PM BLOOD CK-MB-40* MB Indx-4.9
[**2131-4-23**] 01:30PM BLOOD cTropnT-1.33*
[**2131-4-23**] 05:31PM BLOOD CK-MB-46* MB Indx-5.0 cTropnT-2.08*
[**2131-4-24**] 12:45AM BLOOD CK-MB-44* MB Indx-5.6 cTropnT-2.96*
[**2131-4-25**] 04:02AM BLOOD CK-MB-11* MB Indx-4.9 cTropnT-4.25*
[**2131-4-26**] 05:27AM BLOOD CK-MB-4 cTropnT-5.38*
[**2131-4-27**] 05:25AM BLOOD CK-MB-2 cTropnT-5.70*
[**2131-4-28**] 03:18AM BLOOD CK-MB-2 cTropnT-5.21*
Imaging/Reports:
Chest x-ray [**2131-4-23**]
Endotracheal tube positioned appropriately. NG tube appears
also
to be positioned appropriately, though the tip is excluded from
view. Diffuse pulmonary edema with pleural effusions again
seen.
TTE [**2131-4-23**]
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. There is moderate to
severe regional left ventricular systolic dysfunction with near
akinesis of the distal 2/3rds of the septum, anterior wall,
apex, and distal inferior wall. The remaining segments contract
normally (LVEF = 30 %). No intraventricular thrombus is seen.
Tissue Doppler imaging suggests an increased left ventricular
filling pressure (PCWP>18mmHg). Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets are
mildly thickened (?#).No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. No mitral
regurgitation is seen. [Due to acoustic shadowing/suboptimal
image quality, the severity of mitral regurgitation may be
significantly UNDERestimated.] The pulmonary artery systolic
pressure could not be quantified. There is an anterior space
which most likely represents a prominent fat pad.
IMPRESSION: Normal left ventricular cavity size with extensiver
regional systolic dysfunction c/w CAD (mid-LAD distribution) or
Takotsubo cardiomyopathy. No definite valvular dysfunction.
Compared with the prior study (images reviewed) of [**2131-4-19**],
the left ventricular wall motion abnormalities are new and c/w
interim ischemia/infarction.
TTE [**2131-4-27**]:
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is
moderately-to-severely depressed (LVEF = 30 %) secondary to
extensive severe hypokinesis/akinesis involving the anterior
septum, anterior free wall, apex, and inferior septum. Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). Right ventricular chamber size and free
wall motion are normal. The ascending aorta is mildly dilated.
The aortic valve leaflets are mildly thickened (?#). There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. The mitral valve
leaflets are myxomatous. There is mild posterior leaflet mitral
valve prolapse. Moderate (2+) mitral regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is a very small pericardial effusion. There are no
echocardiographic signs of tamponade.
Compared to the prior study of [**2131-4-23**], moderate mitral
regurgitation is now seen.
Renal US:
FINDINGS: The right kidney measures 12.2 cm and the left kidney
measures 11.4 cm. A 6 x 6 x 4 mm non-obstructing stone is
present in the right kidney interpolar region. No left renal
calculus. No hydronephrosis or mass seen in either kidney. The
bladder contains a Foley, is minimally distended, and cannot be
assessed.
IMPRESSION: 6-mm nonobstructing right renal stone. No
hydronephrosis
Cardiac Catheterization [**2131-5-1**]:
1. Selective coronary angiography in this left-dominant system
demonstrated two vessel disease. The LMCA had no
angiographically
apparent disease. The LAD was occluded proximally and filled via
right-to-left collaterals. The LCx was dominant and had mild
disease.
The nondominant RCA was subtotally occluded but provided robust
collaterals to the LAD via an acute marginal.
2. Limited resting hemodynamcis revealed normal systemic
arterial blood
pressure.
FINAL DIAGNOSIS:
1. Two-vessel coronary artery disease.
2. Normal systemic arterial blood pressure.
Dobutamine Stress Test [**2131-5-2**]:
77 yo man presented in respiratory failure secondary
to subacute anterior MI post-op following left carotid
endarterectomy on
[**2131-4-20**], cardiac catheterization revealing 2-vessel CAD and
depressed
LVEF was referred to evaluate for viability in LAD territory.
The
patient was administered 2.5, 5, 10 and 20 mcg/kg/min of
Dobutamine (5
min stages) for a total infusion duration of 20 minutes. No
chest, back,
neck or arm discomforts were reported. No significant ST segment
changes
were noted during the procedure. The rhythm was sinus with rare
isolated
VPBs noted. The heart rate response was appropriate. A blunted
blood
pressure response was noted with the Dobutamine infusion.
IMPRESSION: No anginal symptoms or ischemic ST segment changes.
Blunted
blood pressure response to the Dobutamine infusion. Echo report
sent
separately.
Stress ECHO [**5-2**]:
The patient received intravenous dobutamine in 5 min (low dose
2.5mcg/kg/min) and 3 minute stages (>5mcg/kg/min) to a maximum
of 20 mcg/kg/min. The test was stopped because the viability
protocol was completed. In response to stress, the ECG showed no
diagnostic ST-T wave changes (see exercise report for details).
The blood pressure response to stress was blunted. There was a
normal heart rate response to stress.
.
Resting images were acquired at a heart rate of 72 bpm and a
blood pressure of 136/68 mmHg. These demonstrated regional left
ventricular systolic dysfunction with severe hypokinesis to
akinesis of the septum, anterior wall, mid to distal lateral
wall, apex, and distal inferior wall. The remaining segments
contracted well. (LVEF = 25-30 %). Right ventricular free wall
motion is normal. There is a trivial pericardial effusion.
Doppler demonstrated trace aortic regurgitation and moderate
mitral regurgitation with no aortic stenosis or significant
resting LVOT gradient.
At low dose dobutamine [5mcg/kg/min; heart rate 72 bpm, blood
pressure 134/60 mmHg), there was failure to augment systolic
function of the affected (LAD territory) segments. At mid-dose
dobutamine [5-10 mcg/kg/min; heart rate 74 bpm, blood pressure
130/50 mmHg), there was failure to further augment systolic
function of the affected left ventricular segments. At peak
dobutamine stress [20 mcg/kg/min; heart rate 88 bpm, blood
pressure 128/50 mmHg), no new regional wall motion abnormalities
were identified. Baseline abnormalities persist.
IMPRESSION: No diagnostic ECG changes with 2D echocardiographic
evidence of prior proximal LAD-territory myocardial infarction
without inducible ischemia to dobutamine administration or
evidence of viability of the anterior/septal/apical/distal
inferior wall. The other segments augment appropriately. Trace
aortic regurgitation at rest. Moderate mitral and tricuspid
regurgitation at rest. At least moderate pulmonary hypertension.
Labs on Discharge:
[**2131-5-3**] 04:58AM BLOOD WBC-12.5* RBC-3.48* Hgb-11.1* Hct-33.9*
MCV-98 MCH-31.9 MCHC-32.7 RDW-13.6 Plt Ct-313
[**2131-5-3**] 04:58AM BLOOD Glucose-165* UreaN-32* Creat-1.6* Na-137
K-3.9 Cl-104 HCO3-23 AnGap-14
[**2131-5-1**] 07:40AM BLOOD Calcium-8.1* Phos-4.0 Mg-1.9
Brief Hospital Course:
Dr. [**Known lastname **] is a 77 year old gentleman who presented 2 days s/p
left CEA with new-onset systolic CHF secondary to peri-operative
anterior MI. His course has been complicated by hypoxic
respiratory failure (resolved/extubated after treatment of CHF),
AFib (s/p cardioversion and Amiodarone), and [**Last Name (un) **] (likely from
hypoperfusion, now resolving).
# CAD/acute MI: Enzymes, EKG and history suggested recent MI
associated with pulmonary edema and need for intubation in the
[**Hospital1 18**] ER. Was on lasix GTT and dopamine transiently in the CCU
and ultimately extubated without difficulty once volume status
optimized. Unclear age or extent of infarct but likley had been
>24 hours prior to admission and so did not complete urgent PCI.
TTE showing LVEF 30% with Hypokinesis and akinesis of apex.
Troponins peaked at 5.7. Patient was medically managed. He had
a diagnosstic cardiac catheterization to assess for lesions that
could be intervened upon. It showed left-dominant system two
vessel disease (hydrated pre and post cath to avoid [**Last Name (un) **]). The
LMCA had no angiographically apparent disease. The LAD was
occluded proximally and filled via right-to-left collaterals.
The LCx was dominant and had mild disease. The nondominant RCA
was subtotally occluded but provided robust collaterals to the
LAD via an acute marginal. No intervention was done at that
time. A dobutamine stress test was obtained to assess for
viability. This showed no viability, so patient not candidate
for re-catheterization. Continued home ASA. Started on Toprol
50 XL daily, plavix. Patient initially not on RAAS blocker due
to [**Last Name (un) **], but as Cr trended down, started Lisinopril 2.5. Patient
was seen by representative from the life vest and agreed to use
it on discharge.
.
#. Mild transaminitis: Initially suspicious for drug reaction to
amiodarone or ceftriaxone. Stopped offending agents.
Transaminitis improved. On d/c, patient was tolerating statin.
.
# Paroxysmal Afib: Patient was went into atrial fibrillation
with RVR on morning following admission. He was electrically
cardioverted once in the CCU but promptly flipped back in to
Afib with RVR. He was oaeed with amiodarone and converted to NSR
which he remained in for the duration of his stay. The
amiodarone was eventually discontinued prior to discharge for a
mild transaminitis.
.
# [**Last Name (un) **]: Baseline Cr 1.0 but was 2.5 on arrival. Most likely from
poor perfusion in the setting of decompensated heart failure
however arrived to CCU w/ clot in foley. Changed to 3-way with
CBI. Was never oliguric. Renal ultrasound showed no signs of
obstruction. [**Month (only) 116**] have had some component of ATN. Trended Cr,
avoided nephrotoxins, renally dosed meds. On d/c, Cr was 1.6.
.
# BPH: foley in place. Some pink urine in bag. Urine cultures
were negative x2. Continued Tamsulosin and Finasteride. Team
was in communication with Dr. [**Last Name (STitle) **], the outpt urologist.
Decided to keep foley in on d/c and Dr. [**Last Name (STitle) **] will d/c it as
outpatient.
.
# s/p CEA: Vascular following. Per Vascular Surgery, there was
no concern for bovine graft infection or hematoma on admission.
But given his initial leukocytosis they wanted to empirically
treat with Abx until it is clear he was never bacteremic. Blood
cx from [**4-23**] were negative, so d/c'ed abx on [**4-24**].
.
#. Leukocytosis: On admission, Dr. [**Known lastname **] had persistently mild
leukocytosis (WBC [**12-7**]). WBC was trending up prior to d/c after
CEA, and was discharged on empiric Cipro (had foley in place).
Upon initial presentation this admission, WBC was 21.6 but has
persistently been [**12-7**] since then. Note that he was on
Vanc/Zosyn from admission [**Date range (1) **]. However, here urine culture
negative, initial blood cultures negative, and nothing on
history or physical to suggest PNA. Loose stools but C.diff
negative. Vascular believed there was no bovine CEA graft
infection. No cellulitis. His current leukocytosis was likely
related to MI in addition to ongoing stress response.
Antibiotics were d/c'ed on [**4-24**] as above.
.
TRANSITIONS OF CARE:
- Repeat TTE in 1 month or at cardiology followup to determine
whether he needs the life vest/AICD placement
- Repeat LFTs at PCP visit to ensure transaminitis is resolving
- Will have INR and Chem7 checked on Monday after d/c
- Follow up with urology to have foley removed
- Will need WBC trended and if persistently elevated will need
to be worked up as outpatient
- Emergency Contact : [**Name (NI) 4134**] [**Name (NI) **] (wife/HCP) [**Telephone/Fax (1) 101252**]
Medications on Admission:
1. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Disp:*30 Tablet(s)* Refills:*1*
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
3. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain. Disp:*30 Tablet(s)*
Refills:*0*
4. Vitamin C Oral
5. verapamil 180 mg Tablet Extended Rel 24 hr Sig: 1.5 Tablet
Extended Rel 24 hrs PO once a day.
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation. Disp:*60 Capsule(s)*
Refills:*2*
7. ascorbic acid 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
8. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime). Disp:*30 Capsule,
Ext Release 24 hr(s)* Refills:*2*
9. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 5 days. Disp:*10 Tablet(s)* Refills:*0*
Import Discharge Medications
Discharge Medications:
1. Outpatient Lab Work
Please check Chem-7 and INR on Monday [**5-7**] with results to Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at Phone: [**Telephone/Fax (1) 2010**]
Fax: [**Telephone/Fax (1) 4004**]
ICD 9: 410.01
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Ext Release 24 hr(s)* Refills:*2*
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation.
7. ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO once a
day.
8. ascorbic acid 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
9. Metamucil Powder Sig: Two (2) teaspoons PO once a day as
needed for constipation.
10. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. metoprolol succinate 50 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
12. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. warfarin 2 mg Tablet Sig: 2.5 Tablets PO once a day.
Disp:*75 Tablet(s)* Refills:*2*
14. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual as directed as needed for chest pain: Take 1 tab,
wait 5 min, can take 1 more tab, call 911 if you still have CP.
.
Disp:*25 tab* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Acute systolic congestive heart failure
Myocardial infarction
Acute Kidney Injury
Acute Urinary retention
Transient atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Dr. [**Known lastname **],
You were admitted to [**Hospital1 18**] due to respiratory failure which was
due to heart failure after peri-operative MI. You required
intubation and diuresis but were able to be extubated. Your
stay was complicated by atrial fibrillation (now resolved),
kidney injury due to your heart attack (slowly resolving), and
continued urinary retention (for which you still have a foley
catheter). Please follow up with your PCP, [**Name10 (NameIs) **], and
Urology (appointments listed below).
Due to the decrease in your EF, you should weigh yourself every
morning, call Dr. [**First Name (STitle) **] if weight goes up more than 3 lbs in 1
day or 5 pounds in 3 days.
You have also been fitted with a Lifevest that will defibrillate
ventricular tachycardia or fibrillation if it occurs.
We made the following changes to your medications:
1. START taking clopidogrel to prevent further thrombus
formation
2. START taking metoprolol to slow your heart rate
3. START taking lisinopril to help with remodeling of your heart
and as an afterload reducer
4. START taking tamsulosin and finasteride to shrink your
prostate
5. INCREASE the atorvastatin to 40 mg daily
6. START taking nitroglycerin tablets as needed for chest pain
7. START taking warfarin to prevent clot formation in your left
ventricle and prevent another stroke.
Followup Instructions:
Department: SURGICAL SPECIALTIES
When: TUESDAY [**2131-5-8**] at 11:00 AM
With: [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 276**], M.D. [**Telephone/Fax (1) 164**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 249**]
When: THURSDAY [**2131-5-10**] at 2:50 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD. [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 2010**]
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: THURSDAY [**2131-5-31**] at 2:20 PM
With: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2131-5-5**]
ICD9 Codes: 5845, 2762, 9971, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3595
} | Medical Text: Admission Date: [**2171-12-17**] Discharge Date: [**2171-12-19**]
Date of Birth: [**2128-7-6**] Sex: M
Service: MICU/[**Location (un) **] MEDICINE
CHIEF COMPLAINT: Status post V fibrillation arrest.
HISTORY OF PRESENT ILLNESS: The patient is a 43 year-old
male with a history of metastatic melanoma with course
complicated by duodenal and pancreatic metastases causing
biliary and small bowel obstruction requiring total
parenteral nutrition who presented with worsening abdominal
pain on the day prior to admission. He complained of diffuse
diarrhea, nausea and vomiting. Approximately ten days ago
total parenteral nutrition was discontinued and the patient
was started on po.
On arrival to the Emergency Department the patient appeared
pale and blue and then promptly when into ventricular
tachycardia and V fibrillation arrest. The patient was
shocked at 200 jewels, given Cefepime, Flagyl, Zofran,
morphine, Fentanyl and Propofol. During the code the patient
was given calcium, magnesium, bicarb, insulin and glucose.
The patient was subsequently resuscitated and transferred to
the MICU for further care.
PAST MEDICAL HISTORY:
1. Metastatic melanoma status post DTIC times three, last
echocardiogram two and a half weeks prior to admission.
2. Astrocytoma grade 2 diagnosed eight months ago status
post resection.
3. Metastases to duodenum causing biliary and mechanical
small bowel obstruction on total parenteral nutrition status
post endoscopic retrograde cholangiopancreatography with
biliary stent.
4. Basal cell carcinoma.
MEDICATIONS ON ADMISSION:
1. Compazine 10 mg po q day.
2. Ativan.
3. MS Contin 60 mg po q day.
4. MSIR 15 mg prn.
5. Dulcolax.
6. Megace.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Significant for breast cancer in the family.
SOCIAL HISTORY: Quit alcohol and tobacco use 14 years ago.
The patient is currently not working and sister is health
care proxy.
PHYSICAL EXAMINATION: Temperature 104. Heart rate 129.
Blood pressure 156/107. O2 sat 100%. In general, the
patient is intubated and sedated on mechanical ventilation
500 by 17. HEENT extraocular movements intact. Neck supple.
No JVP. Heart tachycardic. Normal S1 and S2. Lungs clear
to auscultation anteriorly and laterally. Abdomen was soft,
mildly tender. No bowel sounds were heard. Extremities no
edema. Rectal was guaiac positive.
LABORATORY DATA: Significant for a potassium of 2.5 and a
glucose of 241. White blood cell count of 1.3 with 37%
neutrophils, 21% bands and 31% lymphocytes, hematocrit 33.5,
platelets 212, ALT and AST were within normal limits.
Alkaline phosphatase elevated at 246, LDH elevated at 1164,
lipase normal, total bilirubin is .6. PT/PTT/INR were 14.1,
20.8 and 1.3 respectively. Lactate was 7.8. Arterial blood
gas status post cardiac arrest with 7.48, 36 and 530. Free
calcium 1.23 and lactate of 4.6. Electrocardiogram number
one showed a wide complex tachycardia, number two showed a
questionable sides and a wide complex tachycardia at 300
beats per minute. Number three was sinus tach at 130 beats
per minute with left axis deviation. Chest x-ray showed no
acute cardiopulmonary process. CT of the torso showed
worsening metastatic disease in liver, pancrease, small bowel
and mesentery. Pancreatic mass was compressing the IVC.
There was ill defined pulmonary nodules, increased in size
from [**2171-12-16**].
HOSPITAL COURSE: The patient is a 43 year-old male with
metastatic melanoma and abdominal pain status post V
fibrillation arrest.
1. V fibrillation arrest status post resuscitation: It was
initially thought that the V fibrillation arrest was due to
hypokalemia and may have been exacerbated by prolonged QT
from Compazine. His potassium and magnesium were
aggressively repleted and all other medications were stopped.
2. Sepsis: The patient became profoundly hypotensive with a
systolic blood pressure in the 60s and started on
neo-synephrine after initially being tachycardic and
hypotensive. Since some of the hypotension was attributed to
Propofol, but most likely it was due to septic physiology
with a fever of 104, warm extremities and neutropenia. The
patient was given Vancomycin, Cefepime and Flagyl. A PICC
line was planned to be discontinued. A chest CT also showed
new bilateral infiltrates not seen on chest x-ray and it was
thought that the patient was beginning to develop ARDS. He
was continued to be aggressively intravenous fluid hydrated
and he was started on Vasopressin, neo-synephrine and
Levophed drips. Blood cultures were sent, which eventually
grew out strep.
3. Hypoxic respiratory failure from early ARDS or aspiration
pneumonia: H was started on mechanical ventilation with a
low volume regulation strategy.
Throughout the course of the night the patient became
increasingly hemodynamically unstable. Levophed,
neo-synephrine and Vasopressin drips were maximally dosed.
Systolic blood pressures continued to drop to the 50s and 60s
despite multiple normal saline boluses throughout the night.
A cordis catheter was emergently placed and the patient was
still aggressively fluid resuscitated without resolution of
his hypotension. Dopamine was added, but also did not
improve his blood pressure. He then became bradycardic and
had a PEA arrest. After multiple discussions with the family
we decided to stop CPR secondary to medical futility. The
patient passed away at 1:57 a.m. immediately after
discontinuing CPR. The family was notified at bedside and
the health care proxy refused autopsy.
CONDITION ON DISCHARGE: Expired.
DISCHARGE DIAGNOSES:
1. Metastatic melanoma.
2. Gram positive sepsis from unclear source most likely from
PICC line.
3. Septic shock.
4. ARDS.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4561**]
Dictated By:[**Last Name (NamePattern1) 218**]
MEDQUIST36
D: [**2172-4-3**] 11:09
T: [**2172-4-6**] 10:29
JOB#: [**Job Number 45661**]
ICD9 Codes: 0389, 4275, 2762 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3596
} | Medical Text: Admission Date: [**2131-2-28**] Discharge Date: [**2131-3-10**]
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
sudden onset "inability to walk" [**2131-2-28**]
Major Surgical or Invasive Procedure:
External ventricular drain placement
History of Present Illness:
[**Age over 90 **] y/o male who presented with sudden onset "inability to
walk" after standing up from watching television. During the
event he denied any SOB or chest pain, but he is not sure when
all these events transpired today. He went to an outside
hospital where a CT scan revealed a bleeding in the left
cerebellar vermis (~3cm). He was then referred to this
institution where the neurosurgical team saw him.
Past Medical History:
HTN, reports having "slow speech" that developed 3 months
ago ?CVA
Social History:
Ex-tobacco smoker (last cigarette [**8-/2102**]), no ETOH, no drugs.
Lives
with wife in [**Hospital3 **] home; he is the primary caretaker
for wife who has dementia
Family History:
unknown
Physical Exam:
Exam upon admission:
T: 97.1 BP: 196/69 HR: 90 R 20 96%O2Sats
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: surgical pupils EOMs. facial asymmetry on left.
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2. Bradycardic. ?bigenimy on code cart.
Abd: Soft, NT, BS+
Extrem: Warm. LUE more plethoric, but warm.
Neuro:
Mental status: Awake/sedated. Cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**2-14**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Surgical pupils. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: patient not fully cooperative. Left facial droop.
VIII:
IX, X:
[**Doctor First Name 81**]:
XII:
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**6-16**] throughout.
+pronator drift on left.
Sensation: Intact to light touch.
Reflexes: B T Br Pa Ac
Right: +2 0 0 0 0
Left: 0 0 0 0 0
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin: Patient not cooperatiate as he feels
nauseated as he has been bradycardic.
Pertinent Results:
[**2131-2-28**] 07:09PM WBC-18.9* RBC-4.35* HGB-14.6 HCT-41.9 MCV-96
MCH-33.5* MCHC-34.7 RDW-13.0
[**2131-2-28**] 07:09PM NEUTS-89.3* LYMPHS-7.0* MONOS-3.3 EOS-0.1
BASOS-0.3
[**2131-2-28**] 07:09PM PLT COUNT-156
[**2131-2-28**] 07:09PM PT-11.8 PTT-25.5 INR(PT)-1.0
[**2131-2-28**] 10:06PM WBC-16.9* RBC-4.27* HGB-14.3 HCT-41.2 MCV-97
MCH-33.4* MCHC-34.6 RDW-13.0
Head CT [**2131-3-1**](after fall out of bed):
1. Approximate stability of posterior fossa hemorrhage.
Equivocal increase in mass effect on fourth ventricle.
2. New small subgaleal hematoma in the right frontal area
without associated skull fractures.
3. No new areas of intracranial hemorrhage.
Head CT [**2131-3-1**] (after acute MS change):
The posterior fossa bleed is again approximately stable in size.
However compared to the most recent scan of 21:00 on [**2131-3-1**], there is further decrease in the size of the fourth
ventricle. Over the course of the last three head CTs, this has
been progressive and may explain the patient's change in mental
status. The size of the third ventricle and lateral ventricles
is stable. The assessment of the mid-skull is limited due to
motion. No new areas of hemorrhage are identified. There is no
evidence of new infarction. There is interval progression of the
right frontal subgaleal hematoma. Again noted is an old lacunar
infarct in the left thalamus and mucosal thickening in the
maxillary sinuses.
Head CT [**2131-3-7**]:
Unchanged cerebellar hematoma, with slight compression and
anterior displacement of the fourth ventricle. If the patient
remains neurologically stable, the interval time period between
examinations could be increased.
Brief Hospital Course:
[**Age over 90 **] y/o male who presented with sudden onset "inability to
walk" after standing up from watching television. He went to
an outside hospital where a CT scan revealed a bleeding in the
left
cerebellar vermis (~3cm). He was then referred to this
institution where the neurosurgical team saw him.
The initial CT/CTA at [**Hospital1 18**] showed:
Hemorrhage within the posterior fossa as described above. Focal
fusiform dilatation of the LPCA measuring 2-3 mm. Chronic left
thalamus lacunar infarct.
The patient did well for the first two day in the ICU and was
ready to be transferred to the neuro step down unit on [**2131-3-1**].
However, he fell out of bed that evening so he had a repeat head
CT that showed now new bleed. Several hours later he had acute
mental status changes and had another CT scan which showed that
the original cerebellar bleed had increased and was almost
completely occluding the 4th ventricle. An EVD was urgently
placed at that time and the patient improved.
The EVD was raised from 10cm above the tragus, to 15cm on
[**2131-3-4**]. It was raised again to 20cm on [**2131-3-5**] and he was
transferred to the step down unit that day. He continued to
improve and the drain output was decreasing so we removed it on
[**2131-3-7**].
Mr. [**Known lastname 71460**] family member fed him breakfast this morning and
he had been on aspiration precautions per speech and swallow
evaluation. He aspirated oatmeal and eggs so a CXR was obtained
which showed: "No change since prior chest x-ray. No evidence of
aspiration." His family decided to make him DNR/DNI on [**2131-3-9**].
Mental status and repiratory decline ensued over the next day
and Mr. [**First Name (Titles) 71461**] [**Last Name (Titles) **] on [**2131-3-10**] at 10:50 military time.
Medications on Admission:
-ativan
-trazodone
-doxazosin
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Left cerebellar bleed
Fall from bed
Aspiration/Respiratory failure
Discharge Condition:
Deceased
Completed by:[**2131-3-10**]
ICD9 Codes: 431, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3597
} | Medical Text: Admission Date: [**2190-5-27**] Discharge Date: [**2190-6-4**]
Date of Birth: [**2139-2-5**] Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: This is a 51-year-old gentleman
with a past medical history of a type-A dissection which was
emergently repaired on [**2190-4-17**]. He had an uneventful
postprocedure course, and was following up with his primary
surgeon, when his blood pressures noted to be 240 systolic
and 130 diastolic. He was completely asymptomatic.
Specifically, he denied any chest pain, back, neck, abdominal
or headache pain. He also denied any change in his vision
and other neurological symptoms. He denied excessive use of
caffeine, alcohol, or tobacco use. He also denied missing
any doses of his hypertensive medications. The surgeon
referred the patient to the Emergency Room where he was
started on a nitroprusside drip for improvement of his
systolic blood pressure.
His blood pressure was lowered over the next couple of hours
to approximately 150 systolic, and then he was transferred to
the CCU for further observation.
PAST MEDICAL HISTORY:
1. Type A-aortic dissection, status post repair along with
aortic valve repair.
2. Hypertension.
3. Psoriasis.
ALLERGIES: The patient has no known allergies.
MEDICATIONS UPON ADMISSION:
1. Aspirin 325 q day.
2. Labetalol 400 mg po tid.
FAMILY HISTORY: Mother with emphysema. Father with
congestive heart failure. His brother and sister are healthy
without any medical complications.
SOCIAL HISTORY: The patient admits to drinking approximately
two beers every other day. He also smokes an occasional
cigarette approximately one cigarette every week. He is
currently employed as a fireman. He denies any IV drug use.
PHYSICAL EXAM UPON ADMISSION: The patient is afebrile with a
blood pressure of 151/81, his heart rate was 100 beats per
minute, his O2 saturations were 98% on room air. His weight
was 88 kg. In general, this is a well-developed and
well-nourished middle-age gentleman who appears his stated
age. He was in no apparent distress. He was alert and
oriented to person, place, and situation. His pupils are
equal, round, and reactive to light. Extraocular movements
are intact. His mucous membranes were dry and his oropharynx
was clear. His neck was supple without bruit or
lymphadenopathy. He had normal carotid upstroke without
jugular venous distention. His heart was tachycardic with a
2/6 systolic murmur heard best at the left upper sternal
border. The murmur failed to radiate and there was no
obvious heave. His lungs were clear to auscultation
bilaterally. There was no wheezing or crackles. His abdomen
was soft, nontender, nondistended without organomegaly. His
extremities were without clubbing, cyanosis, or edema. He
did have bounding pulses bilaterally in both the upper and
lower extremities. Skin: He had multiple nodular plaques
consistent with psoriasis along his knees, hands, back, and
trunk. Neurologically: Cranial nerves II through XII are
grossly intact. He had no motor or sensory deficits. His
memory was intact.
LABORATORIES UPON ADMISSION: White blood cell count of 5.3,
hematocrit of 36.2, platelet count of 310. His Chem-10
showed a sodium of 139, potassium 4.2, chloride of 105,
bicarb of 24. His BUN was 11 and creatinine 0.8 with a
glucose of 93.
Electrocardiogram showed patient had a sinus tachycardia with
a rate of approximately 105 beats per minute. He had a
normal axis. There were normal intervals. There were no
acute ST-T wave changes. He did have what appeared to be
left ventricular hypertrophy.
An echocardiogram revealed patient had his left atrium was
moderately dilated. His left ventricle showed moderate
symmetrical hypertrophy with an ejection fraction estimated
to be about 75%. He was without any aortic regurgitation.
He showed mild thickening of the mild valve chordae with the
tips of the papillary muscles calcified. The left ventricle
inflow pattern suggested impaired relaxation. He showed a
small pericardial effusion that was loculated. His aortic
root was moderately dilated.
A MRA of his abdomen and chest revealed an aortic dissection
throughout the aorta. The distal extent went to the distal
most aorta to the bifurcation. The dissection did not appear
to extend into the iliac arteries. The celiac and the SMA
were supplied by both true and false lumen. Of note, the
left renal artery appeared to be supplied by the false lumen
while the right renal artery was supplied by the true lumen.
It is also noted that the patient appeared to have
intermittent periods where the left renal artery was
obstructed by the flap.
HOSPITAL COURSE: This 51-year-old gentleman with a type A
aortic dissection status post repair along with an aortic
valve repair one month prior to admission. Was admitted with
asymptomatic hypertension. His hospital course is as
follows: 1. Hypertension: In the Emergency Room, the
patient was initially started on a nitroprusside drip. Once
transferred to the CCU, the oral labetalol dose was increased
and the nitroprusside was gradually weaned off.
Unfortunately, after maxing out the labetalol dose, the
patient's blood pressure remained elevated in the 160-180
range, and he was started up on an ACE inhibitor. The ACE
inhibitor dosage was also maxed out, and he was started on
both Norvasc and hydrochlorothiazide. The patient then
started to have intermittent periods of hypotension which
were resolved by placing him in the Trendelenburg position
and IV fluid bolus.
Gradually, he was weaned down to labetalol 800 tid and
Captopril 75 mg tid with good blood pressure control. During
his initial workup for secondary causes of hypertension, it
was found that the patient had hypothyroidism with a TSH of
approximately 15. He was started on Synthroid.
Additionally, a renal ultrasound was ordered, which showed a
question of possible left renal artery stenosis. A followup
MRA revealed the results which are listed above. He was seen
then by Dr. [**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) **], [**First Name3 (LF) **] Interventional Cardiologist.
On the fifth day of his hospital admission, Dr. [**First Name (STitle) **]
successfully placed a left renal artery stent. He was then
transferred back to the CCU, and he was started on a
labetalol drip along with po labetalol. His blood pressure
remained elevated after maxing out the labetalol, and he was
started on a low dose ACE inhibitor. His blood pressure was
controlled with labetalol 800 mg tid and lisinopril 15 mg at
bedtime.
During his stay, the patient experienced no chest pain, no
back pain, no headache, and his renal function remained
stable.
2. Endocrine: The patient was found to be hypothyroid, and
he was started on low dose of Synthroid. He will be
following up with his primary care physician for further
management of his thyroid condition.
3. Psoriasis: Patient has a long history of psoriatic
lesions for which he was started on a high potent steroid
cream with positive results. He was to followup with a
dermatologist for further management options.
MEDICATIONS UPON DISCHARGE:
1. Lisinopril 15 mg q hs.
2. Labetalol 800 mg tid.
3. Plavix 75 mg q day.
4. Aspirin 325 mg q day.
5. Levothyroxine 25 mcg q day.
DI[**Last Name (STitle) 408**]E INSTRUCTIONS:
1. Follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in one week.
2. Patient should follow up with Dr. [**First Name (STitle) **] on [**6-16**] at
10:30.
3. Patient was to followup with Dr. [**Last Name (Prefixes) **] on [**6-24**] at
12:00.
4. The patient was to contact his primary care physician to
followup in six weeks for further evaluation of his thyroid.
5. The patient should return to the Emergency Room if he
develops any acute throbbing headaches, any back pain, any
chest pain, any extreme shortness of breath. He was also
told not to operate any heavy machinery to include driving
any motor vehicles for at least two weeks while his
medications are being adjusted. If the patient were to
become hypotensive, he was told that he should lay down.
DISCHARGE CONDITION: Stable.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. [**MD Number(1) 1014**]
Dictated By:[**Name8 (MD) 6284**]
MEDQUIST36
D: [**2190-6-4**] 12:31
T: [**2190-6-8**] 09:55
JOB#: [**Job Number **]
ICD9 Codes: 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3598
} | Medical Text: Admission Date: [**2192-4-20**] Discharge Date: [**2192-4-24**]
Date of Birth: [**2124-9-20**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Methotrexate / Fosamax
Attending:[**First Name3 (LF) 1974**]
Chief Complaint:
Sepsis
Major Surgical or Invasive Procedure:
Arthrocentesis
PICC placement.
History of Present Illness:
67 year old female with history of rheumatoid arthritis on
low-dose prednisone, CAD s/p stent, HTN presents with 2 days of
chills, headache, fevers. Patient says she was in store 2 days
PTA and had sudden onset chills followed quickly by onset of
severe headache. The patient says she had been feeling otherwise
well. Headache characterized as severe, associated with
photophobia, no neck stiffness. Says feeling very weak,
light-headed over this time with chills and therefore presented
to [**Hospital1 18**] ER.
.
Says intermittent, non-productive cough. Denies shortness of
breath, chest pain. No dysuria. No abdominal pain, nausea,
vomiting, diarrhea, constipation, hematochezia, melena.
.
Also reports development of right second toe pain last night.
.
In the emergency department, fever to 104.5, initially sBP's in
ED 170's. Treated with vancomycin, levoquin for possible
pneumonia (penicillin allergy). Also got morphine for pain and
then over a few hours BP's down to 80's. Got 3L NS and sBP
increased to 110's. However, when pt would fall asleep BP would
fall to 90's. ECG, CXR, CT torso unrevealing as to etiology. Was
given Vanco, levofloxacin, Dexamethasone 10mg IV, Naloxone 0.4,
Ibuprofren 600mg, Acetominophen 1g, Morphine 6mg IV.
Past Medical History:
1) Rheumatoid Arthritis
2) Coronary Artery Disease: Unstable angina in [**2188**]-- C-cath mid
LAD 30%, mid LCx 50%, Om1 and OM2 70% (stented via kissing
stents)
- [**5-2**] ETT MIBI: [**Doctor Last Name 4001**] X 3.75 min, 57% PMHR, no myocardial
perfusion defects
3) Hypertension
4) Renal Artery Stenosis
5) PUD
6) Iron deficiency Anemia
7) h/o (+) PPD: prior CXR w/ RLL calcified granuloma
8) psoriasis
9) hypercholesterolemia
10)Compression fractures
11)?COPD
Social History:
Pt. lives in apartment with her grandson. She has a roughly 96
pack year history of cigarette use. She denied use of alcohol
or illicit drugs. She walks for exercise approximately 30
minutes/day.
Family History:
Pt. had a brother who suffered from an MI at age 58. She could
not recall any other significant family h/o disease.
Physical Exam:
PE: Temperature: 104.5/99 HR: 92 BP: 110/72 RR: 14 95%2l
General: Spanish-speaking female, A&OX3 but somnolent, coughing
occasionally, speaking in complete sentences, NAD
HEENT: anicteric, pale conjunctiva, MMM, OP clear, neck supple
Cardiac: RR, +murmur (previously noted)
Pulmonary: minimal crackles left base
Abd: +b/s, obese, soft, NT/ND, no masses
Ext: trace ankle edema, no cyanosis
Integument: warm, dry
Heme/Lymph: shotty anterior cervical LAD
Back: No tenderness to percussion over spine
Neuro: AAOx3 but somnolent, CNII-XII intac t
rectal: nl tone, guiaic negative.
Pertinent Results:
[**2192-4-19**] 10:53PM WBC-12.2*# RBC-3.99* HGB-11.2* HCT-34.1*
MCV-86 MCH-28.0 MCHC-32.7 RDW-15.7*
[**2192-4-19**] 10:53PM NEUTS-85.4* BANDS-0 LYMPHS-10.4* MONOS-3.2
EOS-0.6 BASOS-0.5
[**2192-4-19**] 10:53PM PLT COUNT-198
[**2192-4-19**] 10:53PM GLUCOSE-112* UREA N-18 CREAT-1.3* SODIUM-136
POTASSIUM-4.1 CHLORIDE-101 TOTAL CO2-25 ANION GAP-14
[**2192-4-19**] 10:53PM ALT(SGPT)-21 AST(SGOT)-30 ALK PHOS-91 TOT
BILI-0.4
[**2192-4-20**] 02:30AM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.021
[**2192-4-20**] 02:30AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-1 PH-5.0 LEUK-MOD
[**2192-4-20**] 02:30AM URINE RBC-[**1-30**]* WBC-[**5-6**]* BACTERIA-MANY
YEAST-NONE EPI-[**10-16**]
[**2192-4-20**] 06:46AM LACTATE-1.0
[**2192-4-20**] 06:35PM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-4* POLYS-0
LYMPHS-80 MONOS-0 MACROPHAG-20
[**2192-4-20**] 06:35PM CEREBROSPINAL FLUID (CSF) PROTEIN-39
GLUCOSE-69
.
.
CT TORSO:
1) No CT findings to explain the patient's fever.
2) No lymphadenopathy within the chest to correlate with chest
x-ray findings of hilar fullness.
3) Diverticulosis without diverticulitis.
4) Cholelithiasis.
.
.
TTE:
The left atrium is normal in size. There is mild symmetric left
ventricular
hypertrophy. The left ventricular cavity is unusually small.
Left ventricular
systolic function is hyperdynamic (EF 80%). There is no
ventricular septal
defect. Right ventricular chamber size and free wall motion are
normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet
excursion and no aortic regurgitation. No masses or vegetations
are seen on
the aortic valve. The mitral valve leaflets are mildly
thickened. There is no
mitral valve prolapse. No mass or vegetation is seen on the
mitral valve.
There is borderline pulmonary artery systolic hypertension. No
vegetation/mass
is seen on the pulmonic valve. There is no pericardial effusion.
.
.
BLOOD Cultures ([**4-22**]): 4/4 bottles beta strep group A
Brief Hospital Course:
1) SEPSIS:
Patient was admitted to [**Hospital Unit Name 153**]. Never required pressors as BP
responded to fluids. Started on vanco, ceftriaxone, and
levaquin. Initially, there was no clear source of infection.
She had a painful erythematous toe on right foot. Admission
blood cultures grew out group A strep in high grade. Her
antibiotics were narrowed to Ctx only. ID was consulted. It
was felt that the toe was the likely source of infection.
Surveillance blood cultures were clear except for [**12-1**] CNS on
[**4-22**] that was a likely contaminant. Pt's fevers and
leukocytosis resolved with antibiotics. She will complete a 4
week course of Ctx and f/u with ID.
.
2) Septic Arthritis/Cellulitis:
Rheumatology was consulted regarding the 2nd digit on her right
foot. An athrocentesis was done with scant fluid which was
negative on culture. However, it was felt that the pt may have
had a septic arthritis there so pt's abx course was plannned for
4 weeks. The joint was small and there was no fluid there so a
surgical washout was not necessary.
.
3) R.A:
Per rheum, leflunomide was stopped and prednisone was continued.
.
4) CAD/HTN:
Initially, her BP meds were held due to sepsis. After she was
on the floor, her BP rose and her meds were restarted. On
discharge, she is to resume all her pervious cardiac meds.
Medications on Admission:
1. Advair
2. Albuterol
3. Arava 20mg daily
4. Atenolole 100mg daily
5. Asprin 81 mg daily
6. Plavix 75 mg daily
7. Diovan 160 mg daily
8. lasix 40 mg daily
9. lipitor 40mg daily
10. mylanta prn
11. nitro sl prn
12. prilosec 40 mg daily
13. prednisone 5mg daily
14. colace
15. calcium carbonate
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. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Ceftriaxone-Dextrose (Iso-osm) 1 g/50 mL Piggyback Sig: One
(1) gram Intravenous Q24H (every 24 hours) for 26 days.
Disp:*26 gram* Refills:*0*
9. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
10. Atenolol 100 mg Tablet Sig: One (1) Tablet PO once a day.
11. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
12. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
15. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for foot pain.
16. PICC care
as per NEHT protocol
17. Outpatient Lab Work
Weekly CBC, BUN, Creatinine, AST, ALT, alk phos, Total bili
starting [**4-30**]. Please fax results to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (ID at
[**Hospital1 18**]) at [**Telephone/Fax (1) 11959**].
Discharge Disposition:
Home With Service
Facility:
Americare at Home Inc
Discharge Diagnosis:
PRIMARY:
1) Strep bacteremia
2) Septic arthritis, foot
SECONDARY:
Hypertension
CAD
Rheumatoid arthritis
Discharge Condition:
Good--afebrile, vital signs stable.
Discharge Instructions:
1. Take medications as prescribed. DO NOT take Arava until
instructed to restart by Dr. [**Last Name (STitle) 6426**]
2. Follow up as below.
3. Please seek medical attention for fevers, chills, chest
pain, shortness of breath, worsening pain on your toe, abdominal
pain.
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2192-5-21**] 11:30
.
Please call Dr. [**Last Name (STitle) 6426**] to set up a follow up appointment.
.
Please call Dr. [**Last Name (STitle) **] in [**Company 191**] to set up a follow up appointment in
[**11-29**] weeks.
ICD9 Codes: 496, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3599
} | Medical Text: Admission Date: [**2174-3-29**] Discharge Date: [**2174-4-15**]
Service: MEDICINE
Allergies:
Heparin Sodium
Attending:[**First Name3 (LF) 7055**]
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
cardiac catheterization
History of Present Illness:
[**Age over 90 **] year old with hx of HTN, DM, CHF, s/p pacemaker for
bradycardia, and high cholesterol who presented to [**Hospital 61311**] this morning after he experienced a loss of
conciousness. He was in his USOH until 8:30AM today when he had
brief loss of conciousness. Though he was not aware of it, he
was told that his speech was slurred and that his face was
asymmetric. He did not notice any weakness or numbness, denies
difficulty with speech, no vision changes. He did complain of
right arm pain. Denied CP, +mild SOB, An ambulance was called
and brought him to [**Location (un) **].
On arrival to OH ED, VS: 97.2 HR 60 BP 154/35 RR16 O2 Sat 95% on
room air. He was evaluated by neurology who found him to have a
"left homonymous hemianopsia" and "left hemiparesis". NCHCT was
done and was negative. While in the OH ER, he was found to have
positive troponin trop 1.13, CK 56 with EKG changes and was also
noted to have a BP discrepency between the right and left arm
with right arm being roughly 50mm mercury less than BP in left
arm. He was transfered here for cardiology workup and evaluation
for subclavian steal.
According to his family, his mental status has waxed and waned
throughout the day with periods of alterness and lethargy. He
has always been arousable and has been able to communicate a
coherent history at all times. They do note, however, that he
seems to be improved over the last several hours. They have also
noticed that his speech is slurred, he has a tendancy to look
only to the right, and has decreased spontaneous movement of his
left side (though they note that he has been able to move the
left side purposefully).
CT: Mild atrophy, ? hyperdense right MCA, but images out of
focus on re-prints.
At [**Hospital1 18**] ED, no CTA secondary to ARF. He was unable to do MRI
2/s pacemaker. Neurology :?right MCA territory(most likely
embolic vs Sc steal). Repeat NCHCT negative for bleed/edema. He
should have his BP kept in 200s and received 2u PRBC. EKG with
persistent lateral ST depression
On arrival to the floor, he was in respiratory distress
unresponsive to lasix and nitro gtt. He became unresponsive and
respiratory code was called. His initial ABG showed 7.18/67/67.
He was intubated and his BP was in 210/100 and P120. He was
given 10mg IV lopressor and nitro gtt.
Past Medical History:
#CHF
#HTN
#s/p PM [**2-12**] for symptomatic bradycardia
#DM2
#hyperlipidemia
#gout
#h/o BPH
#s/p TURP
#CRI
#CAD
cath 98-?stent [**19**]% LAD, 90%circ
90% LCX
#anemia
Social History:
retired wood worker
remote tobacco
lives alone in NH
3 children
no ETOH
Family History:
no CAD/CVA
Physical Exam:
The patient was unresponsive and found to be breathless,
pulseless, and without heart tones, blood pressure, and corneal
reflexes. The patient was pronounced dead. The patient's
physician and family were notified. They refused anatomic gifts
and autopsy.
Pertinent Results:
Admission Labs [**2174-3-28**]:
WBC-7.8 RBC-3.27* Hgb-9.8* Hct-30.4* MCV-93 MCH-29.9 MCHC-32.2
RDW-15.4 Plt Ct-137* Neuts-79.2* Lymphs-16.1* Monos-3.4 Eos-1.2
Baso-0.2
0PT-13.6 PTT-28.4 INR(PT)-1.2
[**2174-3-28**] 11:50PM BLOOD Glucose-103 UreaN-38* Creat-1.7* Na-144
K-4.2 Cl-106 HCO3-29 AnGap-13 Calcium-8.6 Phos-3.3 Mg-2.1
CK-MB-NotDone cTropnT-0.40* CK(CPK)-62
calTIBC-270 Hapto-199 Ferritn-112 TRF-208
Micro:
No growth/negative: urine cx, blood cx, bile cx, stool for
c.diff
Sputum: MRSA+
EKG on admission:SR 70bpm PR 200ms, nml axis, STD I, AVL, V4-V6,
LVH, QTC 447
CXR on admission -mild CHF, right pleural effusion, no focal
consolidation
CXR [**4-12**] -Worsening congestive heart failure.
Head CT [**3-29**]: Mild atrophy, ? hyperdense right MCA, but images
out of
focus on re-prints.
repeat Head CT [**3-31**]: R occip.parietal hypoattenuation, R
capsular attenuation.
non-invasive head studies: severely stenotic R and L ICA's;
severe vertebrobasilar stenosis
Renal u/s [**4-10**]: No hydronephrosis in either kidney. Left renal
calculus, which is nonobstructing. Slight increase in
echogenicity of both kidneys consistent with underlying renal
parenchymal disease. Small amount of free fluid in the abdomen
as well as a small right pleural effusion.
GB DRAINAGE,INTRO PERC TRANHEP BIL US [**4-8**]: Successful placement
of a percutaneous cholecystostomy tube. A sample of the bile was
immediately sent to microbiology for Gram stain and culture.
LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT [**4-7**]:Acute
cholecystitis, with distended, sludge and stone-filled
gallbladder and wall edema.
[**Month/Day (4) **] [**4-5**]: No masses or thrombi are seen in the left ventricle
(evaluated with Definity). The apex is hypokinetic and the
basal inferior/inferoseptal segments are aneurysmal. Compared to
the prior study of [**2174-4-4**], left ventricular systolic function
appears similar.
[**Date Range **] [**4-4**]: 1. The left atrium is mildly dilated.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is moderately depressed. Resting regional
wall motion abnormalities include inferobasal aneurysm with
inferolateral akinesis and apical akinesis.
3.Right ventricular chamber size is normal. Right ventricular
systolic function is normal. 4.The aortic valve leaflets (3)
are mildly thickened. Trace aortic regurgitation is seen.
5.The mitral valve leaflets are mildly thickened. Mild mitral
regurgitation seen. 6.There is no pericardial effusion. 7.
There appears to be a circular mass in the LV, consistent with
an LV thrombus. Would recommend Definity contrast to beeter view
the mass. Compared with the findings of the prior tape of
[**2174-3-29**], images were equally limited but appears unchanged,
though LV mass not previously seen.
[**Date Range **] [**3-29**]: 1. The left atrium is mildly dilated. 2. There is
mild symmetric left ventricular hypertrophy. The left
ventricular
cavity size is normal. There is mild global left ventricular
hypokinesis.
Overall left ventricular systolic function is mildly depressed.
3. The aortic valve leaflets are mildly thickened. 4. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen.
5. There is mild pulmonary artery systolic hypertension.
CT ABDOMEN W/O CONTRAST 03/29:1. No evidence of retroperitoneal
hematoma.
2. Moderate bilateral pleural effusions.3. Two small
high-attenuation foci in the right kidney which may represent
hyperdense cysts. 4. Tiny nonobstructing left renal calculus.
Carotid u/s [**3-30**]:On the left, there is significant plaque with
an 80% to 99% cervical carotid stenosis. On the right, there is
evidence of an intracranial carotid artery occlusion. In
addition, there is a significant disease in the right subclavian
artery, based on waveforms.
C.CATH Study Date of [**3-29**]: 1. Coronary angiography of this
right dominant circulation demonstrated three vessel coronary
artery disease. The LMCA had no angiograpically apparent
disease. The LAD had an origin 70% stenosis with moderate
calcification. There were serial 50% stenosis through out the
vessel with total occlusion in the apical segment. There was
diffuse diagonal disease with 60-70% stenosis. The LCX had a
widely patent stent proximally with 30% instent restenosis.
Major OM had 60% stenosis prior to bifurcation. The RCA was
totally occluded proximally with left to right collaterals
filling the distal vessel. 2. Left ventriculography was
deferred. 3. Resting hemodynamics demonstrated mildly elevated
left and right sided pressures with mRAP of 11 mmHg and mPCWP of
14 mmHg. There was mild pulmonary hypertension with PASP of 36
mmHg and mPAP of 24 mmHg. Cardiac output and cardiac index were
preserved at 5.9 L/min and 3.4 L/min/M2, respectively. 4. Due to
blood pressure discrepancy in the right arm, subclavian
angiography was performed to determine if vertebral
insufficiency was present. Via access in the right common
femoral artery, a catheter was placed in retrograde fasion
seletively into the right and then left subclavian. Selective
imaging of bilateral subclavians and nonselective imaging of the
bilateral vetebrals were performed. 5. The right subclavian was
widely patent and then occluded at the axillary segment with
what appeared to be atherothrombotic material.
The right vertebral had 95% stenosis. The left subclavian was
widely
patent. The left vertebral had 95% stenosis. 6. During the
procedure, the patient developed atrial tachycardia/atrial
flutter with pacemaker tracking at 2:1 with HR in the 130s. SBP
dropped from 150 to 110 mmHg. The magnet was placed and BP
increased to 140 mmHg with VVO pacing. The EP service was
consulted and reprogrammed the pacemaker to DDI mode without
rate adaption.
Brief Hospital Course:
[**Age over 90 **] yo male h/o HTN, DM, CHF s/p pacemaker for bradycardia, and
high cholesterol p/w CVA, vertebral insufficiency, and demand
ischemia in respiratory distress requiring intubation. The
patient expired after a prolonged cardiac ICU course involving
multiorgan failure (cardiac, pulmonary, renal, stroke, acute
cholecystitis) that was ultimately irreversible in spite of the
maximum medical measures.
Cardiovascular: Patient underwent cardiac cath [**2174-3-29**]
revealing 3 vessel disease (LAD 50% diffuse, Diagonal 60%
diffuse, LCx 30%, OM 60%), right subclavian occlusion, bilateral
vertebral stenosis, PCWP 14, CVP 11, and CO/CI 5.9/3.4. No
intervention was performed as the patient had not ruled in for
MI at that time and there was no culprit lesion. He was
continued on BB, ASA, lipitor, and plavix as possible. While the
goal for beta blockade was titration for HR~60 from a cardiac
standpoint, this goal was not often met due to limitations from
blood pressure that was required to be elevated for preservation
of brain perfusion, considering the patient's severe bilateral
vertebral artery stenosis and recent stroke. Patient's cardiac
enzymes and ECG in setting of flash pulmonary edema [**4-4**] were
suggestive of demand ischemia, considered likely due to the
narrowed circumflex artery. Patient was determined to have an
NSTEMI with increased TnT [**4-5**] thought secondary to pulmonary
edema and HTN. The patient's cardiac enzyems remained elevated
until patient expired. Optimization of medical management was
attempted but limited by increased blood pressure required for
brain perfusion. Patient received blood transfusions to maintain
goal HCT>30.
CHF/pulmonary edema: Patient was initially intubated on
admission for flash pulmonary edema in setting of hypertension
and was successfully extubated. However, on [**2174-4-3**], patient
again went into flash pulmonary edema and required reintubation
likely in the setting of hypertension that was required to
maintain cerebral perfusion. He temporarily required levophed
and nitro gtt for BP control for goal SBP 120-160 determined
with consultation by the neurology service. Echocardiogram [**3-29**]
revealed EF 50%, global LV HK, and 1+MR. [**First Name (Titles) 907**] [**Last Name (Titles) 113**] raised a
question of a mural thrombus; however, echocardiogram [**4-5**] with
definity contrast was negative for thrombus yet revealed EF
35-40%, apical HK, and inferobasal/septal aneurysm. Serial CXR
showed worsening pulmonary edema over time while patient
appeared intravascularly volume depleted (FeUrea 12%) and
received blood products and gentle fluids to maintain blood
volume.
Valves: 1+MR, 1+TR
Rhythm: During the hospital course, patient's pacemaker was
interrogated by the EP service and determined to be functional.
It was set at DDI post cath. Overnight on [**4-9**], patient converted
from NSR to AF and was not paced. Subsequently, patient variably
shifted in and out of AF. He was monitored continuously on
telemetry.
Neuro: Patient presented having had recent right temporal stroke
complicated by ICH that did not progress upon repeat head CT
imaging (MRI contraindicated due to PM). The patient's blood
pressure at first was recommended to be maintained between
140-160 per neurology stroke team recommendation; however, this
was liberalized to >120 as the patient's hemodynamic status
became further compromised due to evolving NSTEMI, worsening
CHF, atrial fibrillation, and renal failure. Nevertheless, when
awake, the patient was responsive to questions and communicative
with the SBP in the 120s. He was able to communicate his wishes
to his family/HCP. On exam, patient had left-sided
hemiparesis/neglect. The hemiparesis improved slightly over
time. He was noted to have vertebral insufficiency from severe
bilateral vertebral stenosis. Per carotid U/S [**2174-3-30**], there was
right total occlusion and left 90% occulsion. Neurosurgical or
endovascular intervention was deferred as patient was not
determined to be an appopriate candidate due to the several
comorbidities and complicating factors. While anticoagulation
with heparin was attempted, it was discontinued as the patient's
HCT and platelets dropped. He was noted to be positive for
heparin-induced thrombocytopenia. He temporarily received
argatroban. Plavix was started for stroke prevention and patient
took aspirin as able.
Respiratory: Patient's respiratory distress requiring intubation
[**4-3**] was likely pulmonary edema in the setting of hypertension
(higher BP needed for cerebral perfusion) vs aspiration
pneumonia since patient has to remain flat for cerebral
perfusion. After successful extubation, patient was reintubated
[**4-4**] for suspected aspiration in setting of heart failure. The
patient's blood pressure was required to be elevated for the
cerebral perfusion, but it was an additional stress to his heart
function, which made the patient's pulmonary edema more
difficult to control. The pulmonary edema persisted and worsened
as the patient underwent NSTEMI; diuresis was limited by renal
failure; the patient was unable to be safely extubated; thus,
per family meeting a tracheostomy was placed for continued
intubation and to help limit aspiration risk. Patient developed
ventilator associated MRSA PNA after being on levoquin and
flagyl x4d. He then started vanco/zosyn/flagyl/cipro on [**4-6**] for
MRSA and cholecystitis. Zosyn was d/c'd [**4-10**] for ? renotoxicity.
Intubation with AC/PS was continued due to infection and
difficulty to diurese. Patient was unable to be successfully
extubated due to worsening pulmonary edema and also required
gentle hydration and blood products for intravascular volume
depletion as well as hypernatremia.
Renal: Patient developed acute renal failure in setting of
chronic renal insufficiency. Patient was intravascularly
depleted and was given gentle hydration blood products to
support HCT>30 for CAD. Suspicion was low for ATN/AIN as the
urine was negative for eosinophils and the sediment was normal.
No hydronephrosis was seen per renal u/s [**4-10**]; however, there was
bilateral echogenicity suggestive of chronic parenchymal
disease. Metabolic acidosis was likely related renal loss as the
renal failure worsened. Renal service consultation raised
concern for irreversible cholesterol embolic renal disease due
to the patient's low C3 level. Medications were renally dosed.
Endocrine: Diabetes was managed with subcutaneous insulin.
Heme: Patient presented with anema and was documented to be
guaiac negative in the ED. He received blood products to keep
his HCT>30 and for iron repletion as iron studies were
concerning for iron deficiency and possible acute phase reactant
in setting of chronic disease: iron 44->20, transferrin
208->139, & TIBC 270->181 all trending down, but ferritin
increasing 112->241. Labs were negative for hemolysis and
abdominal CT [**4-5**] showed no evidence of hematoma or
retroperitoneal bleeding. After worsening thrombocytopenia,
patient was found to be positive for heparin induced
thrombocytopenia and all heparin per IV was discontinued.
Patient was started on argatroban for increased thrombotic risk
in AF rhythm in setting of known SC occluding thrombus, LV
aneurysm, and h/o stroke; however, it was then held for
procedure and discontinued altogether on [**4-14**] after patient made
CMO per family decision.
GI: Patient found to have elevated transaminases, AP, and GGT
but normal amylase and lipase. Abdominal exam evolved to have
RUQ guarding and u/s revealed cholecystitis for which the
patient received a gallbladder drain placed by IR. IR
recommended continuation of the drain until cholecystectomy;
however, the patient was too systemically ill to undergo
surgical intervention. Due to this and risk of aspiration, oral
nutrition including tube feeding, was held. The family did not
decide to proceed with PEJ placement as a goal of care and PICC
placement for TPN was contraindicated given the patient's
infections. Patient had poor gag reflex and required sedation
for comfort on the ventilator.
ID: Patient's temperature was 99 [**4-3**] and he was pancultured and
started on IV levoquin and flagyl. Infectious sources were
determined to be MRSA ventilator associated pneumonia and
evolving acute cholecystitis. He developed fever (102PR) [**4-6**]
that resolved after gallbladder drain placement and treatment
with vancomycin/zosyn/flagyl started [**4-6**]. Ciprofloxacin was
added 3/31 per ID consultation. Zosyn was d/c'd [**4-10**] for
renotoxicity concerns. The patient's fever resolved and
leukocytosis improved. All antibiotics were discontinued [**4-13**]
after family decision was made for CMO given patient's
irreversible multiorgan failure.
Access was per PIVs and central line.
Code on admission was full then the family, with patient's
daughter as HCP, decided to change the code status to DNR/DNI.
Palliative care consultation was assisting. As the [**Hospital 228**]
medical status worsened and became grave, the family decided to
pursue comfort measures as the primary goal of care and the
patient expired while family was present.
Medications on Admission:
asa 325
lasix 40
imdur 60
norvasc 5
catapres 0.1
zocor 20
acebutol 200mg
KCL
Starlix 120 mEQ
flomax 0.4
NKDA
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
ICD9 Codes: 4280, 5070, 2875, 5845, 0389, 2749 |
Subsets and Splits
No community queries yet
The top public SQL queries from the community will appear here once available.