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{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3600
} | Medical Text: Admission Date: [**2150-2-11**] Discharge Date: [**2150-2-15**]
Date of Birth: [**2150-2-11**] Sex: M
Service: NEONATOLOGY
HISTORY OF THE PRESENT ILLNESS: [**Known lastname 1124**] [**Known lastname 52406**] is a former 3.32
kilogram product of a term gestation pregnancy born to a
33-year-old G2, P1 now 2 woman. Prenatal screens: Blood
type O positive, hepatitis B surface antigen negative, RPR
nonreactive, rubella immune, group beta streptococcus
negative. The mother was exposed to fifth's disease on
[**2149-3-2**] and had a subsequent positive parvovirus IgM titer.
The pregnancy was otherwise uncomplicated. The infant was
born via vaginal delivery. It was precipitous in nature and
a tight nuchal cord was noted times one. Apgar scores were
eight at one minute and nine at five minutes. He was
admitted to the Newborn Nursery where he had an episode of
cyanosis accompanied by stridor.
He was transferred to the Neonatal Intensive Care Unit for
further monitoring and evaluation.
PHYSICAL EXAMINATION ON ADMISSION TO THE NEONATAL INTENSIVE
CARE UNIT: Weight: 3.32 kilograms. Length: 49 cm. Head
circumference 34.5 cm. General: Nondysmorphic, term infant
with stridor at rest, oxygen saturation 95-100% in room air.
Pink. No distress. The vital signs were within normal
limits. HEENT: Soft anterior fontanelle. Intact palate.
Normal facies. No grunting, flaring, retracting. Palate
intact. Chest: Clear breath sounds. Cardiovascular: No
murmur. Palpable femoral pulses. Abdomen: Soft, nontender,
nondistended, no masses. Neurologic: Normal tone and
activity.
HOSPITAL COURSE: 1. RESPIRATORY: [**Known lastname 1124**] did have a few
episodes of circumoral cyanosis with documented saturations
to 88-89%. This occurred only with crying or shortly after
crying. There was no cyanosis associated with feeding. The
stridor persisted and he was evaluated by the otolaryngology
team from [**Hospital3 1810**]. The physician's name is Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 174**]. A bedside upper laryngoscopy was performed and
showed large floppy arytenoids. Otherwise, normal upper
airway. The infant was monitored for 48 hours without any
significant episodes of oxygen desaturation. An airway
fluoroscopy is recommended at one month of age to evaluate
for any lower airway anomalies. The parents are to contact
the consulting physician if the infant develops any feeding
difficulties or prolonged episodes of cyanosis.
2. CARDIOVASCULAR: [**Known lastname 1124**] has maintained normal heart rates
and blood pressures. No murmurs have been noted.
3. FLUIDS, ELECTROLYTES, AND NUTRITION: [**Known lastname 1124**] has
exclusively breast fed or bottle fed expressed mother's milk.
The weight on the date of discharge is 3.020 kilograms which
represents his low weight since birth.
4. INFECTIOUS DISEASE: There were no Infectious Disease
issues.
5. NEUROLOGICAL: [**Known lastname 1124**] has maintained a normal neurological
examination and there are no concerns at the time of
discharge.
6. SENSORY: Audiology: Hearing screening was performed
with automated auditory brain stem responses. [**Known lastname 1124**] passed
in both ears.
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Home with parents.
PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 52407**], [**Last Name (un) **],
WACC 715, [**Location (un) 86**], [**Numeric Identifier 18228**]. Phone number [**Telephone/Fax (1) 36947**].
CARE AND RECOMMENDATIONS AT THE TIME OF DISCHARGE:
1. Breast feeding ad lib.
2. No medications.
3. A car seat position screening was performed due to the
mild airway anomaly. [**Known lastname 1124**] was observed for 90 minutes in
his car seat without any episodes of bradycardia or oxygen
desaturation.
4. State newborn screen was drawn on [**2150-2-14**].
5. Immunizations received: Hepatitis B administered on
[**2150-2-14**].
IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be
considered from [**Month (only) 359**] to [**Month (only) 547**] for infants who meet any of
the following three criteria: Born at less than 32 weeks;
second born 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 thirdly with chronic lung disease.
Influenzae immunization should be considered annually in the
fall for preterm infants with chronic lung disease once they
reach six months of age. Before this age, the family and
other caregivers should be considered for immunization
against Influenzae to protect the infant.
FOLLOW-UP APPOINTMENTS RECOMMENDED:
1. Primary pediatrician within three days of discharge.
2. Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 174**], Otolaryngology at [**Hospital3 1810**],
phone number [**Telephone/Fax (1) 36478**]. Follow-up appointment is
recommended at two months of age.
3. Airway fluoroscopy as an outpatient at one month of age.
DISCHARGE DIAGNOSIS: Inspiratory stridor due to enlarged
floppy arytenoids.
[**First Name8 (NamePattern2) 39464**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 37201**]
Dictated By:[**Last Name (Titles) 37548**]
MEDQUIST36
D: [**2150-2-15**] 06:38
T: [**2150-2-15**] 09:13
JOB#: [**Job Number 52408**]
ICD9 Codes: V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3601
} | Medical Text: Admission Date: [**2136-1-1**] Discharge Date: [**2136-1-6**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4309**]
Chief Complaint:
Fever and hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] y/o F with PMH significant for CHF, HTN, dementia, and s/p
CVA admitted to [**Hospital1 18**] on [**1-1**] with fevers and hypoxia. Pt was
apparently in her normal state of health until [**1-1**] when she
was noted at [**Hospital1 100**] Senior Life to be lethargic with a fever of
101, tachypnia, and hyperglycemia with a BS of over 400. Pt was
given a dose of tylenol, started on oxygen via nasal cannula,
and transferred to the ED at [**Hospital1 18**] for further evaluation. In
the ED, the pt's VS were >104.8 132 114/70 --> 94/palp 30
96% 3L NC. The pt received zosyn, vancomycin, and flagyl. She
was started on the sepsis protocol and levophed was required to
support her BP in addition to 3 L of NS. Pt was then transferred
to the [**Hospital Unit Name 153**] for further care.
In the [**Hospital Unit Name 153**], the pt was noted to be lethargic and unable to
answer any questions on arrival. At that time, her temperature
had decreased to 97.5 but she was on a NRB with an oxygen
saturation of 100%. Significantly, her WBC count was 30.4 with
11% bands. The pt's antibiotics were adjusted to vancomycin,
flagyl, and ceftiraxone. She was also started on an insulin drip
to optamize glucose control. In further diagnostic workup, pt
was found to have a positive UA with concern for urosepsis. This
was confirmed when urine and blood cultures from [**1-1**] became
positive for Proteous mirabilis. She was started on zosyn to
cover her infection. In addition, there was a concern for C diff
so the pt was started on PO vancomycin. Pt was weaned of off the
levophed on [**1-2**] and overnight went into rapid atrial fib
requiring a diltiazem drip for control. The dilt drip was able
to be weaned off on [**1-3**] and she was restarted on her PO beta
blocker. In further events, pt had episodes of hyoglycemia on
[**1-3**] for which she was started on D5 drip but this has now been
weaned off and the pt is maintaining stable blood sugars. She
will be transferred to the floor for further care at this time.
Past Medical History:
1. Recurrent episodes of C diff- Reported to be resistent to
flagyl in the past and treated with PO vancomycin.
2. CHF- LVEF of 35% with an inferior wall motion abnormality.
3. S/P CVA with left hemiparesis
4. HTN
5. PVD
6. Dementia
7. Depression
8. H/O endocarditis- Pt was found to have Staph hominnis and
finished treatment with a six week course of vancomycin in
[**5-/2135**]
9. Type 2 DM
10. Cataracts
11. Ostoporosis
Social History:
Pt lives at [**Hospital1 100**] Senior Life. Her son is involved in her care.
Uses a wheelchair at baseline.
Family History:
Noncontributory.
Physical Exam:
Tm- 98.6 97 107/60 77 17 100% 2L NC FS: 75-106
Gen- Elderly lady sitting up in bed. Alert. NAD.
HEENT- NC AT. EOMI. Anicteric sclera. MMM.
Cardiac- Distant heart sounds. Irregularly irregular. II/VI SEM.
Pulm- Poor air movement bilaterally.
Abdomen- Soft. NT. ND. Positive bowel sounds.
Extremities- No c/c/e. Warm. Heel ulcers newly dressed with
boots in place. Of note, pt also with a stage II sacral decub.
Neuro- Alert. Not oriented to place. Unable to move left side.
Pertinent Results:
[**2136-1-1**] 09:35PM BLOOD WBC-30.4*# RBC-4.43# Hgb-12.9# Hct-37.8#
MCV-85 MCH-29.0 MCHC-34.0 RDW-15.4 Plt Ct-363
[**2136-1-1**] 09:35PM BLOOD Neuts-88* Bands-11* Lymphs-1* Monos-0
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2136-1-1**] 09:35PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-OCCASIONAL Microcy-OCCASIONAL Polychr-OCCASIONAL
Ellipto-1+
[**2136-1-1**] 09:35PM BLOOD Plt Smr-NORMAL Plt Ct-363
[**2136-1-1**] 09:35PM BLOOD PT-14.8* PTT-23.7 INR(PT)-1.5
[**2136-1-1**] 09:35PM BLOOD Glucose-483* UreaN-69* Creat-2.6*# Na-141
K-6.2* Cl-100 HCO3-15* AnGap-32*
[**2136-1-1**] 09:35PM BLOOD ALT-10 AST-31 CK(CPK)-101 AlkPhos-88
Amylase-21 TotBili-0.5
[**2136-1-1**] 09:35PM BLOOD CK-MB-3
[**2136-1-1**] 09:35PM BLOOD cTropnT-0.08*
[**2136-1-1**] 09:35PM BLOOD Albumin-3.8 Calcium-10.0 Mg-1.9
.
CHEST, SINGLE AP SUPINE PORTABLE VIEW (01/0/06): There is a new
left internal jugular central venous catheter, whose tip
probably lies in the upper atrium. If clinically indicated, it
could be pulled back by 1-2 cm. The cardiac and mediastinal
contours are unchanged. Again, noted is pulmonary edema, and a
left lower lobe opacity, likely atelectasis.
.
Cardiology Report ECG Study Date of ([**2136-1-1**]):
Atrial flutter with 2:1 A-V conduction. Prior anteroseptal
myocardial
infarction. Compared to the previous tracing of [**2135-7-3**] there
are continued slight ST segment elevations in leads V1-V2, more
prominent ST segment depressions in leads V4-V6 and associated T
wave inversions consistent with concomitant anterolateral
ischemic process. Followup and clinical correlation are
suggested. Rule out myocardial infarction.
.
[**2136-1-1**] 9:30 pm BLOOD CULTURE
AEROBIC BOTTLE (Final [**2136-1-4**]):
_____________________________________________________
PROTEUS MIRABILIS
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- 8 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 8 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
LEVOFLOXACIN---------- =>8 R
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
ANAEROBIC BOTTLE (Final [**2136-1-4**]):
PROTEUS MIRABILIS.
IDENTIFICATION AND SENSITIVITIES PERFORMED FROM AEROBIC BOTTLE.
.
[**2136-1-1**] 9:46 pm URINE Site: CATHETER
URINE CULTURE (Final [**2136-1-4**]):
PROTEUS MIRABILIS. >100,000 ORGANISMS/ML..
_________________________________________________________
PROTEUS MIRABILIS
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- 8 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 8 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
LEVOFLOXACIN---------- =>8 R
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
.
[**2136-1-2**] 12:01 am BLOOD CULTURE
AEROBIC BOTTLE (Preliminary):
GRAM NEGATIVE ROD(S).
BEING ISOLATED FURTHER IDENTIFICATION TO FOLLOW.
ANAEROBIC BOTTLE (Pending):
.
[**2136-1-4**] 5:26 am STOOL CONSISTENCY: SOFT
**FINAL REPORT [**2136-1-4**]**
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2136-1-4**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
Reference Range: Negative.
Brief Hospital Course:
[**Age over 90 **] y/o F with PMH significant for CHF, HTN, dementia, and s/p
CVA admitted to [**Hospital1 18**] on [**1-1**] with fevers and hypoxia. Found to
have urosepsis for which she is being treated with Zosyn. Also
being treated emperically for C diff given very elevated WBC
count on admission and history of multiple episodes of C diff.
Course complicated by rapid atrial fib and hypoglycemia now both
resolved.
.
1. [**Name (NI) 22117**] Pt found to have urosepsis with blood and urine
cultures from [**1-1**] growing Proteus mirabilis. Pt is now
hemodinamically stable off of pressers. She is being treated
with Zosyn with plans to complete a 14 day course. Follow blood
cultures from [**1-2**] to ensure that they remain negative. Avoid
foley catheter.
.
2. Question C diff- Concern for C diff in this pt given her very
elevated WBC count early in admission and history of multiple
episodes of C diff. Her C diff in the past has been resistent to
flagyl and treated with PO vancomycin. At this time, pt is being
emperically treated with PO vancomycin. She has had one C diff
sent on [**1-4**] which was negative. Pt will need to have a total
of three specimins for C diff checked. If these are all
negative, PO vancomycin should be discontinued.
.
3. [**Name (NI) 22118**] Pt initially with a high oxygen requirement.
This has now improved dramatically and her sats are in the high
90s on NC. Are weaning her oxygen as tolerated. Continue to wean
oxygen as tolerated for an oxygen saturation of 94% or greater.
.
4. Atrial fibrillation- Pt has a history of atrial fibrillation.
She is not anticoagulated for this at baseline. On admission,
her beta blocker was held given her hypotension in the setting
of sepsis and pressor requirements. Then, on [**1-2**] her courese
was complicated by the development of rapid atrial fib for which
she required a dilt drip short term. She is now stable on her PO
beta blocker. Have been titrating this as tolerated for optimal
BP and and HR control. Will continue to hold anticoagulation at
this time and this can be readdressed with her PCP at [**Hospital1 100**]
[**Name9 (PRE) 13089**] Life. Continue digoxin at 0.0625 mg QOD.
.
5. Type 2 diabetes mellitus- Pt's course was complicated by
severe hyperglycemia for which she was on an insulin drip for
optimal BS control and then later episodes of hypoglycemia. At
this time, her BS has been stable on a sliding scale. Will not
restart glyburide at this time but this can be done at [**Hospital1 100**]
Senior Life as she continues to improve.
.
6. [**Name (NI) 12329**] Titrated pt's beta blocker for optimal BP control.
.
7. [**Name (NI) 1068**] Pt was continued on paroxetine.
.
8. [**Name (NI) 12296**] Pt with a history of extensive PVD. Has a deep ulcer on
the right foot and a more superficial one on the left. She will
follow-up with vascular surgery as an outpatient.
.
9. FEN- Cardiac, [**Doctor First Name **] diet. Electrolyte replacement as needed.
.
10. Proph- SC heparin; bowel regimen; PPI; aspiration
percautions; fall percautions.
.
11. Code status- DNR/DNI
.
12. [**Name (NI) 2638**] Pt's son is [**Name (NI) **] [**Name (NI) **]. His phone numbers
are [**Telephone/Fax (1) 22119**] and [**Telephone/Fax (1) 22120**].
Medications on Admission:
Medications at home:
1. ASA 81 mg daily
2. Digoxin 0.0625 mg QOD
3. Docusate 250 mg [**Hospital1 **]
4. Ferrous sulfate 325 mg daily
5. Lasix 40 mg PRN
6. Glyburide 5 mg daily
7. Lisinopril 5 mg daily
8. Metoprolol 25 mg [**Hospital1 **]
9. Paxil 20 mg QHS
10. Senna 2 tabs daily
11. Ambien 2.5 mg QHS
12. Combivent neb PRN
13. Tylenol #3 [**Hospital1 **] prior to dressing changes
14. Tylenol PRN
15. Bisacodyl supp PRn
16. MOM PRN
17. Fleets enemas PRN
.
Medications on transfer:
1. 1. ASA 81 mg daily
2. Digoxin 0.0625 IV daily
3. Docusate 100 mg [**Hospital1 **]
4. SC heparin TID
5. Metoprolol 25 mg [**Hospital1 **]
6. Paroxetine 20 mg daily
7. Zosyn 2.25 IV Q8H
8. Vancomycin 250 mg PO Q6H
Discharge Medications:
1. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Insulin Regular Human 100 unit/mL Solution Sig: Per attached
sliding scale Units Injection ASDIR (AS DIRECTED).
9. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
10. Piperacillin-Tazobactam 2.25 g Recon Soln Sig: 2.25 g
Intravenous Q8H (every 8 hours) for 8 days.
11. Vancomycin 250 mg Capsule Sig: Two [**Age over 90 1230**]y (250) mg PO
every six (6) hours: Please give until is ruled out for C diff
with two more negative samples. Should be oral liquid NOT
capsule. Thanks.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - Acute Rehab
Discharge Diagnosis:
Primary diagnosis:
Urosepsis
Secondary diagnosis:
Atrial fibrillation
Type 2 diabetes mellitus
Hypoglycemia
Depression
HTN
PVD
Discharge Condition:
Stable
Discharge Instructions:
1. Please keep all follow up appointments.
2. Please take all medications as prescribed.
3. Seek medical attention for fevers, chills, chest pain,
shortness of breath, abdominal pain, or any other concerning
symptoms.
Followup Instructions:
You will initially be followed by the physicians in the MACU at
[**Hospital1 100**] Senior Life.
Please follow up [**Last Name (un) 22121**] your primary care physician at [**Hospital1 100**]
[**Name9 (PRE) 13089**] Life, Dr. [**First Name (STitle) **] [**Name (STitle) **], within one week of your return.
Completed by:[**2136-1-6**]
ICD9 Codes: 5990, 4280, 311, 4019, 4439 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3602
} | Medical Text: Admission Date: [**2127-7-3**] Discharge Date: [**2127-7-13**]
Date of Birth: [**2050-4-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2127-7-7**] Three Vessel CABG(LIMA to LAD, SVG to OM, SVG to Ramus)
[**2127-7-3**] Cardiac Catheterization
History of Present Illness:
This 77 year old man has a history of mild hyperlipidemia and
prior tobacco abuse, quit 35 years ago. Approximately six months
ago the patient began to notice occasional episodes of mid
sternal chest discomfort occurring with light exertion and
emotional stress. He underwent stress testing which was notable
for a partially reversible distal inferoseptal defect. He has
continued to have angina with his
last episode occurring about four days ago, responsive to SL
nitroglycerin. He denies increased fatigue or dyspnea on
exertion. He has now agreed to proceed with cardiac
catheterization.
Past Medical History:
- Possible Hypertension (although patient denies)
- Borderline hyperlipidemia
- [**2092**] Throat cancer, s/p surgery, chemo and radiation
- History of Hematuria approximately one year ago - diagnosed
with enlarged prostate (treated with medication)
- Cataract surgery bilaterally
- Tonsillectomy
Social History:
Patient is married with four children. He lives with his wife
and was a former air traffic controller. Patient drinks one
beer/day. Tobacco - quit 35 years ago
Family History:
No family history of premature CAD
Physical Exam:
Admission Vitals: 190/90, 68, 18, 97% RA
Gen: 77 yo man in NAD
HEENT: PERRL, EOMI
Neck: supple, no LAD, no JVD
Cardiac: RRR, nl S1, S2
Chest: CTAB, no crackles, wheezes, rhonchi
Abd: + BS, NT, ND, No hepatosplenomegaly
Ext: No edema, cyanosis
Neuro: AAO x3
Psych: Very anxious
Pulses: 2+ radial and DP pulses bilaterally
Pertinent Results:
[**2127-7-3**] 02:14PM BLOOD WBC-5.6 RBC-3.92* Hgb-12.0* Hct-33.5*
MCV-86 MCH-30.6 MCHC-35.8* RDW-13.1 Plt Ct-183
[**2127-7-3**] 02:14PM BLOOD PT-13.5* PTT-33.2 INR(PT)-1.2*
[**2127-7-3**] 02:14PM BLOOD Glucose-120* UreaN-17 Creat-1.0 Na-128*
K-4.1 Cl-97 HCO3-23 AnGap-12
[**2127-7-3**] 02:14PM BLOOD ALT-13 AST-17 AlkPhos-86 TotBili-0.6
[**2127-7-3**] 02:14PM BLOOD %HbA1c-5.9
[**2127-7-3**] CArdiac Cath:
1. Selective coronary angiography of this right dominant system
demonstrated 2 vessel coronary artery disease. The LMCA showed
a 70%
ostial stenosis with dampened blood pressure when the artery was
engaged. LAD showed moderate diffuse disease. LCx showed a 70%
lesion
in OM1. The RCA showed mild diffuse disease.
2. Limited resting hemodynamic measurements revealed elevated
LVEDP (21
mmHg) and elevated systemic arterial pressure (193/82 mmHg).
There was
no transaortic valve gradient on careful pullback of the
catheter from
the LV to the aorta.
3. Left ventriculography showed EF of 71%, no mitral
regurgitation and
normal LV systolic function. Regional wall motion was normal.
[**2127-7-4**] Carotid Ultrasound:
Bilateral 70-79% stenosis. The right-sided stenosis is slightly
more severe than the left. Both vertebral arteries have normal
antegrade
flow.
[**2127-7-10**] 06:50AM BLOOD WBC-14.9* RBC-3.77* Hgb-11.1* Hct-32.5*
MCV-86 MCH-29.5 MCHC-34.2 RDW-14.7 Plt Ct-139*
[**2127-7-8**] 05:53AM BLOOD PT-13.9* PTT-31.3 INR(PT)-1.2*
[**2127-7-9**] 07:05AM BLOOD Glucose-139* UreaN-17 Creat-1.0 Na-134
K-4.5 Cl-101 HCO3-24 AnGap-14
Brief Hospital Course:
Mr. [**Known lastname 1794**] was admitted and underwent cardiac catheterization
which revealed a severe left main lesion and severe two vessel
coronary artery disease. Cardiac surgery was consult for
surgical evaluation and he underwent preoperative workup.
Carotid ultrasound was notable for 70-79% bilateral stenoses of
both internal carotid arteries and asymptomatic. Vascular
surgery evaluated him and there was no indication for
intervention at this time. On [**7-7**] he was taken to the operating
room and underwent coronary artery bypass grafting. See
operative report for further details. He received perioperative
vancomycin because he was in the hospital pre operatively.
Following the operation, he was brought to the CVICU for
invasive monitoring. Within 24 hours, he awoke neurologically
intact and was extubated without incident. Post operative night
he had atrial fibrillation that was treated with amiodarone,
which he converted back to normal sinus rhythm. His CVICU course
was otherwise uneventful and he transferred to the floor on
postoperative day one. He was started on beta blockers and
diuretics. Physical therapy worked with him for strength and
mobility. His urinary catheter was reinserted for failure to
void, he was restarted on Terazosin, foley was removed POD 3 and
he had no further issues. POD#5 serous drainage at the inferior
pole of his sternal incision was noted, along with a right
forearm IV area that appeared erythematous. Mr [**Known lastname 1794**] was placed
on Vancomycin per DrKhabbaz and his discharge was postponed . He
continued to progress and was ready for discharge home POD 6
with services on Ciprofloxacin, with plan for wound check
Tuesday [**7-15**] at 11am. Plan for follow up on carotids with Dr
[**Last Name (STitle) 57956**] (vascular surgery) in 6 months with repeat carotid
duplex.
Medications on Admission:
Terazosin 5mg daily every evening
Hyzaar 50-12.5mg one tablet every morning
Metoprolol Tartrate 50mg one tablet twice a day
Simvastatin 20mg one tablet every morning
Aspirin 81mg daily every morning
Nitroglycerin SL as needed
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. 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*
3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
5. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*0*
6. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
7. Terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
Disp:*30 Capsule(s)* Refills:*0*
8. Losartan-Hydrochlorothiazide 50-12.5 mg Tablet Sig: One (1)
Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
9. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: 1.5
Tablet Sustained Release 24 hrs PO once a day.
Disp:*60 Tablet Sustained Release 24 hr(s)* Refills:*0*
10. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Coronary Artery Disease - s/p CABG
Post operative atrial fibrillation
Carotid stenosis
Hypertension
Hyperlipidemia
History of Throat Cancer
Discharge Condition:
Good
Good
Discharge Instructions:
1)Please shower daily. No baths. Pat dry incisions, do not rub.
2)Avoid creams and lotions to surgical incisions.
3)Call cardiac surgeon if there is concern for wound infection.
4)No lifting more than 10 lbs for at least 10 weeks from
surgical date.
5)No driving for at least one month.
6)Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Please call to schedule all appointments
Dr. [**Last Name (STitle) **] in 4 weeks
Dr. [**Last Name (STitle) 2093**] in 1 weeks
Dr. [**Last Name (STitle) 3321**] in 3 weeks
Dr [**Last Name (STitle) 57956**] (vascular surgery) in 6 months - please call to
schedule appointment for office visit with physician and for
carotid duplex ultrasound.
Wound check appointment Tuesdat [**7-15**] at 11am [**Hospital Ward Name 121**] 6
ICD9 Codes: 9971, 4111, 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3603
} | Medical Text: Admission Date: [**2162-11-21**] Discharge Date: [**2162-12-3**]
Date of Birth: [**2108-9-15**] Sex: F
Service: NEUROSURGERY
Allergies:
ciprofloxacin / Sulfite
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
[**2162-11-22**] Cerebral angiogram
History of Present Illness:
54F presented to an OSH today with headache and nausea. She had
been drinking beers and shots this afternoon and last remembers
being on the phone with her friend and then waking on the floor
with a headache and nausea. She claims her boyfriend was with
her and said she was lifting weights and hit her head. The
exact
events are still unclear. She presented to [**Hospital1 **]-[**Location (un) 620**] with
headache and nausea and a CT performed demonstrated a SAH and
she
was transferred to [**Hospital1 18**]. She was neurologically intact without
any evidence of weakness, change in vision or sensation.
Past Medical History:
- s/p tubal ligation
- s/p knee arthroscopy
- anxiety
- HTN
- Hyperlipidemia
Social History:
Social Hx: lives at home with boyfriend, EtOH abuse, non smoker
She has three children. She is currently not divorced from her
husband but they are not living together. She verbalized that
she would like her daughter to make her decisions for her if she
is not able to.
Family History:
no history of aneurysm
Physical Exam:
O: T: 96.0 BP:160 / 100 HR: 74 R 18 100 % on 2L
Gen: WD/WN, comfortable, NAD, hard collar in place
HEENT: Pupils: EOMs
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**3-11**] 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: Pupils equally round and reactive to light, to
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.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-13**] throughout. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
ON DISCHARGE
aaox3, PERRL, face symmetric, tongue midline, motor and sensory
intact, no drift
Pertinent Results:
[**2162-11-21**] 09:50PM WBC-12.6* RBC-4.53 HGB-13.5 HCT-40.5 MCV-89
MCH-29.9 MCHC-33.4 RDW-14.6
[**2162-11-21**] 09:50PM PLT COUNT-310
[**2162-11-21**] 09:50PM PT-12.7 PTT-21.2* INR(PT)-1.1
[**2162-11-21**] 09:50PM GLUCOSE-140* UREA N-10 CREAT-0.6 SODIUM-138
POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-22 ANION GAP-18
[**2162-11-21**] CT head noncontrast:
IMPRESSION:
1. Diffuse subarachnoid hemorrhage filling the suprasellar
cistern,
perimesencephalic cisterns, and sylvian fissures. The hemorrhage
is
particularly dense in the pontine and medullary cisterns,
raising concern of a vertebral or basilar artery source. No
midline shift.
2. Moderate intraventricular hemorrhage extending inferiorly
into the fourth ventricle with dilatation of the lateral
ventricles and temporal horns, concerning for developing
obstructive hydrocephalus.
3. Punctate focus in the superior right frontal lobe adjacent to
the falx,
which may represent a small focus of intraparenchymal hemorrhage
or additional amount of subarachnoid blood.
[**2162-11-21**] CT cervical spine noncontrast:
No evidence of fracture, malalignment or prevertebral soft
tissue swelling. The lateral masses of C1 are symmetric about
the dens. There is mild degenerative change, most severe at
C5-C6 with intervertebral disc space narrowing and mild anterior
osteophytosis. Outline of the thecal sac is unremarkable without
evidence of critical canal stenosis.
[**2162-11-21**] CTA head:
IMPRESSION:
Focal dilatation of the right vertebral artery on volume
rendered images
[**2162-11-25**] Head CT:
IMPRESSION:
1. No evidence of new hemorrhage.
2. Resorption and redistribution of subarachnoid hemorrhage with
layering of blood products in the occipital horns of the lateral
ventricles and fourth ventricle.
[**2162-11-29**] MRI/MRA Brain:
1. Slow diffusion in the right cerebellar distribution that most
likely is
due to residual subarachnoid blood but cannot exclude an
ischemic process.
2. Occluded distal portion of V4 segment of the right vertebral
artery,
consistent with recent coil embolization.
[**2162-11-29**] LENIS:
Negative for DVT
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the Neurocritical care unit for
close neurological monitoring and critical care in the setting
of Subarachnoid hemorrhage and ruptured aneurysm. She was
started on Nimodipine for vasospasm prophylaxis and dilantin for
seizure prophylaxis. Systolic blood pressure was maintained
less than 140.
She underwent cerebral angiogram on [**11-22**] with coiling of the
diessecting right vertebral artery aneurysm. She was recovered
in the ICU on a heparin gtt for 48 hours. Systolic BP post
procedure was maintained strict under 140 to reduce chance of
migration of coils. Plain skull images were done the following
am and were compared to the intra-angiogram images. No coil
migration was noted.
She remained stable neurologically and follow up CT imaging does
not demonstrate any cerebral infarct on [**11-25**]. Headache
management has been a challenge. There also was concern that
she was exhibiting signs of alcohol withdrawal on hospital day
#5 and small doses of Ativan were given. Her TCD's remained
stable. She remained in the Neuro ICU with a stable exam.
On [**11-27**] she had an episode of bradycardia during which she was
normotensive. Followup EKG was normal and she had no further
episodes. On [**11-28**] she was stable in the ICU with increasing
urine outputs so labs were done to assess for any endocrinologic
abnormalities that could be causing this and she was placed on
florinef by the ICU.
MRI/A imaging on the 21st was stable. Screening Lower extremity
dopplers were negative for DVT. On [**11-30**], dilantin was
discontinued. On [**12-1**], patient remained nonfocal on examination
and was transferred to the floor. Her foley was discontinued.
Now DOD, she is afebrile VSSS. She is tolerating a good oral
diet and pain is well-controlled. She is set for discharge home
in stable condition.
Medications on Admission:
- sertraline
- tramadol
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for Pain.
Disp:*60 Tablet(s)* Refills:*0*
3. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
4. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for anxiety.
5. sertraline 25 mg Tablet Sig: One (1) Tablet PO once a day.
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
7. nimodipine 30 mg Capsule Sig: Two (2) Capsule PO Q4H (every 4
hours) for 7 days.
Disp:*84 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Subarachnoid Hemorrhage
Right vertebral Artery Aneurysm
hydrocephalus / mild
Intraventricular hemorrhage
Headache
Alcohol withdrawal
Delirium
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Angiogram with Embolization of Right Vertebral Artery Dissecting
Aneurysm
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily.
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs.
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
?????? After 1 week, you may resume sexual activity.
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate.
?????? No driving until you are no longer taking pain medications
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call 911 for transfer to closest
Emergency Room!
Followup Instructions:
Please call the office of Dr. [**First Name (STitle) **] at [**Telephone/Fax (1) **] to be seen
in one month. You will need an MRI of the brain with Dr. [**First Name (STitle) **]
protocol at that time.
Completed by:[**2162-12-3**]
ICD9 Codes: 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3604
} | Medical Text: Admission Date: [**2166-7-4**] Discharge Date: [**2166-7-8**]
Date of Birth: [**2090-5-2**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Percodan
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
hemoptysis
Major Surgical or Invasive Procedure:
[**2166-7-4**]
Left Pneumonectomy
[**2166-7-8**]
Digital videostroboscopy
History of Present Illness:
Mr [**Known lastname **] is a 76M with hemoptysis
developing 11/[**2164**]. A chest CT [**2166-12-18**] was unrevealing. It is
unclear when the hemoptysis resolved, but after wintering in
[**State 108**], the pt underwent a bronch [**5-2**] with findings of atypia.
The bronch was repeated [**2166-5-30**]. Path of a LLL biopsy returned as
squamous metaplastic epithelium with local atypia. The LLL
bronchus was severely narrowed. Chest CT [**2166-6-6**] showed new LLL
medial segment collapse.Currently, the pt reports a dry cough
but
otherwise no SOB, DOE, chest pain, hemoptysis, sweats, fever, HA
or new bony pain.
He presents now for resection.
Past Medical History:
1. Paroxysmal atrial fibrillation for 12 years
2. P MIBI [**2158-11-14**]: EF of 60%, prob
inf wall artifact with no definite perfusion abnormality
3. He also has small abdominal aortic aneurysm (abd u/s on
[**2158-10-30**]: mid-distal AAA 3.8 cm max diameter, up from 3.2cm on
last film, ?date)
4. High sugars, but never diagnosed with diabetes mellitus.
5. Hypertension.
6. Hypercholesterolemia.
7. hx of two embolic CVA (most recent in [**2155**]) likely [**1-23**] to
emboli from a fib (little residual ataxia)
8. s/p rotator cuff repair
Social History:
He is a former smoker (40-pack-per-year).
Two to three drinks per week.
He is retired from a security job. A former Marine
Family History:
no CAD, DM, high chol
Physical Exam:
BP: 122/85. Heart Rate: 92. Weight: 210.6. Height: 69.5. BMI:
30.7. Temperature: 97.9. Resp. Rate: 16. Pain Score: 0. O2
Saturation%: 99.
GENERAL [x] All findings normal
[ ] WN/WD [ ] NAD [ ] AAO [ ] abnormal findings:
HEENT [x] All findings normal
[ ] NC/AT [ ] EOMI [ ] PERRL/A [ ] Anicteric
[ ] OP/NP mucosa normal [ ] Tongue midline
[ ] Palate symmetric [ ] Neck supple/NT/without mass
[ ] Trachea midline [ ] Thyroid nl size/contour
[ ] Abnormal findings:
RESPIRATORY [x] All findings normal
[ ] CTA/P [ ] Excursion normal [ ] No fremitus
[ ] No egophony [ ] No spine/CVAT
[ ] Abnormal findings:
CARDIOVASCULAR [x] All findings normal
[ ] RRR [ ] No m/r/g [ ] No JVD [ ] PMI nl [ ] No edema
[ ] Peripheral pulses nl [ ] No abd/carotid bruit
[ ] Abnormal findings:
GI [x] All findings normal
[ ] Soft [ ] NT [ ] ND [ ] No mass/HSM [ ] No hernia
[ ] Abnormal findings:
GU [x] Deferred [ ] All findings normal
[ ] Nl genitalia [ ] Nl pelvic/testicular exam [ ] Nl DRE
[ ] Abnormal findings:
NEURO [x] All findings normal
[ ] Strength intact/symmetric [ ] Sensation intact/ symmetric
[ ] Reflexes nl [ ] No facial asymmetry [ ] Cognition intact
[ ] Cranial nerves intact [ ] Abnormal findings:
MS [x] All findings normal
[ ] No clubbing [ ] No cyanosis [ ] No edema [ ] Gait nl
[ ] No tenderness [ ] Tone/align/ROM nl [ ] Palpation nl
[ ] Nails nl [ ] Abnormal findings:
LYMPH NODES [x] All findings normal
[ ] Cervical nl [ ] Supraclavicular nl [ ] Axillary nl
[ ] Inguinal nl [ ] Abnormal findings:
SKIN [x] All findings normal
[ ] No rashes/lesions/ulcers
[ ] No induration/nodules/tightening [ ] Abnormal findings:
PSYCHIATRIC [x] All findings normal
[ ] Nl judgment/insight [ ] Nl memory [ ] Nl mood/affect
[ ] Abnormal findings:
Pertinent Results:
[**2166-7-4**] 06:00PM WBC-9.9# RBC-4.22* HGB-13.1* HCT-38.5* MCV-91
MCH-31.2 MCHC-34.2 RDW-13.6
[**2166-7-4**] 06:00PM GLUCOSE-208* UREA N-22* CREAT-0.8 SODIUM-137
POTASSIUM-4.9 CHLORIDE-104 TOTAL CO2-25 ANION GAP-13
[**2166-7-4**] 06:43AM PT-13.3* PTT-25.7 INR(PT)-1.2*
[**2166-7-6**] CXR :
Status post removal of a left-sided chest tube from the
pneumonectomy cavity. The height of the air-fluid level is
comparable to the previous examination. Remnant gas collections
in the left lateral chest wall and the cervical soft tissues.
Unchanged moderate cardiomegaly. Unchanged normal appearance of
the right lung.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the hospital and taken the Operating
Room where he underwent a left pneumonectomy. he tolerated the
procedure well and returned to the SICU in stable condition. He
had an epidural catheter placed for pain management which was
effective. He maintained stable hemodynamics and underwent
vigorous pulmonary toilet and remained free of any pulmonary
complications.
Following transfer to the Surgical floor he continued to make
good progress. His chest tube was removed on post op day #2 as
was his epidural catheter. He was placed on scheduled Tylenol
and Dilaudid orally for pain. Serial chest xrays showed the
expected fluid progression in the cavity. He was tolerating a
diabetic diet and ambulating independently. His preadmission
Coumadin was started on [**2166-7-6**] at his home dose and Dr. [**Last Name (STitle) **]
will follow his INR which was 1.2 on [**2166-7-8**].
Of note, his voice seemed a bit hoarse post op and he had a
digital videostroboscopy performed on [**2166-7-8**] which showed an
immobile left vocal cord. He will return in a few weeks to the
[**Hospital **] Clinic for medialization. In the interim he underwent a
video swallow along with a complete speech and swallow exam
which showed that although his vocal cords are not adducting
fully, his laryngeal vestibule and epiglottis are functioning as
expected and diet modification is not needed at this time. He
will follow up with Dr. [**Last Name (STitle) **] in a few weeks.
Following completion of his swallow evaluation he was discharged
to home on a regular diet and will have VNA services for
cardiopulmonary assessment along with INR checks.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Losartan Potassium 50 mg PO DAILY
2. Tiotropium Bromide 1 CAP IH DAILY
3. Metoprolol Succinate XL 50 mg PO DAILY
4. MetFORMIN (Glucophage) 850 mg PO BID
5. Fluticasone Propionate NASAL 2 SPRY NU DAILY
6. Warfarin 2.5 mg PO 4X/WEEK (MO,TU,TH,FR)
2.5 mg q M-Tu-Th-F
5 mg q [**Doctor First Name **]-W-Sa
7. Pravastatin 40 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Aspirin 81 mg PO DAILY
10. Tamsulosin 0.4 mg PO HS
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Losartan Potassium 50 mg PO DAILY
3. MetFORMIN (Glucophage) 850 mg PO BID
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Pravastatin 40 mg PO DAILY
6. Tamsulosin 0.4 mg PO HS
7. Warfarin 5 mg PO SUNDAY, WEDNESDAY, AND SATURDAY
8. Warfarin 2.5 mg PO [**Last Name (LF) **], [**First Name3 (LF) **], [**Last Name (un) **], FRI
9. Acetaminophen 1000 mg PO Q6H
10. Tiotropium Bromide 1 CAP IH DAILY
11. HYDROmorphone (Dilaudid) 2-4 mg PO Q3H:PRN pain
RX *hydromorphone 2 mg [**12-23**] tablet(s) by mouth every four (4)
hours Disp #*60 Tablet Refills:*0
12. Fluticasone Propionate NASAL 2 SPRY NU DAILY
13. Multivitamins 1 TAB PO DAILY
14. Docusate Sodium 100 mg PO BID
15. Senna 2 TAB PO HS:PRN constipation
Discharge Disposition:
Home With Service
Facility:
VNS Home Healthservices
Discharge Diagnosis:
squamous cell lung carcinoma
left vocal cord immobility
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
* You were admitted to the hospital for lung surgery and you've
recovered well. You are now ready for discharge.
* Continue to use your incentive spirometer 10 times an hour
while awake.
* Check your incisions daily and report any increased redness or
drainage. Cover the area with a gauze pad if it is draining.
* Your chest tube dressing may be removed in 48 hours. If it
starts to drain, cover it with a clean dry dressing and change
it as needed to keep site clean and dry.
* You will continue to need pain medication once you are home
but you can wean it over a few weeks as the discomfort resolves.
Make sure that you have regular bowel movements while on
narcotic pain medications as they are constipating which can
cause more problems. Use a stool softener or gentle laxative to
stay regular.
* No driving while taking narcotic pain medication.
* Take Tylenol 1000 mg every 6 hours in between your narcotic.
* Continue to stay well hydrated and eat well to heal your
incisions
* Shower daily. Wash incision with mild soap & water, rinse, pat
dry
* No tub bathing, swimming or hot tubs until incision healed
* No lotions or creams to incision site
* Walk 4-5 times a day and gradually increase your activity as
you can tolerate.
* Resume your Coumadin at your pre op dosing and the VNA will
draw an INR on Friday with results to Dr. [**Last Name (STitle) **].
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if you experience:
-Fevers > 101 or chills
-Increased shortness of breath, chest pain or any other symptoms
that concern you.
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2166-7-22**] at 1 PM
With: [**Name6 (MD) 1532**] [**Name8 (MD) 1533**], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Please report 30 minutes prior to your appointment to the
Radiology Department on the [**Location (un) **] of the [**Hospital Ward Name 23**] Clinical
Center for a chest xray.
Department: OTOLARYNGOLOGY-AUDIOLOGY
When: WEDNESDAY [**2166-7-30**] at 3:00 PM
With: [**Name6 (MD) 15040**] [**Last Name (NamePattern4) 15041**], 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
Department: PULMONARY FUNCTION LAB
When: TUESDAY [**2166-9-2**] at 10:40 AM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2166-7-8**]
ICD9 Codes: 4019, 2720, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3605
} | Medical Text: Admission Date: [**2148-3-25**] Discharge Date: [**2148-4-4**]
Date of Birth: [**2076-10-30**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Niacin / Colestid / Accupril
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2148-3-26**] Coronary Artery Bypass Graft x 4 (Left internal mammary
artery to left anterior descending, Saphenous vein graft to
diagonal, Saphenous vein graft to obtuse marginal, Saphenous
vein graft to posterior descending artery)
[**3-29**] bronchosccopy-reintubated
History of Present Illness:
[**Known firstname **] [**Last Name (NamePattern1) **] is a 71-year-old gentleman who experienced an
episode of congestive heart failure while in [**State 108**]. Work up
was notable for abnormal stress test and he underwent cardiac
catheterization, which was significant for severe three-vessel
coronary artery disease. At the time of catheterization, there
was also notable for severe mitral regurgitation and an ejection
fraction of approximately 40%. Given these findings, he was
referred to me for cardiac surgical evaluation. Currently, his
symptoms include a cough and dyspnea on exertion.
Past Medical History:
Coronary Artery Disease
Mitral Regurgitation
Hypertension
Hypercholesterolemia
Congestive heart failure
Tobacco abuse
Carotid disease
Subclinical hypothyroidism
Fatty liver
Kidney stones
Social History:
Retired. Quit smoking in [**2142**] after [**11-24**] ppd x 40 years. Denies
alcohol use.
Family History:
Brother died from myocardial infarction at age 52. Another
brother had bypass surgery at age 62
Physical Exam:
Vital signs: Pulse of 80, respirations of 16, and blood pressure
of 112/72.
In general, he was a well-developed and well-nourished male in
no acute
distress. His skin was unremarkable. His oropharynx was
benign. He was noted to have poor dentition. Neck was supple
with full range of motion. There was no JVD. Lungs were clear
to auscultation bilaterally. Heart had a regular rate and
rhythm, normal S1 and S2, with a III/VI holosystolic murmur best
heard at the left lower sternal border and apex. Abdomen was
benign. Extremities were warm and well perfused without edema.
He had no varicosities of the greater saphenous vein.
Neurologically, he was alert and oriented x3. Cranial nerves II
through XII were grossly intact. He had 5/5 strength and no
focal deficits were appreciated. His distal pulses were 2+ and
carotid bruits could not been appreciated secondary to his
cardiac murmur.
Pertinent Results:
[**2148-3-25**] 02:17PM GLUCOSE-87 NA+-138 K+-4.2
[**2148-3-25**] 01:42PM UREA N-23* CREAT-1.2 CHLORIDE-116* TOTAL
CO2-23
[**2148-3-25**] 01:42PM WBC-22.2* RBC-3.05*# HGB-9.6*# HCT-28.3*#
MCV-93 MCH-31.4 MCHC-33.8 RDW-14.9
[**2148-3-25**] 12:32PM WBC-16.2* RBC-2.29*# HGB-7.1*# HCT-21.8*#
MCV-95 MCH-30.8 MCHC-32.3 RDW-15.0
[**2148-3-25**] 12:32PM PLT COUNT-151
[**2148-4-3**] 06:10AM BLOOD Hct-34.6*
[**2148-4-2**] 05:29AM BLOOD WBC-14.3* RBC-3.89* Hgb-11.5* Hct-34.1*
MCV-88 MCH-29.4 MCHC-33.6 RDW-16.4* Plt Ct-250
[**2148-4-2**] 05:29AM BLOOD Plt Ct-250
[**2148-3-30**] 05:23AM BLOOD PT-16.7* PTT-26.5 INR(PT)-1.5*
[**2148-4-3**] 06:10AM BLOOD Glucose-83 UreaN-38* Creat-1.3* Na-141
K-4.4 Cl-104 HCO3-27 AnGap-14
[**2148-4-1**] 04:13AM BLOOD ALT-34 AST-30 LD(LDH)-346* AlkPhos-96
Amylase-226* TotBili-0.7
[**2148-3-25**] Echo: PREBYPASS: 1. The left atrium is moderately
dilated. No atrial septal defect or patent foramen ovale is seen
by 2D, color Doppler or saline contrast with maneuvers. 2. Left
ventricular wall thicknesses and cavity size are normal. LV EF
is 60%. 3. Right ventricular chamber size and free wall motion
are normal. 4. There are complex (>4mm) atheroma in the aortic
arch and descending thoracic aorta. Epiaortic imaging at the
site of cross clamping and aortic cannulation revealed simple
atheroma. 5. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and trace aortic
regurgitation. 6. The mitral valve leaflets are mildly
thickened. There is partial mitral leaflet flail. 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). 7. There is no pericardial
effusion. 8. Dr. [**Last Name (STitle) **] was notified in person of the results
during the surgery on [**2148-3-25**] at 821. POSTBYPASS: 1. Patient is
on epinepherine and phenylepherine infusions. AV and later A
paced. 2. There is a mitral annuloplasty ring insitu with a
shortened posterior leaflet consistent with a mitral valve
repair. There is trace mitral regurgitation. Peak and mean
gradients are less than 6 mm hg. 3. There is preserved
biventricular function on low dose epinepherine infusion.
Initial septal diskinesis resolves when converted from AV to A
pacing. 4. Aortic contours are intact. 5. Remaining exam is
unchanged. 6. All findings are discussed with surgeons at the
time of the exam.
[**Known lastname 2922**],[**Known firstname 4075**] [**Medical Record Number 8709**] M 71 [**2076-10-30**]
Radiology Report CHEST (PA & LAT) Study Date of [**2148-4-3**] 10:45
AM
[**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG FA6A [**2148-4-3**] 10:45 AM
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 8710**]
f/u ptx
Final Report
STUDY: PA and lateral chest radiograph.
INDICATION: Patient is status post CABG, MVR, for evaluation.
TECHNIQUE: Frontal and lateral chest radiographs were obtained.
COMPARISON: Radiograph is compared to [**2148-1-31**].
REPORT:
The patient is status post sternotomy and mitral valve repair as
well as LIMA grafting. There has been interval removal of a
right-sided central line. The patient's right-sided pneumothorax
probably effectively has resolved. There are persistent changes
along the left pleura superiorly likely representing a loculated
pleural process. Interestingly, the left lower lobe effusion has
somewhat improved and there is continued improved aeration in
the left lower lobe. A small amount of blunting in the right
costophrenic sulcus is unchanged. A right upper lobe opacity
persists and continued attention to this is recommended.
CONCLUSION:
Effective resolution of pneumothorax.
Improved postoperative changes in the right and left lung bases,
but with
worsening left apical opacity which is lobulated and broad-based
to the left pleura, suggesting pleural origin. Small right-sided
opacity for which continued followup is recommended.
DR. [**First Name11 (Name Pattern1) 8711**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Brief Hospital Course:
Mr. [**Known lastname **] was a same day admit after undergoing all
pre-operative work-up as an outpatient. On day of admission he
was brought to the operating room where he underwent a coronary
artery bypass graft x 3 and mitral valve repair. Please see
operative report for surgical details. Following surgery he was
transferred to the CVICU for invasive monitoring in stable
condition. Within 24 hours he was weaned from sedation, awoke
neurologically intact and extubated. He was weaned off Nitro and
Milrinone by post-op day two and was transferred to the
telemetry floor for further care. Chest tubes and epicardial
pacing wires were removed per protocol. He was gently diuresed
towards his preoperative weight. The physical therapy service
was consulted for assistance with his postoperative strength and
mobility. He developed atrial fibrillation for which amiodarone
and coumadin were started. A chest x-ray revealed a right
pneumothorax which had increased in size. The interventional
pulmonology service was consulted who elected to place an
anterior chest tube (DART). The procedure was hemoptysis
requiring intubation. He was transferred back to the intensive
care unit and a chest tube was placed. A bronchoscopy revealed
fresh clot but patent airways. He developed hemodynamic
instability which was thought to be related to a blood
transfusion as his hemodynamics improved with steroids. A
transesophageal echocardiogram was without significant
abnormalities. As he fully stabilized, he was extubated the next
day. He was transferred back to the step down unit for further
recovery.
He continued to make steady progress and was discharged home on
POD 10. He will follow-up with Dr. [**Last Name (STitle) **], his cardiologist and
his primary care physician as an outpatient.
Medications on Admission:
Carvedilol 6025 mb [**Hospital1 **], Lisinopril 10mg daily, Crestor 40mg
daily, Aspirin 81mg daily, Lasix 20mg daily, Plavix 75mg daily
(stopped [**3-6**]), Nitro 0.3mg SL prn
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for temperature/pain.
4. 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*
5. Rosuvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): [**Hospital1 **] x10 days then QD.
Disp:*40 Tablet(s)* Refills:*0*
7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400mg [**Hospital1 **] x7 days, then 400mg QD x7 days, then 200mg QD.
Disp:*60 Tablet(s)* Refills:*1*
8. Carvedilol 3.125 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
Disp:*180 Tablet(s)* Refills:*2*
9. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Coronary Artery Disease
Mitral Regurgitation
Hypertension
Hypercholesterolemia
Congestive heart failure
Tobacco abuse
Carotid disease
Subclinical hypothyroidism
Fatty liver
Kidney stones
Discharge Condition:
Good
Discharge Instructions:
shower daily, no baths or swimming
no lotions, creams or powders to incisions
no driving for 4 weeks and off all narcotics
no lifting more than 10 pounds for 10 weeks
report any redness of, or drainage from incisions
report any fever greater than 100.5
report any weight gain greater than 2 pounds a day or 5 pounds a
week
take all medications as directed
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks
Dr.[**Last Name (STitle) **] in [**12-26**] weeks
Dr. [**Last Name (STitle) 1683**] in [**11-24**] weeks
Completed by:[**2148-4-4**]
ICD9 Codes: 2762, 4240, 2449, 4280, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3606
} | Medical Text: Admission Date: [**2189-12-30**] Discharge Date: [**2190-1-5**]
Service: NEUROLOGY
DATE OF DISCHARGE: Pending at this time.
HISTORY OF THE PRESENT ILLNESS: [**Known firstname **] [**Known lastname 102182**] is an
88-year-old retired ophthalmologist with the past medical
history of CLL in remission, peripheral neuropathy,
hypertension times 20 years, history of irregular heart
beats, history of gastritis and history of gout. The patient
presented originally for elective stenting of left internal
carotid artery. He is known to have bilateral high-grade
stenoses. In [**Month (only) 359**] of this year he had had some repeated
episodes of difficulty expressing himself and difficulty
finding words, but no focal weakness. He was worked up at
that time for presumed TIA and he was found to have the
carotid stenosis, as described above. On the day of
admission he underwent elective stenting and he was doing
well. However, during the procedure it was noted acutely
that he was not moving his right hand and face well and that
he had difficulty responding to questions, and he became
progressively less verbal, although he was still alert.
Angiogram was done emergently, which revealed likely
occlusion of the left angular branch of the middle cerebral
artery on the left, but because the patient could not
tolerate the placement of the catheter, he could not receive
intra-arterial TPA. He was started Reapro and Heparin and
transferred to the PACU. The CT done at that time showed no
bleed and only slight contrast extravasation.
PAST MEDICAL HISTORY: History is as described above.
ALLERGIES: The patient has allergies to CODEINE and
TETRACYCLINE.
OUTPATIENT MEDICATIONS:
1. Cardura.
2. Allopurinol.
3. Prilosec.
4. Baby aspirin.
At the time that he was seen in the neurological ICU he was
on a Integrilin 3 ml per hour, Heparin, Zantac, Labetalol
p.r.n. for blood pressure control.
SOCIAL HISTORY: History is significant for the fact that he
quit smoking 30 years ago and before that he smoked one pack
per day. He does not use alcohol at present. He is a
retired ophthalmologist. He was previously head of the
Department of Ophthalmologist at the [**Hospital1 190**].
PHYSICAL EXAMINATION: On examination, vital signs were blood
pressure 165/56, pulse 60, respirations 20 and temperature
908.5. Heart showed a regular rate and rhythm with
occasional PVCs intruding. Lungs were clear to auscultation.
Abdomen was soft, and nontender. Neurological examination
revealed that the patient is alert, awake, and only saying
minimal words. He was not able to say the date. He
initially called the thumb the "thumble" and after that,
during all subsequent questions he would simply repeat
thumble in a perseverative fashion. He was able to repeat
accurately. He could read simple sentences. He could not
write. His comprehension was intact for some simple
commands, but inconsistent overall.
On motor examination, he was moving the right arm left, but
he was able to lift it and did not have any appreciable
drift. His hand seemed somewhat clumsy, but this was
difficult to assess. It was not clear whether he was apraxic
or simply weak. He was able to move his lower extremities
equally well. On cranial nerve examination, he had equal and
round and reactive pupils. Extraocular movements were
intact and he blinks to threat bilaterally. He had a right
facial droop. Tongue was midline. It was difficult to
assess sensation secondary to language. Coordination tests
were not able to be done secondary to comprehension problems.
HOSPITAL COURSE: The patient was kept in the ICU under the
care of Neurology and his blood pressure was controlled at
140 to 150 systolic. He was kept flat initially. He
initially tolerated the Heparin and Integrilin well, but on
the day after admission it was noted that his hematocrit had
dropped to 30 from a preoperative level of 37. The following
day, he had had a drop to 29. He then dropped to 25.7. The
Heparin and Reapro were held. Urinalysis and stool guaiac
were obtained, which were negative for bleed. He was given
two units of packed red blood cells and the hematocrit came
up nicely.
While he was in the unit, he also received some
Neo-Synephrine for blood pressure support. This was able to
be discontinued on [**2189-12-31**] and he did not have any change
in his symptoms or clinical condition following this.
Slowly, over the course of his hospital stay, the aphasia,
which was predominately a conduction aphasia previously,
began to resolve. He was more fluent, able to comprehend
complex commands, and had a very mild residual anomia for
low-frequency words.
Following the discontinuation of the Integrilin and Heparin,
he was started on Aspirin and Plavix. He was also seen by PT
and Occupational Therapy who felt that he would do well with
three to five outpatient visits per week for continued
rehabilitation of the right upper extremity. Bedside swallow
test was performed, which demonstrated that he could swallow
thickened liquids and diet was advanced as tolerated with no
adverse events.
DISCHARGE PLANNING: This will be included as an addendum to
the current dictation.
DISCHARGE DIAGNOSIS:
1. Acute stroke.
2. Hypertension.
3. History of CLL in remission.
4. Gout.
5. History of irregular heart beat.
6. Peripheral neuropathy.
7. History of gastritis.
MEDICATIONS:
1. Aspirin at 325 mg p.o.q.d.
2. Plavix 75 mg p.o.q.d.
OTHER MEDICATIONS: Other medications will be included in the
discharge addendum.
[**Doctor Last Name **] [**Name8 (MD) 8346**], M.D. [**MD Number(1) 8347**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2190-1-4**] 14:08
T: [**2190-1-4**] 14:14
JOB#: [**Job Number **]
ICD9 Codes: 4019, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3607
} | Medical Text: Admission Date: [**2139-12-4**] Discharge Date: [**2139-12-13**]
Date of Birth: [**2081-8-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Unstable Angina
Major Surgical or Invasive Procedure:
[**2139-12-8**] Coronary Artery Bypass Graft x 4 (Lima to LAD, SVG to
OM, SVG to Ramus, SVG to PDA)
[**2139-12-4**] Cardiac Catheterization
History of Present Illness:
58 y/o male with mulitple cardiac risk factors who presented to
outside hosptial with unstable angina/bilateral arm pain. ECG
showed small ST depressions, but was ruled out for an MI. He
then had a stress MIBI which was postive for symptoms and ST
depressions. Also revealed small reversible inferior defect and
old fixed defect. Patient was then transferred to [**Hospital1 18**] for
cardiac cath. Cath revealed three vessel coronary artery
disease, 80% distal left main stenosis, and 70-80% instent
restenosis of the RCA. Cardiac surgery was then consulted for
surgical revascularization.
Past Medical History:
Coronary Artery Disease s/p s/p NSTEMI w/ PTCA/Stenting to RCA
in [**2136**] and again in [**2138**]
Hypertension
Hypercholesterolemia
Diabetes Mellitus
Peripheral Neuropathy
Chronic Renal Insufficiency
Social History:
Lives with wife. Retired, previously worked as electrical
lineman. Now runs catering service. Previous 15 pack year
smoker, quit 30 years ago. ETOH: [**1-23**] drinks [**11-23**] time per week.
Family History:
CAD in Sister and Father
Physical Exam:
VS: 60 140/80
HEENT: EOMI, PERRL, NC/AT, OP Benign
Neck: Supple, FROM, -JVD
Lungs: CTAB -w/r/r
Heart: RRR, +S1/S2, -c/r/m/g
Abd: Soft, NT/ND, +BS
Ext: Warm, well-perfused, 2+ pulses, -Edema
Neuro: A&O x 3, MAE, Non-focal
Pertinent Results:
Cardiac Cath [**2139-12-4**]: 1. Coronary angiography revealed a right
dominant system status post RCA stenting. The LMCA showed a
complex 80% distal stenosis with involvement of the LAD and LCX
ostia. The LAD showed a 70% ostial stenosis with 70% stenosis of
the D1. The LCX showed an ostial 80% stenosis with diffuse
disease, including a 50% midsegment stenosis. The RCA showed
sequential 80% and 70% instent restenoses within the most
proximal RCA stent, with milder 20-30% restenosis of the mid and
distal stents.
Echo [**2139-12-7**]: Overall left ventricular systolic function is
normal (LVEF>55%). The mitral valve leaflets are mildly
thickened. No mitral regurgitation is seen in suboptmal views
(cannot exclude). There is a trivial/physiologic pericardial
effusion.
Head CT Scan [**2139-12-10**]: There is no evidence of intra- or
extra-axial hemorrhage. The ventricles, cisterns, and sulci are
unremarkable, without effacement. There does seem to be a slice
through the suprasellar cistern, which is missing, limiting
evaluation but the other slices suggest no abnormality. There is
no mass effect, hydrocephalus, or shift of the normally midline
structures. The [**Doctor Last Name 352**]-white matter differentiation appears
preserved.
Carotid Ultrasound [**2139-12-11**]: Significant amount of plaque at the
origins of the bilateral internal carotid arteries, associated
with luminal narrowing estimated between 80 and 99% in diameter
on both sides.
EEG [**2139-12-11**]: Abnormal EEG due to the presence of diffuse
background
slowing and superimposed bursts of generalized mixed frequency
delta and
theta slowing. No focal or epileptiform features were seen.
Common
causes of encephalopathy include medications, metabolic causes,
and
infectious processes.
Brain MRI [**2139-12-12**]: The diffusion images demonstrate subtle areas
of slow diffusion in the right frontal cortical region with a
small area of subcortical acute infarct in the right frontal
lobe. A similar small area of signal abnormality is seen on
diffusion images in the left parietal cortical region. The
findings are suggestive of acute infarcts. There is no mass
effect, midline shift, or hydrocephalus seen. There are no
chronic territorial infarcts visualized. There is no evidence of
significant subcortical white matter ischemic disease seen.
[**2139-12-13**] 06:00AM BLOOD WBC-7.1 RBC-3.09* Hgb-9.9* Hct-28.0*
MCV-90 MCH-31.9 MCHC-35.3* RDW-14.1 Plt Ct-167
[**2139-12-13**] 06:00AM BLOOD Glucose-122* UreaN-34* Creat-1.9* Na-140
K-4.0 Cl-101 HCO3-28 AnGap-15
[**2139-12-7**] 09:35AM BLOOD %HbA1c-6.9* [Hgb]-DONE [A1c]-DONE
[**2139-12-4**] 06:00PM BLOOD Triglyc-235* HDL-35 CHOL/HD-3.8
LDLcalc-52
Brief Hospital Course:
As mentioned in the HPI, patient was transferred from OSH for
cardiac catheterization. After cardiac catheterizaion - see
above results, cardiac surgery was consulted for surgical
revascularization. Patient had usual work-up along with an
echocardiogram - see above results. Plavix was stopped on [**12-4**].
Patient was consented for surgery and brought to the operating
room on [**2139-12-8**]. He underwent a coronary artery bypass graft x
4. Please see op note for surgical details. Following surgery
patient was transferred to the CSRU in stable condition on a
Neo-synephrine drip. Within 24 hours, he awoke neurologically
intact. Mechanical ventilation was weaned and patient was
extubated. Beta blockers and diuretics were initiated. Patient
was gently diuresed towards pre-op weight. His creatinine peaked
to 2.3 on postoperative day two. He required foley reinsertion
at that time for urinary retention but did not become oliguric.
Mr. [**Known lastname 52049**] [**Last Name (Titles) 52050**] experienced altered mental status, along
with fluctuations in level of alertness and incoherent speech.
The neurology service was consulted to evaluate for potential
embolic etiology and/or seizure. A head CT scan on [**12-10**]
showed no evidence of intracranial hemorrhage or of acute
territorial infarction. Carotid ultrasound was notable for
bilateral carotid disease, report stating that there was a
significant amount of plaque at the origins of the bilateral
internal carotid arteries, associated with luminal narrowing
estimated between 80 and 99% in diameter on both sides. An EEG
on [**12-11**] was deemed abnormal due to the presence of
diffuse background slowing and superimposed bursts of
generalized mixed frequency delta and theta slowing. No focal or
epileptiform features were seen. Findings were suggestive of an
encephalopathy. Narcotics were avoided and blood sugar managment
was optimized. He was also transfused to maintain hematocrit
near 30%. MRI imaging of the brain on [**12-12**] was notable
for findings suggestive of small acute cortical and subcortical
infarcts in the right frontal lobe and possibly in the left
parietal lobe. There was no evidence of mass effect or
hydrocephalus. There was no indication for Warfarin
anticogulation. Over several days, his neurological symptoms
improved as did his renal function. He continued to make
clinical improvements with medical therapy and made steady
progress with physical therapy. He remained in a normal sinus
rhythm. He responded nicely to diuresis and was tolerating room
air by discharge. He was cleared for discharge to home on
postoperative day five. At discharge, his BP was 130/70 with a
HR in the 80's. Room air saturations were 99% and all wounds
were clean, dry and intact. Given his carotid disease, his goal
SBP was between 120-140 to ensure adequate cerebral perfusion.
Also at discharge, he was voiding without difficulty.
Medications on Admission:
ASA 325mg qd
Plavix 75mg qd
Lipitor 20mg qd
Lisinopril 20mg qd
Lopressor 25mg [**Hospital1 **]
Glyburide 2.5mg qd
Glucophage 1000mg [**Hospital1 **]
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. 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. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
7. 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*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 6138**] Home Services
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery bypass Graft x 4
Hypertension
Hypercholesterolemia
Diabetes Mellitus
Acute on Chronic Renal Insufficiency
Postoperative Stroke with ?encephalopathy
Bilateral Carotid Disease
Discharge Condition:
Good
Discharge Instructions:
Can take shower. Wash incisions with water [**Doctor Last Name **] gentle soap.
Gently pat dry. Do not apply lotions, creams, or ointments to
incisions.
Do not bath.
Do not drive for 1 month.
Do not loft greater than 10 pounds for 2 months.
Make follow-up appointments and take all medications.
If you notice any redness or drainage from incisions, please
contact office immediately
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 170**] Follow-up appointment
should be in 1 month
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 177**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 5315**] Follow-up
appointment should be in 3 weeks
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Telephone/Fax (1) 52051**] Follow-up appointment
should be in 2 weeks
Completed by:[**2140-1-6**]
ICD9 Codes: 4111, 3572, 4019, 2720, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3608
} | Medical Text: Admission Date: [**2115-3-12**] Discharge Date: [**2115-3-20**]
Date of Birth: [**2054-3-15**] Sex: F
Service: MEDICINE
Allergies:
Thorazine / Penicillins
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
60F with schizoaffective disorder and COPD presents with
increased SOB x1 day. Patient has h/o chronic cough and SOB
(able to walk ~15 minutes on level ground, says she "can't climb
stairs"). Cough has been increasing over the last several days,
worsened last evening. Abdomen hurts with deep coughing. Cough
is productive, but patient hasn't noticed change in quality of
sputum. Has been wheezing as well, took friend's albuterol
nebulizer which helped her SOB. No sick contacts or recent
travel, did not receive influenza vaccination this year. No leg
pains, h/o thrombosis, recent travel. Denies
dizziness/lightheadedness, does feel thirsty.
Review of systems otherwise negative for fevers, chills, sweats,
headache, rhinitis, sore throat, myalgias,
diarrhea/constipation, dysuria. Denies h/o cardiac disease, HTN,
high cholesterol, or family h/o cardiac disease. Does have h/o
chronic dysphagia with regurgitation.
In the ED, vitals were T 98.5, P 88, BP 124/66, RR 38, O2 87% on
RA. She was given solumedrol 125mg IV, azithromycin 500mg PO,
combivent, ceftriaxone, and ASA 325mg once. She was put on CPAP
briefly with good effect. ABG obtained showed 7.25/60/72.
Past Medical History:
* COPD - patient denies h/o intubation, no PFTs availble in OMR
* Schizoaffective disorder, bipolar
* Chronic low back pain, followed at pain clinic
* duodenal polyp, adenoma on bx [**9-/2114**]
* esophageal stricture s/p dilatation
* h/o urinary retention
* h/o ovarian cysts
* s/p ccy
Social History:
Lives alone, long history of smoking ~1ppd since age 14, denies
EtoH or ilict drug use.
Family History:
no h/o cardiac or pulmonary disease
Physical Exam:
Vitals T 96F P 74 BP 142/45 RR 24 O2 92% 2L
BP 110/60 P 80 supine and sitting without significant change
General Anxious appearing, tachypneic but able to speak in full
sentences
HEENT Sclera white, conjunctiva pink, dry mucus membranes
Neck JVP flat
Pulm resonant to percussion, bilateral wheezing and few right
sided crackles
CV distant regular S1 S2 no m/r/g
Abd Soft, nontender +bowel sounds
Extrem Warm, no edema
Neuro/psych Suspicious affect but answers appropriately
Pertinent Results:
Data
CBC 8.0>13.8/39.3<178 N88.7% L 7.2% M 3.8% E 0.1% Baso 0.1%
Chem 122/4.1/86/27/11/0.9<168
Ca 8.8, Mg 1.9, Phos 3.0
CK 748 MB 14 Tropn <0.01
proBNP 345
ABG 7.25/60/72/28 lactate 1.9
Micro
[**3-12**] blood cx [**2-16**] NGTD
Imaging
[**3-12**] CXR
CHEST, SINGLE VIEW: Heart size and mediastinal borders are
normal. No focal consolidation, pneumothorax, or pleural
effusion. No gross osseous abnormality.
IMPRESSION: No acute cardiopulmonary process.
EKG noisy baseline but apparent SR @91bpm, normal axis and
intervals, no s1/q3/t3, no evidence of acute ischemia or strain
Brief Hospital Course:
60 yo F longtime smoker with h/o COPD and schizoaffective
disorder per records presented with increased SOB and cough x1
day without fever.
1. Dyspnea: Symptoms were most consistent with COPD
exacerbation. ABG suggested acute respiratory acidosis.
Pneumonia was less likely in absence of fever. Clinically did
not appear volume overloaded, and BNP<450 making CHF
exacerbation less likely. Chest CTA ruled out PE. MI was ruled
out by enzymes. She was treated with BiPAP and found to be
optimal respiratory-wise with O2 saturation in the mid-to-high
80s. She finished a 7-day course of azithromycin and
ceftriaxone. She was given nebulizers and started on prednisone,
which was tapered by discharge. By discharge, she was breathing
comfortably on room air with O2 saturation in mid-to-high 80s.
She underwent pulmonary tests the results of which were still
pending by discharge.
2. Altered mental status: might be due to hypercarbic
respiratory failure on admission versus worsening psychiatric
disorder. She was continued on outpatient thioridazine and
chlordiazepoxide. Her mental status improved to orientation x 3
by discharge.
Medications on Admission:
Meds (per patient):
mellaril 50mg PO BID
topamax 25mg PO BID
librium 10mg PO BID
no inhalers
Discharge Medications:
1. Chlordiazepoxide HCl 10 mg Capsule Sig: One (1) Capsule PO
once a day.
2. Thioridazine 100 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
3. Topiramate 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily) for 7 days.
Disp:*7 Patch 24 hr(s)* Refills:*0*
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
Disp:*30 doses* Refills:*0*
6. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) Inhalation Q6H (every 6 hours) as needed for shortness
of breath or wheezing.
Disp:*30 doses* Refills:*0*
7. Prednisone 10 mg Tablet Sig: As directed Tablet PO once a day
for 16 days: 40mg x 4 days
30mg x 4 days
20mg x 4 days
10mg x 4 days.
Disp:*42 Tablet(s)* Refills:*0*
8. Oxygen
Titrate oxygen, via nasal cannula to 88-90%.
9. Nebulizer
One nebulizer machine.
Discharge Disposition:
Home With Service
Facility:
Caregroup home
Discharge Diagnosis:
Primary:
1. Chronic obstructive pulmonary disease
2. Hypercarbic respiratory failure
Secondary:
1. Schizoaffective disorder
Discharge Condition:
Hemodynamically stable. Oxygen saturation 88% on 2 liters of
oxygen via nasal cannula.
Discharge Instructions:
You were admitted after experiencing a worsening of your COPD.
Your oxygen levels are quite low and you would benefit from home
oxygen therapy.
For your safety, YOU MUST QUIT SMOKING. If you do continue
smoking, you CANNOT use the oxygen, nor can you use the nicotine
patch.
If you continue to experience worsening shortness of breath with
exertion, chest pains, wheezing, fevers/chills, please be sure
to call your primary care doctor or go to an emergency room.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 2903**] on Monday [**3-25**] at 11:15.
You would also benefit from an outpatient sleep study. The
phone number is [**Telephone/Fax (1) 6856**].
ICD9 Codes: 2762, 2761, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3609
} | Medical Text: Admission Date: [**2125-10-23**] Discharge Date: [**2125-11-5**]
Date of Birth: [**2060-7-29**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Linezolid / Morphine / Oxycodone
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
Tranferred from rehab for replacement of J tube and elevated
creatinine
Major Surgical or Invasive Procedure:
[**10-26**] J tube placement
Arterial line
Midline PICC
History of Present Illness:
The patient is a 65 yo F with multiple medical problems
including HTN/DM/PVD, recent chylothorax, pancreatitis s/p
necrosectomy, s/p trach and PEG whose recent hospitalization was
from [**2125-7-13**] - [**2125-9-28**]. She was sent to rehab and is coming in
today with a rising creatinine and malpositioned J tube.
.
Briefly, the patient originally presented to [**Hospital1 18**] in [**2125-5-15**]
for a repair of an innominate aterial aneurysm. She was
discharged to rehab but returned on [**2125-6-14**] with respiratory
distress and sepsis. During this hospital course she had a PEA
arrest, inferior MI, and upper extremity DVT. She was ultimately
transferred to [**Hospital1 **] on [**2125-6-29**] on a 4 week course of
daptomycin for VRE/MRSA infection. She was readmitted to [**Hospital1 18**]
on [**2125-7-12**] after being found to have new neurological symptoms.
Eventually, she was diagnosed with severe brain injury. She had
a number of complications during this hospital course. She
developed a chylothroax and required multiple procedures
including a right VATS, thoracic duct [**Last Name (LF) 94710**], [**First Name3 (LF) **] duct
embolization, talc pleurodesis, and decortication. She was
trach'd and PEG'd on [**2125-8-8**]. She unfortunately the developed
near total pancraetic necrosis that required pancreatic
debridement and necrosectomy and abdominal drainage of numerous
absecesses. She was bacteremia on pressors at numerous points
during her hospital course. She was discharged to [**Hospital1 **] again
on [**2125-9-28**] with plans to complete a 14 day course of daptomycin
for VRE/MRSA and continue weaning from the vent if possible.
.
While at [**Hospital1 **], the patient continued to have full body
anasarca and was aggressively diuresed with a rise in her
creatine over time from 0.9 to 3.4. Prior to transfer to [**Hospital1 18**]
her lasix was being held. Also, her PEG jeujunostomy tube came
out and reposition was attempted. She was transferred to [**Hospital1 18**]
for replacement of her peg jeujunostomy tube.
Past Medical History:
-- DM2
-- chronic foot ulcers/PVD
-- HTN
-- Osteoarthritis
-- Obesity
-- Asthma
-- leg pain/neuropathy
-- Depression
-- Anemia
-- h/o MRSA bacteremia [**11-18**], also septic arthritis
-- Right thalamic hemorrhage resulting in a gait disorder and
incontinence of urine, followed by Dr. [**Last Name (STitle) **].
-- Hypercholesterolemia.
-- Right VATS and thoracic duct ligation [**2125-7-20**]
-- Thoracic duct embolization and talc pleurodesis [**2125-7-27**]
-- Tracheostomy and percutaneous endoscopic gastrostomy [**2125-8-8**]
-- Exploratory laparotomy, pancreatic necrosectomy, gastrostomy
tube [**2125-8-22**]
-- Exploratory laparotomy, abdominal wash out [**2125-8-23**]
-- Exploratory lap, takedown gastrostomy, debride necrotic
pancreas and multiple retroperitoneal abscesses [**2125-8-25**]
-- Abdominal closure and vac dressing application [**2125-8-26**]
-- Left thoracotomy and decortication, flexible bronchoscopy
[**2125-9-19**]
-- Aorto innominate and left carotid bypass [**2125-5-22**]
-- Left carotid to left subclavian bypass using 8 mm PTFE and
thoracic aortic stent graft placement [**2125-5-23**]
Social History:
Currently living at [**Hospital1 **] after a prolong hospital course.
Has seven children, many grandchildren.
Family History:
Brother died of an MI in his 30's, she denies diabetes mellitus
in the family. Cancer in parents (mother died in 40s, father in
80s), at least two siblings, but unsure what kind.
Physical Exam:
Vitals - HR89 BP 144/32 RR16 O298% on Vent FIO2 100%
General - obese african american female, lying in bed
HEENT - PERRL, patient not following commands
Neck - trach in place
CV - regular rate, distant heart sounds
Lungs - clear to auscultation bilaterally
Abdomen - obese, G/J tube in place; large midline incision with
VAC (healing well, no signs of infection)
Ext - + edema
Pertinent Results:
Admission labs:
[**2125-10-23**] 06:17PM BLOOD WBC-13.1* RBC-3.19*# Hgb-9.7* Hct-28.1*
MCV-88 MCH-30.5 MCHC-34.6 RDW-16.0* Plt Ct-67*
[**2125-10-23**] 06:17PM BLOOD Neuts-95* Bands-5 Lymphs-0 Monos-0 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2125-10-23**] 06:17PM BLOOD PT-13.7* PTT-30.5 INR(PT)-1.2*
[**2125-10-23**] 06:17PM BLOOD Glucose-144* UreaN-160* Creat-3.6*#
Na-138 K-4.2 Cl-99 HCO3-20* AnGap-23*
[**2125-10-25**] 07:10PM BLOOD ALT-63* AST-47* LD(LDH)-297* CK(CPK)-16*
AlkPhos-484* TotBili-0.3
[**2125-10-25**] 07:10PM BLOOD CK-MB-NotDone cTropnT-0.41*
[**2125-10-26**] 04:20AM BLOOD CK-MB-NotDone cTropnT-0.37*
[**2125-10-26**] 04:20AM BLOOD CK(CPK)-17*
[**2125-10-23**] 06:17PM BLOOD Calcium-9.8 Phos-5.0* Mg-2.8*
[**2125-10-24**] 10:19AM BLOOD Type-ART pO2-146* pCO2-31* pH-7.39
calTCO2-19* Base XS--4
[**2125-10-26**] 04:24AM BLOOD Lactate-1.0
[**2125-10-26**] 04:24AM BLOOD freeCa-1.16
Hospital course labs:
[**2125-11-4**] 04:50AM BLOOD WBC-8.5 RBC-3.42* Hgb-10.3* Hct-29.9*
MCV-88 MCH-30.0 MCHC-34.3 RDW-16.0* Plt Ct-45*
[**2125-11-4**] 04:50AM BLOOD Plt Ct-45*
[**2125-11-1**] 04:26AM BLOOD PT-13.7* PTT-30.1 INR(PT)-1.2*
[**2125-11-4**] 04:50AM BLOOD Glucose-124* UreaN-169* Creat-5.4*
Na-146* K-4.3 Cl-114* HCO3-14* AnGap-22*
[**2125-10-30**] 04:12AM BLOOD ALT-29 AST-13 LD(LDH)-227 AlkPhos-275*
Amylase-41 TotBili-0.3
[**2125-10-30**] 04:12AM BLOOD Lipase-68*
[**2125-11-4**] 04:50AM BLOOD Calcium-8.6 Phos-4.0 Mg-2.4
[**2125-10-30**] 04:12AM BLOOD Albumin-2.0* Calcium-8.7 Phos-4.0 Mg-2.2
[**2125-10-31**] 06:08PM BLOOD TSH-31*
[**2125-10-31**] 06:08PM BLOOD Free T4-0.53*
[**2125-10-29**] 05:43PM BLOOD Cortsol-43.8*
[**2125-10-29**] 04:54PM BLOOD Cortsol-41.4*
[**2125-10-29**] 04:31PM BLOOD Cortsol-25.2*
[**2125-10-27**] 01:53PM BLOOD Type-ART Temp-36.2 Rates-/28 FiO2-50
pO2-90 pCO2-34* pH-7.20* calTCO2-14* Base XS--13
Intubat-INTUBATED
[**2125-11-2**] 10:07AM BLOOD Type-ART pO2-138* pCO2-31* pH-7.30*
calTCO2-16* Base XS--9
[**2125-10-28**] 04:55AM BLOOD Lactate-3.2*
[**2125-11-2**] 10:07AM BLOOD Lactate-1.2
Brief Hospital Course:
65yo F c complex medical history, who is s/p a prolonged
hospital course complicated by sepsis, pancreatic necrosis
requiring pancreatic necrosectomy, and cylothorax requiring
numerous surgical procedures, presented from rehab with
malpositioned J tube and an elevated creatinine. She was
admitted to the MICU because she was chronically
ventilated/trached. Her J tube was replaced by IR on [**10-26**]
without compications. She had limited to no cognative response
during her MICU course. During her complicated MICU course, she
developed worsening renal failure and a GI bleed along with a
rising WBC count and hypotension. After many family discussions
including with her HCP daughter, it was decided to not escalate
care on [**11-2**]. On [**11-5**] the family decided to make her DNR/DNI
and begin comfort care. Her vent was turned to room air settings
with minimal pressure support. She was started on a morphine
drip and the patient passed away. Family requested autopsy.
Her course was complicated by the following:
# Respiratory Failure - s/p trach in [**7-21**]. She had difficulty
weaning off the vent at rehab and was continued to be 24 hour
vent dependent at the time of transfer to [**Hospital1 18**].
# ID - s/p course of Synercid, Meropenem, and Caspofungin
(finished on [**2125-10-5**]) prior to hospitalization. Patient likely
colonized with multiple resistant organisms. WBC recently
declined on Meropenem for Proteus UTI and was started on bactrim
on [**2125-10-31**] for Stenotrophomonas infection. She developed
proteus UTI and pneumonia along with MRSA pneumonia. She had a
pleural vac inplace on admission which had fluid draining which
was growing VRE and MRSA. She was on vanco and meropenem. She
still had an abdominal vac inplace s/p pancreatic surgery.
# ARF - Etiology likely prerenal and progressed to ATN. She
continued to have rising creatinine and uremia. Renal consult
was called and many discussions were held regarding the utility
of hemodialysis for her. Ultimately, it was decided on [**2125-11-2**]
with HCP daughter not to escalate care. In addition, it was felt
by the renal consult team and the primary team that HD was not
medically indiacated given poor prognosis and lack of bridge to
intermittent HD.
# Anemia - Patient required several units of PRBCs to keep HCT
above 21. During her hospitalization she began to pass clots per
her rectum. GI was consulted and it was decided that the risk of
endoscopy was greater than the benefits at that time.
# Hypothyroid - continued synthroid and increased dose and gave
it IV as her TSH was above 30 and it was thought that her GI
absorption was very poor.
# Diabetes - continued insulin
# skin - several areas of breakdown without signs of infection.
FEN - tube feeds
PPx - PPI, bowel regimen
Access - midline, a-line, EJ
Code - DNR, no pressors; family meeting again on [**2125-11-2**]-
family decided to not escalate care. Will continue current care.
If patient decompensates, will call family and change to
morphine and ativan to help keep her comfortable and will stop
all other care.
Contact - daughter/HCP, [**Name (NI) **] [**Name (NI) 1557**] Cell [**Telephone/Fax (1) 94711**]; home -
[**Telephone/Fax (1) 94712**]
.
Medications on Admission:
Mucomyst nebs [**Hospital1 **]
Vitamin C 500mg [**Hospital1 **]
Bacitracin to the PEG site
Colace 100mg [**Hospital1 **]
Advair HFA 1 puff [**Hospital1 **]
Heparin SQ TID
Regular ISS
Synthroid 50mcg via PEG daily
MVI daily
Accuzyme topically daily to the wounds
Beneprotein 1 scoop daily
Senna daily
Zinc sulfate 220mg via tube daily
Tylenol 650mg PRN
Atrovent and Albuterol q2 PRN
Aspirin 325mg daily
Dulcolax 10mL PR daily
Glycerine suppository PR PRN
Lactulose 20grams daily PRN
Reglan 10mg via tube q4 PRN
Nitroglycerin PRN
Seroquel 12.5mg q12 PRN - has not needed at [**Hospital1 **]
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
Completed by:[**2125-12-13**]
ICD9 Codes: 0389, 5849, 5990, 5789, 5856, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3610
} | Medical Text: Admission Date: [**2116-2-3**] Discharge Date: [**2116-2-10**]
Date of Birth: [**2037-8-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
angina and abnormal ETT
Major Surgical or Invasive Procedure:
OPCABG x3 [**2116-2-3**] (LIMA to LAD, SVG to RAMUS, SVG to LPDA)
History of Present Illness:
78 yo male with recent onset of angina and dyspnea with
exertion. He also noted increased fatigue. ETT was abnormal and
referred for cath.
Past Medical History:
HTN
elev. chol.
CRI
secondary hyperparathyrodism
anemia
osteopenia
PVD with carotid disease
prostatectomy s/p Ca with XRT
Social History:
light smoker; quit 20 years ago
widowed, lives alone
Family History:
sister had a CABG in her 50's; mother died CVA at 66
Physical Exam:
5'6" 145#
(no preop exam completed by cardiac surgical team as pt. came
emergently from cath lab to OR table)
Pertinent Results:
[**2116-2-9**] 06:15AM BLOOD WBC-7.2 RBC-3.05* Hgb-9.8* Hct-27.4*
MCV-90 MCH-32.0 MCHC-35.6* RDW-14.3 Plt Ct-249
[**2116-2-10**] 04:30AM BLOOD PT-17.8* INR(PT)-1.6*
[**2116-2-9**] 06:15AM BLOOD Plt Ct-249
[**2116-2-9**] 06:15AM BLOOD Glucose-84 UreaN-34* Creat-1.3* Na-144
K-3.6 Cl-104 HCO3-30 AnGap-14
[**2116-2-9**] 06:15AM BLOOD Mg-2.3
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 76335**]
(Complete) Done [**2116-2-3**] at 2:50:47 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2037-8-17**]
Age (years): 78 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Chest pain. Coronary artery disease. Hypertension.
ICD-9 Codes: 786.51, 440.0, 441.2, 424.0
Test Information
Date/Time: [**2116-2-3**] at 14:50 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 929**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW2-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: 50% to 55% >= 55%
Aorta - Sinus Level: *3.8 cm <= 3.6 cm
Aorta - Ascending: *3.9 cm <= 3.4 cm
Aortic Valve - Peak Velocity: *5.0 m/sec <= 2.0 m/sec
Findings
LEFT ATRIUM: Normal LA size. No spontaneous echo contrast in the
body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. No mass/thrombus in the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. Good
(>20 cm/s) LAA ejection velocity.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or
pacing wire is seen in the RA and extending into the RV. Dynamic
interatrial septum. Aneurysmal interatrial septum. PFO is
present. Left-to-right shunt across the interatrial septum at
rest.
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Mild
regional LV systolic dysfunction.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
Normal RV systolic function.
AORTA: Mildly dilated aortic sinus. Mildly dilated ascending
aorta. Normal aortic arch diameter. Normal descending aorta
diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Mildly thickened
aortic valve leaflets (3). No AS. Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. Calcified tips of papillary
muscles. No MS. Trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with physiologic PR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The patient received antibiotic prophylaxis. The
TEE probe was passed with assistance from the anesthesioology
staff using a laryngoscope. No TEE related complications.
patient.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
PRE-CPB:1. The left atrium is normal in size. No spontaneous
echo contrast is seen in the body of the left atrium or left
atrial appendage. No mass/thrombus is seen in the left atrium or
left atrial appendage.
2. The interatrial septum is aneurysmal. A trivial patent
foramen ovale is present. A left-to-right shunt across the
interatrial septum is seen at rest.
3. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. There is mild regional
left ventricular systolic dysfunction with anteroseptal and
anteroapical hypokinesis.
4. . Right ventricular chamber size and free wall motion are
normal. with normal free wall contractility.
5. The aortic root is mildly dilated at the sinus level. The
ascending aorta is mildly dilated. There are simple atheroma in
the descending thoracic aorta.
6. There are three aortic valve leaflets. The aortic valve
leaflets (3) are mildly thickened. There is no aortic valve
stenosis. Trace aortic regurgitation is seen.
7. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen.
Off-pump, transient regional wall motion changes seen, esp with
PDA occlusion. SvO2, CCO stable throughout. ST segment elevation
with PDA occlusion, normal post reopening. LVEF= 55%.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2116-2-3**] 16:52
RADIOLOGY Preliminary Report
CHEST (PORTABLE AP) [**2116-2-9**] 5:21 PM
CHEST (PORTABLE AP)
Reason: evaluate effusion
[**Hospital 93**] MEDICAL CONDITION:
78 year old man with s/p cabg
REASON FOR THIS EXAMINATION:
evaluate effusion
AP CHEST 5:45 P.M. [**2-9**]
HISTORY: Status post CABG.
IMPRESSION: AP chest compared to [**2-5**] and [**2-7**]:
Bilateral pleural effusion, moderate in volume, left greater
than right, has improved since [**2-7**] as previous pulmonary
and mediastinal vascular congestion have resolved and borderline
cardiomegaly improved. Some opacification at the lung bases,
particularly the left is attributable to atelectasis, not
appreciably changed. No pneumothorax.
DR. [**First Name8 (NamePattern2) **] [**Name (STitle) 7410**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
??????
Brief Hospital Course:
Admitted for cath on [**2-3**] and went to OR emergently on IABP and
IV dopamine drip after developing angina during unsuccessful
PCI. Dr. [**First Name (STitle) **] performed an off-pump cabg x3 and pt.
transferred to the CVICU in fair condition. Amiodarone started
for Afib and remained in the unit for volume management. IABP
removed by cardiology sevice on POD #1. Required levophed
support for a couple of days and extubated on [**2-6**]. Chest tubes
removed and transferred to the floor on POD #5.Coumadin started
for continuing intermittent a fib. Target INR 2.0-2.5. Cleared
for discharge to rehab on POD #7. Pt. is to make all follow up
appts. as per discharge instructions. Please contact Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 17918**] (PCP) when pt. is ready to be discharged from rehab .He
will be following the INR/coumadin dosing.
Medications on Admission:
ASA 81 mg daily
Lipitor 40 mg daily
zetia 10 mg daily
diovan 320 mg daily
atenolol 12.5 mg daily
amlodipine 2.5 mg daily
iron 65 mg daily
omeprazole 20 mg daily
procrit injection every 4-6 weeks
SL NTG prn
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for off pump cabg.
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 2 days: 400 mg [**Hospital1 **] until [**2-12**]; then 400 mg daily until
[**2-19**], then 200 mg daily.
8. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: One (1)
Tablet PO Q4H (every 4 hours) as needed.
9. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) neb Inhalation Q2H (every 2 hours) as needed.
10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12
hours): hold for K > 4.5.
11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
13. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO today [**2-10**] only
as needed for afib: [**2-10**] only, then daily dosing per rehab
provider.
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location 15289**]
Discharge Diagnosis:
s/p off pump cabg (OPCABG)
postop A fib
CAD
HTN
CRI
secondary hyperparathyroidsim
carotid artery disease
osteopenia
anemia
prostate cancer s/p radical prostatectomy and XRT
GERD
intermittent urinary incontinence
Discharge Condition:
stable
Discharge Instructions:
no lifting greater than 10 pounds for 10 weeks
no driving for one month
no lotions, creams, or powders on any incision
call for fever greater than 100.5, redness or drainage
SHOWER daily and pat incisions dry
target INR 2.0-2.5 for A fib- contact Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 17918**] (PCP)
[**Telephone/Fax (1) 17919**] when pt. is ready to be discharged. He will be
following coumadin dosing/INR.
Followup Instructions:
see Dr. [**Last Name (STitle) 17918**] in [**1-8**] weeks
see Dr. [**Last Name (STitle) 7047**] in [**2-9**] weeks
see Dr. [**First Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2116-2-10**]
ICD9 Codes: 9971, 5859, 2762, 4111 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3611
} | Medical Text: Admission Date: [**2125-4-27**] Discharge Date: [**2125-5-17**]
Service: SURGERY
Allergies:
Celebrex
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
bile duct injury
Major Surgical or Invasive Procedure:
ERCP with stent removal and placement of stent
Endovascular placement of inferior vena cava filter
History of Present Illness:
87y female with recent admission to an outside hospital for
cholecystitis, cholelithiasis, and choledocholithiasis. She was
treated with antibiotics and discharged with the plan for future
removal of the common bile duct stone. On the day of admission,
she had gone to [**Hospital3 3583**] for ERCP (with the intent of
having the CBD stone removed). During the procedure, there
appeared to be a perforation of the common bile duct by the
stent, as dye was visualized extraluminally. The stent was left
in place and she was transferred to [**Hospital1 18**] for further
management.
Past Medical History:
arthritis
gout
hypertension
glaucoma
congestive heart failure
Past Surgical History:
appendectomy
hysterectomy
right total knee replacement
breast lumpectomy
Social History:
Lives alone. No tobacco. No EtOH.
Family History:
Noncontributory
Physical Exam:
T 97.0, HR 59, BP 158/79, RR 16, O2 sat 95% on room air
GEN: awake, pleasantly demented, no distress; poor historian
HEENT: extraocular muscles intact, no scleral icterus, mucous
membranes moist
CV: regular rate and rhythm
Pulm: clear to auscultation bilaterally
Ab: soft, nontender, nondistended. No masses. Well healed left
paramedian scar.
Ext: well healed scar on right knee. No clubbing, cyanosis, or
edema.
Pertinent Results:
[**2125-4-27**] 09:00PM WBC-15.8* RBC-4.15* HGB-12.1 HCT-36.1 MCV-87
MCH-29.2 MCHC-33.6 RDW-14.4
[**2125-4-27**] 09:00PM PLT COUNT-226
[**2125-4-27**] 09:00PM GLUCOSE-110* UREA N-26* CREAT-1.0 SODIUM-144
POTASSIUM-3.3 CHLORIDE-106 TOTAL CO2-25 ANION GAP-16
[**2125-4-27**] 09:00PM CALCIUM-8.6 PHOSPHATE-3.1 MAGNESIUM-1.6
[**2125-4-27**] 09:00PM LIPASE-536*
[**2125-4-27**] 09:00PM PT-13.2 PTT-25.4 INR(PT)-1.2
Brief Hospital Course:
Mrs. [**Known lastname 61977**] was transferred to [**Hospital1 18**] on [**4-27**] and admitted to
the hepatobiliary surgery service. A GI consult was obtained
immediately for ERCP and she was taken for this procedure. They
removed the stent that had been placed at the outside hospital,
and placed a stent across the common bile duct. The stone was
left in place. After the procedure, subcutaneous air was noted
in her back, tracking up to her neck. She complained of
abdominal pain, which was in contrast to her pain free
presentation at the time of admission. She was tranferred to
the ICU and a CT scan was done. The CT scan showed a large
amount of air in the retroperitoneum extending into the
mediastinum and subcutaneous tissues. There was no definite
evidence of intraperitoneal air. Multiple pulmonary emboli were
noted in the right lower lobe, as was a small right-sided
pneumothorax. She was started on Unasyn and watched closely in
the ICU. She was kept NPO. Her abdominal pain resolved. She
was started on subcutaneous heparin, but she was not fully
anticoagulated for the finding of pulmonary emboli because she
had active GI bleeding (bleeding noted at the time of ERCP and
guaiac postive stools). On [**4-29**], she was stable, and therefore
transferred to the floor.
On [**4-30**], a picc line was placed and she was started on TPN. A
plan was formulated to keep her on TPN with bowel rest for two
weeks to allow her duodenum/bile ducts to heal. Repeat CT scan
demonstrated improvement in the pneumothorax as well as the
retroperitoneal air. On [**5-1**], she was transfused with two units
of blood for blood loss anemia. On [**5-2**], an ECHO was done which
showed that overall, left ventricular systolic function was
normal (LVEF>55%). There were no clots or vegetations.
On [**5-5**], lower extremity doppler ultrasound was performed to
look for evidence of deep vein thrombosis, since she had known
pulmonary emboli. DVT of the left femoral and popliteal veins
was seen. She was started on a low dose heparin drip. A
pulmonary consult was obtained to determine the risks versus
benefits of long term anticoagulation. They recommended 6 months
of anticoagulation, but given the fact that she still had active
loss of blood from her GI tract and because she was at increased
risk for falls based on her age and health status, they agreed
that IVC filter placement would be adequate treatment/prevention
for the time being. A vascular consult was obtained and an IVC
filter was placed on [**5-7**]. After this, her heparin drip was
stopped.
On [**5-9**], she spiked a temperature of 102.1. She was
pan-cultured. A CT scan was done which showed improving
pneumomediastinum and retroperitoneal air. No source was
identified on the CT scan for the patient's fever.
On [**5-10**], her TPN was tapered, and she was started on sips. Her
picc line was removed. On [**5-11**] the patient was restarted on her
home medications, her diet was advanced to clears, she was
started on IV vancomycin for a positive blood culture that grew
gram + cocci. A GI consult was obtained to further investigate
her guaiac positive stools. Her stool tested positive for c
difficle, and she was started on flagyl. On [**5-12**], her blood
cultures grew vancomycin resistant enterococcus, and so she was
switched from vancomycin to linezolid.
On [**5-16**], she underwent a colonoscopy which was unremarkable - no
evidence of cancer, bleeding or collitis, diverticulosis, but no
diverticulitis
Medications on Admission:
digoxin 0.25 daily
lasix 20mg po every other day
allopurinol 300mg daily
omeprazole 20mg daily
enalapril 20mg daily
probenacid [**Hospital1 **]
atenolol 50mg daily
Discharge Medications:
1. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed).
2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 10 days.
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
5. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: 5000
(5000) units Injection [**Hospital1 **] (2 times a day).
6. Enalapril Maleate 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 7 days.
10. Furosemide 10 mg IV BID
please hold
Discharge Disposition:
Extended Care
Facility:
Life Care [**Location (un) 3320**]
Discharge Diagnosis:
Cholelithiasis
Choledocholithiasis
Biliary duct injury
Duodenal injury
blood loss anemia
arthritis
gout
hypertension
glaucoma
congestive heart failure
pulmonary embolism
deep vein thrombosis
C difficile colitis
Enterococcus bacteremia
Discharge Condition:
Good
Discharge Instructions:
[**Name8 (MD) **] MD for temp >101.5, persistent pain, nausea or vomiting, or
any other questions.
Followup Instructions:
With Dr. [**Last Name (STitle) **] in 2 weeks. Please call for appointment.
[**Telephone/Fax (1) 1231**].
ICD9 Codes: 5789, 4280, 2851, 7907, 4019, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3612
} | Medical Text: Admission Date: [**2104-8-8**] Discharge Date: [**2104-8-27**]
Date of Birth: [**2027-2-15**] Sex: M
Service: MEDICINE
Allergies:
Lisinopril
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
hypoxia and confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
77 y/o M with h/o CHF (EF= 40-45% on ECHO [**4-/2104**]), atrial
fibrillation on Coumadin presented to [**Hospital1 18**] as transfer from
[**Hospital6 5016**] in [**Location (un) 7661**], MA for further management of
hypoxia due to left upper lobe pneumonia and and ongoing
delirium due to previous aspiration pneumonia (right middle
lobe). The patient's current history starts [**2104-7-15**], when he was
hospitalized at [**Hospital1 18**] (requiring a brief ICU stay) for left
upper lobe pneumonia, treated with levofloxacin X7 day course.
He was discharged home with [**Hospital1 269**], but around [**7-25**] he started
having hypoxia (resting O2sat of 95%, ambulatory O2sat of 85%),
and also had cloudy urine. He was treated with Ciprofloxacin
X2-3 days for UTI, but because his hypoxia persisted and he had
progressively worse dyspnea, he was admitted to [**Hospital1 18**] on [**7-27**]. A
new right middle lobe infiltrate was noted on CXR during that
admission, which was felt to be an aspiration pneumonia. Patient
was evaluated by Speech and Swallow who felt he had silent
aspirations. He was treated with an 8 day course of broad
antibiotics (Vancomycin and Zosyn) which ended on [**2104-8-4**]. He
was discharged to [**Hospital3 **] on the 20th, but on the 21st
he was sent to the [**Hospital6 5016**] because his O2 sats were
down in the 80s. At the OSH, a CT chest was performed that
showed bilateral pulmonary fibrosis with brochiectasic changes
and a small acute infiltrate in the left upper lobe. Patient
received 4 days of levofloxacin IV. On the 24th, the patient and
his family requested transfer to [**Hospital1 18**] for further management of
his treatment because this is where he gets the majority of his
treatment.
.
Of note, the CTA chest from [**7-15**] states: "Extensive
consolidation involving the left upper lobe, could represent
infection. However, given the clinical history of elevated INR,
hemoptysis, and lack of symptoms of pneumonia, this could
represent pulmonary hemorrhage."
.
Also, since the patient's discharge from first admission, on
[**7-20**] there has been concerns regarding ongoing altered
mental status. For a while, the patient's wife had to have
friends take turns supervising him at home when she was out.
Geriatrics was involved during the patient's last [**Hospital1 18**]
admission for difficult to manage delirium which was felt
somewhat more consistent with that of acute brain injury.
Psychiatry at [**Hospital6 5016**] saw the patient during his
current admission and felt he was delirious from ongoing
hypoxia, and pulmonary disease. Prior to his presentation to
[**Hospital1 18**] on [**7-15**], the patient had been functional and travelling
through [**Country 18084**] where he climbed up to Edinburgh Castle.
.
Upon transfer to the [**Hospital1 18**], the patient was stable. When
interviewed, however, he was alert and oriented X2 but not
making much sense in his answers. When asked about his symptoms,
he would talk about his coming from [**Location (un) **] many years ago. He
did endorse trouble breathing and anxiety. The RN noted he
coughed up mucous with blood.
.
Review of systems:
Difficult to get an accurate ROS as patient's responses do not
make sense.
Past Medical History:
- Atrial fibrillation, chronic, on warfarin and beta blocker
- History of CAD s/p MI in [**2088**] and CABG (LIMA-->LAD,
SVG-->RPDA-RPL, SVG--> LCX) w/ severe residual disease and
inferior ischemia on stress testing, minimal exercise tolerance
and BP drop during stress
- Systolic heart failure, LVEF 40-45% ([**4-/2104**])
- Chronic kidney disease, stage 3
- Hyperlipidemia on meds, LDL 58 ([**1-/2103**])
- Hypertension
- AAA s/p endovascular repair in [**2102**], s/p L limb endovascular
leak repair, now with decreasing aneurysm size on CT abd (63 x
62 mm, [**2104-7-15**])
- Mitral regurgitation, 2+ ([**4-/2104**])
- History of chronic DOE, likely multifactorial
- Depression
- s/p appendectomy
Social History:
Lives at home with wife in [**Name2 (NI) **] Hempshire
Patient reports 40 year h/o smoking but quit ~20y ago.
H/o drinking [**2-18**] pints of beer daily for nearly 20 years. Cut
down 3-4 years ago, drinking one glass daily.
Denies illicit drug use
Family History:
He was the youngest of 10 children and he has lost numerous
siblings to heart disease. Some where young, in their 40??????s, and
some where older.
Both parents died of CVA??????s.
Physical Exam:
Vitals: T:afebrile BP:117/71 P:76 R:18 O2:94% on 4L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry mouth, EOMI
Neck: supple, JVP not elevated, no hepatojugular reflux
Lungs: Expiratory crackles present in lower lung bases, L>R, no
wheezing/rhonchi/rales
CV: irregularly irregular. No murmurs/gallops/rubs
Abdomen: soft, non-tender, non-distended, BS+
Ext: Warm, well perfused, no peripheral edema, no
cyanosis/ecchymosis
.
Pertinent Results:
[**2104-8-8**] 06:00PM GLUCOSE-77 UREA N-23* CREAT-1.2 SODIUM-144
POTASSIUM-3.9 CHLORIDE-110* TOTAL CO2-25 ANION GAP-13
[**2104-8-8**] 06:00PM proBNP-[**Numeric Identifier 18091**]*
[**2104-8-8**] 06:00PM ALBUMIN-3.0* CALCIUM-9.1 PHOSPHATE-3.7
MAGNESIUM-2.1
[**2104-8-8**] 06:00PM WBC-5.7 RBC-4.32* HGB-11.3* HCT-36.0* MCV-83
MCH-26.2* MCHC-31.4 RDW-19.2*
[**2104-8-8**] 06:00PM PLT COUNT-172
[**2104-8-8**] 06:00PM PT-36.5* PTT-36.9* INR(PT)-3.8*
[**2104-8-8**] 06:00PM ALT(SGPT)-44* AST(SGOT)-74* LD(LDH)-392* ALK
PHOS-95 TOT BILI-1.5
Brief Hospital Course:
Mr. [**Known lastname **] is a 77 year old man with CAD, CHF, who was admitted
with hypoxia and AMS. Respiratory failure worsened during his
hospital course despite treatments. He was made CMO and
terminally extubated on [**2104-8-27**]. The patient died at 7:03pm.
.
.
# HYPOXIA/DYSPNEA: The patient was transfered from OSH with
hypoxia and dyspnea. We began treatment of LUL pneumonia
empirically with levofloxacin (for CAP coverage), vancomycin
(HAP coverage), and cefepime (for pseudomonal coverage). On the
second day of hospitalization, levofloxacin was stopped and he
was continued on vanc/cef for total of a 14 day course. Due to
the fact that his pneumonia was not improving since his original
diagnosis [**2104-7-15**], pulmonology was consulted. Urine legionella
was negative, LDH was elevated at 392. A CT of the Chest on
[**8-9**] showed marked worsening of nonspecific multifocal
ground-glass opacities and consolidations predominantly
involving the left upper, right upper, left lower and portions
of the right lower lobes of infectious v. inflammatory v.
hemorrhagic etiology. Bronchoscopy on [**8-14**] was grossly normal,
no signs of hemorrhage (only abnormality small nonobstructing
membrane extending about one-third of the way into the airway
lumen in the posterior segment of the left upper lobe). BAL
showed hemosiderin-laden macrophages and multinucleated
histiocytes and was negative for malignant cells, PCP,
[**Name10 (NameIs) 18092**], and CMV, and was significant only for 1+ PMNs and
10-100K yeast, most likely colonizer). Blood cultures were
negative x 5, HIV was negative, aspergillus negative, hepatitis
serologies were negative. Infectious w/u was significant only
for a positive serum beta glucan (163), and at time of transfer
to the MICU cryptococcus and quantiferon gold were pending.
Inflammatory w/u negative for anti-GBM negative, complement
normal, ANCA negative, ESR elevated at 60. He completed a 14
day course of vanc/cef without improvement in pulmonary status.
Repeat chest CT on [**8-17**] showed interval progression of
multifocal consolidations, likely representing infections,
although inflammatory condition is a possibility as well as new
small bilateral pleural effusions. He was again started on 40 mg
IV lasix daily with appropriate diuresis. Infectious disease
was consulted on [**8-21**] and recommended VATS for definitive
diagnosis as it was not felt that the underlying pulmonary
process represented an infectious etiology, however he was not
deemed to be a surgical candidate due to his many comorbidities.
Per chest CT, there was concern that the ground glass opacities
on repeat chest CT may represent usual interstitial pneumonitis,
the treatment of which would be steroids. On [**8-21**] he was
started on empiric IV solumedrol 80 mg TID which was tapered to
80 mg IV BID on [**8-23**]. Repeat CXR on [**8-24**] showed no significant
change from prior and plans were for steroid taper.
Throughout hospital stay, Mr. [**Known lastname **] was on supplementary O2 as
needed, incentive spirometry, and albuterol/ipratropium nebs. O2
was weaned and sats were consistently in the low 90s on room air
and in the mid-high 90s on 2L O2 NC.
.
# DELIRIUM: Patient came in with delirium, which he did not have
at baseline (was travelling in [**Country 18084**], hiking with family in
[**Month (only) 216**]). The likely etiology of his delirium was considered his
ongoing infection +/- hospitalizations. UA was performed and was
negative, a UCx showed no growth, which ruled out UTI as the
cause of delirium. A CT head at last admission was negative for
any intracranial process and repeat head CT on [**8-19**], obtained
after an unwitnessed fall from bed with no signs of trauma again
showed no acute intracranial process, again showed small vessel
ischemic disease, unchanged old lacunar infarcts in the
bilateral basal ganglia and extreme capsule, and prominent
ventricles and sulci. On admission he was initially given
Olanzapine 5mg po q6h PRN agitation and haldol. Geriatrics
follwoed the patient for management of his persistent delerium
and sundowning and per their recommendations olanzapine was
swithced to seroquel and uptitrated to 12.5 QAM and 37.5 QHS
with PRN seroquel and haldol. Delerium was also managed with
soft restraints and cage bed in order to keep Mr. [**Known lastname **] from
injuring staff and pulling out his lines.
Neurology was consulted on admission and initially felt his
confusion was due to his underlying pulmonary process. However,
when he failed to improve despite antibiotics and no source of
infection was identified, they were reconsulted on [**8-21**] and
recommended LP, MRI w/ and w/o contrast, and EEG due to concern
for limibic encephalitis vs. paraneoplastic process vs. temporal
lobe epilepsy. Patient is not a candidate for MRI due to his
Zenith AAA stent graft. At the time of transfer LP had so far
shown normal glucose, protein, and WBC, no organisms on Gram
stain, no growth on preliminary bacterial, fungal, and acid fast
cultures, negative cryptococcal antigen. CSF HSV and VDRL
pending at time of transfer. Anti-[**Doctor Last Name **] antibodies were negative.
Serum RPR and [**Location (un) **]-[**Location (un) **] antibody panel, and 1,25 vitamin D
were pending. Patient was also undergoing EEG monitoring at the
time of transfer.
.
# CHF: The patient has a history of CHF (EF 40-45% per TTE done
in [**4-/2104**]) and his CXR has presence of some mild pulmonary
edema. He was initially continued on his home Lasix 40 mg po qd
for CHF management, and medical management was continued with
continued Carvedilol and Losartan. His lasix was discontinued
for several days due to worsening delerium and no IV access and
NPO status. Repeat chest CT on It was restarted intermittently
at 40 mg [**Hospital1 **]. On [**8-19**] a loud MR murmur was noted on physical
exam and repeat TTE was poor quality and showed EF of 30-35%,
question of worsening MR, and antero/anterolateral hypokinesis.
.
# CAD with h/o MI: Isosorbide Mononitrate ER 30mg daily and ASA
were held the day after admission for systolic blood pressures
in the low 100s, some bloody sputum and supratherapeutic INR
(3.8 on admission). He was a poor historian and intermittently
[**Month/Day (1) 12861**] substernal chest pain. EKGs demonstrated TWI in the
anterior, anterolateral, and inferolateral leads. Troponins
were elevated at 0.07 to 0.1 with normal CK-MB and cardiology
was consulted and felt this was most likely demand ischemia so
he continued on medical management, Asa was restarted, and he
was placed on carvedilol and [**Last Name (un) **] ([**Last Name (un) **] until [**8-18**] when his Cr
bumped.) On the morning of transfer, Mr. [**Known lastname **] [**Last Name (Titles) 12861**] [**4-24**]
substernal chest pressure, as he had intermittently reported
throughout hospitalization and cardiac enzymes were again
checked and showed troponin 0.02 (down from prior) and ECG
showed no significant change from baseline.
.
# AFIB: Patient was rate controlled on admission and remained
irregularly irregular throughout his hospital course. Patient
had an elevated INR (3.8) on admission with no evidence of acute
bleed, so coumadin was held but rate control was continued with
carvedilol. His carvedilol dose was stopped and restarted after
he developed an episode of A.fib with RVR on [**8-13**]. INR trended
down and coumadin was again started on [**8-14**] at a low dose of 2
mg daily. It was deemed to be safely stopped on [**8-16**] in
preparation for G-J tube placement in IR, as the patient had no
reported history of stroke, and patient was given one dose of 1
mg of IV vitamin K on [**9-1**] and [**8-22**] (3 mg total).
Warfarin has been held since [**8-18**].
.
# HTN: Pt has a history of HTN. We continued home Losartan 100
mg Tablet until [**8-18**] when Cr bumped.
.
# FEN: During previous hospitalizations, patient was evaluated
by speech and swallow who thought he might be having silent
aspiration and recommended soft diet and nectar thick fluids
with monitoring when taking in by mouth food and medications. We
continued soft diet and nectar thick fluid with aspiration
precautions. Video swallow on [**8-11**] showed aspiration of all
consistencies and he was made NPO. Repeat video swallow on [**8-15**]
again showed florid aspiration. On [**8-21**] he was allowed to take
sips and eat a dysphagia diet because he had been NPO for 10
days, had poor IV access, and had not tolerated multiple
attempts at dobhoff placement on the floor and G-J placement in
the IR suite. It was also felt that his underlying lung process
was due to a significantly more severe process than aspiration
alone. He was also started on PPN on the evening of [**8-22**] and
received intermittent PPN. On the evening of transfer he was
permitted to receive supervised milkshake spoon-feeding
administered at bedside by his daughter.
# Hypernatremia:
On [**8-21**] the patient developed hypernatremia to the 140s with a
max of 153 on [**8-22**] in the setting of IV lasix followed by no IV
access. He was spoon fed water and intermittently received up
D5W with improvement in his Na to 144 on the day of transfer
([**8-24**]).
# ARF:
On [**8-18**] the patient developed a Cr bump to 1.4 in the setting of
lasix administration. A true vanc trough the following morning
was elevated at 42. Vancomycin was d/c'd and the patient was
hydrated with D51/2NS. His creatinine remained elevated, FeNa
was <0.1% on [**8-24**], and his [**Last Name (un) **] and lasix continued to be held
until the patient triggered on the evening of [**8-24**], prompting
him to receive 40 mg of IV lasix prior to transfer to the MICU.
# Rash:
On admission the patient was noted to have a mild petechial rash
and on [**8-12**] the patient the rash was notably brightly
erythematous, purpuric, confluent, and morbiliform rash and
extended to all four extremities and his back. He has a
concurrent eosinophilia (14.3%). Biopsy was consistent with
leukocytoclastic vaculitis. Ddx included vasculitis vs. drug
reaction. He had started cefepime 3-4 days prior to the rash.
He was continued on cefepime and the rash resolved as did the
eosinophilia (5.5% when last checked on [**8-17**]).
# Transaminitis:
Patient had elevated LFTs at admission, statin was held. LFTs
trended down, statin was restarted. LFTs inadvertently checked
[**8-23**], mildly elevated again, statin held.
Medications on Admission:
1. Warfarin 2.5 mg daily
2. Carvedilol 12.5 mg Tablet twice daily
3. Isosorbide Mononitrate 30 mg Tablet Sustained Release daily
4. Losartan 100 mg Tablet daily
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) daily
6. Nitroglycerin 0.3 mg Tablet, Sublingual as needed for chest
pain
7. Simvastatin 80 mg Tablet daily
8. Lasix 40 mg Tablet daily
9. Potassium Chloride 20 mEq Tab Sust.Rel. daily as needed
for hypokalemia
10. Olanzapine 2.5 mg Tablet, Rapid Dissolve twice daily
11. Olanzapine 2.5 mg Tablet, Rapid Dissolve q6h PRN severe
agitation
.
Discharge Medications:
none
Discharge Disposition:
Extended Care
Discharge Diagnosis:
respiratory failure
Discharge Condition:
died
Discharge Instructions:
None
Followup Instructions:
None
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
ICD9 Codes: 5070, 2760, 5849, 4280, 2724, 311, 4240, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3613
} | Medical Text: Admission Date: [**2123-4-29**] Discharge Date: [**2123-5-12**]
Date of Birth: [**2072-4-26**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Penicillins / Latex / morphine / Sulfa (Sulfonamide Antibiotics)
/ Codeine
Attending:[**Doctor Last Name 1350**]
Chief Complaint:
Nonunion C45
Major Surgical or Invasive Procedure:
Stage 1
1. Exploration of spinal fusion C4-C5.
2. Removal of hardware C4-C5.
3. Open deep biopsy, bone.
4. C4 partial corpectomy.
5. C5 vertebral body partial excision, removal of intrinsic
lesion.
6. Allograft for fusion.
7. C4-C5 arthrodesis.
Stage 2:
1. Exploration of spinal fusion C4-C5, C5-C6, C6-C7.
2. C4-C5 bilateral hemilaminotomy.
3. Posterior cervical fusion C4-C5.
4. Instrumentation C4 to C5.
5. Allograft for fusion.
6. Iliac crest bone graft for fusion.
History of Present Illness:
In summary, she is a 50-year-old female who underwent anterior
cervical discectomy and fusion, [**2122-6-12**], for treatment of disc
segment disease. She developed postoperative infection,
osteomyelitis, requiring suppressive antibiotics. For that
reason in part she wants to become a candidate for hardware
removal with a goal of eradicating her infection.
We did perform a CT scan for her on [**2123-3-9**] to assess the
status of her fusion. She also want flexion and extension
radiographs. Both her CT scan and flexion and extension
radiographs are most consistent with a nonunion. Since she did
not have a healed spinal fusion, revision surgery treatment will
require a two-staged approach.
We discussed at length the surgical strategy and also the
rationale for surgery. We discussed the alternatives, risks and
benefits of both surgical and ongoing nonsurgical care. With
the
goal of eradicating infection, ultimately hopefully desisting
the
use of antibiotics, she has elected to undergo surgical
treatment.
This would be a two-staged approach.
The first stage would be anterior cervical hardware removal at
C4-C5 with debridement of the surgical site. This would then
allow cultures to also be taken, and first to follow her
inflammatory markers as an inpatient following that surgery.
She
would then be treated with postoperative antibiotics. If
postoperative antibiotics offer to have a normal decline in her
CRP trend, we may then pursue posterior spinal fusion with iliac
crest bone graft in the same hospitalization. If further
antibiotics are required, with infectious disease consultation
as
an inpatient, then we would do a second staged surgery for her
some weeks in the future after the goals of _____ sepsis have
been achieved in order to decrease the risk of potential wound
infection in her posterior cervical spine.
Past Medical History:
HTN
HL
.
PAST SURGICAL HISTORY
s/p revision ACDF C4-5 and s/p washout
S/P ACDF C5-C6 and C6-C7 3 years ago.
Tubal ligation
Lithotripsy
Cholecystectomy
Partial hysterectomy
Salivary gland removal
Social History:
nc
Family History:
nc
Physical Exam:
intact neuro
Brief Hospital Course:
Patient was admitted to the [**Hospital1 18**] Spine Surgery Service and
taken to the Operating Room for the Stage 1 procedure. Refer to
the dictated operative note for further details. The surgery
was without complication and the patient was transferred to the
PACU in a stable condition. TEDs/pnemoboots were used for
postoperative DVT prophylaxis. Intravenous antibiotics were
continued per ID recommendations. Initial postop pain was
controlled with a PCA.
[**4-30**]: Code blue for unresponsive/apneic episode. O2 sat 35%, but
with poor wave form. Pt never lost pulse. Arousable by sternal
rub. Alert after dose of narcan. Transferred to SICU for close
monitoring
[**5-1**]: Transferred to floor without event
[**5-3**]: Stage 2 surgery was done (Posterior cerivcal fusion)
[**5-4**]: Overnight: temp from 99.9 to 101.7
[**5-5**]: HVAC drain was remioved. PCA and foley were discontinued.
[**5-6**]: Change Antibiotic to Vancomycin per ID
[**5-7**]: Tmax 100
[**5-8**]: PICC line was placed.
[**5-10**]: Vanco trough low. Dose adjusted (increased)
[**5-11**]: Vanco trough 13.9.
Diet was advanced as tolerated. The patient was transitioned to
oral pain medication when tolerating PO diet.
Physical therapy was consulted for mobilization OOB to ambulate.
On the day of discharge the patient was afebrile with stable
vital signs, comfortable on oral pain control and tolerating a
regular diet.
Medications on Admission:
Gabapentin 1200''', Toprol XL 50', OMeprazole 20', ZOfran prn,
Seroquel 100hs, simvastatin 40', cetirizine 1-', Colace prn,
Minocycline 50'', Vitamin D qweek, levothyroxine 25mcg',
Cymbalta 20'', Lasix 20', Tomapax 25hs, Terazosin 2mg hs, Zoloft
50', sertraline 50', lorazepam 0.5'''
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. senna 8.6 mg Tablet Sig: 1-2 Tablets PO QHS (once a day (at
bedtime)) as needed for constipation.
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever, pain.
5. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
6. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
Disp:*80 Tablet(s)* Refills:*0*
7. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
8. prazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
9. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
10. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. topiramate 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
12. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
14. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. quetiapine 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
17. gabapentin 400 mg Capsule Sig: Three (3) Capsule PO TID (3
times a day).
18. vancomycin 500 mg Recon Soln Sig: Three (3) Recon Soln
Intravenous Q 8H (Every 8 Hours).
Disp:*180 Recon Soln(s)* Refills:*1*
19. heparin, porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
Disp:*qs ML(s)* Refills:*0*
20. Outpatient Lab Work
Weekly tests
1. ESR CRP
2. CBC diff
3. BUN Cr
4. VAnco trough
Results fax to ID RNs at [**Numeric Identifier 10738**]
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
1. C4-C5 suspected nonunion.
2. C4-C5 suspected osteomyelitis.
3. Retained hardware.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Immediately after the operation:
- Activity:You should not lift anything greater than 10 lbs
for 2 weeks. You will be more comfortable if you do not sit in a
car or chair for more than ~45 minutes without getting up and
walking around.
- Rehabilitation/ Physical Therapy:
o 2-3 times a day you should go for a walk for 15-30 minutes as
part of your recovery. You can walk as much as you can
tolerate.
o Isometric Extension Exercise in the collar: 2x/day x 10 times
perform extension exercises as instructed.
- Swallowing: Difficulty swallowing is not uncommon after
this type of surgery. This should resolve over time. Please
take small bites and eat slowly. Removing the collar while
eating can be helpful ?????? however, please limit your movement of
your neck if you remove your collar while eating.
- Cervical Collar / Neck Brace: You need to wear the brace
at all times until your follow-up appointment which should be in
2 weeks. You may remove the collar to take a shower. Limit
your motion of your neck while the collar is off. Place the
collar back on your neck immediately after the shower.
- Wound Care:Remove the dressing in 2 days. If the
incision is draining cover it with a new sterile dressing. If
it is dry then you can leave the incision open to the air. Once
the incision is completely dry (usually 2-3 days after the
operation) you may take a shower. Do not soak the incision in a
bath or pool. If the incision starts draining at anytime after
surgery, do not get the incision wet. Call the office at that
time. If you have an incision on your hip please follow the same
instructions in terms of wound care.
- You should resume taking your normal home medications.
- You have also been given Additional Medications to
control your pain. Please allow 72 hours for refill of narcotic
prescriptions, so plan ahead. You can either have them mailed
to your home or pick them up at the clinic located on [**Hospital Ward Name 23**] 2.
We are not allowed to call in narcotic (oxycontin, oxycodone,
percocet) prescriptions to the pharmacy. In addition, we are
only allowed to write for pain medications for 90 days from the
date of surgery.
- Follow up:
o Please Call the office and make an appointment for 2 weeks
after the day of your operation if this has not been done
already.
o At the 2-week visit we will check your incision, take
baseline x rays and answer any questions.
o We will then see you at 6 weeks from the day of the
operation. At that time we will most likely obtain
Flexion/Extension X-rays and often able to place you in a soft
collar which you will wean out of over 1 week.
Please call the office if you have a fever>101.5 degrees
Fahrenheit, drainage from your wound, or have any questions.
Physical Therapy:
see discharge instructions
Treatments Frequency:
see discharge instructions
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 79306**], MD Phone:[**Telephone/Fax (1) 3736**]
Date/Time:[**2123-5-18**] 11:15
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 79306**], MD Phone:[**Telephone/Fax (1) 3736**]
Date/Time:[**2123-5-18**] 11:15
OPAT attending visit [**5-25**] and [**6-15**] [**Location (un) **]
All questions regarding antibiotics please call [**Numeric Identifier 79307**].
PLease call above number for ID FU appointment
ICD9 Codes: 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3614
} | Medical Text: Admission Date: [**2147-1-10**] Discharge Date: [**2147-1-22**]
Date of Birth: [**2070-2-8**] Sex: M
Service: CCU
CHIEF COMPLAINT: Generalized weakness and fatigue for one
month.
HISTORY OF PRESENT ILLNESS: 76-year-old white male with a
history of coronary artery disease, status post coronary
artery bypass graft times two, also with CHF with an ejection
fraction of 75%, who presents with one month history of
generalized weakness and fatigue. He notes that for the past
6 months he has had history of increasing orthopnea from [**3-12**]
pillows. He also has had shortness of breath and dyspnea on
exertion. He also has had paroxysmal nocturnal dyspnea. He
has a chronic, non productive cough since last four months.
He reports having had epistaxis yesterday. Denies any
lightheadedness, dizziness, nausea, vomiting or abdominal
pain. Denies any dysuria, bright red blood per rectum or
change in bowel movements. He recalls having a syncopal
episode in [**Month (only) 216**] while playing golf, but was not worked up
at that time since patient refused electrophysiological
studies.
When patient presented to the Emergency Room, he was found to
be bradycardic down to the 30's. He was also hypotensive
with systolic blood pressure in the 90's. He was found to be
hyperkalemic with potassium of 6.3. He was given Furosemide
60 mg IV, ?????? amp of sodium bicarbonate, one amp of D50 plus 10
units of IV insulin. He was given 60 mg of po Kayexalate.
In the Emergency Room he was also given Levofloxacin 500 mg
po.
PAST MEDICAL HISTORY: Coronary artery disease including two
coronary artery bypass graft surgeries, St. [**Male First Name (un) 1525**] aortic
valve replacement, bilateral carotid disease, having had a
left carotid endarterectomy for hypertension, diabetes,
chronic renal insufficiency, CHF with an ejection fraction of
25%, hypercholesterolemia, status post myocardial infarction,
benign prostatic hypertrophy, cervical degenerative joint
disease, diabetic neuropathy.
ALLERGIES: No known drug allergies.
MEDICATIONS: Aspirin 81 mg po q d, Lanoxin .125 mg po q d,
Folate 1 mg po q d, Proscar 5 mg po q d, Nitro Patch .3 mg,
Lasix 120 mg po q d plus 40 mg po q h.s., Lisinopril 5 mg po
q d, Iron once a day, Multivitamin once a day, Lipitor 80 mg
po q d, Coumadin 7.5 mg po q d, Micardis 40 mg po q d,
Claritin 10 mg po q d, Insulin 10 units in the morning, 12
units in the evening, Lente insulin 15 units in the morning,
18 units in the evening, Nortriptyline 10-20 mg po q h.s.
SOCIAL HISTORY: The patient lives at home with his wife. [**Name (NI) **]
has remote tobacco history 30 years ago. He reports
occasional drinking of wine.
FAMILY HISTORY: Positive for coronary artery disease.
PHYSICAL EXAMINATION: Heart rate 55, respiratory rate 15,
blood pressure 96/33, oxygen saturation 96% on two liters
nasal cannula. In general, patient is alert, in no apparent
distress. HEENT: Jugulovenous distension to angle of the
jaw, oropharynx with moist, mucus membranes. Cardiovascular,
regular rate and rhythm, no murmurs, positive bowel click.
Lungs, patient had bilateral crackles, left greater than
right at the bases. Abdomen soft, nontender, non distended,
positive bowel sounds. Extremities, no edema.
LABORATORY DATA: White count 6.3, hematocrit 35.6, platelet
count 109,000, INR 4.3, PTT 50.7, neutrophils 72, lymphs 18,
monocytes 8, eosinophils 2 and sodium 138, potassium 6.4,
chloride 101, CO2 30, BUN 95, creatinine 2.4, glucose 103,
baseline creatinine 1.8 and 2.0. Digoxin level 2.1.
Urinalysis showed many bacteria with 0-2 red blood cells,
[**7-17**] white blood cells, positive for nitrites. Chest x-ray
showed evidence of mild congestive heart failure,
cardiomegaly, right lower lobe opacity with elevated right
hemidiaphragm. Chest x-ray CT showed positive ground glass
findings, possible congestive heart failure vs chronic
infiltrate. Questionable Amiodarone toxicity. He also had
mediastinal lymphadenopathy with increased right pleural
effusion. Also evidence of air trapping. Electrocardiogram
showed sinus bradycardia with rate of 50, increased prolonged
PR interval, evidence of intraventricular conduction delay, Q
waves in 2 and 3 and AVF, biphasic T waves in 1 and AVL. T
wave inversions in V1 through V6, 1, 2 and AVL.
ASSESSMENT: This is a 76-year-old white male with
significant cardiac history including two episodes of
coronary artery bypass graft and low ejection fraction. He
now presents with dyspnea and generalized weakness which was
attributed to his congestive heart failure.
HOSPITAL COURSE:
1. Cardiac: The patient was felt to be in congestive heart
failure by exam and by history. He was initially diuresed
with IV Lasix. The other cardiac issue for him was his
bradycardia which may have been due to increased Digoxin
level. Consequently his Digoxin was initially held. Since
he was hypotensive, his Nitro paste was also held. Given his
history of coronary artery disease, he was also ruled out for
a myocardial infarction. His Aspirin and Statin were
continued. Cardiology was consulted regarding his
symptomatic bradycardia. Cardiology initially recommended to
continue with the diuresis. They recommended holding the
angiotensin receptor blocker and to continue holding the
Digoxin. Because of his elevated INR, they also recommended
holding his Coumadin until it drifted back down to 2-3.
Cardiology was consulted on the first day of admission.
Cardiology also recommended starting him on Hydralazine 25 mg
po tid to improve his afterload reduction. He ruled out for
myocardial infarction with peak CK of 135. However, his
troponin was elevated at 2.1 but drifted down to .6. The
elevated troponin may have been in the setting of congestive
heart failure. On the second day of admission, the patient
felt better, having had diuresis. He was practically
negative 300 ml after the first day. He was also continued
back on his Nitro paste to improve preload reduction.
Telemetry showed that his heart rate was generally in the
50's but would decrease down to 30's occasionally. His
elevated troponin was thought to be secondary to his CHF,
particularly in the setting of acute renal failure. Because
of his bradycardia, the electrophysiology service was
consulted. It was felt that he would benefit from
electrophysiology study. Based on that, he may have needed a
pacemaker. His history of having a syncopal episode was
concerning. The syncopal episode occurred in [**Month (only) 216**]
approximately 4 months prior to admission. The goal is to do
these studies when his INR was less than 1.8. As of the
second day of admission, the patient's INR was 2.7. Because
of the patient's blood pressure, it was difficult for him to
receive his Hydralazine and his Furosemide. Secondary to
admission, the patient received echocardiogram which showed
moderate left atrial enlargement, mild symmetric left
ventricular hypertrophy, mild left ventricular dilatation and
severely depressed left ventricular systolic function. It
also showed moderate global right ventricular free wall
hypokinesis, trace aortic regurgitation, 1+ mitral
regurgitation and an ejection fraction of 20%. Compared to
echocardiogram done in [**2139-6-7**], showed significant decrease
in left ventricular function. For his bradycardia,
electrophysiology also felt that functional status of his
heart would also be important prior to the electrophysiology
study. Consequently he was to go for stress thallium test.
By the third day of admission, the patient's heart rate had
gradually improved to 60's to 70's. This is more suggestive
of a possible Digoxin as the cause. His stress thallium was
done on the third day of admission. During the exercise
portion, the patient had no angina, no ischemic
electrocardiographic changes. The patient was on Heparin
since his Coumadin was being held for his aortic valve
replacement anticoagulation. His stress thallium test showed
no angina, no ischemic EKG changes. Showed moderate partly
reversible perfusion defects in the inferior and inferior
septal wall. Had mild reversible perfusion defects in the
apex, apical septum and distal anterior wall with liable
myocardium. Showed dilated left ventricle. Had global
hypokinesis of left ventricle and akinesis at the apex.
Ejection fraction was listed at 29%. Because of these partly
reversible defects, he was considered a cardiac
catheterization candidate. However, his creatinine was still
elevated at 2.1. In the hopes of improving his renal
function, the patient was considered for no known therapy.
The goal was to improve his cardiac but to improve his renal
function such that he would better tolerate a cardiac
catheterization without reducing his chances of
complications. Consequently, for the Milrinone to be
administered, the patient was transferred to the CCU on the
5th day of his admission. After the cardiac catheterization,
the patient would then be a candidate for the EP study. He
was continued on his Lasix, first 120 mg IV bid. He was also
continued on his Heparin drip for the aortic valve
replacement while his Coumadin was held. He was monitored
closely with the Milrinone for possible arrhythmias. In the
CCU he had a Swan Ganz catheter placed to monitor his
hemodynamics. His initial pressures were such that his
pulmonary artery pressure was 51/22, pulmonary capillary
wedge pressure was 22. CVP was 17. Cardiac output was 4.5,
based on the situation. Cardiac index was 2.36 and his
systemic vascular resistance was 800. The following day,
[**1-15**], the patient's pulmonary artery pressure was 58/22,
pulmonary capillary wedge pressure was 20, CVP was 12,
cardiac index was 2.62 and systemic vascular resistance was
720. He did show some improvement with Milrinone; at that
point 33 mcg/kg/minute. His urine output had decreased by
the 6th day of admission. Subsequently he was started on
Furosemide IV drip. Initially started at 10 mg/hour and then
increased to 20 mg per hour. With the increase to 20 mg per
hour, he responded with increased urination. On the 6th day
of admission, his pulmonary artery pressure was 63/29 and CUP
was 17. He had a diuresis of only 200 ml during that day.
He had a cardiac catheterization done on the 7th day of
admission. With the Milrinone, he had episodes of non
sustained ventricular tachycardia. However, he was
asymptomatic during these episodes. Because he was having
sustained V tach, his Milrinone was decreased. His Milrinone
was decreased by half to .16 mcg/kg/minute. His cardiac
catheterization showed diffuse disease. Proximal RCA was
100% occluded. Left main with 80% osteal lesion. Proximal
LAD showed 100% occlusion, mid left circumflex showed 80%.
Saphenous vein grafts, two were 100% occluded. The saphenous
vein grafts to the first diagonal, showed 99% occlusion. Two
stents were placed in the saphenous vein graft to the
diagonal artery first branch. He had resulting good flow.
During the procedure, he had intra-aortic balloon pump
placed. However, prior to coming to the CCU, it was removed.
During this period he also had two units of packed red blood
cells transfused. He had evidence of fluid overload during
the second unit of packed red blood cells. Consequently he
was given 100 mg IV times one. He was finally started on IV
drip 15 mg per hour. He responded with a 250 ml urine
output. He did have bleeding from the catheterization site.
There was some discussion of whether to intervene later on
his left main and left circumflex. However, at this time the
SVG to first diagonal was intervened upon. Because of the
intervention, he was started on Plavix for a total course of
30 days. He was subsequently started on Integrilin for a
total course of 18 hours. He had evidence of continued fluid
overload. Because of low blood pressure, his Hydralazine was
discontinued. It was thought that it might also help with
increasing the renal perfusion. To more accurately assess
his blood pressure, he had an arterial line placed on the 8th
day of his admission. Since there was some evidence that he
was extremely hypotensive, his Furosemide drip was
discontinued. He was started on a Nitroglycerin drip to
decrease the load and to possibly improve cardiac output. On
the 9th day of admission, the patient continued to have
anuria. However, it seemed to be mostly due to a Foley
situation. He, during the night of his 8th day of
admission, became hypotensive. His hematocrit decreased to
27. His pulmonary artery pressure was 69/27, with mean
arterial pressure of 50 and CVP of 14. Pulmonary capillary
wedge pressure had been done earlier and decreased to 26. It
was thought that he was becoming hypovolemic from the over
diuresis and from the epistaxis. He was given a unit of
packed red blood cells. His blood pressure improved after
that. The Heparin and Nitroglycerin were discontinued in the
setting of bleeding. On the next day of admission, the
patient had an episode of vomiting after which he went into
pulseless ventricular tachcardia. He was shocked once and
continued to be in ventricular fibrillation. He was then
given a mg of Epinephrine and was shocked two more times and
converted to sinus rhythm. During the code, CPR was
performed. He was started on Amiodarone drip and was also
intubated at that time. After the code, it was decided that
to improve his hemodynamics, he would benefit from dialysis
to improve his volume overload. He was started on
ultrafiltration. He was also started on pressors, initially
Vasopressin. Because it was ineffective, he was then started
on Dopamine which improved his blood pressure. He initially
had Dopamine rate of 4 mcg/kg/minute. His Aspirin was
continued. His bleeding had to be balanced against the risk
of clotting his stent. The Heparin was discontinued. After
the 9th day of admission, his CHF was managed by dialysis.
He was also started on Dopamine to improve his contractility
and to improve flow. Because of his ventricular fibrillation
arrest, he was started on Amiodarone. The Amiodarone was 1
mg/kg drip per 24 hours. During that first day he had nearly
three liters removed. He was becoming more hypotensive and
his Dopamine was increased to 11 mcg/kg. His Heparin was
restarted as his bleeding was under better control. However,
after the Heparin was started, he had increased bleeding, he
was transfused two units additionally, and his hematocrit
increased from 29 to 31. Because of his bleeding, the
Heparin was again stopped. The goal was to keep his
hematocrit above 30. He had been on Milrinone but that was
stopped after the code situation. The ventricular
tachycardia may have been related to his Milrinone but the
exact etiology is unclear. On the 10th day of admission, he
was in atrial fibrillation, despite being on Amiodarone. He
was considered for cardioversion. Heparin was again
restarted on the 10th day of admission, particularly because
of the stent placement and his aortic valve replacement. He
was dialyzed with a goal of removing fluid. Predialysis his
CVP was between 19 and 22. Post dialysis his CVP had been
between 15 and 24. His pulmonary artery diastolic pressures
went from 72 to 34 predialysis. After dialysis was 28 to 33.
During then night of his 9th night of his admission, he had
two episodes of ventricular tachycardia. He was shocked one
time each and was converted to a non tachycardic rhythm. He
was considered for atrial fibrillation, cardioversion, but it
was deferred after his episodes of ventricular tachycardia.
On the 10th day, his dialysis was stopped early because of
blood pressure decrease. MAP decreased to 50's. After
dialysis decreased to 70's. He was still on Vasopressin drip
and Dopamine drip at this time. On the 11th day of
admission, patient had decreased distal pulses. His
Vasopressin was stopped. The decreased distal pulses were
thought to be due to peripheral vasoconstriction due to the
Vasopressin and also the Dopamine. Since the patient was
thought to be in cardiogenic failure, the goal was to try to
wean him off the Dopamine and to place him on Dobutamine.
Because his low blood pressure would not be able to tolerate
intermittent dialysis, he was then started on CVVH for more
gentle diuresis through dialysis. Because of the episodes of
ventricular tachycardia that required cardioversion or shock,
Amiodarone was discontinued as possibly increasing his QT
interval. He had reverted back to sinus rhythm. On the 11th
day, after discussion with the family he was made no
defibrillation. When Dobutamine was added his cardiac output
and systemic vascular resistance improved. However, his mean
arterial pressures were still less than 60. Consequently it
was difficult to wean off the Dopamine and had to be
continued. Because the patient was hypothermic and possibly
having septic etiology, with a very low SVR down to 472, he
was started on Vasopressin. The goal was to try to wean off
the pressors. During the 13th day of admission, the patient
had another episode of ventricular tachycardia that was
pulseless. Since family did not want him to have
defibrillation, he was not shocked. He spontaneously
converted to sinus bradycardia and then to sinus
tachy/arrhythmia with increased systolic blood pressure.
However, then his mean arterial blood pressure decreased to
45 and then the patient remained in sinus rhythm after
restarting pressors. Lidocaine drip was initiated.
Discussion was had with the family concerning the patient's
code status. Since the patient had a very poor prognosis,
the family decided they did not want him to continue to
suffer. They wanted to wean pressor support. They also felt
that he should withdraw the dialysis. This was on the 13th
day of admission.
2. Renal: The patient had an elevated creatinine during
this admission. It was thought to be initially due to
setting of congestive heart failure exacerbated by having
angiotensin receptor blockers and also ACE inhibitors. He
had hyperkalemia which was thought to be due to the acute
renal failure. His increased Digoxin and Coumadin were also
thought to be due to acute renal failure. Consequently the
angiotensin receptor blocker was held. For his hyperkalemia,
he was on telemetry and had the ER course as stated above.
On the second day of admission his creatinine was essentially
stable at 2.4. On the third day, his creatinine increased to
2.6. The management remained the same, most likely due to
his congestive heart failure. On the 4th day of admission,
decreased to 2.3. On the 5th day, the patient's creatinine
was 2.1, close to his baseline. He was sent to the CCU for
Milrinone therapy to improve his cardiac output and
subsequently improved his renal function. His creatinine on
the first day in CCU was 2.2, essentially stable. He did
receive anecetalcistine prior to and day after
catheterization. His creatinine remained stable at 2.2 prior
to catheterization. After catheterization, his creatinine
increased to 2.3. This was on the 8th day of admission. He
had evidence of decreased urine output. Consequently he was
started on Furosemide IV drip. He was essentially anuric on
the 9th day of admission, however, he had multiple clots in
his Foley. It was then forcefully flushed and he was placed
on continuous irrigation. His urine output improved after
that. His creatinine increased to 3.6 in the setting of
having probably an obstructed Foley. On the 9th day of
admission, he had an episode of ventricular fibrillation and
was shocked. He was then started on hemodialysis for fluid
overload management. His increased creatinine was thought to
be mostly due to the obstructed Foley. His creatinine
remained stable at 3.8. Goal was to try to improve his fluid
outflow to improve his renal perfusion. He had a renal
ultrasound which showed no evidence of hydronephrosis or
obstruction. The ultrasound was done approximately on the
day of admission. Because of difficulty maintaining his
blood pressure, he was converted to CVVH for more gentle
diuresis and dialysis. His creatinine continued to increase
to 4.6. However, on the 12th day of admission the patient's
creatinine improved to 3.3. The CVVH was thought to be
helping. On day of his death, the patient's creatinine
improved to 2.6 in the setting of continued diuresis with
dialysis and continued dialysis. His potassium was under
control. However, his family felt that because of his poor
prognosis, he would not want to suffer further.
Consequently, CVVH was withdrawn on the 13th day of
admission.
3. Heme: The patient had episodes of epistaxis during this
admission. He had had a previous history of epistaxis for
the past week. However, it intensified while he had been on
anticoagulation. However, because of the importance of his
anticoagulation, it was difficult to completely wean him off
the therapy. He had episodes of epistaxis which were
controlled with pressure. However, he continued to have
bleeding from the epistaxis and from his right groin site
from the catheterization. He also had evidence of guaiac
positive stool. Consequently because the bleeding was coming
to a point where he was requiring blood transfusions, the
ear, nose and throat department was consulted. His
hematocrit decreased to 27 from 30. The otolaryngology
service recommended packing the nose. They suggested
avoiding nasal cannula. They also felt that he should
continue to have packing. He also had bleeding from the
Foley. He had evidence of hematuria. He was not
cardiopathic, his INR remained between 1.4 and 1.5. His PTT
though, was elevated in the setting of using Heparin. When
his bleeding worsened, his Heparin was stopped, however, as
the bleeding improves, the Heparin would be restarted.
During the course of admission he required multiple
transfusions. When he became hypovolemic in the setting of
bleeding, he received one unit of packed red blood cells and
improved. It was thought that from his viremia he would have
dysfunctional platelets. On the 11th day of admission, his
INR was slowly increasing to 1.7. Consequently he was given
Vitamin K 1 mg IV. The increase in the INR was thought to be
secondary to possibly from his Heparin use. The following
day his INR decreased to 1.6. The bleeding improved when the
Heparin was decreased.
4. ID: The patient had evidence of urinary tract infection.
Initially when he presented, he was treated with
Levofloxacin. On the day of admission he had evidence of
possible pneumonia. He had a temperature max of 100.8. He
has had increased white blood cells to 15.3. He was treated
for possible pseudomonas pneumonia given that he was on a
ventilator. He was started on Ceftazidime and Vancomycin for
possible line infection. He also had decreased SVR on the
12th day of admission. Consequently he was developing a
septic physiology. He had increased cardiac output,
decreased SVR and was hypothermic. He had multiple sources
of infection. He was covered broadly with Vancomycin and
Ceftazidime.
5. Pulmonary: The patient had episodes of congestive heart
failure discussed in the cardiac section. He also had
evidence of possible pneumonia towards the end of his
admission treated with Ceftazidime. However, because of the
code situation, the patient was intubated. He was initially
placed on assist control with respiratory rate set at 16.
His total volume was 650 ml, rate was 12, FIO2 was decreased
down to 50% and PEEP was 5. He did not really have any
respiratory issues besides the CHF and was satting well at
98-100%. However, in the setting of continued diuresis with
dialysis, he continued on the ventilator. He did not really
have any ventilator issues except for possible pneumonia
which was treated with Ceftazidime. He was able to maintain
decent oxygenation and ventilation with ventilator support.
FIO2 was decreased down to 40%. He was mainly kept on a
ventilator because of diuresis. His last ABG was 7.42 PH,
CO2 43, PO2 67.
On the 13th day of admission, the patient's family felt that
they did not want the patient to suffer any longer
considering his poor prognosis. Consequently they wanted to
withdraw pressor support and CVVH. Shortly thereafter, the
patient passed away on [**2147-1-22**]. He was found to have no
spontaneous respiration, and no evidence of heart sounds.
His pupils were fixed and dilated. He was not responsive to
pain. Patient's family was made aware of the situation and
was there when the patient passed away. Patient's family
declined any autopsy.
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 53716**]
Dictated By:[**Name8 (MD) 4523**]
MEDQUIST36
D: [**2147-4-19**] 15:20
T: [**2147-4-21**] 17:03
JOB#: [**Job Number 95345**]
ICD9 Codes: 4280, 4271, 4275, 5849, 2767, 2765 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3615
} | Medical Text: Admission Date: [**2132-2-23**] Discharge Date: [**2132-3-2**]
Date of Birth: [**2084-12-19**] Sex: M
Service: MEDICINE
Allergies:
Flagyl
Attending:[**Known firstname 943**]
Chief Complaint:
Transfer to [**Hospital1 18**] MICU fr/OSH for ? TIPS procedure.
Major Surgical or Invasive Procedure:
TIPS (Transjugular intrahepatic portosystemic shunt)
Central venous line
History of Present Illness:
HPI: Pt in USOH, awoke on [**2-22**] c/o nausea, lightheadedness, and
SOB. These symptoms resolved on their own, however at 10:30am
had a dark/tarry BM, called his PCP which told pt to present to
the ED given his h/o previous GIB and transfusion requirements.
Pt denied any CP/palpitations, hematemesis or coffee ground
emesis. No intial abdominal pain (gassy abdominal pain post EGD
today at OSH). In [**Name (NI) **] pt's hct was 27, dropped to 23 and received
3UPRBC, started on Octreotide gtt and Pantoprazole gtt. Also s/p
gastric banding today at [**Hospital6 **]. VSS throughout
course at OSH with HR stable 70s-80s, SBP 100-130s.
Pt initially dx with Cryptogenic cirrhosis 3years ago in setting
of extreme weakness and anemia. In [**11/2130**] pt had 1st episode of
hematemesis and BRBPR which required variceal banding. Pt was
found to have grade 4 varices at that time. In [**12-4**]/[**2132**] pt
was hospitalized again for melena but no hematemesis or coffee
ground emesis. During that admission hct at presentation was 22
and at discharge hct increased to 28.7, unclear #PRBC
transfusion requirement. Pt does not know his baseline Hct nor
his current transfusion requirements but has noticed increasing
frequency of transfusions in the last year.
ROS: Pt denies any constitutional sx, no F/C/Cough. No
CP/palpitations/Diaphoresis. Mild Diarrhea however at baseline
[**2-7**] medications. No dysuria, polyuria.
Past Medical History:
PMH:
-Cryptogenic Cirrhosis
-Esophageal Varices s/p banding ([**11/2130**]-grade IV & [**1-/2132**]-grade
III)
-GERD
-DMII, dx 1 yr ago
.
PSH:
-Appy
Social History:
Married, no children. Previous occupation=truck driver,
currently unemployed.
-Denies any TOB-quit 10 years ago, denies any ETOH use
Family History:
-ETOH cirrhosis, alcoholism (father and two aunts), liver cancer
(two aunts [**2-7**] EtOH cirrhosis)
Physical Exam:
VS BP 129/61 HR 71 RR 15 100% 2LNC
GEN: comfortable, well nourished appearing man in NAD
SKIN: No spider angiomata, no jaundice
HEENT: PERRL, EOMI, Anicteric sclera, Dry MM
RESP: CTA B/L, No crackle, no wheezing
CV: reg, nml s1,s2, no M/R/G
ABD: soft, obese,mildly distended, mildly tender over epigastric
& RUQ area, minimal guarding, no rebound, loud BS, liver edge
difficult to appreciate
EXT: no C/C/E, warm, 2+DP pulses b/l
Pertinent Results:
[**2132-3-2**] 06:40AM BLOOD WBC-3.9* RBC-4.04* Hgb-10.2* Hct-31.3*
MCV-77* MCH-25.2* MCHC-32.6 RDW-21.4* Plt Ct-68*
[**2132-3-2**] 06:40AM BLOOD Plt Ct-68*
[**2132-3-2**] 06:40AM BLOOD PT-17.3* PTT-27.8 INR(PT)-1.6*
[**2132-3-2**] 06:40AM BLOOD Glucose-117* UreaN-5* Creat-0.7 Na-141
K-3.9 Cl-110* HCO3-21* AnGap-14
[**2132-2-23**] 06:07AM BLOOD ALT-25 AST-31 LD(LDH)-222 CK(CPK)-51
AlkPhos-72 TotBili-1.0
[**2132-2-25**] 05:20AM BLOOD TotBili-0.7
[**2132-2-26**] 05:30AM BLOOD ALT-26 AST-31 AlkPhos-71 TotBili-0.8
[**2132-2-27**] 08:20AM BLOOD TotBili-1.1
[**2132-2-28**] 05:30AM BLOOD TotBili-0.5
[**2132-2-29**] 04:33AM BLOOD ALT-64* AST-77* LD(LDH)-253* AlkPhos-96
TotBili-1.8*
[**2132-3-1**] 07:05AM BLOOD ALT-153* AST-163* LD(LDH)-232 AlkPhos-110
TotBili-1.5
[**2132-3-2**] 06:40AM BLOOD ALT-160* AST-144* AlkPhos-163*
TotBili-1.4
[**2132-3-1**] 07:05AM BLOOD Albumin-3.2* Calcium-7.8* Phos-2.2*
Mg-1.9
[**2132-2-24**] 06:45PM BLOOD calTIBC-410 Ferritn-6.7* TRF-315
[**2132-2-24**] 06:45PM BLOOD AFP-2.4
[**2132-2-24**] 06:45PM BLOOD AFP-2.4
[**2132-2-24**] 06:45PM BLOOD HCV Ab-NEGATIVE
[**2132-2-25**] 12:15PM BLOOD ALPHA-1-ANTITRYPSIN-Test
ALPHA-1-ANTITRYPSIN 152 83 - 199 MG/DL
Abd U/S [**2132-2-23**]
FINDINGS: Directed son[**Name (NI) 493**] examination demonstrated a patent
portal vein with appropriate hepatopetal flow. The hepatic veins
are also patent with appropriate direction of flow.
CTA [**2132-2-24**] 8:40 PM Abd/Pelvis:
IMPRESSION:
1. Several too small to characterize foci, low in attenuation,
within the left and right hepatic lobe at the dome. No enhancing
hepatic lesions. Two right hepatic lobe cysts.
2. Cholelithiasis.
3. Moderate amount of ascites, mesenteric stranding with small
nodes, consistent with portal hypertension.
4. Minimal colonic wall thickening likely due to portal
hypertension rather than colitis
5. Retroperitoneal lymphadenopathy.
6. Splenomegaly.
[**2132-2-28**] TIPS
PROCEDURE/FINDINGS: After the risks and benefits were explained
to the patient, written informed consent was obtained. The
patient was placed supine on the angiographic table. A
pre-procedure timeout was obtained to confirm the patient's
name, procedure and the site. The right neck was prepped and
draped in the standard sterile fashion. This procedure was
performed under general anesthesia and local anesthesia with 5
cc of 1% lidocane. Under ultrasonographic guidance, a 21-guage
needle was used to access the right internal jugular vein. A
0.018 guidewire was placed through the needle under fluoroscopic
guidance with the tip in the superior vena cava. The needle was
exchanged for a micropuncture sheath and the wire was exchanged
for a 0.035 [**Doctor Last Name **] guidewire with the tip in the inferior vena
cava. The venous access was dilated by using 10-French dilator.
A 10-French vascular sheath was then placed over the wire with
the tip positioned in the inferior vena cava under fluoroscopic
guidance. A 5-French C2 catheter was then advanced through the
sheath over the wire with its tip engaged into the hepatic vein
under fluoroscopic guidance. The catheter was advanced distally
and the venogram was performed. The catheter was then exchanged
for a balloon occlusion catheter over the wire and CO2 portogram
was performed after inflation of the balloon. This confirmed the
position of the balloon occlusion catheter within the right
hepatic vein. After the catheter was removed, a TIPS puncture
set was advanced through the sheath into the right hepatic vein.
A shunt was created between the right hepatic vein and the right
branch of the portal vein. A Glidewire was then advanced into
the main portal vein. A multi- side- hole catheter was placed
over the wire and venogram was performed which demonstrated
patent common portal vein, splenic vein and superior mesenteric
vein. Gastric varices were also noted. The pressure gradient
between the portal vein and the right atrium was 15 mmHg. The
liver parenchyma tract was dilated with an 8-mm balloon, with an
inflation pressure up to 12 atmosphere. A 10 mm x 68 mm
Wallstent was then deployed, extending from the main portal vein
into the hepatic vein. The stent was then dilated with 10 mm, 12
mm balloons. Pressure gradient between the portal vein and the
right atrium was decreased to 5 mmHg. The catheter was then
repositioned into the splenic vein and a followup venogram was
performed which demonstrated patent shunt. There was no
opacification of the previously seen small gastric varices. The
catheter and the sheath were then withdrawn into the IVC and
then exchanged for a 9- French trauma line over the wire. The
catheter was flushed and secured to the skin with sutures.
During the procedure, one pass caused a small liver capsule
perforation. The track was then embolized by using Gelfoam.
The patient was transferred to post-anesthesia unit in stable
condition.
MEDICATIONS: During the procedure approximately 250 mL Optiray
contrast were applied.
IMPRESSION: Successful transjugular intrahepatic portosystemic
shunt placement with reduction of a pressure gradient between
the portal vein and right atrium from 15 mmHg to the 5 mmHg.
[**2132-2-29**] Abd U/S
The liver parenchyma again contains a simple cyst corresponding
to that seen on CT. The amount of ascites has lessened. The
gallbladder contains extensive sludge but is otherwise normal.
TIPS is identified. This shows wall to wall flow. Peak systolic
velocities in the proximal TIPS approximately 40 cm per second,
from the mid TIPS approximately 150 cm per second, from he
distal TIPS approximately 119 cm per second are seen. There is a
reversal of flow within the anterior and right portal vein and
the left portal vein consistent with functional TIPS. The
hepatic veins appear patent.
MPV velocity of approx 40 cm/sec
CONCLUSION:
Functional TIPS with wall to wall flow and baseline parameters
estabilished as above.
2) Simple cyst.
3) Gallbladder sludge without other evidence of biliary
pathology.
[**2132-3-1**] 11:38 AM
LIMITED ABDOMINAL ULTRASOUND: The right upper, right lower, left
lower and left upper quadrants of the abdomen were examined to
assess for fluid. There is no ascites identified within the
abdomen, and therefore, a spot could not be marked.
Brief Hospital Course:
Mr. [**Known lastname 46630**] is a 47 year old man with cryptogenic cirrhosis and
a history of multiple GI bleeds who presented from an outside
hosptial s/p banding for upper GI bleed from variceal bleeding.
He was transferred here for a TIPS procedure. His problem list
included:
Problem [**Name (NI) **]:
1. GI bleed
2. ? Colitis
3. Thrombocytopenia
4. Cryptogenic cirrhosis
5. Diabetes Mellitus (Type II)
6. Peptic Ulcer Disease
7. GERD
8. Anxiety
In brief, his hospital course proceeded as follows:
(1) GI Bleed: On transfer, the patient was on an octreotide drip
and pantoprazole drip. He was also on levofloxacin for SBP
prophylaxis in the setting of GI bleed. Both the octreotide drip
and pantoprazole drip were continued while the patient was in
the MICU. He was switched to protonix [**Hospital1 **] on trasfer to the
floor and eventually taken off the octreotide drip and
levofloxacin. He was kept on propranolol to control his portal
hypertension and prevent variceal bleeding..
The patient received three units of PRBCs at the outside
hospital and banding of his esophageal varices. On transfer to
[**Hospital1 18**], he has two EGDs which showed 2 cords of grade II varices
in the lower third of the esophagus. 2 cords of grade I varices
were seen in the lower third of the esophagus. The stomach
mucosa showed erythema, friability and congestion of the mucosa
with contact bleeding noted in the stomach body, fundus and
antrum. The findings were compatible with severe portal
gastropathy. The patient was seen and evaluated by the liver
and transplant teams and scheduled for a TIPS procedure,
However, during his early hospital course, his hematocrit
dropped from 28.2 on admission to 25.0, likely from slow GI
bleeding. At this point he was transfused two units of PRBCs.
Following transfusion, his hematocrit remained stable in the low
30s. He continued to pass guaiac positive stools during his
hospital course. He was monitored on telemetry and remained
hemodynamically stable throughout his hosptial course. He was
started on FeSO4 for iron deficiency anemia. His vitamin B12
and folate levels were normal.
The patient underwent a successful TIPS procedure on [**2-28**].
During the procedure, one pass caused a small liver capsule
perforation. The track was then embolized by using Gelfoam. The
patient was transferred to post-anesthesia unit in stable
condition. A follow-up ultrasound on [**2-29**] showed patency of the
TIPS tract. He had serial hcts which remained stable from 30-32
at time of discharge.
(2) Colonic thickening on CT: Abdominal CT showed minimal
colonic wall thickening likely due to portal hypertension rather
than colitis. However, on physical exam the patient did have
some RUQ and RLQ abdominal pain. He also had consistently
positive guaiac positive, dark/tarry stools. The ob+ stools
were attributed to his portal hypertensive gastropathy and
thought to be due to old blood, as his hct remained stable. C.
diff was sent given that he had been on levofloxacin, but was
negative times 2. He is recommended to receive a colonoscopy as
an outpatient.
.
(3) Thrombocytopenia: This is likely secondary to his liver
disease. His platelet count has remained in the low 50-80s
since admission.
(4) Cryptogenic cirrhosis: The patient is Child??????s Class A
cirrhosis (MELD SCORE =10). His transaminase levels are normal.
His hepatits A, B and C serologies were negative. His
alpha-1-antitrypsin level was normal. His cirrhosis is
complicated by esophageal varices and severe portal hypertensive
gastropathy. He is not currently on the transplant list. The
patient was vaccinated for Hepatitis A and B. He was advised to
follow up with his PCP as an outpatient to complete the
vaccination course.
He is status post TIPS procedure on [**2-28**]. His ALT, AST, and
Tbili were slightly elevated from baseline following his TIPS
procedure. This is likely secondary to inflammation of the
liver parenchyma due to the TIPS procedure. These were stable
at time of discharge, though his bilirubin was trending down.
During his hospital course he was treated with his home regimen
of propranolol.
(5) Type II Diabetes Mellitus: His fingersticks remained stable
on regular insulin sliding scale. We held his metformin on
admission until his TIPS procedure. He was restarted on his
metformin as an outpatient.
(6) Peptic ulcer disease: Treated with Pantoprazole 40 mg PO
Q12H and sucralfate 1g QID.
(7) Anxiety: Patient was continued on his outpatient regimen of
Lexapro.
Medications on Admission:
MEDS at home:
-Protonix 40 Daily
-Inderal 20 [**Hospital1 **]
-Lexapro 20 daily
-Metformin 500mg [**Hospital1 **]
MEDS on Transfer:
-Octreotide gtt
-Protonix gtt
Discharge Medications:
1. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
2. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
6. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 5 days: To complete 7 day course on .
Disp:*5 Tablet(s)* Refills:*0*
7. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day:
Home dose.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
Portal Hypertension
Esophageal varices
Severe portal hypertensive gastropathy
Secondary Diagnoses:
Cryptogenic cirrhosis
Type II Diabetes Mellitus
GERD
Iron deficiency anemia
Discharge Condition:
Afebrile, pain well controlled and stable for discharge home.
Discharge Instructions:
1. Please take all medications as prescribed.
2. Please keep all follow-up appointments.
3. Please seek medical attention if you develop fevers, chills,
nausea, vomiting, black or bloody stools, lightheadedness, chest
pain, shortness of breath or have any other concerning symptoms.
.
You will need to followup with Dr. [**Last Name (STitle) 497**] or Dr. [**Last Name (STitle) **] at the
Liver Center within 10 days after discharge.
.
You will need to continue Levoflox for a total of 7 days (4 more
days left). Continue your ferrous sulfate and use laxatives for
regular bowel movements.
Followup Instructions:
Please make a follow-up appointment with Dr. [**Last Name (STitle) 497**] at
[**Telephone/Fax (1) 2422**] for within the next 1-2 weeks.
Please make a follow up appointment with Dr. [**Last Name (STitle) 8338**] at
[**Telephone/Fax (1) 8340**] for within the next 1-2 weeks.
Please follow up with Dr. [**Last Name (STitle) 8338**] or Dr. [**Last Name (STitle) 497**] to schedule your
Hepatitis A and B boosters. You need a second booster for both
Hepatitis A and Hepatitis B at one month, and a third hepatitis
B booster in 6 months.
Completed by:[**2132-3-2**]
ICD9 Codes: 5715, 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3616
} | Medical Text: Admission Date: [**2149-2-19**] Discharge Date: [**2149-3-12**]
Date of Birth: [**2100-2-23**] Sex: F
Service: Plastic Surgery
HISTORY OF PRESENT ILLNESS: The patient is a 48 year old
female admitted to [**Hospital6 256**] on
[**2149-2-19**] from a rehabilitation facility. The patient
had been healthy and in her usual state of health until late
in [**2148**] when she developed a case of Streptococcus pneumonia,
complicated by disseminated intravascular coagulation,
sepsis, acute renal failure, and two episodes of
pneumothorax. During the course of the patient's sepsis the
patient required vasopressor support but as a result of the
low flow state, the patient developed ischemia and gangrene
of the distal end of both of her feet. Following discharge
from [**Hospital 9464**] Hospital, the patient was transferred to a
rehabilitation facility for further management. The patient
was transferred to [**Hospital6 256**] from
this rehabilitation facility for further management of her
gangrenous feet.
PAST MEDICAL HISTORY: Streptococcus pneumonia complicated by
septic shock, DIC, bilateral lower extremity ulcers with
necrotic toes and feet, acute renal failure, pneumothorax.
MEDICATIONS ON ADMISSION: Tylenol prn; Colace 100 mg p.o.
b.i.d.; Heparin 5000 units b.i.d.; Protonix 40 mg p.o. q.d.;
Duragesic patch; Zyprexa.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: On admission the patient was afebrile
with stable vital signs. Her physical examination was
notable for dry gangrene of both feet from above the mid foot
distally.
HOSPITAL COURSE: The patient was admitted to the [**Hospital6 1760**] as noted on [**2149-2-19**].
On [**2149-2-20**] the patient had bilateral lower extremity
doppler studies to evaluate the blood flow to her feet. The
results of the study were essentially normal except for the
possibility of mild tibial artery occlusive disease. On the
same day, the patient was taken to the Operating Room, had -
1. Amputation of the right foot at the intermetatarsal level
2. Amputation of the left foot at tarsometatarsal joint
level with radical debridement of soft tissues.
On the left a significant rectus flap was left and it
appeared the patient's foot on that side could be closed
primarily for longer on a vacuum-assisted closure dressing.
On the right it appeared that the patient would need a free
flap with possible split thickness skin graft. Following
that, the patient's surgical sites were dressed with
vacuum-assisted closure dressings, and the patient thereafter
transferred out to the floor with an epidural for pain
control. The patient was returned to the Operating Room on
[**2149-2-23**] for vacuum-assisted closure dressing change.
At the time of the vacuum-assisted closure dressing change
the patient's wound bed looked excellent with good viable
tissue at both amputation stumps. Minimal debridement was
required. On [**2149-2-27**], the patient was taken to
surgery for definitive closure of her wounds.
Procedure performed on [**2149-2-27**] included -
1. Free rectus abdominis muscle flap to the amputation stump
of the right foot.
2. Local flap coverage of the left foot amputation stump.
3. Split thickness skin graft to the vascularized muscle on
the right foot.
4. Debridement of the soft tissue of both feet.
Following the procedure, the patient was transferred to the
Intensive Care Unit for further close monitoring of her free
flap. The patient had an uneventful stay in the Intensive
Care Unit. Her arterial doppler signal to the right foot,
free flap remained stable throughout. Appropriate
adjustments to her pain medication were made as needed. The
patient's hematocrit which had been noted to be 38.2 on
admission decreased to a low of 19.3 on [**2149-3-2**].
The patient was started on Epoetin, the patient was
transferred from the Intensive Care Unit to the regular
surgical floor on postoperative day #6. The patient had been
placed on Dextran for anticoagulation following the surgery.
Dextran was discontinued on [**2149-3-4**]. The surgical
dressings for the patient's feet were taken down on
postoperative day #7 and the patient's flap and split
thickness skin graft was found to have thickened well and was
viable over greater than 95% of the area. The patient was
seen by physical therapy following transfer to the floor and
training initiated on bed to wheelchair transfers. The
patient continued to have activity restrictions and the feet
needed to be elevated at all times. It was expected that
dangling would start approximately two weeks following the
procedure. By postoperative day #12 which was [**2149-3-11**], the patient appeared stable and ready for discharge to
a rehabilitation facility. The dressing changes of the feet
had been changed to simply dry gauze dressing on the right
foot with no dressing needed on the left foot. The patient's
rectus flap harvest site was healing well. The patient's
right thigh split thickness skin graft donor site was also
stable and healing well with Xeroform dressing was applied.
The patient continued to be seen by physical therapy. The
patient remained on gentamicin and Ancef, but it was expected
that both of these antibiotics would be discontinued prior to
the patient's discharge. The patient was to begin dangling
on postoperative day #13. It is expected that the patient
will initially start by dangling her feet for a minute and a
half every hour during the day while awake and gradually
increasing by three to five minutes a day. Further
instructions on the dangling protocol will be relayed to the
patient and to her rehabilitation facility. It was expected
that the patient's Epoetin therapy will be discontinued prior
to discharge.
DISCHARGE CONDITION: Stable.
DISCHARGE MEDICATIONS:
1. Colace 100 mg p.o. b.i.d.
2. Heparin 5000 units subcutaneously b.i.d.
3. Ranitidine 150 mg p.o. b.i.d.
4. Milk of magnesia prn
5. Ambien 5 mg p.o. q.h.s. prn
6. Elanzepine 5 mg p.o. q.d.
7. Fentanyl patch 25 mcg per hour q. 3 days
8. Gabapentin 300 mg p.o. t.i.d.
9. Dilaudid 28 mg p.o. q. 4 hours prn
10. Aspirin 325 mg p.o. q.d.
11. Ferrous Sulfate 325 mg p.o. q.d.
12. Ascorbic acid 500 mg p.o. b.i.d.
13. Multivitamin tablets
14. Miconazole cream to perineum prn
FOLLOW UP: The patient is to contact Dr.[**Name2 (NI) 23346**] office for
follow up appointment one to two weeks following discharge.
MISCELLANEOUS: Regarding management of the patient's
surgical sites - The patient's abdominal incision is to be
left open to air and is expected to heal without
complications. The patient's right side donor site is to
remain exposed to air with the Xeroform in place. The
patient's left foot transmetatarsal amputation site is to
remain open to air and dressed only for protection and
comfort. The sutures along her surgical incision will be
discontinued at an appropriate time by Dr. [**Last Name (STitle) 5385**]. The
patient's right foot transmetatarsal site is to be dressed
with a dry gauze dressing once or twice a day as needed.
Sutures and the small cotton plugs, ringing the patient's
surgical incision on the right should be left untouched.
Instructions on the patient's dangling protocol will be
relayed to care providers.
DISCHARGE DIAGNOSIS:
1. Bilateral foot gangrene
2. Anemia
3. Yeast infection of skin
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 7738**]
Dictated By:[**Name8 (MD) 997**]
MEDQUIST36
D: [**2149-3-11**] 18:45
T: [**2149-3-11**] 18:52
JOB#: [**Job Number 46392**]
ICD9 Codes: 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3617
} | Medical Text: Unit No: [**Numeric Identifier 70162**]
Admission Date: [**2150-10-29**]
Discharge Date: [**2150-10-29**]
Date of Birth: [**2150-10-29**]
Sex: M
Service: NB
HISTORY: Baby boy [**Known lastname **] is a 39 week gestation male infant
admitted to the newborn intensive care unit for evaluation of
dusky episodes with associated apnea.
OBSTETRICIAN: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD.
PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) **], MAMC.
PREGNANCY: The mother is a 26-year-old gravida 2, para 0, 2,
1 woman. Her prenatal screen included blood type B positive,
antibody negative, hepatitis B surface antigen negative, RPR
nonreactive, rubella immune, group B strep negative. The
pregnancy was complicated by maternal asthma and finding of
oligohydramnios with an amniotic fluid index of only 6.
DELIVERY: Labor was induced with Cytotec and Pitocin and she had
epidural anesthesia. Second stage of labor was 1 hour and 50
minutes. Delivery was uncomplicated with Apgars of 9 and 9.
The baby was admitted to the newborn nursery where he was noted
to have his first episode of duskiness and apnea at 3 1/2 hours
of age. This was associated with a bottle feeding attempt and was
treated with bulb suctioning and blow by oxygen. He had two more
episodes. The first episode was at 7:40 p.m. and the second
episode was at 8:30 p.m., the third episode at 9:30 p.m.
All responded quicklly to blow by oxygen. Also of note on
admission to the newborn nursery, the baby was noted to have
acrocyanosis and a low resting respiratory rate of approximately
20. He also had some mild grunting on admission but this
resolved quickly. On transfer to the newborn intensive care unit,
he was noted to have a spontaneous episode of apnea with
associated desaturation to the low 80s in room air. He was
again treated with blow by oxygen.
FAMILY HISTORY: Unremarkable with no family history of seizure
disorders or cardiac disease.
PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 98.2, heart
rate 134, respiratory rate 36, blood pressure 65/38 with a
mean of 47, oxygen saturation 96% in room air.
GENERAL APPEARANCE: The baby appeared AGA, ruddy pink,
breathing comfortably in room air.
Weight 3145 grams, length 49.5 cm, head circumference 34 cm.
The baby was noted to have some periodic breathing during the
course of my examination.
HEENT: The anterior fontanel was found to be soft and flat.
There was prominent molding a caput in the occipitoparietal
region. Examination of the eyes revealed the pupils to be
equal and reactive to light with normal red reflexes.
EARS: Normal in appearance. Nasopharynx: Nares appear patent
and we were able to pass suction catheter down both sides.
His palate was noted to be intact.
RESPIRATORY: Breath sounds were clear and equal with no
retractions noted.
CARDIOVASCULAR SYSTEM: S1 and S2 were of normal intensity. No
S3 and no S4. He had a [**12-19**] low pitched systolic murmur heard
best at the left lower sternal border. Femoral pulses are
normal and his perfusion is good.
ABDOMINAL: Unremarkable with soft abdomen and no
organomegaly.
GENITOURINARY: The baby has normal male genitalia with testes
descended bilaterally.
NEUROLOGIC: The baby's tone was noted to be symmetrical and
within normal limits. No abnormal movements were observed.
Head control was within normal limits.
HIPS: Hips are noted to be stable.
Chest x-ray was unremarkable with small nonretained fetal
lung fluid noted interstitially and normal cardiothymic
silhouette. His Dextrostix was noted to be at 73.
ASSESSMENT: This is a term male infant with multiple episodes of
apnea and associated duskiness. The etiology of these
episodes is unclear at this time. Evaluation for sepsis has
been performed with CBC, differential and blood culture and
antibiotics were initiated. The apneic episodes could
potentially be of neurologic origin. If they persist,
evaluation with neuro imaging including CT scan or MRI is
recommended as well as EEG.
CONDITION ON DISCHARGE: Fair/ stable.
DISCHARGE DISPOSITION: The baby is being transferred to
[**Hospital3 **] newborn intensive care unit because of
the high NICU census at [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **]
[**Last Name (Titles) **] and lack of bed space.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) **].
DISCHARGE DIAGNOSES:
1. Dusky/ cyanotic episodes with apnea.
2. Rule out sepsis.
3. Rule out neurologic etiology of apnea including seizure.
4. Rule out intracranial hemorrhage.
5. Cardiac murmur.
The baby is being transferred to 7 North newborn intensive
care unit attending physician. [**Name10 (NameIs) **] was reviewed with Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 174**], neonatology fellow.
Of note newborn hearing screening has not yet been performed.
State screening has been sent, but should be repeated
after feedings have been established.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**MD Number(1) 37238**]
Dictated By:[**Last Name (NamePattern4) 55751**]
MEDQUIST36
D: [**2150-10-29**] 23:14:01
T: [**2150-10-30**] 00:17:55
Job#: [**Job Number 70163**]
ICD9 Codes: V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3618
} | Medical Text: Admission Date: [**2200-7-10**] Discharge Date: [**2200-7-22**]
Date of Birth: [**2140-1-12**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
s/p fall down stairs
Major Surgical or Invasive Procedure:
None
History of Present Illness:
60 yo male s/p fall down stairs. Taken to an area hospital where
found to have right subdural and subarachnoid hemorrhages. He
was then transfered ti [**Hospital1 18**] for continued trauma care.
Past Medical History:
Hypertension
Anxiety
Depression
Irritable Bowel Syndrome
Sciatica
Chronic Back pain
"Breathing problems"
Social History:
Married, lives with wife and 2 small children
Family History:
Noncontributory
Pertinent Results:
[**2200-7-10**] 08:00PM GLUCOSE-113* LACTATE-0.7
[**2200-7-10**] 07:45PM GLUCOSE-111* UREA N-24* CREAT-1.3* SODIUM-135
POTASSIUM-3.8 CHLORIDE-100 TOTAL CO2-25 ANION GAP-14
[**2200-7-10**] 07:45PM CALCIUM-7.7* PHOSPHATE-1.7* MAGNESIUM-2.8*
[**2200-7-10**] 07:45PM WBC-12.2* RBC-3.78* HGB-11.0* HCT-30.7*
MCV-81* MCH-29.0 MCHC-35.7* RDW-13.7
[**2200-7-10**] 07:45PM PLT COUNT-279
[**2200-7-10**] 07:45PM PT-14.0* PTT-29.7 INR(PT)-1.2*
MR HEAD W/O CONTRAST [**2200-7-12**] 1:00 AM
MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST
Reason: 60 M s/p fall-4 days ago, not waking up appropriately-
neuro
[**Hospital 93**] MEDICAL CONDITION:
60 year old man with
REASON FOR THIS EXAMINATION:
60 M s/p fall-4 days ago, not waking up appropriately-
neurosurgery would like to evaluate for diffuse axonal injury
CONTRAINDICATIONS for IV CONTRAST: None.
EXAM: MRI brain.
CLINICAL INFORMATION: Patient with status post fall four days
ago, not waking up appropriately, neurosurgery would like
further evaluation to exclude diffuse axonal injury.
TECHNIQUE: T1 sagittal and FLAIR T2 susceptibility and diffusion
axial images of the brain were obtained. Three time-of-flight
MRA of the circle of [**Location (un) 431**] was acquired. Correlation was made
with CT of [**2200-7-10**].
FINDINGS: There are several areas of T2 hyperintensity with
associated low signal on susceptibility images seen in both
frontal region at the [**Doctor Last Name 352**]-white matter junction. Additional
area of signal abnormality and blood products is seen in the
inferior right frontal lobe. Subtle increased signal in the
sylvian fissures indicate associated subarachnoid hemorrhage.
There is widening of the subdural space in both frontal region
measuring approximately 1 cm with CSF intensities indicative of
bilateral subdural effusions. There is no evidence of acute
infarct seen. No midline shift or hydrocephalus identified.
Evaluation of the brainstem demonstrate no focal abnormalities
or blood products to indicate brain stem injury. The corpus
callosum also demonstrate no focal abnormalities.
Extensive soft tissue changes are seen in the paranasal sinuses,
which could be related to intubation.
Multiple small white matter hyperintensities seen indicative of
small vessel disease.
There is a tiny left parietal subdural collections seen
measuring 2-3 mm. No associated mass effect seen.
IMPRESSION: 1. Bilateral frontal lobe [**Doctor Last Name 352**]-white matter junction
abnormalities with blood products are suggestive of diffuse
axonal injury. 2. Inferior right frontal lobe abnormality could
be due to hemorrhagic contusion. 3. Bilateral frontal subdural
effusions and probable subarachnoid hemorrhage in the right
sylvian fissure. 4. No evidence of brain stem injury. No
evidence of acute infarct.
MRA OF THE HEAD:
The head MRA demonstrates normal flow signal within the arteries
of anterior and posterior circulation.
CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST [**2200-7-11**] 10:36 AM
CT SINUS/MANDIBLE/MAXILLOFACIA
Reason: S/P FALL, EVAL FOR FRACTURES
[**Hospital 93**] MEDICAL CONDITION:
60 year old man s/p fall w/ multiple facial fractures.
REASON FOR THIS EXAMINATION:
fractures?
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Multiple facial fractures.
COMPARISON: CT head from [**2200-7-10**].
TECHNIQUE: Non-contrast axial CT imaging of the facial bones
with multiplanar reformats was reviewed.
FINDINGS: There are multiple displaced fractures including
fractures of the anterior, medial, and lateral wall of the left
maxillary sinus. There is also a fracture of the left lateral
anterior inferior orbital rim that extends posteriorly into the
left orbital floor. There is no evidence for displacement of
this fracture, and there is an no herniation of orbital fat.
There is also a fracture of the right posterior maxillary sinus
and nondisplaced fracture of the right zygoma. A small minimally
displaced left nasal bone fracture is also present. The globes
appear normal and there is no evidence for intra or extraconal
abnormalities. There is near total opacification of the left
maxillary sinus and both ethmoid sinuses from a combination of
blood and mucous. Lobulated mucosal thickening in addition to
fluid is present within the right maxillary sinus as well. The
lamina propecia appear intact, there is mild mucosal thickening
of the frontal sinuses. The patient is intubated, and an NG tube
is present.
IMPRESSION: Multiple facial fractures including both maxillary
sinuses and right zygoma, and left nasal bone, as well is a
nondisplaced fracture from the lateral inferior orbital rim
extending posteriorly into the left orbital floor without
evidence for fat herniation or orbital abnormality.
CHEST (PORTABLE AP) [**2200-7-16**] 9:55 AM
CHEST (PORTABLE AP)
Reason: STAT X RAY RESP DISTRESS
[**Hospital 93**] MEDICAL CONDITION:
60 year old man s/p fall, wbc elevation, s/p intubation
REASON FOR THIS EXAMINATION:
STAT X RAY RESP DISTRESS
CHEST ONE VIEW PORTABLE
INDICATION: 60-year-old man status post fall.
COMMENTS: Portable erect AP radiograph of the chest is reviewed,
and compared with the previous study of yesterday.
The previously identified mild congestive heart failure has been
improving. There is also gradual improvement of the multifocal
pneumonia, possibly due to aspiration. The heart is normal in
size. There is continued tortuosity of the thoracic aorta. No
evidence for pneumothorax is identified.
Brief Hospital Course:
Patient admitted to the trauma service. Neurosurgery was
consulted because of his head bleed. Serial head CT scans were
followed and were stable; an MRI of the brain also revealed
Diffuse Axonal Injury ([**Doctor First Name **]). He was started on Dilantin which
will need to continue until follow up with Neurosurgery. His
Dilantin dose has been adjusted several times because of
subtherapeutic levels; these levels will need to rechecked in
the next several days. Plastics was consulted as well because of
his facial fractures; these were non operative.
Behavioral Neurology was consulted because of the behavioral
issues associated with his head injury; he was started on
Olanzapine standing dose; a prn dose was added for episodes of
increased agitation. Trazodone was also added to help regulate
his sleep/wake cycle. He initially required 1:1 sitters because
of his increased agitation; these have been discontinued. His
mental status has improved, although there are still problems
with decreased short term memory; there have been no further
episodes of agitation.
He had episodes of loose stool during his hospital stay; a stool
for C-Diff was obtained and was negative. His WBC was also
elevated; thought to be related to a small aspiration pneumonia
noted on chest radiograph. His white count has trended downward
over the past several days.
Speech and Swallow were consulted to evaluate for dysphagia
given his head injury and altered mental status; initially he
did not pass the bedside evaluation. As his mental status
improved his diet was upgraded to regular with thin liquids.
Physical and Occupational therapy were consulted and have
recommended rehab for improving function and cognitive
abilities.
Medications on Admission:
Neurontin
Nortriptyline
Albuterol MDI
Lisinopril
Lorazepam
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
4. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for SOB/wheeze.
5. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): hold for HR <55 and/or SBP <110.
7. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q 5PM (): Notify MD for increased sedation.
8. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
9. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Packet Sig: One
(1) Packet PO BID (2 times a day).
10. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Phenytoin Sodium Extended 100 mg Capsule Sig: Three (3)
Capsule PO TID (3 times a day) for 4 weeks.
12. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
s/p Fall
Right Subdural and subarachnoid hemorrhages
Multiple facial fractures
Discharge Condition:
Good
Discharge Instructions:
Follow up with Neurosurgery in 4 weeks.
Continue with the Dilantin until follow up with Neurosurgery.
Follow up with Behavioral Neurology in [**2-28**] weeks.
Followup Instructions:
Call [**Telephone/Fax (1) 9986**] for an appointment with Neurosurgery to be
seen in 4 weeks. Inform the office that you will need a repeat
head CT for this appointment.
Call [**Telephone/Fax (1) 1690**] for an appointment with Behavioral Neurology
to be seen in 2 weeks. You may also choose to contact Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] at the number he provided to you to schedule an appointment.
Completed by:[**2200-7-21**]
ICD9 Codes: 5185, 5070, 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3619
} | Medical Text: Admission Date: [**2187-7-30**] Discharge Date: [**2187-8-2**]
Date of Birth: [**2148-4-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
nausea, vomiting, abd pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 39 yo M with DM1 c/b ESRD and severe gastroparesis,
HTN, CAD s/p STEMI, and multiple line infections who presents
with nausea, vomiting, abdominal pain, and hypertensive urgency.
He was discharged from [**Hospital1 18**] on [**7-26**] for HTN urgency which
resolved after labetalol gtt and restarting his home BP meds. He
was feeling well until this am when he awoke and had abdominal
pain similar to his usual abdominal pain that subsequently
progressed to nausea and multiple episodes of non-bloody emesis.
He was unable to tolerate any of his medications and presented
to the ED.
Past Medical History:
1. Diabetes Mellitus Type I
- Gastroparesis with chronic hospitalizations
- ESRD on HD since [**2-/2184**]
- Autonomic dysfunction, frequent HTN emergency & orthostatic
hypotension
- Peripheral neuropathy
2. Coronary artery disease
- STEMI [**2186-12-17**] in setting of cocaine, s/p BMS to LAD
3. Aortic valve endocarditis ([**4-21**])
- In the context of coag neg staph bacteremia ([**Month (only) 404**] and
[**2187-3-16**]) and positive intravenous catheter tip [**2187-4-6**] had
his HD catheter changed over a wire. known MRSE bacteremia for
which he completed a course of vancomycin for possible
endocarditis on [**5-18**]
4. Hypertension
5. History of line sepsis with coag negative staph and
priors with klebsiella and enterobacteremia
6. Esophageal ulceration: H pylori neg, active esophagitis seen
on EGD [**2187-4-18**], h/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-[**Doctor Last Name **] tear
7. History of substance abuse (cocaine, marijuana, alcohol)
9. History of thrombosed AV fistula in LUE [**4-20**], [**Doctor Last Name **]-tex in
place
10. Fungemia completed caspofungin IV on [**2187-7-12**]
11. GI bleed associated with hypotension-colonscopu showed
friable and inflammed ascending and transverse colon,suggestive
either of ischemia or infection [**2187-7-19**]
Social History:
Patient has a prior history of tobacco and marijauna use, but he
does not currently smoke. He has a prior history of alcohol
abuse and has been sober for 9 years. He has a past history of
cocaine use. He currently denies illicit drugs. Currently lives
with his mother and brothers.
Family History:
Father deceased of ESRD and DM. Mother aged 50's with
hypertension. Two sisters, one with diabetes. Six brothers, one
with diabetes. There is no family history of premature coronary
artery disease or sudden death.
Physical Exam:
VS: Temp 97.3 BP 100/62 HR 86 RR 20 O2 sat 98% RA
GEN: NAD
HEENT: AT, NC, PERRLA, EOMI, no conjuctival injection,
anicteric, OP clear, slightly dry MM
Neck: supple, no LAD, no carotid bruits, JVP approximately 10 cm
above sternal notch
Chest: tunneled HD line over RSV, covered with bandage, NT to
palpation
CV: RRR, nl s1, s2, systolic murmur at RUSB
PULM: CTA b/l
ABD: soft, diffusely slightly tender to palpation but more so
over RLQ, + BS, no HSM
EXT: warm, dry, +1 distal pulses BL, no femoral bruits, R
femoral TLC in place
NEURO: alert & oriented x3
Pertinent Results:
ADMISSION LABS
[**2187-7-30**] 02:10PM BLOOD WBC-14.1*# RBC-3.95* Hgb-9.9* Hct-34.4*
MCV-87 MCH-25.0* MCHC-28.7* RDW-19.2* Plt Ct-285
[**2187-7-30**] 02:10PM BLOOD Neuts-84.2* Lymphs-10.1* Monos-2.1
Eos-3.1 Baso-0.5
[**2187-7-30**] 02:10PM BLOOD PT-11.6 PTT-27.2 INR(PT)-1.0
[**2187-7-30**] 02:10PM BLOOD Glucose-292* UreaN-70* Creat-10.8*#
Na-143 K-5.4* Cl-100 HCO3-27 AnGap-21*
[**2187-7-30**] 06:46PM BLOOD Calcium-9.7 Phos-5.8*# Mg-2.1
[**2187-7-30**] 02:10PM BLOOD CK(CPK)-139
[**2187-7-31**] 03:47AM BLOOD CK(CPK)-78
[**2187-7-30**] 02:10PM BLOOD cTropnT-0.28*
[**2187-7-30**] 02:10PM BLOOD CK-MB-7
[**2187-7-31**] 03:47AM BLOOD CK-MB-NotDone cTropnT-0.32*
DISCHARGE LABS
[**2187-8-1**] 11:37AM BLOOD WBC-7.0 RBC-4.09* Hgb-10.4* Hct-35.0*
MCV-85 MCH-25.4* MCHC-29.8* RDW-19.6* Plt Ct-213
[**2187-8-1**] 11:37AM BLOOD Plt Ct-213
[**2187-8-1**] 11:37AM BLOOD Glucose-202* UreaN-52* Creat-9.0*# Na-135
K-5.1 Cl-93* HCO3-28 AnGap-19
[**2187-7-31**] 03:47AM BLOOD Calcium-9.6 Phos-7.8*# Mg-2.1
IMAGING
CXR-Interval improvement in pulmonary vascular congestion.
Brief Hospital Course:
39 year old man with hx of DM1 c/b gastroparesis, autonomic
instability, ESRD on HD, CAD s/p MI presenting with hypertensive
urgency in the setting of nausea, vomiting, and abdominal pain.
.
# HTN urgency - Presents with pt's usual pattern of abdominal
pain, nausea, and vomiting which leads to hypertensive urgency.
Autonomic dysfunction also contributing. He had no focal
neurologic complaints or deficits on exam. BP better controlled
with labetolol gtt, now back on PO antihypertensives. He was
continued on his home dose labetolol PO and clonidine patch.
.
# Gastroparesis - His vomiting ceased and his nausea resolved.
He was able to tolerate a po diet, had minimal abd pain. He was
on standing metoclopramide PO, antiemetics prn and hydromorphone
prn.
.
# Leukocytosis -He had no bands on differential, afebrile since
presentation, denied fevers, chills, or any other localizing
symptoms other than abd pain, n/v on ROS. He is s/p treatment 2
weeks ago with vancomycin and caspofungin for coag negative
staph bacteremia and fungemia (sp. Trichosporon). Had HD line
resited and currently appears clean. Blood cultues had no growth
to date and his WBC decreased.
.
# DM1 with complications -
He was continued on his home dose lantus with insulin sliding
scale as well as his home regimen of gastroparesis meds: reglan,
dilaudid, ativan
.
# CAD s/p MI - With continued ST elevations on EKG, elevations
in V4-5 slightly more prominent than prior. No clinical symptoms
of active ischemia. Troponin elevated to 0.28 on presentation;
however, at baseline. CK flat, no chest pain or shortness of
breath. He was continued on [**Month/Day/Year **], [**Month/Day/Year 4532**], statin. He was not on
ACE-I given recent admission for transverse and ascending
colitis thought to be [**3-17**] ischemia.
.
# ESRD on HD: Renal aware of pt's admission, no needs for urgent
[**Month/Day (2) 2286**] on admission he had HD as scheduled.
.
#ACCESS: HD line, R femoral TLC, no peripheral IV access
#PPx - hep sq, ppi, bowel regimen prn given narcotics
#CODE: full, confirmed with pt
Medications on Admission:
Aspirin 325 mg daily
Clopidogrel 75 mg daily
Gabapentin 300 mg qTues, Thurs, Sat
Gabapentin 200 mg qSun, Mon, Wed, Fri
Lanthanum 1000 mg tid with meals
Pantoprazole 40 mg q12h
Labetalol 200 mg po tid
Simvastatin 80 mg daily
Metoclopramide 10 mg qidachs
Dilaudid 4 mg q4h prn
Lorazepam 1 mg q6h prn
Clonidine 0.3 mg/24 hr Patch qWed
Lantus 6 units SQ qhs
Nephrocaps 1 cap daily
HISS
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO QTUTHSA
(TU,TH,SA).
4. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO 4X/WEEK
([**Doctor First Name **],MO,WE,FR).
5. Lanthanum 500 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
7. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QWED (every Wednesday).
9. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
10. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
11. Lorazepam 1 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
12. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS
(4 times a day (before meals and at bedtime)).
13. Labetalol 200 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
14. Insulin Glargine 100 unit/mL Solution Sig: Six (6) units
Subcutaneous at bedtime.
15. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: as per
sliding scale units Subcutaneous qachs.
Discharge Disposition:
Home
Discharge Diagnosis:
hypertensive urgency
Diabetes Mellitus Type I
- Gastroparesis with chronic hospitalizations
- ESRD on HD since [**2-/2184**]
- Autonomic dysfunction, frequent HTN emergency & orthostatic
hypotension
- Peripheral neuropathy
-Coronary artery disease
- STEMI [**2186-12-17**] in setting of cocaine, s/p BMS to LAD
-Aortic valve endocarditis ([**4-21**])
- In the context of coag neg staph bacteremia ([**Month (only) 404**] and
[**2187-3-16**]) and positive intravenous catheter tip [**2187-4-6**] had
his HD catheter changed over a wire. known MRSE bacteremia for
which he completed a course of vancomycin for possible
endocarditis on [**5-18**]
-History of line sepsis with coag negative staph and
priors with klebsiella and enterobacteremia
-Esophageal ulceration: H pylori neg, active esophagitis seen
on EGD [**2187-4-18**], h/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-[**Doctor Last Name **] tear
-History of substance abuse (cocaine, marijuana, alcohol)
-History of thrombosed AV fistula in LUE [**4-20**], [**Doctor Last Name **]-tex in
place
-Fungemia completed caspofungin IV on [**2187-7-12**]
-GI bleed associated with hypotension-colonscopu showed friable
and inflammed ascending and transverse colon,suggestive either
of ischemia or infection [**2187-7-19**]
Discharge Condition:
stable, afebrile, good po intake
Discharge Instructions:
You were admitted with abdominal pain, nausea, vomiting. Your
symptoms improved with blood pressure control. You were briefly
treated in the MICU (intensive care unit) then your care was
transferred to a medical floor. You continued to do well and
were able to tolerate food.
Please take your medications as prescribed. It is extremely
important that you take your medications to control your blood
pressure.
Please follow up as outlined below.
If you have any headaches, dizzyness, nausea, vomiting,
abdominal pain, chest pain, shortness of breath, bleeding from
the rectum or any other concerning symptoms please call your
doctor or go the emergency room
Followup Instructions:
please call your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 92872**] at [**Telephone/Fax (1) 1247**] for a follow
up appointment within two weeks
continue on your regularly scheduled hemodialysis appointments
Completed by:[**2187-8-3**]
ICD9 Codes: 5856, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3620
} | Medical Text: Admission Date: [**2166-7-11**] Discharge Date: [**2166-7-16**]
Date of Birth: [**2104-8-9**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Aspirin / Phenergan
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Aymptomatic
Major Surgical or Invasive Procedure:
[**2166-7-11**] - CABGx1 (left internal mammary artery to left anterior
descending artery)/Resection of atrial myxoma.
History of Present Illness:
The patient is a 61-year-old woman who presented with multiple
medical problems including abdominal abscesses. Due to fever an
echocardiogram was done and an
incidental finding of left atrial myxoma was found. Due the
patient's poor nutritional status, resection of the left atrial
myxoma was deferred until her albumin was greater than 3. The
patient was seen in the office last week and her
albumin was 3.2. Therefore, it was felt that she could safely
proceed with left atrial myxoma resection. Diagnostic cardiac
catheterization showed that there was a 50% lesion in the
proximal LAD. The patient was therefore thought to be a good
candidate for simultaneous coronary bypass grafting with the
mammary to the LAD.
Past Medical History:
1. Rheumatoid arthritis
2. GERD
3. HTN
4. Hypothyroidism
5. Hypercholesterolism
6. Bilateral TKR
7. Left ankle replacement [**2166-4-9**]
8. s/p right ankle fusion
Social History:
Lives in [**Location 2199**] with her husband. [**Name (NI) **] tobacco or EtOH.
Family History:
NC
Physical Exam:
97.8 18 120/68
Gen: well-appearing, NAD
HEENT: PERRL, EOMI, dry mucous membranes, OP clear
Lung: CTA bilaterally
Cor: RRR, nml S1S2
Abd: NABS, soft NTND
Ext: no edema, 2+ pulses
Pertinent Results:
[**2166-7-11**] ECHO
Prebypass
1. No atrial septal defect is seen by 2D or color Doppler. The
is a 2cm left atrial myxoma attached to the interatrial septum
by a 1cm stalk.
2. There is mild symmetric left ventricular hypertrophy.
3. Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%).
4.Right ventricular chamber size and free wall motion are
normal.
5.There are simple atheroma in the descending thoracic aorta.
6.The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen.
7. The mitral valve leaflets are mildly thickened. Trivial
mitral
regurgitation is seen.
8.There is a small pericardial effusion.
Post bypass
1. Patient is AV paced and receiving an infusion of
phenylephrine.
2. Biventricular systolic function is unchanged.
3. Interatrial septum is intact.
4. Aorta intact post decannulation.
Brief Hospital Course:
Mrs. [**Known lastname 41684**] was admitted to the [**Hospital1 18**] on [**2166-7-11**] for surgical
management of her atrial myxoma and coronary artery disease. She
was taken directly to the operating room where she underwent
coronary artery bypass grafting to one vessel and resection of
her atrial myxoma. Please see operative note for details.
Postoperatively she was taken to the cardiac surgical intensive
care unit for monitoring. Later on [**2166-7-11**], Mrs. [**Known lastname 41684**] awoke
neurologically intact and was extubated. On postoperative day
one, aspirin, beta blockade and a statin were resumed. Plavix
was started for her small, poor quality mammary and left
anterior descending artery. On postoperative day two, she was
transferred to the step down unit for further recovery. She was
gently diuresed towards her preoperative weight. The physical
therapy service was consulted for assistance with her strength
and mobility. Mrs. [**Known lastname 41684**] continued to make steady progress and
was discharged home on [**2166-7-16**]. She will take lasix 40mg daily
for 1 week with potassium 20mEq to complete her diuresis. She
has also been instructed to wear a surgical bra for 1 month.
Mrs. [**Known lastname 41684**] will follow-up with Dr. [**Last Name (STitle) 914**], her cardiologist and
her primary care physician as an outpatient.
Medications on Admission:
Atenolol 25mg QD
Protonix 40mg QD
Prednisone 10mg QD
Potassium
Syhthroid 75mcg QD
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*1*
5. 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*
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Prednisone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
8. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 1 months.
Disp:*60 Tablet(s)* Refills:*0*
10. Zinc Sulfate 220 (50) mg Capsule Sig: One (1) Capsule PO
DAILY (Daily) for 1 months.
Disp:*30 Capsule(s)* Refills:*0*
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7
days.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
13. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 1 months.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA of [**Location (un) 270**]-East & Visiting Nurse Hospice
Discharge Diagnosis:
Atrial Myxoma
CAD
GERD
Rheumatoid arthritis
HTN
Hypothyroid
Discharge Condition:
Stable
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Please shower daily.
No bathing or swimming for 1 month. Use sunscreen on incision if
exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month.
7) Take lasix for 1 week with potassium and then stop. Weigh
yourself daily.
8) Take zinc, vitamin C and iron for 1 month and then stop.
9) Take plavix indefinitely until otherwise instructed by Dr.
[**Last Name (STitle) **].
10) Wear surgical bra at all times for 1 month.
11) Call with any questions or concerns.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 914**] in 1 month. ([**Telephone/Fax (1) 1504**]
Please follow-up with Dr. [**Last Name (STitle) **] in [**12-17**] weeks. [**Telephone/Fax (1) 5003**]
Please follow-up with pcp [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in [**1-18**] weeks. [**Telephone/Fax (1) 39260**]
[**Hospital Ward Name 121**] 2 wound clinic in 2 weeks.
Please call all providers for appointments.
Completed by:[**2166-7-16**]
ICD9 Codes: 4019, 2449, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3621
} | Medical Text: Admission Date: [**2194-4-25**] Discharge Date: [**2194-5-7**]
Date of Birth: [**2122-7-16**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
Slurred speech
Major Surgical or Invasive Procedure:
[**2194-4-29**] 1. Ultrasound-guided left common femoral access for
sheath
placement.
2. Right lower extremity angiogram.
3. Angioplasty of tibioperoneal trunk and posterior tibial
artery, right leg.
4. Right superficial femoral artery stent, [**6-/2163**] Zilver
postdilated with 680 Submarine.
5. Right transmetatarsal amputation.
History of Present Illness:
71M with a history of venous stasis ulcers and bilateral lower
extremity ischemia had a recent right lower angio w/ AT stent
[**2194-4-11**]. On the same admission the patient had a Right 4th toe
open ray amputation [**4-13**] complicated by sepsis that resolved
with a VAC dressing. The patient was discharged home on PO
augmentin for unspeciated mixed wound flora. The plan was for
the patient to return to the hospital for a repeat
angio/possible Right TMA. He then returned to [**Location **] from his rehab
facility on [**2194-4-25**] with slurred speech and a non-productive
cough. A CXR demonstrated volume overload associated
with decreased oxygen sats.
Past Medical History:
PAD
CHF Ef 50%([**2193**])
ESRD, dialysis dependent T/Th/Sat schedule
COPD
atrial fibrillation
s/p pacemaker for bradycardia
s/p AV fistula left wrist (clotted off)
s/p AV fistula ([**2194-1-26**]) in LUE
Social History:
From [**Location (un) 686**], lives in [**Location (un) **] with wife, 2 daughters.
Retired social worker (21 years). 60-80 pack year history quit
25 years ago. No alcohol or recreational drugs. We recently
discharged to Rehab on [**2194-4-23**].
Family History:
Non-contributory
Physical Exam:
VS: 98.2 HR: 70 BP: 90/42 RR: 14 SPo2: 95%
NAD, alert and oriented x 3
VC: RRR, no mrg
Resp: CTA bilaterally
Abd- soft, NT, ND
Wound: right TMA site CDI, dry dressing intact
Trace edema
Pulse exam: Fem DP PT
Left palp dop dop
Right palp dop dop
Pertinent Results:
[**2194-5-6**] 08:45AM BLOOD WBC-12.4* RBC-2.55* Hgb-8.4* Hct-27.6*
MCV-108* MCH-32.9* MCHC-30.4* RDW-17.1* Plt Ct-188
[**2194-5-3**] 01:50AM BLOOD WBC-10.5 RBC-2.45* Hgb-8.2* Hct-26.4*
MCV-108* MCH-33.5* MCHC-31.1 RDW-18.6* Plt Ct-208
[**2194-5-2**] 12:55AM BLOOD WBC-11.2* RBC-2.46* Hgb-8.2* Hct-25.6*
MCV-104* MCH-33.5* MCHC-32.2 RDW-18.7* Plt Ct-191
[**2194-5-1**] 02:52AM BLOOD WBC-11.9* RBC-2.62* Hgb-8.7* Hct-27.1*
MCV-104* MCH-33.3* MCHC-32.1 RDW-19.2* Plt Ct-180
[**2194-5-6**] 08:45AM BLOOD Plt Ct-188
[**2194-5-6**] 04:34AM BLOOD PT-22.5* PTT-37.7* INR(PT)-2.1*
[**2194-5-5**] 04:29AM BLOOD PT-19.7* PTT-34.8 INR(PT)-1.8*
[**2194-5-4**] 04:45AM BLOOD PT-18.8* INR(PT)-1.7*
[**2194-5-6**] 08:45AM BLOOD Glucose-114* UreaN-49* Creat-5.1* Na-135
K-4.3 Cl-98 HCO3-26 AnGap-15
[**2194-5-5**] 04:29AM BLOOD Glucose-123* UreaN-37* Creat-4.3* Na-134
K-4.2 Cl-98 HCO3-28 AnGap-12
[**2194-5-4**] 04:45AM BLOOD Glucose-145* UreaN-26* Creat-3.5* Na-136
K-4.2 Cl-99 HCO3-32 AnGap-9
[**2194-5-3**] 01:50AM BLOOD Glucose-80 UreaN-18 Creat-2.5* Na-136
K-4.2 Cl-102 HCO3-30 AnGap-8
[**2194-5-2**] 12:55AM BLOOD Glucose-83 UreaN-26* Creat-3.0* Na-135
K-4.4 Cl-100 HCO3-27 AnGap-12
[**2194-5-1**] 02:52AM BLOOD Glucose-89 UreaN-19 Creat-2.4* Na-134
K-4.0 Cl-99 HCO3-30 AnGap-9
[**2194-4-30**] 04:45PM BLOOD CK(CPK)-64
[**2194-4-30**] 07:57AM BLOOD CK(CPK)-32*
[**2194-4-30**] 12:56AM BLOOD CK(CPK)-20*
[**2194-4-27**] 02:49PM BLOOD CK(CPK)-30*
[**2194-4-27**] 09:01AM BLOOD ALT-15 AST-35 LD(LDH)-184 AlkPhos-97
Amylase-61 TotBili-0.6
[**2194-4-25**] 11:15AM BLOOD ALT-11 AST-36 AlkPhos-101 TotBili-0.4
[**2194-4-30**] 04:45PM BLOOD CK-MB-4 cTropnT-0.39*
[**2194-4-30**] 07:57AM BLOOD CK-MB-4 cTropnT-0.31*
[**2194-4-30**] 12:56AM BLOOD CK-MB-4 cTropnT-0.25*
[**2194-4-27**] 02:49PM BLOOD CK-MB-5 cTropnT-0.29*
[**2194-5-6**] 08:45AM BLOOD Calcium-7.7* Phos-5.3* Mg-2.2
[**2194-5-5**] 04:29AM BLOOD Calcium-7.9* Phos-4.6* Mg-2.1
[**2194-5-4**] 04:45AM BLOOD Calcium-8.4 Phos-4.3 Mg-2.1
[**2194-5-3**] 01:50AM BLOOD Calcium-8.2* Phos-3.1 Mg-2.0
[**2194-5-2**] 12:55AM BLOOD Calcium-8.6 Phos-4.0 Mg-2.1
[**2194-5-6**] 08:45AM BLOOD Vanco-16.3
[**2194-5-2**] 12:55AM BLOOD Vanco-13.7
[**2194-5-3**] 01:54AM BLOOD Type-ART pO2-129* pCO2-56* pH-7.34*
calTCO2-32* Base XS-3
[**2194-5-2**] 04:45PM BLOOD Type-ART pO2-104 pCO2-64* pH-7.31*
calTCO2-34* Base XS-2
[**2194-5-2**] 04:32AM BLOOD Type-ART Temp-37.7 pO2-133* pCO2-58*
pH-7.29* calTCO2-29 Base XS-0 Intubat-NOT INTUBA
[**2194-5-5**]
INDICATION: 71-year-old male with end-stage renal disease,
admitted [**2194-4-25**]
with mental status changes and dysarthria. Evaluate for evidence
of evolving
infarct.
COMPARISON: [**2194-4-25**] and [**2194-1-26**].
NON-CONTRAST HEAD CT:
There is little change compared to prior studies. There is no CT
evidence of
acute or evolving subacute territorial infarct. Periventricular
and
subcortical white matter hypodensities are again seen,
compatible with chronic
small vessel infarcts, most discrete in the in the right
thalamus and left
corona radiata/centrum semiovale. There is no acute intracranial
hemorrhage
or mass effect, including no shift of midline structures or
effacement of the
basal cisterns. Mild prominence of the ventricles and sulci
suggests global
volume loss. The bones remain unremarkable. There is a small
mucus retention
cyst in the imaged portion of the left maxillary sinus,
incompletely
visualized. There are extensive arterial calcifications.
IMPRESSION: No evidence of an acute intracranial process,
including no CT
evidence for an evolving acute or subacute infarct. Grossly
unchanged chronic
small vessel infarcts.
The study and the report were reviewed by the staff radiologist.
[**2194-4-26**]
[**2194-4-26**] 5:05 am SWAB Source: R 4th toe amp site.
**FINAL REPORT [**2194-5-2**]**
GRAM STAIN (Final [**2194-4-26**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
3+ (5-10 per 1000X FIELD): GRAM NEGATIVE DIPLOCOCCI.
SMEAR REVIEWED; RESULTS CONFIRMED.
WOUND CULTURE (Final [**2194-5-2**]):
Due to mixed bacterial types (>=3) an abbreviated workup
is
performed; P.aeruginosa, S.aureus and beta strep. are
reported if
present. Susceptibility will be performed on P.aeruginosa
and
S.aureus if sparse growth or greater..
ANAEROBIC CULTURE (Final [**2194-4-30**]): NO ANAEROBES ISOLATED.
Brief Hospital Course:
NEURO/PAIN: Upon admission, Neurology was initially consulted
regarding concern for sepsis and infectious encephalopathy. They
recommended a head CT on [**4-25**] which showed no evidence of acute
intracranial process. The patient was closely monitored with
stable neurologic exams. A repeat head CT was obtained for
follow-up, after transfer from the ICU, which was deemed stable
and without intracranial process. The patient was maintained on
IV pain medication in the immediate post-operative period and
transitioned to PO narcotic medication with adequate pain
control on POD#[**1-30**]. The patient remained neurologically intact
and without change from baseline during their stay. The patient
remained alert and oriented to person, location and place.
CARDIOVASCULAR: The patient remained hemodynamically stable
intra-op and in the immediate post-operative period. Their
vitals signs were closely monitored with telemetry. The
patient's home statin medication was continued. Patient had a
previous right 4th toe amputation on [**4-13**] and on this admission,
presented with concern for sepsis requiring ICU admission and
minimal pressor support transiently during dialysis sessions. On
[**2194-4-29**] he was taken for right lower extremity angiography and
eventually a TMA amputation.
The patient did well following their vascular procedures. The
patient was closely monitored with serial pulse exams in the
post-op period. If appropriate, doppler signaling was frequently
assessed in the involved extremity. Their post-op pulse exam
demonstrated dopplerable signals in his DP/PT bilaterally. The
patient's cardioprotective dose of Aspirin was continued
post-op. The patient was placed on a heparin gtt for
anticoagulation and was bridged to oral Coumadin without issues
upon transfer from the ICU -- with a regimen of Coumadin 1 mg PO
every other day, with close monitoring of his INR (goal [**1-30**]).
Their PTT was assessed every 6 hours until therapeutic levels
were achieved (PTT goal 60 - 80). The patient was continued on
Plavix 75 mg PO daily in the post-op period, for their Rigth AT
stent.
Of note, his pacemaker failed to fire with a significant pause
in the ICU on [**2194-4-26**], EP interrogated the pacer and it was
deemed stable.
RESPIRATORY: The patient was initially intubated and required
ICU admission, but was successfully extubated in the unit once
his initial volume overload was controlled with dialysis. Serial
CXRs were obtained to monitor his pulmonary fluid status. The
patient had no episodes of desaturation or pulmonary concerns
following extubation. He was transitioned to on/off biPAP
assistance (mainly in the evenings), until weaning to nasal
cannula, and fianlly weaned of oxygen. The patient denied cough
or respiratory symptoms. Pulse oximetry was monitored closely
and the patient maintained adequate oxygenation.
GASTROINTESTINAL: The patient was NPO following their procedure
and transitioned to sips and a clear liquid diet on POD#[**1-30**]
following his TMA. The patient experienced no nausea or
vomiting. The patient was transitioned to a
regular/cardiac/diabetic healthy diet on POD#3 and IV fluids
were discontinued once adequate PO intake was established.
GENITOURINARY: The patient's hemodialysis was continued on
admission to the ICU. His urine output was minimal. The
patient's intake and output was closely monitored. The patient's
creatinine was stable following dialysis and volume was removed
during his dialysis sessions.
HEME: The patient's post-op hematocrit was stable and trended
closely. The patient remained hemodynamically stable and did not
require transfusion. The patient's coagulation profile remained
closely monitored with adjustment of his Coumadin dosing, with
an INR of [**1-30**]. The patient had no evidence of bleeding from
their incision.
ID: The patient was admitted and maintained on Vancomycin,
Ciprofloxacin and Flagyl IV for his right toe infection.
Cultures were obtained which showed a mixed bacteria specimen,
and upon discharge PO Augmentin was continued for 2-weeks. Their
white count was monitored closely post-operatively and their
incision was closely monitored for any evidence of infection or
erythema.
ENDOCRINE: The patient's blood glucose was closely monitored in
the post-op period with Q6 hour glucose checks. Blood glucose
levels greater than 120 mg/dL were addressed with an insulin
sliding scale. His home Lantus/glargine was continued with close
blood glucose monitoring.
PROPHYLAXIS: The patient was maintained on heparin 5000 units SQ
TID for DVT/PE prophylaxis and encouraged to ambulate
immediately post-op once cleared by physical therapy. The
patient also had sequential compression boot devices in place
during immobilization to promote circulation. GI prophylaxis was
sustained with Protonix/Famotidine when necessary. The patient
was encouraged to utilize incentive spirometry, get out of bed
early and was discharged to rehab in stable condition.
Medications on Admission:
1. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [**12-29**]
Puffs Inhalation Q6H (every 6 hours).
2. sevelamer HCl 400 mg Tablet Sig: Eight (8) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
3. ascorbic acid 250 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO DAILY (Daily).
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
6. fenofibrate micronized 145 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO BID (2 times a day).
8. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Three (3)
Tablet PO DAILY (Daily).
9. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q24H
(every 24 hours).
14. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
15. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed
for constipation.
16. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for constipation.
17. white petrolatum-mineral oil Cream Sig: One (1) Appl
Topical QID (4 times a day) as needed for dry skin.
18. amoxicillin-pot clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily): give after HD on HD days. cont through
TMA operation.
19. warfarin 1 mg Tablet Sig: One (1) Tablet PO ONCE (Once):
check pt/inr frequently.
20. Lantus 100 unit/mL Solution Sig: Eight (8) units
Subcutaneous once a day: at breakfast.
21. insulin regular human 100 unit/mL Solution Sig: sliding
scale Injection four times a day: please see below
.
22. sliding scale
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Regular Regular Regular Regular
Glucose Insulin Dose
0-70mg/dL ----Proceed with hypoglycemia protocol----
71-150mg/dL 0Units 0Units 0Units 0Units
151-200mg/dL 2Units 2Units 2Units 2Units
201-250mg/dL 4Units 4Units 4Units 4Units
251-300mg/dL 6Units 6Units 6Units 6Units
301-350mg/dL 8Units 8Units 8Units 8Units
351-400mg/dL 10Units 10Units 10Units 10Units
Instructons for NPO Patients: Evening Prior to
Surgery/Procedure: If on glargine or detemir: give 80% of usual
dose; If on NPH: give 100% usual dose. Morning of
Surgery/Procedure: If on glargine or detemir: give 80% of usual
dose; If on NPH: give 50% of usual dose; If on premix insulin
(e.g. 70/30, 75/25): take total number of AM units ordered,
divide by 3, and give that many units as NPH; If on sliding
scale of short acting insulin: administer according to HS
schedule. Hold all oral antidiabetic medications, and consider
sliding scale coverage; If appropriate, give IVF with dextrose
to prevent hypoglycemia.
23. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
24. Outpatient Lab Work
please check PT/INR at least two - three times per week
Goal INR: 2.0-3.0
Dx: Afib
Discharge Medications:
1. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
2. heparin (porcine) 1,000 unit/mL Solution Sig: One (1)
Injection PRN (as needed) as needed for line flush.
3. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
4. warfarin 1 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day): please titrate for goal INR [**1-30**].
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
6. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
13. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q24H
(every 24 hours).
14. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. sevelamer HCl 400 mg Tablet Sig: Six (6) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
16. amoxicillin-pot clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q12H (every 12 hours): total of 2 weeks. Please give
after HD.
17. Insulin sliding scale
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Humalog
Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose
0-70 mg/dL Proceed with hypoglycemia protocol
71-109 mg/dL 0 Units 0 Units 0 Units 0 Units
110-140 mg/dL 2 Units 2 Units 2 Units 0 Units
141-180 mg/dL 4 Units 4 Units 4 Units 1 Units
181-210 mg/dL 6 Units 6 Units 6 Units 3 Units
211-240 mg/dL 8 Units 8 Units 8 Units 5 Units
> 240 mg/dL Notify M.D.
18. warfarin 1 mg Tablet Sig: One (1) Tablet PO every other day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 2251**] Nursing and Rehabilitation - [**Location (un) 2251**]
Discharge Diagnosis:
Gangrene and infection, right foot
Discharge Condition:
Mental Status: Confused - sometimes.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Lower Extremity Angioplasty/Stent Discharge Instructions
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily
?????? If instructed, take Plavix (Clopidogrel) 75mg once daily
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
What to expect when you go home:
It is normal to have slight swelling of the legs:
?????? Elevate your leg above the level of your heart (use [**1-30**]
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
?????? It is normal to feel tired and have a decreased appetite, your
appetite will return with time
?????? Drink plenty of fluids and 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:
?????? When you go home, you may walk and go up and down stairs
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
?????? After 1 week, you may resume sexual activity
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate
?????? No driving until you are no longer taking pain medications
?????? Call and schedule an appointment to be seen in [**2-28**] weeks for
post procedure check and ultrasound
What to report to office:
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site)
?????? Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office [**Telephone/Fax (1) 1237**]. If bleeding does not stop, call
911 for transfer to closest Emergency Room.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2194-5-30**] 10:00
ICD9 Codes: 0389, 5856, 496, 2720, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3622
} | Medical Text: Admission Date: [**2153-8-30**] Discharge Date: [**2153-9-3**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4765**]
Chief Complaint:
Epigastric pain
Major Surgical or Invasive Procedure:
Angiogram.
History of Present Illness:
81 M c CAD c hx remote MI, CABG in [**2130**] c SVG to [**Last Name (LF) **], [**First Name3 (LF) **] and
SVG to RCA; recent cath in [**11-11**] demonstrating patent SVG to
[**Date Range **]/OM with OM supplying collaterals to RCA/LAD. SVG to RCA
graft occluded proximally. Severe native vessel disease: LMCA
70% diffuse, LAD 80% diffuse, LCX occluded prox, RCA occluded
prox. Also has history of CHF c EF 20% 3/05 c 3+ MR, 3+TR,
moderate pulmonary HTN, and a history of atrial flutter s/p
cardioversion to NSR in [**2-11**] followed by [**Hospital1 **]-V ICD placement.
.
Presented to ED complaining of 1 day history of sharp, RUQ and
epigastric pain, nausea c 1 episode of vomiting. He reported
missing his medications on [**8-28**] and taking them on [**8-29**] on an
empty stomach. No other GI complaints; normal BM last on [**8-29**],
no BRBPR, melena, diarrhea. CT abdomen done showing known
distal abdominal aneurysm 3.9*3.5 cm extending into both
proximal common iliac arteries, cholelithiasis, and no acute
abdominal pathology. Labs notable for 2 negative cardiac
enzymes. ETT-MIBI done; exercised 5.75 min on modified [**Doctor Last Name 4001**]
protocol; test stopped [**1-11**] hypotension and 2 six beat runs of
NSVT c exertion. Imaging showed a new partially reversible
inferior wall defect, stable fixed defect in the distal anterior
wall/apex, and stable moderate partially reversible
antero/infero-septal defect. After return to [**Name (NI) **], pt. had 2
episodes of sustained polymorphic VT for which he received 2 ICD
shocks. Received amiodarone and started on heparin gtt and sent
to cath lab; since pt. stable in cath lab c native v-paced
rhythm and no complaints, decision made to defer cath to AM and
pt. transfered to CCU for monitoring.
Past Medical History:
CAD: CABG in [**2130**] (SVG->RCA and SVG-> OM); [**11-11**] Cath: severe
3-vessel disease, occluded RCA graft, patent OM graft
CHF (ischemic, global hypokinesis, EF=20-30%)
Severe MR
[**First Name (Titles) 650**] [**Last Name (Titles) **]
Severe pulmonary hypertension
NSTEMI [**2-11**]
h/o Afib ([**2-11**])-> converted
[**Hospital1 **]-V ICD pacemaker placed [**2-11**]
CRI
Eczema
History of hematuria
anemia
Hypothyroid
Social History:
Former smoker (quit in [**2116**]'s, 30 pk yr hx), 7oz wine/day,
former high school science teacher. Lives with wife, second
marriage, a daughter in
[**Name (NI) **], one son and daughter from first marriage
Family History:
NC
Physical Exam:
VS: 98.7 116/51, P 60 VPaced, R 14, 100% 2LNC,
GEN: Comfortable at 45 degrees, pleasant
HEENT: MMM. EOMI.
NECK: JVP to ear when patient laying at 20 degrees.
CV: RRR. S1,S2, gallop (?S4). Soft systolic murmurs at tricusip
and mitral areas. No rub.
PULM: Decreased movement of air throughout. Crackles at bases.
Occasional scattered expiratory wheezes.
ABD: Softly distended, shifting dullness, nontender, +BS
EXT: No edema. 2+ DP/PT pulses BL. Changes of Venous stasis L>R.
Onchychomycosis. Warm/well perfused.
Pertinent Results:
[**2153-8-30**] 03:45PM GLUCOSE-192* UREA N-28* CREAT-2.0* SODIUM-138
POTASSIUM-4.3 CHLORIDE-104 TOTAL CO2-21* ANION GAP-17
[**2153-8-30**] 03:45PM CK(CPK)-111
[**2153-8-30**] 03:45PM CK-MB-4 cTropnT-0.04*
[**2153-8-30**] 03:45PM CALCIUM-9.9 PHOSPHATE-3.6 MAGNESIUM-2.1
[**2153-8-30**] 03:45PM PT-12.8 PTT-24.5 INR(PT)-1.1
[**2153-8-30**] 06:30AM CK(CPK)-88
[**2153-8-30**] 06:30AM CK-MB-NotDone cTropnT-<0.01
[**2153-8-30**] 12:40AM GLUCOSE-165* UREA N-31* CREAT-2.2* SODIUM-138
POTASSIUM-4.5 CHLORIDE-103 TOTAL CO2-22 ANION GAP-18
[**2153-8-30**] 12:40AM ALT(SGPT)-12 AST(SGOT)-25 CK(CPK)-111 ALK
PHOS-61 AMYLASE-92 TOT BILI-0.9
[**2153-8-30**] 12:40AM LIPASE-49
[**2153-8-30**] 12:40AM cTropnT-<0.01
[**2153-8-30**] 12:40AM CK-MB-3
[**2153-8-30**] 12:40AM CALCIUM-11.2* PHOSPHATE-3.4 MAGNESIUM-2.3
[**2153-8-30**] 12:40AM WBC-8.4 RBC-4.97 HGB-10.5* HCT-31.3* MCV-63*
MCH-21.1* MCHC-33.5# RDW-15.9*
[**2153-8-30**] 12:40AM NEUTS-90.3* LYMPHS-7.6* MONOS-1.8* EOS-0.2
BASOS-0.1
[**2153-8-30**] 12:40AM HYPOCHROM-2+ POIKILOCY-1+ MICROCYT-3+
[**2153-8-30**] 12:40AM PLT COUNT-171#
.
ETT: 81 yo man (s/p CABG and h/o ischemic cardiomyopathy
with LVEF ~ 30%) was referred to evaluate his shortness of
breath and an
atypical chest discomfort. The patient completed 5.75 minutes of
a
[**Doctor Last Name 4001**] protocol representing a limited functional exercise
tolerance.
Although the patient was near fatigue secondary to shortness of
breath,
the exercise test was stopped secondary to a hypotensive blood
pressure
response accompanied by ventricular irritability. No chest,
back, neck
or arm discomforts were reported during the procedure. The ECG
changes
are uninterpretable in the presence of ventricular pacing.
Atrial and
ventricular pacing was noted at baseline. Sinus with rhythm with
occasional VPDs were noted in exercise and post-exercise. Toward
peak
exercise, two 6-beat runs of nonsustained VT were noted. As
noted, a
hypotensive blood pressusre response to exercise was noted.
MIBI: 1. Transient cavitary dilitation. 2. New, moderate,
partially reversible defect in the inferior wall. Stable,
moderate, predominantly fixed defect in the distal anterior wall
and apex. Stable , moderate, partially reversible antero- and
inferoseptal defect. 3. Global hypokinesis, with best
preserved motion in the anterior and lateral walls. LVEF 31%.
Cath: [**8-31**]: 1. Selective coronary angiography of this right
dominant system
revealed severe native three vessel disease. The LMCA is
heavily
calcfied and diffusely diseased. The LAD is proximally occluded
after a
small diagnonal. The LCx is proximally occluded. The RCA is
known to
be proximally occluded and not engaged (compared to angiography
in
[**11-11**], the LAD is now completely occluded).
2. Graft angiography showed that the SVG to D1 to OM graft is
patent
with 50% lesion at the anastamosis with D1 and distal 50%
discrete
stenosis.
3. Hemodyanmic measurements shows elevated right and left sided
filling
pressure, severe pulmonary hypertension, as well as reduced
cardiac
output (see table above).
4. Left ventriculogram was not performed due to concerns about
the
patient's renal insufficiency. In addition, non-invasive
assessment of
the patient's left ventricular systolic function is available.
Brief Hospital Course:
A/P: 81 yo male w/ CAD s/p CABG, CHF, [**Hospital1 **]-V ICD presents with
epigastric pain, developed V-fib post ETT-MIBI.
1.) Cardiovascular: a) Ischemia: Patient with known severe 3
vessel disease, s/p CABG with subsequent occlusion of RCA graft,
now presents with atypical chest pain and new reversible defect
on MIBI suggesting unstable angina. The episode of Vfib after
ETT was likely [**1-11**] ischemia; however, we cannot anatomically
localize polymorphic VT, therefore must also consider
medications and electrolyte abnormalities are also on the
differential although much less likely. The patient was treated
with 24 hours of heparin and underwent cardiac cath, and was
found to have severe disease however, no lesions were amenable
to cath. He was continued on aspirin, plavix, statin,
betablocker and ace-inhibitor. b) Pump- Mr [**Known lastname **] has severe
ischemic CHF, with an EF of ~30%. He will be discharged on a low
Na diet, and instructed to perform daily weights. c) Rhythm: BiV
ICD in place, paced rhythm currently. S/p VF in ED with ICD
firing x2. As above, this is likely secondary to ischemia,
however there were no treatable lesions found with cath. His
metoprolol was increased and he was loaded with Amiodarone in an
attempt to maintain normal rhythm. He will follow up with
cardiology.
.
2.) Leukocytosis- This is most likely secondary to his [**1-11**] ICD
firing, however, he did have a small area of erythema on his arm
due to phlebitis. He was treated with a 2 week course of
cefazolin.
.
3.) CKD: Baseline Cr appears to be 1.5-1.8, however, may be
higher as no recent values are available in his records. His
Creatinine is currently 2.0, which may represent a mild prerenal
state. Likely not obstructive as no hydronephrosis observed on
CT. He was given gentle hydration and Mucomyst prior to cath
(although hydration limited by severe CHF), and nephrotoxic meds
were avoided as much as possible. Kidney function remained
stable throughout admission.
.
4) Endocrine- Hypothyroid- The patient was continued on his home
dose levoxyl.
.
FULL CODE
Medications on Admission:
(pt unclear re: exact meds, doses)
Furosemide
Lisinopril
Levoxyl 50
Toprol XL 100 mg qday
Aspirin 81 mg qday
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Toprol XL 200 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*
6. 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*
7. Keflex 500 mg Capsule Sig: One (1) Capsule PO twice a day for
14 days.
Disp:*28 Capsule(s)* Refills:*0*
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
Disp:*48 Tablet(s)* Refills:*0*
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
10. 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:*2*
11. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO as directed:
take 2 tabs (400mg) three times per day for 6 days, then 2 tabs
(400mg) once per day for 2 weeks, then 1 tab (200mg) once per
day thereafter.
Disp:*80 Tablet(s)* Refills:*1*
13. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Vfib.
Secondary: CAD. CHF. CRI
Discharge Condition:
Good- stabilized on new medication regimen, no events on tele,
asymptomatic. Patient has a cephalic vein thrombosis and
resultant phlebitis for which he is taking antibiotics for two
weeks.
Discharge Instructions:
During this admission you have been treated for ventricular
tachycardia. Your medications have been changed. Please
continue to take all medications as prescribed. Please call
your doctor immediately if your ICD fires again. Please seek
immediate medical care if you develop chest pain, palpatations,
shortness of breath, or any other symptom that is concerning to
you.
If you begin to notice increasing swelling in your arm, please
call your PCP right away.
Followup Instructions:
You have the following appointments:
1. DEVICE CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2153-9-10**] 9:30
2. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 1989**] Date/Time:[**2153-9-10**]
10:00
3. Ultrasound, [**Hospital Ward Name 517**], [**Location (un) 470**] Phone number [**Telephone/Fax (1) 49745**],
[**2153-9-18**] at 9AM.
ICD9 Codes: 5859, 4168, 412, 2449, 4240 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3623
} | Medical Text: Admission Date: [**2193-1-17**] Discharge Date: [**2193-1-27**]
Date of Birth: [**2134-12-30**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
RUQ pain
Major Surgical or Invasive Procedure:
Paracentesis
History of Present Illness:
The patient is a 58 year old male with new diagnosis of
alcoholic cirrhosis who was recently admitted to [**Hospital1 18**] for
significant GI bleeding. He was discharged five days prior to
presentation, and reports that he had no pain at the time of
discharge. Over the next few days, he developed right upper
quadrant abdominal pain. Two days prior to discharge saw his
PCP, [**Name10 (NameIs) 1023**] ordered a RUQ US that was performed on the day of
admission. That imaging test showed a probable portal vein
thrombosis and he was sent to the [**Hospital1 18**] ED for further
management.
.
In the ED, his VS were T 97.8, BP 121/73, HR 70, RR 16, SpO2
100% on RA. The patient appeared jaundiced (present at
discharge) but had a quite distended abdomen, which he said was
worse than baseline. After discussion with Hepatology the
patient was admitted for further work up. Given his recent GIB,
Heparin was held pending cross sectional imaging and discussion
with attending in the AM.
.
On arrival to the floor, the patient reported mild RUQ
discomfort but denied pain, confusion, tremor, or any other
acute changes.
.
REVIEW OF SYSTEMS: Positive per HPI for RUQ discomfort,
abdominal distention, and ~10 lb weight gain. Also endorsed
loose stools getting worse since discharge. Finally, endorsed
darkened urine. Denies fevers, chills, night sweats, rash,
pruritus, confusion, somnolence, slurred speech, chest pain,
dyspnea, headache, or visual changes.
Past Medical History:
# Alcoholic cirrhosis -- newly diagnosed at last admission
# GI Bleeding -- known esophageal varices
# Gastritis
# Hypertension
Social History:
The patient is a project manager for an electronics contractor.
He was working up until his recent hospitalization. No history
of tobacco use. Up until his last hospitalization, he was
drinking 3-4 beers/day. He denies any alcohol over the last two
weeks. Denies any illicit drug use.
Family History:
Coronary artery disease, diabetes mellitus. His mother had
emphysema.
Physical Exam:
Physical Exam On Admission:
VS: T 96.3, BP 122/76, HR 94, RR 18, O2 97% on RA
Gen: NAD. Alert and oriented x3. Mood and affect appropriate.
Pleasant and cooperative. Resting in bed.
HEENT: NCAT. PERRL, EOMI. Markedly icteric sclera. MMM, OP
benign.
Neck: Supple. JVP elevated to ~8 cm. No cervical
lymphadenopathy.
CV: RRR. Normal S1, S2. Holosystolic murmur [**1-6**] heard best at
the apex with radiation to the axilla.
Chest: Respiration unlabored, no accessory muscle use.
Decreased breath sounds and coarse crackles at bilateral bases,
right greater than left. No wheezes or rhonchi.
Abd: BS present. Tensely distended with ascites. Unable to
assess for organomegaly due to distention.
Ext: WWP, no cyanosis or clubbing. Trace LE edema. Digital cap
refill <2 sec. Distal pulses radial 2+, DP 2+, PT 2+.
Skin: Marked jaundice. No spiders, palmar erythema, or other
stigmata of liver disease.
Neuro: CN II-XII grossly intact. Moving all four limbs. No
asterixis.
.
Pertinent Results:
Labs on Admission:
[**2193-1-17**] 08:52PM BLOOD WBC-7.0# RBC-3.51* Hgb-13.4* Hct-39.0*
MCV-111* MCH-38.2* MCHC-34.3 RDW-18.6* Plt Ct-106*#
[**2193-1-17**] 08:52PM BLOOD Neuts-72* Bands-0 Lymphs-9* Monos-17*
Eos-2 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2193-1-17**] 08:52PM BLOOD Hypochr-NORMAL Anisocy-OCCASIONAL
Poiklo-2+ Macrocy-OCCASIONAL Microcy-NORMAL Polychr-NORMAL
Burr-2+
[**2193-1-17**] 08:52PM BLOOD PT-35.8* PTT-63.2* INR(PT)-3.7*
[**2193-1-17**] 08:52PM BLOOD Glucose-136* UreaN-19 Creat-1.2 Na-132*
K-4.2 Cl-97 HCO3-22 AnGap-17
[**2193-1-17**] 08:52PM BLOOD ALT-80* AST-153* LD(LDH)-341*
AlkPhos-201* TotBili-34.6* DirBili-25.5* IndBili-9.1
[**2193-1-17**] 08:52PM BLOOD Lipase-162*
.
Parcentesis:
[**2193-1-18**] 04:25PM PERITONEAL WBC-105* RBC-192* Polys-3*
Lymphs-13* Monos-0 Meso-5* Macro-79*
[**2193-1-18**] 04:25PM PERITONEAL TotProt-0.3 Albumin-LESS THAN
.
Urinalysis:
[**2193-1-18**] 09:51PM URINE Color-AMBER Appear-Hazy Sp [**Last Name (un) **]-1.022
[**2193-1-18**] 09:51PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-LG Urobiln-NEG pH-5.5 Leuks-NEG
[**2193-1-18**] 09:51PM URINE Hours-RANDOM UreaN-543 Creat-203 Na-LESS
THAN K-72 Cl-15
.
Imaging / Studies:
# CT ABD & PELVIS WITH CONTRAST ([**2193-1-18**] at 1:14 AM):
The lungs are clear. There are coronary artery calcifications
and calcifications are noted in the thoracic aorta without any
aneurysmal dilatation. There is a very large esophageal varix
seen just superior to the gastroesophageal junction. In
addition, there are numerous tortuous periesophageal varices as
well. These varices are fed by a dilated coronary vein the
appears to be decompressing the patient's portal hypertension.
The cirrhotic liver is shrunken and nodular suggestive of end
stage liver disease. The portal vein and all the major portal
branches are patent. There is no focal lesion seen within the
parenchyma. The gallbladder is partially collapsed and
unremarkable. The spleen, adrenals and kidneys and pancreas are
unremarkable. There is ascites seen surrounding the liver and
the spleen and tracking inferiorly along the right paracolic
gutter. There is a small spleno-renal shunt. There are scattered
mesenteric lymph nodes; however, none meet CT criteria for
lymphadenopathy. Note is made of edematous wall of the ascending
colon, likely the result either from underlying hypoalbuminemia
or the portal hypertension. Otherwise, remaining loops of small
and large bowel appear essentially unremarkable.
BONES: There is an old compression fracture seen at T12.
Otherwise, there are no other additional evidence of acute
fracture. There are no lytic or sclerotic lesions suggestive of
metastatic disease.
IMPRESSION:
1. Nodular shrunken liver suggestive of cirrhosis.
2. Ascites seen surrounding the liver and the spleen.
3. Large coronary vein with gastric varices and very large
esophageal and perasophageal varices.
4. The portal vein is well opacified and there is no evidence of
any filling defect (clot) within the portal vein or the major
branches, including the SMV and the splenic vein.
5. Edematous ascending colon bowel wall likely secondary to low
albumin and portal hypertension.
.
# CHEST (PA & LAT) ([**2193-1-18**] at 2:49 PM):
An NG tube lies with its tip in the duodenum. The trachea is
central and the cardiomediastinal contour is normal. There is
volume loss evident in the right lung base with an airspace
opacity adjacent to the right heart border, better appreciated
on the lateral view consistent with right lower lobe
consolidation or atelectasis. While this could reflect
atelectasis given the volume loss, in the appropriate clinical
setting pneumonia is also a possiblity. Small bilateral pleural
effusions. Multiple old rib fractures.
IMPRESSION: Right lower lobe airspace opacity may reflect
atelectasis or pneumonia.
.
Brief Hospital Course:
The patient is an 58 year old male who was recently discharged
on [**2193-1-12**] after an admission for significant GI bleeding, with
newly diagnosed with alcoholic cirrhosis, esophageal varices,
and severe portal hypertensive gastropathy. He presented
several days after discharge with RUQ pain, decompensated
cirrhosis, and question of portal vein thrombosis on RUQ
ultrasound which was later ruled out with CTA abdomen.
.
# Acute on Chronic Liver Failure: He was recently diagnosed with
alcoholic cirrhosis on his prior admission from [**2193-1-10**] to
[**2193-1-12**] for GI bleeding and discharged with outpatient followup
after being stabilized. His transaminases, bilirubin, and coags
this admission had worsened significantly compared to those at
his prior admission. He had MELD score 36 and DF 145. Portal
vein thrombosis was an initial concern given the reported
results of his RUQ ultrasound, but was ruled out by CTA. Other
possible etiologies include infection, recent alcohol use, or
medication effects. There are no obvious medication changes
that would explain his decompensation, but he did receive
Ceftriaxone during his prior admission and was started on
Nadolol. Paracentesis showed no evidence of SBP, and UA was
unremarkable. His CXR showed a possible infiltrate in the RLL,
but he has not demonstrated any other signs or symptoms of
pneumonia. He was started on Prednisone 40 mg PO daily given
the relatively low likelihood of pneumonia. Given his
significant illness, however, he was started on Ceftriaxone 1000
mg IV daily and Azithromycin 500 mg PO daily for a 7 day course.
.
His mental status deteriorated on [**2193-1-24**] and he became no
longer responsive to noxious stimuli and was noted to no longer
have a gag reflex. His antibiotics were broadened to vancomycin,
zosyn, and flagyl and he was transferred to the MICU. In the
MICU, he was continued on the broad spectrum antibiotics though
his culture data was negative. He was also continued on IV
steroids for alcoholic hepatitis though his liver failure
persisted and had a MELD of 48 on [**1-26**]. Was showing signs of end
organ failure with worsened liver function, renal function (near
anuric) and unresponsiveness. Goals of care discussions where
held with his wife and he was transitioned to DNR/DNI on [**1-26**],
however was not made comfort measures only. Palliative care
consult was declined. His blood pressures proved labile and he
was treated with fluid boluses with initial response since the
family had decided not to escalate care. By the end of the day,
patient was no longer responding to fluid boluses and dropped
his pressures. He passed away on [**2193-1-27**] at 12:01AM with family
at his bedside.
.
# [**Last Name (un) **]: Cr increased from 1.2 on admission to 1.9 two days later.
He appeared to have mild intravascular volume depletion on
exam, with dry MMs and a new aortic outflow tract murmur. His
urine electrolytes were consistent with a prerenal picure with
urine Na <10. He was volume repleted with Albumin (25%) 75 g
daily for two days. Ultimately, developed worsening renal
failure with creatinine of 2.1 prior to expiration- attributed
to hepatorenal syndrome.
.
# GI bleeding History: His Hct was stable at 39.0 on admission
from Hct 32.0 on his recent discharge on [**2193-1-12**]. There were no
signs of active bleeding. His EGD showed no evidence of active
bleeding, but did show significant esophageal varices and
gastropathy. He was continued on Omeprazole 40 mg PO daily and
Nadolol 20 mg PO daily. His Type and Screen was kept active and
he was montitored closely for any bleeding- he did not have any
active bleeding during this hospitalization.
.
# Contacts: Wife -- [**First Name9 (NamePattern2) 100569**] [**Known lastname **] (Phone: [**Telephone/Fax (1) 100570**])
Medications on Admission:
Nadolol 20 mg PO DAILY
Omeprazole 40 mg PO DAILY
Hydrochlorothiazide 25 mg PO DAILY
Discharge Medications:
None.
Discharge Disposition:
Expired
Discharge Diagnosis:
Alcoholic hepatitis
Discharge Condition:
Expired.
Discharge Instructions:
None.
Followup Instructions:
None.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2193-1-27**]
ICD9 Codes: 0389, 5845, 2760, 486, 2875, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3624
} | Medical Text: Admission Date: [**2196-3-28**] Discharge Date: [**2196-4-2**]
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Total abdominal colectomy
[**Doctor Last Name **] ileostomy
Splenorrhapy
Arterial line placement
Bronchoalveolar lavage
Nasogastric tube placement
Endotracheal intubation
History of Present Illness:
Mr. [**Known lastname 14921**] is a Spanish-speaking only [**Age over 90 **]-year-old gentleman
who presents today for evaluation of abdominal pain, nausea, and
vomiting. He reportedly experienced acute onset of mid-abdominal
pain around noon today. He had an associated episode of
non-bilious, non-bloody emesis. His abdomen has been distended
the past few days and he has been constipated (no bowel movement
in the last 5 days). He continues to pass small amounts of gas.
His PMH from OMR shows that he has had prior episodes of
diverticulitis but his daughter today denied previous episodes.
He was recently hospitalized [**Date range (1) 14922**] for a streptococcal
pneumonia complicated by respiratory distress requiring
intubation.
Past Medical History:
Recent strep PNA (admit [**Date range (1) 14923**], intubated)
CAD s/p MI [**10**] yrs ago s/p PTCA
Asthma/COPD on home O2
Syncope s/p pacemaker implant
Diverticulitis
Gout
Mild chronic renal insufficiency (baseline Cr ~1.4)
Elevated PSA
Urinary retention
HPL
HTN
GERD
Social History:
Lives with wife. 3 grown children. Smoked 1 ppd x 40 years, quit
20 years ago.
Family History:
Noncontributory
Physical Exam:
Vitals: 101.5 72 129/64 22 87%
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: appears short of breath with labored breathing,
rhonchorous
ABD: Soft, severely distended and tympanitic, diffusely tender,
DRE: diminished rectal tone, large amount of stool in rectal
vault, initially guaiac negative but after manual disimpaction,
fresh blood coating the stool was noted
Ext: No LE edema, LE warm and well perfused
Pertinent Results:
[**2196-3-28**] 05:52PM BLOOD WBC-14.0*# RBC-4.00* Hgb-13.4* Hct-37.9*
MCV-95 MCH-33.5* MCHC-35.3* RDW-14.1 Plt Ct-248
[**2196-3-28**] 05:52PM BLOOD Neuts-91.4* Lymphs-4.9* Monos-3.2 Eos-0.1
Baso-0.3
[**2196-3-28**] 05:52PM BLOOD Plt Ct-248
[**2196-3-29**] 03:22AM BLOOD PT-17.4* PTT-31.6 INR(PT)-1.6*
[**2196-3-29**] 03:22AM BLOOD Fibrino-309
[**2196-3-28**] 05:52PM BLOOD Glucose-100 UreaN-35* Creat-2.2* Na-138
K-4.0 Cl-100 HCO3-29 AnGap-13
[**2196-3-28**] 05:52PM BLOOD ALT-29 AST-35 AlkPhos-84 TotBili-0.5
[**2196-3-31**] 04:49PM BLOOD CK(CPK)-1353*
[**2196-3-29**] 05:25AM BLOOD CK-MB-5 cTropnT-0.04*
[**2196-3-29**] 04:45PM BLOOD proBNP-1223*
[**2196-3-31**] 04:49PM BLOOD CK-MB-24* MB Indx-1.8 cTropnT-0.38*
[**2196-3-28**] 05:52PM BLOOD Albumin-3.8 Calcium-9.9 Phos-3.7 Mg-1.9
[**2196-4-2**] 01:28AM BLOOD TSH-3.2
[**2196-3-28**] 06:05PM BLOOD Lactate-1.9
[**2196-3-29**] 01:37AM BLOOD freeCa-1.13
[**2196-3-29**] 01:37AM BLOOD Hgb-11.5* calcHCT-35 O2 Sat-98
Brief Hospital Course:
GI/GU: The patient presented with abdominal pain and a CT
Abd/Pelvis showed diffuse wall thickening of the proximal to mid
sigmoid colon with associated surrounding fat stranding, most
consistent with colitis. Due to his deteriorating status in the
ED thought to be secondary to sepsis from this acute abdominal
process, he was taken emergently to the OR for exploratory
laparotomy. In the OR, he was found to have an enlarged,
necrotic but not yet perforated loop
of sigmoid colon with the rest of the colon deeply congested and
compromised. A total abdominal colectomy, [**Doctor Last Name **] ileostomy, and
splenorrhapy was performed. The skin was closed with surgical
staples and an ileostomy appliance applied; EBL was 350 mL and
the patient was returned to the TSICU in critical condition.
CV: After total abdominal colectomy, the patient developed
atrial fibrillation with rapid ventricular response. He was
initially rate controlled with a diltiazem drip. He had
intermittent episodes of atrial fibrillation and hypotension.
Once a TEE established the absence of thrombus, the patient was
cardioverted with amiodarone but continued to have intermittent
return to atrial fibrillation. His cardiac enzymes were
elevated, which was attributed to cardiac enzyme leak from the
stress of surgery, hypotension, and tachycardia vs. a small
perioperative MI. He was started on aspirin, but catheterization
was not a possibility at the time given inability to
anticoagulate.
Resp: The patient developed hypoxia and increased work of
breathing in the ED requiring intubation. His respiratory
distress was thought to be due to sepsis from an acute
intraabdominal process, and the patient was taken to the OR for
an exploratory laparatomy, which resulted in a total abdominal
colectomy, [**Doctor Last Name **] ileostomy and splenorrhapy. The patient
remained intubated after surgery. He was extubuated, but had to
be reintubated 2 days later for worsening respiratory status.
CXR and bronchoalveolar lavage revealed MRSA pneumonia. He was
treated with vancomycin, cefepime and ciprofloxacin. After
several days of antibiotic therapy without much clinical
improvement, the family approached the team with the wish to
change Mr. [**Known lastname 14924**] status to comfort measures only and to
extubate him. The extended family was present in discussions
with the attending physician, [**Name10 (NameIs) **] after extensive conversation
about options for care, elected for extubation and comfort
measures. The patient was extubated and expired shortly
thereafter from respiratory failure.
Neuro: The patient's was sedated for intubation. His mental
status deteriorated with his clinical status.
Renal: The patient was thought to have acute on chronic renal
insufficiency. His Cr trended down to 1.8 from a baseline of 2.2
over his hospital course. His urine output was monited with a
foley and his electrolytes repleted.
Heme: Following surgery patient's hematocrit trended down, he
was transfused 1U PRBC during his hospital course.
ID: CXR and bronchoalveolar lavage revealed MRSA pneumonia. He
was treated with vancomycin, cefepime and ciprofloxacin.
Medications on Admission:
Lipitor 10mg daily
Advair diskus 250-50 twice daily
Senna PRN
Duoneb prn
ASA 81mg daily
Tylenol PRN
Diltiazem 240 mg daily
Proventil 90 q4hrs prn
Lasix 20mg daily
Finasteride 5mg daily
Nitroglycerin SL prn
Amlodipine 5mg daily
Ranitidine 150mg daily
Metoprolol succinate 50mg daily
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Diverticulitis
Perforated bowel
Sepsis
Pneumonia
Discharge Condition:
Deceased
Discharge Instructions:
N/A
Followup Instructions:
N/A
ICD9 Codes: 5849, 412, 2749, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3625
} | Medical Text: Admission Date: [**2108-12-29**] Discharge Date: [**2109-1-10**]
Date of Birth: [**2036-11-27**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: This is a 72-year-old male with
a known history of coronary artery disease, status post
percutaneous transluminal coronary angioplasty ten years ago.
He presented to an outside hospital emergency department on
[**2108-12-29**] with complaints of dyspnea. He was found to be
bradycardiac with a heart rate in the 30's and had ST
depressions and congestive heart failure. He was transferred
to [**Hospital1 69**] for evaluation and
treatment. He was admitted to the hospital on [**2108-12-29**] via
the Medical Service and then referred to the Cardiology
service for treatment of his congestive heart failure and
evaluation of his coronary artery disease. He was diuresed
over the first two days of admission.
PAST MEDICAL HISTORY:
1. Coronary artery disease status post percutaneous
transluminal coronary angioplasty ten years ago.
2. Hypertension.
3. Congestive heart failure.
Please note, the patient denied a history of hypertension.
PAST SURGICAL HISTORY: Tonsillectomy.
ALLERGIES: No known drug allergies.
MEDICATIONS: At the time being seen by Cardiac Surgery
consult:
1. Cardizem 30 mg daily.
2. Aspirin 325 mg p.o. daily.
The patient lives with his wife, he works part time as an
instructor at the Buck [**Doctor Last Name **] Community College. He quit
smoking four years ago with an approximately 30 to 40 pack
year history. He admits to one glass of wine or beer at
dinner occasionally.
FAMILY HISTORY: Noncontributory.
He stated that he was "exceedingly healthy."
PHYSICAL EXAMINATION: On examination he is 5 feet, 10 inches
tall, 175 pounds. Blood pressure 150/70, heart rate 70,
respiratory rate 18, sating 96 percent on room air. He was
laying flat in bed in no apparent distress when he was seen
on consult. He was alert and oriented times three and
appropriate and grossly neurologically intact. His lungs
were clear to auscultation bilaterally anteriorly. His heart
was regular rate and rhythm with frequent premature
ventricular contractions and premature atrial contractions.
He had a Grade 1/6 systolic ejection murmur heard best at
apex. His abdomen was soft, nontender, nondistended with
bowel sounds. His extremities were warm and well perfused.
He had 2 plus radial pulses on the right, 1 plus on the left.
2 plus dorsalis pedis pulses on the right, 1 plus on the
left, 1 plus posterior tibial pulses on the right, 2 plus on
the left.
LABORATORY FINDINGS: Preoperative labs were as follows,
white count 6.9, hematocrit 41.8, platelet count 167,000.
Sodium 143, creatinine 3.8, chloride 107, bicarbonate 26, BUN
16, creatinine 0.9 with a blood sugar of 164. Preoperative
chest x-ray showed minimal upper zone redistribution and
small bilateral pleural effusions indicating possible left
heart failure. No other significant cardiopulmonary
abnormality was identified. Please refer to the final report
dated [**2108-12-30**].
Additional labs: Protime 12.5, PTT 53.1, INR 1.2, ALT 15,
AST 15, alkaline phosphatase 59, total bilirubin 0.7, albumin
3.6.
Preoperative echocardiogram showed an ejection fraction of 15
percent and left ventricular hypokinesis.
The patient was treated for his congestive heart failure in
preparation for cardiac catheterization to evaluate his
coronary artery disease. Cardiac catheterization was
performed on [**2108-12-31**] with the following results. The patient
was right dominant coronary system. He had a tapering 20
percent distal left main lesion, 80 percent left anterior
descending coronary artery lesion, 80 percent circumflex
lesion proximally and a 50 percent posterior descending
coronary artery lesion. The patient was referred to Dr.
[**Last Name (STitle) **] for coronary artery bypass surgery.
Urinalysis was negative. Please refer to the final report.
The patient was seen by Dr. [**Last Name (STitle) **]. Risks and benefits of
surgery were discussed. The patient's cardiac enzymes were
negative. He was started on Carvedilol preop 3.125 mg p.o.
twice a day. He was also continued on aspirin, Lipitor and
intravenous Heparin therapy. Given his poor ejection
fraction Dr. [**Last Name (STitle) **] requested a myocardial viability study
which showed that there was perfused myocardium. The patient
had a left bundle branch block on electrocardiogram
preoperatively as well as many premature ventricular
contractions.
The patient was accepted for coronary surgery and on [**2109-1-3**]
underwent coronary artery bypass graft times two by Dr.
[**Last Name (STitle) **] with a left internal mammary artery to the left
anterior descending coronary artery and vein graft to the
circumflex. He was transferred to Cardiothoracic intensive
care unit in stable condition. Of note, Swann-Ganz catheter
was unable to be placed in the operating room despite
multiple attempts under echocardiography by Anesthesia Team.
The patient was transported to the cardiac catheter
laboratory prior to the start of his surgery for Fluoroscopic
placement of a right IJ Swann. Fluoroscopy and injection at
Catheter laboratory revealed a communication of the right IJ
with a persistent left SVC without flow through any right
SVC. Swann-Ganz catheter in the Catheterization Laboratory
was placed using left femoral vein approach. Please refer to
the Catheterization laboratory report dated [**2109-1-3**].
On postop day one the patient had no events overnight,
remained ventilated on Propofol drip at 0.8 mcg per kg per
minute. He was also on an epinephrine drip at 1.0 and
Lidocaine drip at 2.0. Postop labs are as follows: White
count 10, hematocrit 31, K 4.1, BUN 11, creatinine 0.9 with a
blood sugar of 90.
On postoperative evening on [**2109-1-3**] the Swann-Ganz catheter
was inadvertently pulled out. The Swann-Ganz catheter was
refloated by Cardiology under fluoroscopy in the
Cardiothoracic Intensive care unit. The patient continued to
be followed as he was preoperatively by Dr. [**Last Name (STitle) **] from
Cardiology Heart Failure Service. On postop day two the
patient was extubated and was weaned off his epinephrine
drip. Lasix diuresis was begun. He was hemodynamically
stable at blood pressure 117/56, slightly tachycardiac in the
90's but sating at 96 percent on four liters nasal cannula.
Melranone drip continued at 0.4 mcg per kg per minute and
insulin drip at 4 units per hour. His creatinine remained
stable at 1.0, the patient was doing well. Was alert and
oriented appropriately and he remained in the CSRU for
monitoring.
On postop day three, Melranone drip was weaned off, Neo-
Synephrine was off, the patient remained on an insulin drip
at 3 units per hour. His Carvedilol was restarted at 3.125
mg p.o. twice a day to try and bring his heart rate back
down. On examination his heart rate was at 78 with
Carvedilol in sinus rhythm and a stable blood pressure
110/51. His hematocrit also remained stable at 30.6. Swann-
Ganz catheter was removed later in the day as was the cortis
introducer and his radial A-line.
On postop day four the patient's pacing wires were removed.
He was switched over to p.o. Percocet for pain. He was
hemodynamically stable, alert and oriented. His examination
was unremarkable. Incisions were clean, dry and intact. His
pacing wires were removed. He continued on his aspirin
therapy and Ace inhibitor therapy was restarted with
Lisinopril at 2.5 mg p.o. once daily. The patient was
transferred out to the floor where he was evaluated by
physical therapy and continued to be seen by the Congestive
Heart Failure fellow every day who recommended continuing him
on Carvedilol. The patient did have some slightly
erythematous areas over his coccyx with some broken skin
spots. His coccyx was covered with DuoDerm for protection,
also a small area of skin sloughing and to help keep the area
cleaned. He also had some small skin tears at his right
groin catheter site, this was also treated with DuoDerm, his
incisions continued to heal. The patient was out of bed and
ambulating. He had occasional premature atrial contractions
on telemetry but continued to progress. He also had one
episode of wide complex tachycardia, approximately 20 beats
in the heart rate range of 112 to 180.
On the evening of the 13th electrocardiogram was done which
showed his original bundle branch block and heart rate back
in 70 to 80 range with frequent premature ventricular
contractions and couplets. At the time his potassium was
5.1,, his magnesium 2.2. He maintained his blood pressure
throughout the episode.
His 12 lead electrocardiogram showed no ischemia. The
patient was evaluated by the Cardiac Surgery Fellow at the
time this occurred. He was evaluated by the EP Fellow the
next morning who recommended he should be worked up in
approximately one month for re-evaluating his very low
ejection fraction at 15 percent and be evaluated as an
outpatient with a cardiac MRI and repeat viability study by
Dr. [**Last Name (STitle) 60086**]. His Carvedilol was increased to 6.125 mg
twice a day.
On postop day six, his exam was again unremarkable other
than some rales at the left base. He continued with his
Carvedilol and Lisinopril therapy and remained on sliding
scale insulin for slightly elevated blood sugars. His
hematocrit remained stable at 29.7, white count of 9.0 and
creatinine of 1.1. He continued to have frequent premature
ventricular contractions and some couplets but no other
episodes of V-tach in that 24 hour period. He continued to
improve his ambulation status and ambulated four times during
that day prior to discharge. Request was filed for cardiac
MR to be performed at the request of Dr. [**Last Name (STitle) 60086**].
On postop day seven the patient completed a Level Five, was
doing very well with plans to discharge him during the day.
He was in sinus rhythm at a rate of 70 with a blood pressure
of 141/72 and respiratory rate of 18.
LABORATORY FINDINGS: Before discharge white count 8.4,
hematocrit 28.6, platelet count 307, sodium 141, K 4.4,
chloride 103, bicarbonate 31. BUN 22, creatinine 1.0, blood
sugar 115. Magnesium 2.0. His examination was unremarkable.
His heart was regular rate and rhythm on examination. Lungs
clear bilaterally. The incisions were clean, dry and intact.
His Lisinopril was increased to 5 mg p.o. once a day, Lasix
was decreased to once a day therapy. He was discharged to
home with VNA services on [**2109-1-10**] after his final evaluation
by Physical Therapy.
DISCHARGE DIAGNOSIS:
1. Status post coronary artery bypass graft times two.
2. Cardiomyopathy.
3. Coronary artery disease status post percutaneous
transluminal coronary angioplasty ten years ago.
4. Hypertension.
DISCHARGE MEDICATIONS:
1. Lasix 20 mg p.o. once a day times two weeks.
2. Potassium chloride 10 mEq p.o. once a day times two weeks.
3. Colace 100 mg p.o. twice a day times one month.
4. Percocet 5/325 mg one to two tablets p.o. q 4 hours as
needed for pain.
5. Aspirin Entericoated 81 mg one tablet p.o. once a day.
6. Lisinopril 5 mg once a day.
7. Carvedilol 6.25 mg p.o. twice a day.
The patient was instructed to follow-up with Dr. [**First Name8 (NamePattern2) **]
[**Name (STitle) 39288**] in approximately one to two weeks post discharge and
do follow-up with Dr. [**Last Name (STitle) 60086**] of the Electrophysiology
Service in one month after he completed his Magnetic
resonance imaging study. The patient was told the Radiology
Department would schedule his magnetic resonance imaging for
approximately one month after surgery and he should see Dr.
[**Last Name (STitle) 60086**] after that. The patient was also instructed to
follow-up with Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 2031**], his heart failure
cardiologist in approximately three to four weeks post
discharge and to see Dr. [**Last Name (STitle) **] in the office in three to
four weeks after his operation for his postop surgical check.
He was discharged to home in good condition on [**2109-1-10**].
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2109-2-13**] 09:58:19
T: [**2109-2-13**] 12:55:14
Job#: [**Job Number 60087**]
ICD9 Codes: 4280, 4111, 4240, 496, 4254, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3626
} | Medical Text: Admission Date: [**2150-1-12**] Discharge Date: [**2150-1-17**]
Date of Birth: [**2077-8-1**] Sex: M
Service: Medical Intensive Care Unit with transfer to [**Company 191**]
internal medicine firm.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 72-year-old man
with multiple medical problems including admission to the
medical Intensive Care Unit in [**2149-11-8**] to [**2149-12-9**]
for urosepsis complicated by myocardial infarction,
congestive heart failure, and worsening renal failure
resulting in initiation of dialysis. During this admission
the patient had a prolonged intubation for hypoxic
respiratory failure secondary to his congestive heart
failure. The patient had been discharged to [**Hospital1 **] Care
Hospital on [**1-2**] where he was noted to have melena for 24
hours with a hematocrit drop from 34 to 28%. He was
transfused two units of packed red blood cells with only some
compensation of his hematocrit to 31.6. He was sent to the
Emergency Room on [**2150-1-12**] for evaluation where he was
hypotensive to 70/48 and started on IV fluids and Dopamine.
An NG lavage was negative for bright red blood or coffee
grounds. Due to his hypotension and history of nosocomial
infection, she was given Vancomycin and Ceftazidime and
transferred to the medical Intensive Care Unit for further
management.
REVIEW OF SYSTEMS: The patient reported feeling sleepy and
lethargic. He denied chest pain, shortness of breath, or
abdominal pain.
PAST MEDICAL HISTORY: Coronary artery disease status post
cardiac catheterization with LAD stent on [**2149-12-15**], status post
myocardial infarction [**11-8**], congestive heart failure with an
EF of 25-30%, type 2 diabetes times 20 years, peripheral
vascular disease status post toe amputation times two, atrial
fibrillation, pseudomonas urinary tract infection [**2149-11-8**], hypertension, chronic renal insufficiency, now on
hemodialysis Monday, Wednesday and Friday, gout, chronic
lower extremity edema, obstructive sleep apnea on C-PAP,
history of MRSA pneumonia, history of GI bleed with no EGD or
colonoscopy report available.
ALLERGIES: No known drug allergies.
MEDICATIONS: On admission, Protonix 40 mg po q day,
Captopril 12.5 mg po tid, Levaquin 250 mg po q day, Day 8 of
15, Epogen 5,000 units three times per week, Colace 100 mg po
bid, Lipitor 40 mg po q h.s., Nephrocaps 1 tablet po q day,
NPH 10 units subcu q a.m., 6 units subcu q p.m., Paroxetine
20 mg po q day, Reglan 5 mg po qid, Calcium Carbonate 500 mg
po tid, Digoxin .125 mg three times per week.
SOCIAL HISTORY: The patient quit tobacco 20 years ago and
quit alcohol use 4-6 weeks prior to admission. The patient
is married and has a daughter.
PHYSICAL EXAMINATION: Temperature 99.8, heart rate 80, blood
pressure 131/51, respiratory rate 26, oxygen saturation 97%
on four liters. In general this is a lethargic but alert and
elderly man in no acute distress. HEENT exam indicated
pupils are equal, round and reactive to light, there was a
right subconjunctival hemorrhage, had dry oral mucosa. The
neck was supple with no jugular venous distention. A Quinton
catheter was in place in the right subclavian position.
Cardiovascular exam indicated regular rhythm, normal S1 and
S2, no murmurs, gallops or rubs. Chest was clear to
auscultation bilaterally. On abdominal exam the patient had
bruising on his lower abdomen which was soft, nontender, non
distended with normal bowel sounds. He had a rectal bag in
place with black, running stool. On extremity exam the
patient had 2+ peripheral pulses and no edema. He does have
a small ulcer on his left lateral shin with an eschar. On
his back he had a stage II sacral decubitus ulcer.
Neurologically the patient was alert and oriented to place,
month, year and current events. He responded to verbal
commands and was moving all extremities against gravity. EKG
indicated normal sinus rhythm. Chest x-ray indicated an
elevated right hemidiaphragm, unchanged from previous study
on [**12-29**]. There was no congestive heart failure or
infiltrates. Remainder of his laboratory studies were
notable for a white blood count of 28.4 with differential of
74% neutrophils and 20% lymphocytes, hematocrit 31.6, BUN 69,
creatinine 6.1, glucose 188. Urinalysis indicated specific
gravity of greater than 1.030, nitrites positive with 3-5
white blood cells and a few bacteria. Arterial blood gas
indicated a PH of 7.31 with a PCO2 40 and PAO2 of 62.
Lactate level was 2.3. Blood cultures times two were sent as
was a urine culture and a C. diff.
HOSPITAL COURSE: The patient was admitted to the Intensive
Care Unit for management of a GI bleed. He was continued on
Dopamine and slowly weaned off over the course of the first
two hospital days. He was transfused one unit of packed red
blood cells for a hematocrit of 25.9 on hospital day #2 and
was transfused another 2 units of packed red blood cells on
hospital day #3. The renal team was consulted and suggested
DDAVP and ultrafiltration without Heparin on hospital day #2
as well as initiation of conjugated estrogens. The GI
service saw the patient on hospital day #2 and felt that he
was not actively bleeding since his blood pressure was stable
and his blood counts were stable and it was therefore opted
for upper and lower endoscopy when his coagulation parameters
were optimized. On the evening of hospital day #2 the
patient had development of transient new first degree AV
block. Amiodarone and Digoxin were held. On hospital day #3
the patient was transferred to the floor. As all of his
cultures were negative antibiotics were discontinued. On
hospital day #4 the patient received upper and lower
endoscopy. Upper endoscopy indicated normal esophagus,
stomach and duodenum with the exception of a small polyp in
the stomach which was likely hyperplastic. Colonoscopy
indicated localized discontinuous granularity with friable
erythematous mucosa in the ascending colon. There was no
active bleeding. These findings were thought to be
consistent with ischemic colitis. As the patient was not
actively bleeding and was status post myocardial infarction
on last admission, he was restarted on 81 mg of Aspirin. He
was also restarted on his Amiodarone for rate control. The
patient was to be seen by physical therapy and occupational
therapy whose evaluations are pending at the time of this
discharge dictation. He was being screened for placement in
an acute rehabilitation facility. The patient was to
follow-up with his primary care provider, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Name (STitle) 1683**].
DISCHARGE DIAGNOSIS:
1. Ischemic bowel.
2. Congestive heart failure.
3. Coronary artery disease.
4. End stage renal disease on hemodialysis.
5. Type 2 diabetes mellitus.
6. Peripheral vascular disease.
7. Atrial fibrillation.
8. Hypertension.
DISCHARGE MEDICATIONS: Protonix 40 mg po q day, Captopril
12.5 mg po tid, enteric coated Aspirin 81 mg po q day, Epogen
5000 units three times per week with hemodialysis, Colace 100
mg po bid, Lipitor 40 mg po q day, Amiodarone 200 mg po q
day, Nephrocaps one tablet po q day, Paxil 20 mg po q day,
Reglan 5 mg po qid, TUMS 500 mg po tid, NPH 10 units q a.m.,
6 units q p.m.
DISPOSITION: The patient was to be discharged to an acute
rehabilitation facility.
CONDITION ON DISCHARGE: Improved.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 8873**] [**Name8 (MD) **], M.D. [**MD Number(1) 8874**]
Dictated By:[**Last Name (NamePattern1) 194**]
MEDQUIST36
D: [**2150-1-16**] 17:43
T: [**2150-1-16**] 18:31
JOB#: [**Job Number 7718**]
ICD9 Codes: 4280, 2765 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3627
} | Medical Text: Admission Date: [**2105-2-19**] Discharge Date: [**2105-2-23**]
Service: VASCULAR
CHIEF COMPLAINT: Ischemic left leg.
HISTORY OF PRESENT ILLNESS: Information was obtained from
the patient in the discharge summaries. The patient is a
reliable historian.
This is an 80-year-old white female with recurrent thrombosis
of her axillo.-femoral graft and femoral-femoral
graft. She has undergone TPA, and she status post ligation
and excision of the right axillo.-femoral bypass with
revision of the proximal right femoral anastomosis. She
returned with graft thrombosis. Onset of symptoms was on
[**2-16**] when she noted that her leg, "couldn't hold me
discharged home. Her symptoms progressed since discharge
from the outside hospital with increasing rest pain in the
leg and claudication at less than 50 ft. The foot was pale,
cool, with no sensory loss.
REVIEW OF SYSTEMS: Positive for myocardial infarction. No
chest pain, paroxysmal nocturnal dyspnea, orthopnea, or
palpitations. She is non-diabetic. Her neurovascular
history is negative for symptoms.
ALLERGIES: QUESTIONABLE IODINE.
PAST MEDICAL HISTORY: Coronary artery disease with
myocardial infarction in [**2082**], hypertension,
hypercholesterolemia, gallstones, abdominal aortic aneurysm.
PAST SURGICAL HISTORY: Ventral hernia repair. Hysterectomy.
Aorto-bifemoral bypass in [**2103-2-13**]. Left colectomy.
axillo.-bifemoral and thrombolysis of the right
subclavian artery and axillary artery in [**2103-4-14**].
Thrombolysis of the right femoral-femoral. Right external
iliac angioplasty with stent placement in [**2103-4-14**].
Thrombolysis of the femoral-femoral graft in [**2103-7-14**].
Renal artery bypass in [**2092**]. Thrombolysis of the right
femoral-popliteal and femoral-femoral in [**2103-9-14**].
Angioplasty of the right external iliac artery in [**2103-9-14**]. Ligation and excision of the axillo.-femoral graft
with ligation of the right SFA with revision of the
femoral-femoral popliteal anastomosis.
Echocardiogram in [**2103-9-14**] showed normal left
ventricular function with an ejection fraction of 55% with
basilar akinesis, severe mitral regurgitation, and moderate
aortic insufficiency.
MEDICATIONS ON ADMISSION: Lasix 40 mg q.d., Hydrocodone
5/500 h.s. p.r.n., Temazepam 30 mg h.s., Quinine tab 260 mg
p.r.n., Nifedipine XL 30 mg q.d.
SOCIAL HISTORY: This is a widowed female who lives alone.
She ambulates independently. She smokes [**3-16**] cigarettes per
day. No caffeine or alcohol intake.
PHYSICAL EXAMINATION: Vital signs: Temperature 98.6??????, heart
rate 78, respirations 16, blood pressure 120/70, oxygen
saturation 96% on room air. General: She was an alert white
female. HEENT: Unremarkable. Pulse: Exam showed intact
carotid, brachial pulses bilaterally. The radial pulse was
palpable. The left was absent. The abdominal aorta was
nonprominent. The right femoral and popliteal were palpable
with biphasic Doppler signals of the dorsalis pedis and
posterior tibial. The left femoral and popliteal were
monophasic Doppler signals only with absent dorsalis pedis
and posterior tibial by Doppler significant and palpation.
There were no carotid or femoral bruits. Chest: Exam showed
basilar crackles bilaterally. Heart: Regular, rate and
rhythm. Normal S1 and S2. There was a [**2-18**] pansystolic
murmur at the apex. There were heave thrills. No S3 or S4.
Abdomen: Unremarkable. Rectal: Exam showed good tone. No
masses. Guaiac negative. Musculoskeletal: Exam showed
degenerative joint changes of the feet and hands. The left
foot was pale and cold. There was no cyanosis or mottling.
Sensory was intact. Motor showed dorsiflexion of the foot
and wiggling of toes. Right foot was cool but not as cool as
the left. Neurological: The patient was oriented times
three. Grossly intact.
HOSPITAL COURSE: The patient underwent a noninvasive duplex
of the femoral-femoral graft which was found to be occluded
with a patent left profunda and popliteal arteries. Lab work
obtained included a CBC with a white count of 6.7, hematocrit
37.6, platelet count 250; BUN 21, creatinine 1.1, potassium
4.3; PT, INR, and PTT were normal.
Chest x-ray was unremarkable. Electrocardiogram showed
normal sinus rhythm with a ventricular rate of 56, with no
acute ischemic changes, old inferior wall myocardial
infarction.
The patient was hydrated and prepared for surgery and
underwent on [**2105-2-20**], thrombectomy of the
femoral-femoral bypass graft with a Dacron patch angioplasty
to the left femoral anastomosis. She tolerated the procedure
well and was transferred to the PACU in stable condition.
Her immediate postoperative course was unremarkable, and she
was transferred to the VICU for continued monitoring and
care. There were no overnight events. Her postoperative
hematocrit was 34. Her electrolytes were stable. Her groin
was clean, dry, and intact, with serous drainage. She had a
Dopplerable dorsalis pedis and posterior tibial bilaterally
with Dopplerable femoral-femoral graft.
Ambulation was begun. Fluids were Hep-Locked, and diet was
advanced as tolerated. The remaining hospital course was
unremarkable. The patient was discharged in stable condition
with clean, dry wound, with a palpable graft in both groins.
The patient should follow-up with Dr. [**Last Name (STitle) **] on [**3-5**] for skin clip removal. A Tegaderm was applied to the skin
clip area prior to discharge.
DISCHARGE MEDICATIONS: Unchanged from preoperative
medications and include Vicodin 5/500 tab [**1-14**] q.4-6 hours
p.r.n. pain.
DISCHARGE DIAGNOSIS: Thrombosed femoral-femoral graft status
post thrombectomy with Dacron patch angioplasty to the left
femoral artery.
[**First Name11 (Name Pattern1) 1112**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **], M.D. [**MD Number(1) 6223**]
Dictated By:[**Last Name (NamePattern1) 1479**]
MEDQUIST36
D: [**2105-2-23**] 09:11
T: [**2105-2-23**] 09:42
JOB#: [**Job Number 29738**]
ICD9 Codes: 412, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3628
} | Medical Text: Admission Date: [**2192-5-18**] Discharge Date: [**2192-5-28**]
Date of Birth: [**2122-5-19**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Known firstname 30**]
Chief Complaint:
Neck Pain
Major Surgical or Invasive Procedure:
[**2192-5-20**]: C5 partial corpectomy, C5-6 arthrodesis, C5-6
application interbody cage, C5-6 anterior cervical
instrumentation, Biopsy C5-6 disk and bone
NG tube placement
History of Present Illness:
69 yo male with history of esophagectomy for Barrett's
esophagus, HLD, HTN, CAD, AFib, DM T2, COPD, DVTs/[**Hospital **]
transfered from [**Location (un) 12017**] for c5-c6 epidural abscess and MSSA
bacteremia. The patient was transfered given his primary
surgeons, Dr. [**Last Name (STitle) **], are here at [**Hospital1 18**]. He was initially
seen on [**2192-5-9**] at [**Hospital 8641**] hospital for leukocytosis, had evidence
of UTI. Subsequently Blood and urine cultures grew MSSA and he
was treated as an outpatient with Bactrim. He then had acute on
chronic neck pain on [**2192-5-13**] and presented to [**Location (un) 12017**] regional
hospital. There, he was found to have herpes zoster in his
anus, started on acyclovir and treated with keflex for known
MSSA UTI/bacteremia. Cervical MRI was obtained for neck pain
which showed cervical discitis and epidural phlegmon at C5-C6.
Then, he was transitioned to nafcillin. His last blood cultures
were positive on [**2192-5-14**]. Reports increasing incontinence of
urine and stool. Has been treated with large pain regimen of
gabapentin, morphine PCA.
.
The patient was transferred and appeared well and not in acute
distress. He was complaining of neck pain, as well as pain in
the right shoulder. No fevers. No urinary complaints.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
1. Extensive h/o DVT/PE in past
2. Chronic diastolic CHF
3. Paroxysmal AFib
4. CAD: No history of MI per pt.
5. HTN
6. HLD
7. Barretts esophagus s/p esophagectomy (by [**Doctor Last Name **]) in [**2181**].
His last check up was in [**Month (only) 547**] in [**2189**]. No recurrence at that
time.
8. COPD
9. DM2
10. Obesity
11. OSA, intolerant of CPAP
12. Recurrent falls of unclear etiology
13. Aortic stenosis
Social History:
The patient lives in [**Location (un) 31384**] with his wife. [**Name (NI) **] is retired.
He quit smoking in [**2169**]. He has a couple of alcoholic drinks
every other day.
Family History:
Noncontributory
Physical Exam:
Admission exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, systolic murmur
which patient states is old
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly, patient has
right gluteal erythema with small vesicles in the S3-S4
distribution
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Discharge exam:
Physical Exam
96.3, 71, 135/83, 71, 16 96 3 L
in/ out: /1700
General: Alert, oriented male, no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, JVP elevated to clavicle, no LAD
Lungs: Bibasilar insp. crackles with decreased lung sounds
toward the bases, no wheezes, rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, harsh systolic
murmur in the 2nd intercostal space radiating to the left 2nd
intercostal space and systolic murmur in the left 4th
intercostal space radiating to the right axilla.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly, patient has
bilateral gluteal erythmea with no vesicles visulaized.
GU:no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis.
Nonpitting edema to the ankles bilaterally
Pertinent Results:
Admission labs:
[**2192-5-18**] 10:17PM BLOOD WBC-6.6 RBC-2.82* Hgb-8.4* Hct-25.1*
MCV-89 MCH-29.8 MCHC-33.4 RDW-17.9* Plt Ct-330
[**2192-5-18**] 10:17PM BLOOD PT-15.2* PTT-27.1 INR(PT)-1.3*
[**2192-5-18**] 10:17PM BLOOD Glucose-115* UreaN-10 Creat-0.8 Na-139
K-4.0 Cl-102 HCO3-26 AnGap-15
[**2192-5-18**] 10:17PM BLOOD Calcium-8.8 Phos-3.8 Mg-1.9
[**2192-5-18**] Blood culture: No growth
[**2192-5-19**] Urine culture: No growth
[**2192-5-20**] C. diff - negative
[**2192-5-20**] Tissue culture - MSSA
HSV viral culture - negative
VZV viral culture - negative
MRI C-spine, L-spine, T-spine:
IMPRESSION:
1. Increased signal intensity in the C5-C6 disc and C5 and C6
vertebral
bodies along with an epidural component of soft tissue
enhancement with
moderate canal stenosis and compression on the cervical cord as
seen on the prior study. Findings were discussed with Dr.
[**Last Name (STitle) 1352**] by Dr. [**Last Name (STitle) **] on
[**2192-5-20**].
CT C-spine:
1. Diffuse demineralization, without fracture or traumatic
malalignment.
2. Disc space narrowing and anterior/posterior osteophytes,
resulting is
moderate-to-severe canal narrowing at this level. This, as well
as findings concerning for discitis/osteomyelitis, were better
assessed on the MRI performed earlier the same day. Please see
that report for further details.
TEE:
There are simple atheroma in the aortic arch. There are simple
atheroma in the descending thoracic aorta. The aortic valve
leaflets (3) are mildly thickened. No masses or vegetations are
seen on the aortic valve. No aortic valve abscess is seen.
Significant aortic stenosis is present (not quantified). Trace
aortic regurgitation is seen. The mitral valve leaflets are not
well seen. No vegetation/mass is seen on the pulmonic valve.
IMPRESSION: Limited study. Mildly thickened aortic valve
leaflets without discrete vegetation. Likely aortic stenosis
(not quantified). Mitral valve not well seen due to anatomic
abnormality of prior esophagectomy/hiatal hernia.
EKG:
Atrial fibrillation with rapid ventricular response.
Intraventricular
conduction delay of right bundle-branch block type. ST-T wave
abnormalities. Since the previous tracing of [**2190-1-13**] limb lead
voltage is now less prominent at a faster rate.
.
Discharge Labs
[**2192-5-25**] 07:45AM BLOOD WBC-5.9 RBC-3.92* Hgb-11.6* Hct-35.5*
MCV-90 MCH-29.6 MCHC-32.7 RDW-17.1* Plt Ct-247
[**2192-5-24**] 03:30AM BLOOD WBC-6.7 RBC-3.66* Hgb-11.2* Hct-32.6*
MCV-89 MCH-30.7 MCHC-34.4 RDW-17.1* Plt Ct-253
[**2192-5-23**] 04:06AM BLOOD WBC-6.9 RBC-3.50* Hgb-10.5* Hct-30.7*
MCV-88 MCH-30.1 MCHC-34.3 RDW-17.0* Plt Ct-210
[**2192-5-25**] 07:45AM BLOOD Plt Ct-247
[**2192-5-25**] 07:45AM BLOOD PT-15.9* PTT-26.3 INR(PT)-1.4*
[**2192-5-24**] 03:30AM BLOOD PT-15.4* PTT-27.8 INR(PT)-1.3*
[**2192-5-23**] 04:06AM BLOOD Plt Ct-210
[**2192-5-23**] 04:06AM BLOOD PT-15.0* PTT-27.1 INR(PT)-1.3*
[**2192-5-20**] 05:40PM BLOOD PT-15.3* PTT-27.5 INR(PT)-1.3*
[**2192-5-20**] 05:28AM BLOOD Plt Ct-339
[**2192-5-18**] 10:17PM BLOOD PT-15.2* PTT-27.1 INR(PT)-1.3*
[**2192-5-20**] 05:40PM BLOOD Fibrino-580*#
[**2192-5-19**] 04:25PM BLOOD ESR-140*
[**2192-5-25**] 07:45AM BLOOD Glucose-136* UreaN-12 Creat-0.5 Na-139
K-3.2* Cl-99 HCO3-31 AnGap-12
[**2192-5-24**] 03:30AM BLOOD Glucose-132* UreaN-12 Creat-0.6 Na-138
K-3.8 Cl-101 HCO3-28 AnGap-13
[**2192-5-23**] 10:30PM BLOOD Glucose-109* UreaN-10 Creat-0.6 Na-138
K-3.1* Cl-101 HCO3-28 AnGap-12
[**2192-5-23**] 04:06AM BLOOD Glucose-117* UreaN-8 Creat-0.5 Na-139
K-3.4 Cl-104 HCO3-27 AnGap-11
[**2192-5-22**] 05:30AM BLOOD Na-137 K-3.7 Cl-104
[**2192-5-25**] 07:45AM BLOOD Calcium-9.1 Phos-2.7 Mg-2.1
[**2192-5-24**] 03:30AM BLOOD Calcium-8.8 Phos-3.8 Mg-2.0
[**2192-5-23**] 10:30PM BLOOD Calcium-8.7 Phos-2.6* Mg-2.1
[**2192-5-23**] 04:06AM BLOOD Calcium-8.6 Phos-3.0 Mg-2.1
[**2192-5-20**] 05:28AM BLOOD calTIBC-296 Ferritn-129 TRF-228
[**2192-5-19**] 04:25PM BLOOD CRP-50.6*
[**2192-5-23**] 04:36AM BLOOD Type-ART Temp-38.1 pO2-139* pCO2-42
pH-7.43 calTCO2-29 Base XS-3 Intubat-INTUBATED
[**2192-5-22**] 10:13AM BLOOD Type-ART Temp-37.0 Rates-/15 PEEP-15
FiO2-40 pO2-121* pCO2-41 pH-7.45 calTCO2-29 Base XS-4
Intubat-INTUBATED
[**2192-5-23**] 04:36AM BLOOD freeCa-1.15
[**2192-5-22**] 10:13AM BLOOD freeCa-1.20
[**2192-5-23**] 10:57PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.023
[**2192-5-23**] 10:57PM URINE Blood-MOD Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-TR
[**2192-5-23**] 10:57PM URINE RBC-28* WBC-17* Bacteri-NONE Yeast-NONE
Epi-0
.
[**5-21**] ECHO
There are simple atheroma in the aortic arch. There are simple
atheroma in the descending thoracic aorta. The aortic valve
leaflets (3) are mildly thickened. No masses or vegetations are
seen on the aortic valve. No aortic valve abscess is seen.
Significant aortic stenosis is present (not quantified). Trace
aortic regurgitation is seen. The mitral valve leaflets are not
well seen. No vegetation/mass is seen on the pulmonic valve.
IMPRESSION: Limited study. Mildly thickened aortic valve
leaflets without discrete vegetation. Likely aortic stenosis
(not quantified). Mitral valve not well seen due to anatomic
abnormality of prior esophagectomy/hiatal hernia.
.
[**5-23**] CXR
The ET tube tip is 5 cm above the carina. The location of the NG
tube tip is unchanged. Cardiomediastinal silhouette is
unchanged. Mild interstitial
edema and bilateral pleural effusions appear to be slightly more
pronounced on the current study.
.
DVT study [**5-23**]
Non-occlusive thrombus of the mid and distal right superficial
femoral vein.
Brief Hospital Course:
69 yM h/o DVT/PE, chronic neck pain recently admitted to OSH
found to be bacteremic and discharged with PO abx, readmitted to
another OSH and found to have C5-6 diskitis w/ phelgmon and
continued bacteremia, transferred for further care.
#. Bacteremia: Patient had blood cultures at [**Hospital 8641**] Hospital
that grew MSSA as well as 1 set of blood cultures from
[**Hospital 12017**] Hospital grew out MSSA. Last positive on [**5-13**].
Etiology of MSSA likley cervical injections by an
anesthesiologist in NH. Patient had transthoracic ECHO at OSH
that did not show endocarditis, but could not have TEE done
because of difficult anatomy. Patient also had MSSA growing
from urine. Likely that initial source of infection was
cervical injections leading to diskitis and phlegmon, leading to
bacteremia and hematogenous spread to urine.
Following transfer to [**Hospital1 18**], continued naficillin. Patient had
blood cultures drawn, which did not grow MSSA. Orthospine
consulted and patient underwent surgery to treat C5-6 phlegmon
[**5-20**]. Patient underwent TEE and mitral valve was not well
visualized but no vegetations were seen. Infectious disease
consulted and recommended 6 week antibiotic course from date of
washout on [**5-20**] and ID follow-up within two weeks of discharge.
#. Cervical diskitis w/ C5-6 phelgmon: Patient has chronic neck
pain that was acutely worsening. MRI done at OSH did show C5-6
diskitis phelgmon. This could likely be the source of the
bacteremia, or conversely the bacteremia could have seed the
phelgmon. Patient had repeat MRI at [**Hospital1 18**] showing persistent
epidural abnormailty with enhancement at C5/6 and moderate canal
stenosis with deformity on the cord. Minimal prevertebral soft
tissue swelling. CT scan of c-spine showed diffuse
demineralization, without fracture or traumatic malalignment,
disc space narrowing and anterior/posterior osteophytes
resulting is moderate-to-severe canal narrowing at this level.
Patient went to OR for debridement/laminectomy of diskitis they
took out disk which was already necrosed. Patient did well post
surgery. He was kept intubated following surgery to allow
swelling in neck to decrease.He was extubated without
complications. On the general floor the patient was stable on 2
L NC without any complaints of dyspnea. Naficillin was
continued. His NG tube was placed in because of poor oral
intake though he was tolerating pre thickened diet well. Speech
and Swallow determined in the next couple of days the patient's
post op swelling should decrease which would allow advanced diet
and adequate caloric intake. The patient will be followed by
speech and swallow at rehab.
.
#. Anticoagulation: Patient is on coumadin for a.fib as well as
extensive history of PEs/DVTs in the past and has current DVT.
Presented to [**Location (un) 12017**] with INR of 13. He was not actively
reversed. He had his coumadin held and was subtherapeutic on
arrival to [**Hospital1 18**]. Patient was initially started on heparin gtt,
which was stopped for spinal surgery. On [**5-23**], patient was
restarted on coumadin and SQH. Patient had b/l lower extremity
ultrasound as he had low grade fevers showing non-occlusive clot
in right superficial femoral vein, however it is unclear if the
clot is acute or chronic. Patient was not started on heparin
gtt given risk of bleeding. He does have a patent IVC filter in
place. Goal INR is between [**2-9**] and INR as of [**5-25**] was 1.4 on 5mg
Coumadin daily and slowly trending up. His INR was 1.5 on [**5-28**]
and his Coumadin was increased to 7.5mg daily from 5mg daily on
[**5-28**].
.
#Diarrhea- The patient has been experiencing 7 days of diarrhea
in the abscence of any fevers/chills. Not experiencing any
abdominal pain. He has been negative 3 times for c.diff stool
antigen test.Could be antibiotic induced/ tube feed induced.
Prescribed Loperamide to slow his diarrhea on [**5-28**]. His
potassium has been repleted for the last 2 days.
.
#. Lower back rash: Patient went to [**Hospital 12017**] hospital
complaining of total body pain including pain around his anus.
Was found to be guaiac positive with vesicles around the anus
and right gluteal area. On transfer patient was taking valtrex.
Infectious disease team did not think patient's ulcer was
consistent with zoster. Wound culture was negative for zoster
and valtrex was discontinued. Likely pressure in etiology though
no skin breakdown seen.
.
# Pain: Patient with uncontrolled pain from neck . Prior to
surgery patient was intubated and pain was controlled with
fentanyl. Following extubation patient was started on dilaudid
PCA. Patient's home dose of gabapentin was uptitrated for
neuropathic leg pain. He was transitioned from PCA pump to IV
Bolus's of Dilaudid on [**5-25**].
.
#. UTI: The patient had dysuria as an original complaint. He
also had positive urine culture from [**Hospital **] hospital with MSSA.
Patient was continued on naficillin as above. Patient's urine
cultures at [**Hospital1 18**] had no growth.
.
#. h/o A.fib: On admission patient was in sinus rhythm. He was
continued on metoprolol. Patient's coumadin was initially held
as above. Following surgery patient had atrial fibrillation
with RVR. Patient's metoprolol dose was uptitrated and he
received IVF.Coumadin has been restarted per above.
.
#. DM2: Treated patient with humalog insulin sliding scale.
-----------------
Outpatient follow up
-Continue Nafcillin 8 weeks from [**5-20**]
- Coumadin with goal INR of between [**2-9**]
-Have speech and swallow follow the patient and assess when NG
tube can be removed. Patient was tolerating prethickened diet
well on discharge.
Medications on Admission:
Medications on transfer:
Vitamin D 4000units daily
Celexa 20mg daily
Neurontin 600mg TID
Lopressor 25mg [**Hospital1 **]
Lasix 80mg Mon Thurs
Finasteride 5mg dialy
Protonix 40mg daily
Folic acid 1mg daily
Nafcillin 2gm Q4H - started [**2192-5-14**]
Novolog sliding scale
Valacyclovir 1000mg TID
Morphine PCA
Tylenol PRN
Ativan 0.5mg q6H prn
Ambien 5mg QHS prn
Tums 1000mg Q4h prn
Maalox prn
Duoneb prn
percocet PRN
ultram PRN
Zofran PRN
Compazine PRN
.
Home medications:
Opana 10mg Q6H for 10 days
lopressor 25mg [**Hospital1 **]
lasix 80mg mon and thurs
zetia 10mg daily
proscar 5mg daily
protonix 40mg daily
folic acid 1mg [**Hospital1 **]
compazine 10mg [**Hospital1 **]
vitamin 2000mg daily
potassium 10mEq daily
neurontin 600mg TID
coumadin 5mg daily
Discharge Medications:
1. cholecalciferol (vitamin D3) 400 unit Tablet [**Hospital1 **]: Two (2)
Tablet PO DAILY (Daily).
2. citalopram 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
3. finasteride 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
4. folic acid 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
5. Nafcillin 2 g IV Q4H
6. nystatin 100,000 unit/g Cream [**Hospital1 **]: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
7. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension [**Hospital1 **]:
15-30 MLs PO QID (4 times a day) as needed for abd pain .
8. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Hospital1 **]:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed for
wheezing.
9. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler [**Hospital1 **]:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed for
wheezing.
10. metoprolol tartrate 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID
(3 times a day).
11. acetaminophen 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain.
12. lorazepam 0.5 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
13. zolpidem 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
14. gabapentin 400 mg Capsule [**Hospital1 **]: Two (2) Capsule PO Q8H (every
8 hours).
15. docusate sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
16. bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
17. senna 8.8 mg/5 mL Syrup [**Hospital1 **]: One (1) Tablet PO BID (2 times
a day) as needed for constipation.
18. zinc sulfate 220 mg Capsule [**Hospital1 **]: One (1) Capsule PO DAILY
(Daily).
19. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
20. heparin (porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1)
Injection TID (3 times a day): continue until INR therapeutic .
21. hydromorphone 2 mg/mL Syringe [**Last Name (STitle) **]: One (1) Injection Q3H
(every 3 hours) as needed for pain .
22. loperamide 2 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO QID (4 times
a day) as needed for diarrhea .
23. warfarin 2.5 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO Once Daily
at 4 PM.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 8957**]
Discharge Diagnosis:
MSSA Bacteremia
Cervical Discitis
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:
It was a pleasure to care for you as your doctor.
.
You were brought to the hospital becasue of bacteria found to be
growing in your blood. You were found to have a spine infection
in your neck and underwent surgical debridement of it.
.
You will need to take an antibiotic Nafcillin for 8 weeks from
[**2192-5-20**].
.
You were started on Dilaudid as needed for pain.
.
Followup Instructions:
Department: [**Year (4 digits) **] SURGERY
When: TUESDAY [**2193-3-19**] at 10:00 AM
With: [**Year (4 digits) **] LMOB (NHB) [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: [**Hospital Ward Name **] SURGERY
When: TUESDAY [**2193-3-19**] at 11:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: [**Hospital Ward Name **] SURGERY
When: TUESDAY [**2193-3-19**] at 11:00 AM
With: [**Year (4 digits) **] LMOB (NHB) [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
ICD9 Codes: 7907, 5990, 2724, 4019, 496, 4241, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3629
} | Medical Text: Admission Date: [**2183-1-17**] Discharge Date: [**2183-1-24**]
Date of Birth: [**2114-4-26**] Sex: M
Service: SURGERY
Allergies:
Lidocaine / Wheat Starch / Lipitor / Zetia / Percocet / Nexium
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
He has had 6 weeks of lower back/hip pain.
Major Surgical or Invasive Procedure:
Open AAA repair
History of Present Illness:
64M with admitted with reports of a AAA. He has had 6 weeks of
lower back/hip pain. He had an MRI of his lumbar spine to
evaluate for spinal canal stenosis. A 8.8 cm AAA was discovered.
(mild R foraminal encroachment at L5/S1). The pain he relates
is
more laterally then midline. No substernal chest pain.
Other recent medical hisotry is a L vitrectomy and retinal
repair
in [**4-23**]. Then on [**1-8**] he had a headache and complete loss
of
vision in that left eye. He was seen by his opthalmologist who
saw nothing wrong with his eye and diagnosed amaurosis fugax.
His
vision resolved within a few hours although it is still mildy
blurry. Unclear what diagnostic tests he underwent for this but
he was started on coumadin w/ lovenox bridge.
Past Medical History:
1. Hypercholesterolemia
2. HTN
3. CAD as in HPI
4. GERD
Social History:
etoh: social
tob: quit [**2164**]
drugs: none
Family History:
no family history of aneurysmal disease
Physical Exam:
Vitals: T 98 HR 89 RR 18 BP 130/107 O2 sat 97% RA
Gen: middle-aged man, pleasant
Skin: warm and dry skin, no rash
HEENT: nc/at, mmm
CV: RRR
Lungs: CTAB
Abd: soft, nt, nd, no HSM
Ext: no lower extremity edema, no
clubbing, cyanosis or erythema
Neuro: nonfocal exam, sensation intact
Fem [**Doctor Last Name **] DP PT
R P P P tri
L P P P tri
Pertinent Results:
[**2183-1-17**] 01:25PM BLOOD
WBC-5.5 RBC-4.41* Hgb-14.9 Hct-39.7* MCV-90 MCH-33.8* MCHC-37.6*
RDW-13.1 Plt Ct-189
[**2183-1-21**] 05:07PM BLOOD
Hct-26.1*
[**2183-1-22**] 04:51AM BLOOD
WBC-5.1 RBC-3.04* Hgb-10.2* Hct-27.5* MCV-90 MCH-33.4*
MCHC-37.0* RDW-13.1 Plt Ct-215
[**2183-1-24**] 05:19AM BLOOD
WBC-6.3 RBC-3.35* Hgb-11.4* Hct-30.0* MCV-89 MCH-33.9*
MCHC-37.9* RDW-12.8 Plt Ct-318
[**2183-1-17**] 01:25PM BLOOD
PT-44.6* PTT-52.0* INR(PT)-5.0*
[**2183-1-24**] 05:19AM BLOOD
PT-13.5* PTT-28.9 INR(PT)-1.2*
Brief Hospital Course:
Mr. [**Name13 (STitle) **] was admitted from a med-flight transfer on [**2183-1-17**]
with reports of a large AAA as reported on the HPI.
He had a CTA of this aneurysm which confirmed its size and
enabled pre-op planning. A carotid duplex was obtained to look
for a cause of his amaurosis. This did not show any stenosis.
The CTA of his torso also did not reveal any obvious source of
emboli. The AAA was deemed not a good architecture for EVAR
repair. Because of his elevated Inr he was given 1mg of vit k
and was transfused with 5 packs of ffp on the way to the OR. He
underwent midline, open AAA repair on [**1-18**].
He was transferred to the CVICU post-op. He remained intubated
overnight and was extubated in the morning. He required 1 PRBC
transfusion. He did well. He made adequate urine and his pain
was controlled with a pca.
POD #2 because of continued abd distension a ngt was placed. He
had no complications of afib or hypotension.
He was transferred to the VICU
POD #3. He was diuresed. His swann was removed and his cordis
changed to a TL. A popliteal u/s was obtained which was
negative for aneurysms.
NGT output remained high for the next several days.
He was able to get oob and his physical activity was advanced
day by day. He did not require a pt consult as he was able to
walk with nursing help only.
POD 4 his ngt was taken out and he was kept on limited sips.
POD 5 he was advanced to clears.
POD 6 regular and CVC taken out. Home meds were resumed with
the exception of coumadin and lovenox. He should be continued
on plavix and asa, more for his coronary arteries than for his
AAA repair.
Medications on Admission:
slow release nitro, asa 81', lisinopril 2.5', nitroquick prn,
protonix 40', niacin 1500', cymbalta 100', plavix 75', cymbalta
60', ativan 1', cataflan 50''', ultram 50'''', folic acid 400',
metoprolol 25'', coumadin 5', lovenox 80'.
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
5. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
6. Niacin 100 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
7. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
AAA
post op illeus
AAA
history Hyperlipidemia
HTN
CAD w/mult stents. Last in [**9-19**] when RCA dissected and IABP
placed for 2days.
history of GERD
amaurosis fugax
history of L vitrectomy
s/p retinal repair
Discharge Condition:
good
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Abdominal Aortic Aneurysm (AAA) Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel weak and tired, this will last for [**6-23**]
weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? 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 incisional and leg swelling:
?????? Wear loose fitting pants/clothing (this will be less
irritating to incision)
?????? Elevate your legs above the level of your heart (use [**2-18**]
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
?????? You should get up every day, get dressed and walk, gradually
increasing 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 (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 101.5F for 24 hours
?????? Bleeding from incision
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2183-1-31**] 10:30
Completed by:[**2183-1-24**]
ICD9 Codes: 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3630
} | Medical Text: Admission Date: [**2151-7-28**] Discharge Date: [**2151-8-9**]
Date of Birth: [**2077-1-26**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
Sub arachnoid hemorrhage presenting with severe headache
Major Surgical or Invasive Procedure:
[**7-29**] Cerebral angiogram
[**8-3**] Repeat angiogram
History of Present Illness:
Per report this 74 y/o female with PMH of Hep C and HTN
awoke this afternoon from a nap with a headache called her
daughter to come home and the daughter found her vommiting but
awake was reportedly neurologically intact went for CT scan and
came back was unresponsive with nausea and vomitting she was
intubated. Outside CT shows diffuse SAH she was transferred
here
for further management.
Past Medical History:
anemia, hypertension, hepatitis C, B12 deficiency, hx of
transfusion, cataract, foot and stomach surgeries.
Social History:
Non smoker, occ alcohol no illicit drugs, Portugese
speaking
Family History:
unknown
Physical Exam:
Exam on admission ([**7-28**]):
T: BP:139/61 HR:88 R 14 O2Sats100%
Gen: Intubated and previously sedated
HEENT: Pupils: 3-2mm EOMs can't test
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Intubated and sedated from flight
Pupils 3-2mm briskly reactive
Localizes briskly with upper extremities
Grimaces to pain face appears symmetric
Slight withdrawl of lower extremities
Toes downgoing
Pertinent Results:
CTA HEAD W&W/O C & RECONS [**2151-7-28**]
1) Extensive subarachnoid hemorrhage as above with
intraventricular extension and mild-to-moderate hydrocephalus.
No aneurysm identified; conventional angiogram is recommended if
clinically warranted.
2) Likely chronic lacunar infarction involving the anterior limb
of the right internal capsule.
CAROT/CEREB [**Hospital1 **] [**2151-8-3**] 9:37
1. No evidence of aneurysm, AVM, or other cause for patient's
subarachnoid hemorrhage.
2. 1 cm long focal stenosis of the P2 segment of the left PCA is
similar to prior study [**2151-7-29**]
CT HEAD W/O CONTRAST [**2151-7-31**]
No significant short-interval change compared to [**2151-7-29**]
Brief Hospital Course:
The patient was admitted from an outside hospital on [**7-28**] when a
head CT showed subarachnoid hemorrhage with intraventricular
extension and mild-to-moderate hydrocephalus. She was admitted
to the ICU. An initial cerebral angiogram showed no aneurysm or
other source of the hemorrhage. On [**3-/2073**] the patient was advanced
to regular diet. On [**8-2**] a low sodium was noted and the patient
was started on NaCl supplementation and began fluid restriction
[**8-3**] day resulting in a correction of the sodium level over the
following days. A repeat angiogram was done [**8-3**] which also
showed no evidence of aneurysm or other source of hemorrhage. On
[**8-4**] the patient was transferred from the ICU to the hospital
floor. On [**8-6**] the patient spiked a temperature to 102. A work
up was done including cultures and right upper quadrant
ultrasound which was negative. The fever abated [**8-8**]. The
patient was evaluated by physical therapy and determined that
she would be transferred to a rehab facility on discharge.
Dischagre was planned for [**8-9**].
Medications on Admission:
prednisone
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. Lisinopril 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
4. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: [**2-2**]
Inhalation Q6H (every 6 hours) as needed.
5. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 8 days.
6. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain for 2 weeks.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] health care center
Discharge Diagnosis:
sub arachnoid hemorrhage
Discharge Condition:
neurologically stable
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY
??????Take your pain medicine as prescribed
??????Exercise should be limited to walking; no lifting, straining,
excessive bending
??????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
??????Fever greater than or equal to 101??????
Followup Instructions:
You have a follow up appointment with Dr. [**Last Name (STitle) **] on [**2151-8-26**]. Please come to the [**Hospital Ward Name 121**] Building at [**Hospital1 827**], [**Location (un) **] at 9:30AM. You will need to take no
food or drink after midnight the night before. Please stop any
aspirin 5 days before the appointment
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
ICD9 Codes: 4019, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3631
} | Medical Text: Admission Date: [**2121-4-4**] Discharge Date: [**2121-4-27**]
Date of Birth: [**2051-8-25**] Sex: M
Service: Vascular Surgery Service
CHIEF COMPLAINT: Right foot pain
HISTORY OF PRESENT ILLNESS: This is a 69 year old male with
multiple medical problems and end stage renal disease who is
status post cadaveric renal transplant with peripheral
vascular disease who presented to our service with a
gangrenous right foot. He underwent an arteriogram which
demonstrated diffuse superficial femoral artery disease with
reconstruction of the posterior tibial artery. He is now
admitted for further evaluation and treatment. The patient
denies any changes in ambulation. He can walk a maximum of
[**Age over 90 **] yards with a walker. He denies rest pain.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Imdur 30 mg q.h.s., Lipitor 10 mg
q.h.s., Combivent multidose inhaler puffs 2, Glyburide 5 mg
q. AM and 2.5 mg q. PM, Hytrin 5 mg at h.s., Prograf tablets
2 b.i.d. 2 mg tablets, total dose of 4 mg b.i.d., Niferex 5
mg q.h.s., Prednisone 10 mg q.d., Cellcept 1 gm q. AM and 500
mg q. PM, Bactrim double strength 1 tablet q. AM, Protonix 40
mg q.d., Insulin NPH 14 units q. AM and q. PM with sliding
scale before meals as follows, 0-150 no insulin, 151-200 4
units, 201-250 6 units, 251-300 8 units, 301-350 10 units,
351-400 12 units of regular insulin.
PAST MEDICAL HISTORY: Past medical illnesses include - 1.
Asbestos lung disease; 2. Noninsulin dependent diabetes
mellitus Type 2 with neuropathy, retinopathy and nephropathy,
status post a cadaver renal transplant; 3. History of
asthma; 4. History of cerebrovascular accident remote; 5.
Coronary artery disease. No history of myocardial
infarction, Dobutamine stress in [**2120-5-26**] showed an
ejection fraction of 35% with a fixed inferior wall defect
and global hypokinesis of the left ventricle. The patient
also has a history of hypertension and hypercholesterolemia.
PAST SURGICAL HISTORY: A cadaveric renal transplant in
[**2121-2-24**] by Dr. [**Last Name (STitle) **], a left arteriovenous fistula and a
right knee arthroscopy in the past.
SOCIAL HISTORY: Not available on this admission.
PHYSICAL EXAMINATION: Vital signs revealed 99.0 temperature,
94% oxygen saturation on room air, heartrate 94, blood
pressure 160/84. General appearance, this is an alert, awake
white male in no acute distress. His head, eyes, ears, nose
and throat examination is with questionable bilateral carotid
bruits, otherwise unremarkable. Chest was clear to
auscultation bilaterally with diminished distant heartsounds
in all lung fields. Heart was a regular rate and rhythm
without murmur, gallop or rub. Abdominal examination showed
a mild abdominal distention but was soft. It was nontender.
He had well healed incision scars at the transplant sites
with the kidney felt in the right iliac fossa. The rectal
examination shows guaiac negative stool and this is by
previous report. The patient refused rectal examination on
this admission. Extremity pulse examination shows femoral
pulses bilaterally are palpable, femorally popliteal pulse on
the right is dopplerable signal and on the left palpable.
There are absent dorsalis pedis pulses bilaterally with
dopplerable signals of the posterior tibial pulses
bilaterally. There are ulcerations noted on toes 2, 3 and 4.
The anterior tibial area of the right leg shows a dry area of
eschar with mild surrounding cellulitis which is tender to
palpation.
LABORATORY DATA: Admitting laboratory data included complete
blood count with white count 5.5, hematocrit 25.3, platelets
of 252. Complete blood count on [**2121-4-27**], white count
was 5.4, hematocrit 30.6, platelets 458. Electrolytes showed
sodium 138, potassium 5.1, chloride 99, total carbon dioxide
30, BUN 40, creatinine 1.9 with the admitting glucose of 149.
Electrolytes on [**2121-4-27**] showed sodium 137, potassium
5.1, chloride 101, carbon dioxide 28, BUN 16, creatinine 1.7,
and glucose 90. PTT and PT/INR were within the normal range.
Admitting chest x-ray showed extensive pleural plaguing
consistent with previous asbestos exposure. This was
approximately a 1.9 cm diameter focal opacity in the left
lower lobe not clearly seen on previous chest x-rays. This
possibly could be due to pleural plaguing but a discrete
neoplasm in this region can not be ruled out and further
evaluation is recommended. Carotid ultrasounds were obtained
preoperatively secondary to carotid bruits auscultated on
physical examination. This demonstrated mild plaguing with
bilateral stenosis less than 40%. Of note, the right
vertebral artery was not visualized. Microbiology cultures
obtained during this admission on [**2121-4-18**] for an
elevated temperature showed enterococcus fecalis and
Corynebacterium species and Beta which the enterococcus was
sensitive to Ampicillin, Penicillin and Vancomycin. The
blood cultures were [**1-26**] positive, both aerobic and anaerobic
cultures growing enterococcus. Sensitivities as described
earlier. Urine culture and sensitivity was sent also and the
final report was no growth. Cultures of the right central
venous line, internal jugular were obtained at the time of
the temperature spike. These cultures were positive for
Enterococcus species, 15 colonies times two, sensitivity
showed the patient was sensitive to Ampicillin, penicillin
and Vancomycin. Repeat blood cultures were obtained, per
Infectious Disease advice on [**2121-4-24**]. The cultures are
no growth at the time of dictation but not finalized. The
patient's electrocardiogram showed a normal sinus rhythm with
a ventricular rate of 76 with a left ventricular hypertrophy
with secondary ST-T wave changes but ischemia could not be
ruled out. He had a normal axis deviation. There were no
acute ischemic changes noted.
HOSPITAL COURSE: The patient was admitted to the Vascular
Service on [**4-4**]. He was placed on bedrest with strict
intakes and outputs. Fasting glucoses were obtained q.i.d.
A foot cradle was placed over the end of the foot for
protection. Routine laboratory data was obtained, see
laboratory data and diagnostic procedures for results. He
was continued on [**First Name8 (NamePattern2) **] [**Doctor First Name **] 1800 renal diet. He was continued on
his preadmission medications, Morphine 1 to 4 mg
intravenously q. 3 hours prn was ordered for analgesic
control, but to be held if the patient was sedated or
respiratory rate was less than 12. Intravenous Kefzol 1 gm
q. 8 hours was begun and Flagyl 500 mg intravenously q. 8
hours was begun. Subcutaneous Heparin 5000 units b.i.d. was
initiated for deep vein thrombosis prophylaxis. His
immunosuppressive regime was continued. The patient did
receive 1 unit of packed cells for his low hematocrit with
improvement in his hematocrit post transfusion. Subcutaneous
heparinization was discontinued on [**4-5**] and intravenous
heparinization was begun with a 3000 unit bolus with an 1800
unit/hour drip which was monitored by PTTs and adjusted for
PTT greater than 60 and less than 80. The Kefzol was
discontinued on Levaquin 250 mg by mouth was begun q. 24
hours. The Renal Transplant Service followed the patient
during his hospitalization and managed his immunosuppressive
regimes. Because of the patient's renal status and ischemic
right foot an magnetic resonance imaging scan of the lower
extremity was obtained which demonstrated no significant
inflow disease, superficial femoral arteries bilaterally
showed multifocal diffuse high grade stenosis and popliteals
right and left both showed significant disease above and
below the knee. Popliteals and tibials, there is no straight
line of arterial flow to either foot and the bilateral
occlusions of the anterior tibials and dorsalis pedis were
noted. The right foot is supplied by a single vessel
posterior tibial artery which is reconstituted approximately
10 cm above the ankle joint. On the left foot it was also
supplied by the posterior tibial artery which was
reconstituted at the ankle. After deciding the patient was
revascularable, Cardiology requested to evaluate them for
perioperative risk assessment. They felt that there was no
reversible ischemia and no segmental wall abnormalities,
despite the fixed defect and he was cardiac-wise at mild to
moderate risk and we could proceed with the surgery.
Recommendations were to continue ARBs and ACE inhibitors to
ensure a systolic blood pressure of 120, diastolic of 80 and
the patient is also followed by the [**Hospital1 **] Service for
management of his diabetes. Their recommendations initially
after assessment are to continue the NPH 14 units at h.s.,
increase his NPH to 18 units q. AM and a new sliding scale
was ordered. His low agents glyburide dosing remained
unchanged. With this, there seemed to be significant
improvement in the patient's glucoses, especially fastings.
ACE inhibitor was begun, Lisinopril 2.5 mg q.d. and to be
titrated as necessary to maintain the parameters recommended
by Cardiology. The patient underwent, on [**2121-4-10**], a
right femoral-posterior tibial bypass for in situ saphenous
vein with angioscopy and valve lysis. The patient tolerated
the procedure well and was transferred to the Post Anesthesia
Care Unit in stable condition with a palpable right posterior
tibial and graft pulse at the end of the procedure.
Immediate postoperatively the patient remained afebrile and
hemodynamically stable with a complete blood count of 8 and a
PA pressure of 34/20. His systolic was 138, diastolic 58.
He was 97% on 3 liters of oxygen. He was awake. His
dressings showed some drainage staining with a palpable graft
pulse, dopplerable distal posterior tibial. Post hematocrit
was 28.5. His BUN was 23, creatinine 1.8. He continued to
do well, although both feet were slightly cool. The patient
was transferred to the Vascular Intensive Care Unit for
continued monitoring and care. He was begun on intravenous
heparin without a bolus. He required Dilaudid for analgesic
control. He received a second unit of blood for a hematocrit
of 26.2. His BUN and creatinine remained stable. He
received Lasix post blood transfusion. His intravenous
heparin drip was continued. He remained in the Vascular
Intensive Care Unit.
On postoperative day #2 there were no overnight events.
T-Max was 100.1, defervesced to 99.8. His hematocrit post
transfusion was 30. His creatinine did bump to 2.0. His PA
catheter was converted to central venous line. He was
allowed up in a chair with nonweightbearing. He was begun on
his oral medications. Because of his systolic hypertension,
his Lisinopril was continued at 2.5 mg q.d. but his Lopressor
was increased to 37.5 mg b.i.d., hold for heartrate less than
60. The foot continued to show demarcation with a coolness
of the foot and cyanotic changes of the middle three toes to
mid foot. His pulse graft was noted to be monophasic and
slow. His heparin was continued. He was prepared for an
arteriogram and Mucomyst at 600 b.i.d. times four doses was
begun and intravenous hydration was begun. He underwent on
[**4-14**] an arteriogram of the right lower extremity. The
arteriogram demonstrated a high grade stenosis involving a
native distal posterior tibial just beyond the distal
anastomosis of the right femoral posterior tibial bypass.
The mid lateral plantar artery was also stenosed at 50% in
its mid portion. The patient returned to Surgery on [**2121-4-16**]. He underwent a right posterior tibial artery patch
angioplasty. He had a dopplerable posterior tibial signal at
the end of the procedure. Immediately postoperatively he
remained hemodynamically stable with a hematocrit of 29.4 and
potassium of 4.9. He was transferred to the Vascular
Intensive Care Unit for continued monitoring and care. On
postoperative day #7 and 1 he continued on his antibiotics,
Levofloxacin and Flagyl and his Heparin was at 850
units/hour. He was continued on his immunosuppressive
medications. He was given Lopressor 5 mg intravenously q. 6
hours while he was NPO. His hematocrit remained stable at
29.6. His creatinine showed improvement to 1.8. His PA
catheter and arterial line were discontinued. His diet was
advanced as tolerated. He was continued on bedrest but was
placed on floor status. Plavix was begun on [**2121-7-19**]
and heparin would be weaned. His CK 506 levels were elevated
at 19.5, previous levels had been 13 to 14.9. His dose was
adjusted and he was begun on 2 mg q. AM and the PM dose was
changed to 1 mg. The level would be followed and adjustments
made as indicated. His renal function continued to show
improvement. On [**2121-4-19**], the patient had a fever spike
to 103.0. He was pancultured and blood cultures were
positive. After review of sensitivities Vancomycin was added
to his antibiotic regime and the Levofloxacin and Flagyl were
continued. Vancomycin was added on [**2121-4-19**]. The
patient defervesced over the next 24 hours with the addition
of a new antibiotic therapy. Transesophageal echocardiogram
was obtained to rule out the cardiac source for his fever and
this was negative for any vegetations or intracardiac
thrombus. He would need at least a total of four to six
weeks of antibiotic therapy for his positive blood cultures.
Infectious Disease was consulted to make final
recommendations on antibiotic therapy.
On [**4-23**], these recommendations were a ten day course of
ampicillin, post line removal for Enterococcal line sepsis.
The patient underwent on [**2121-4-24**], a right
transmetatarsal amputation without complications. He
tolerated the procedure well and was transferred to the Post
Anesthesia Care Unit for continued monitoring and care. The
right foot bandage remained essentially dry. The patient was
transferred back to the Vascular Floor for continued care.
Vancomycin was discontinued on [**4-20**], and Ampicillin was
begun. The dosing was changed on [**4-25**] to 2 gm
intravenously q. 8 hours. The patient did have episodes of
intermittent small voids, a post residual urine was obtained
which was 100 cc. Renal fellow recommended this to be
followed up on an outpatient basis or by his primary care
physician but no other intervention at this time. The
patient continued to have frequent episodes of urination.
This should be followed up on an outpatient basis.
He will be discharged on his in-house immunosuppressive
regime. The patient should follow up with [**Hospital 159**] Clinic and
[**Hospital 1326**] Clinic at the same time, two weeks post discharge.
He should also follow up with his primary care physician, [**Name10 (NameIs) **]
he may be aware of what has transpired during this admission.
The patient's primary care physician is [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 2411**] [**Last Name (NamePattern1) 1693**].
The patient should also follow up with [**Hospital1 **] people as
directed in Dr.[**Name (NI) 1392**] office in two weeks. The patient
will remain strict nonweightbearing for a total of four weeks
from the date of his transmetatarsal amputation. His skin
clip sutures should be removed prior to discharge. The
transmetatarsal amputation wound site sutures will remain in
place until followed up by Dr. [**Last Name (STitle) 1391**]. When the patient is
not ambulating, nonweightbearing on the right extremity, then
the leg should be elevated.
DISCHARGE MEDICATIONS:
1. Ditropan 5 mg b.i.d.
2. Ampicillin 2 gm intravenously q. 8 hours
3. Dilaudid 2 to 4 mg p.o. q. 4 to 6 hours prn for pain
4. Prednisone 10 mg q.d.
5. Ganciclovir 500 mg q. 12 hours
6. Mycophenolate Mofetil 500 mg b.i.d.
7. Ranitidine 500 mg b.i.d.
8. Bactrim SF1 q.d.
9. Albuterol puffs 1 to 2 q. 6 hours prn
10. Dulcolax tablets 5 mg two p.o. or Dulcolax suppository 10
mg prn
11. Tylenol 325 to 650 mg q. 4 to 6 hours prn
12. Colace 100 mg b.i.d.
13. Plavix 75 mg q. day
14. Tacrolimus 2 mg b.i.d.
15. Insulin, as of [**2121-4-24**], the insulin NPH 16 units q.
AM and 10 units at bedtime
16. Humalog sliding scales q.i.d. before meals and at bedtime
as follows, glucose 0-50 no insulin, 51-100 no insulin,
101-150 no insulin, 151-200 2 units at breakfast, lunch,
dinner and bedtime, 201-250 4 units at breakfast, lunch,
dinner and bedtime, 251-300 6 units breakfast, lunch, dinner
and bedtime, 301-350 8 units breakfast, lunch, dinner and
bedtime, 351-400 10 units breakfast, lunch, dinner and
bedtime, greater than 400 12 units at breakfast, lunch,
dinner and bedtime.
DISCHARGE DIAGNOSIS:
1. Right foot ischemia, status post right femoral-posterior
tibial bypass graft with in situ saphenous vein on [**2121-4-10**].
2. Recurrent right foot ischemia, status post right femoral
artery to posterior tibial bypass with vein angioplasty on
[**2121-4-16**].
3. Gangrenous right toes, 2, 3, and 4
4. Status post right transmetatarsal amputation on [**2121-4-24**]
5. Blood loss anemia, corrected.
6. Type 2 diabetes with hyperglycemia, corrected.
7. Status post renal transplant with elevated creatinine,
corrected.
8. Hypertension, controlled.
9. Questionable urinary tension frequency etiology
undetermined, treated
DISCHARGE INSTRUCTIONS: Evaluation in outpatient department.
Dressings to right transmetatarsal, dry sterile dressings
q.d. Antibiotics, Ampicillin 2 gm intravenously q. 8 hours
for a total of 14 days, this was begun on [**2121-4-22**] and is
to continue for a total of ten more days, so will be
discontinued after [**2121-5-5**]. The Levofloxacin and
Flagyl were discontinued on [**2121-4-24**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4417**]
Dictated By:[**Last Name (NamePattern1) 1479**]
MEDQUIST36
D: [**2121-4-27**] 16:23
T: [**2121-4-27**] 16:59
JOB#: [**Job Number 25438**]
ICD9 Codes: 7907, 3572 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3632
} | Medical Text: Admission Date: [**2140-12-19**] Discharge Date: [**2140-12-28**]
HISTORY OF PRESENT ILLNESS: This is an 89 year old
right-handed man with a history of questionable hypertension,
hypercholesterolemia, aortic aneurysm and prostate cancer who
was in general good health when he got up and went to the
left arm and leg weakness in the bathroom at 07:05. This
made him fall. EMS came by 07:30 and he was brought to [**Hospital1 1444**] at 08:45. Was proptly evaluated
by Dr [**Last Name (STitle) 35880**] from the stroke team, MRI confirmed the diagnosis
of stroke and since he met the NINDS criteria, he was treated
with IV 0.9 mg/kg of IV tPA. The patient had an initial
improvrment of his symptoms and recovered his deficit
PHYSICAL EXAMINATION: On arrival, blood pressure 134/80;
heart rate 80. Chest clear bilaterally. Cardiovascular:
Regular rate and rhythm, no murmurs, no bruits. Abdomen
soft, nontender, nondistended. Extremities with no cyanosis,
clubbing or edema. Neurologic: Alert and oriented times
three. Attention and memory intact. No dysarthria. No
aphasia. "My left arm and leg are weak" is what the patient
said. Can repeat no ifs, ands or buts. Makes jokes
appropriate. Cranial nerves: Pupils equal and reactive.
Extraocular movements are intact. I through III intact.
Mild left nasolabial fold decrease. Uvula, tongue midline.
No sternocleidomastoid on the left. Motor examination: No
movement in the left upper and lower extremities. Five out
of five on the right. Finger-to-nose, heel-to-shin, no
ataxia on the right. Sensory symmetric to light touch and
pinprick. No extinction to double simultaneous stimulation.
No extinction in his visual fields.
LABORATORY: An MRI showed an area of restricted diffusion in
the right ACA territory. MRA shows no flow in the right ICA,
right middle cerebral artery, right ACA likely secondary to
low flow state.
The patient had labs done at that time pre-TPA. White count
of 4.3, hematocrit of 40, platelets 132,000. PT 11.9, PTT 25.4,
INR 1.0. Electrolytes showed a potassium of 7.4, otherwise
normal. Calcium, magnesium and phosphorus were also normal.
Repeat potassium was done which came out at 8.6 and was
grossly hemolyzed. He had another repeat potassium 20
minutes after that which showed a potassium of 4.2.
HOSPITAL COURSE: Blood pressure was controlled with a
Labetalol drip and following TPA, Mr. [**Known lastname 54239**] actually did
well. However, later that same day, six hours after TPA it
was noted that he had decreased movement in the left leg. He
was taken emergently for an angiogram that showed a 99% right ICA
stenosis. After a long discussion with Dr [**Last Name (STitle) 1391**] from the
Vascular Surgery team, Dr [**Last Name (STitle) **] form the NES/INR team and the
stroke team it was deicided that it was prudent not to operate
emergently and he was started on heparin.
The angiogram also showed ICA to ECA collateralization and a
large (5 cm) AAA. On day 3 of his NICU stay The patient had
bleeding through his Foley catheter, thus the heparin was
stopped. Urology was consulted who inserted a Foley catheter and
started a three-way irrigation. Fenestram and Flomax was
started and Levaquin was started for a presumptive urinary
tract infection.
A follow-up CT scan was obtained to evaluate the abdominal aortic
aneurysm which showed that it was stable without dissection,
which is the final read. Vascular Surgery at that point, decided
that the patient should not be anti-coagulated on Coumadin long-
term prior to repair of the abdominal aortic aneurysm.
The Foley catheter irrigation continued through [**2140-12-26**].
In addition, a transesophageal echocardiogram was considered,
but since Vascular Surgery requested no anti-coagulation on
the patient, no change in therapy would result from getting
the test so we deferred the transesophageal echocardiogram.
The patient was transferred out to the Floor on [**2140-12-22**].
On the Floor, it was noted that his left arm became weaker.
The patient's head was put down to flat and he was given
intravenous hydration. At that point, movement in his arm
came back. The head of his bed was raised slowly, gradually,
over three or four days, about 15 degrees a day, until the
patient was able to tolerate sitting up and getting out of
bed without loss of function of his arm. He was also cleared
by ORL and Swallowing.
He remained somewhat confused because it is likely that his
urinary tract infection had not cleared and Physical Therapy
and Occupational Therapy recommended placement at
rehabilitation.
DISCHARGE DIAGNOSES:
1. Right internal carotid artery occlusion.
2. Right anterior cerebral artery territory infarction.
3. Abdominal aortic aneurysm.
DISCHARGE MEDICATIONS:
1. Flomax 0.4 mg p.o. q. a.m.
2. Fenestram 5 mg p.o. q. day.
3. Levofloxacin 250 mg p.o. q. p.m. times seven days.
Follow-up on a urine culture.
4. Heparin 5000 units subcutaneously twice a day.
5. Protonix 40 mg p.o. q. day.
6. Levothyroxine 0.5 mg p.o. q. day.
7. Lopressor 25 mg p.o. twice a day; hold for systolic blood
pressure of less than 140.
8. Colace 100 mg p.o. twice a day.
9. Senna one p.o. q. day.
10. Aspirin 325 mg p.o. q. day.
11. Lactulose 30 cc p.o. q. 24 p.r.n.
12. Baby aspirin.
13. [**Name2 (NI) **].
DISCHARGE INSTRUCTIONS:
1. He will follow-up with Dr. [**Last Name (STitle) **] for his abdominal
aortic aneurysm in one month.
2. He will follow-up with Stroke Team, phone number
[**Telephone/Fax (1) 34520**].
[**Name6 (MD) 725**] [**Name8 (MD) 726**], M.D. [**MD Number(1) 727**]
Dictated By:[**Last Name (NamePattern1) 8853**]
MEDQUIST36
D: [**2140-12-28**] 10:10
T: [**2140-12-28**] 10:27
JOB#: [**Job Number 109916**]
ICD9 Codes: 5990, 2765, 2449, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3633
} | Medical Text: Admission Date: [**2155-7-8**] Discharge Date: [**2155-7-12**]
Date of Birth: [**2084-5-20**] Sex: F
Service:
ADMITTING DIAGNOSIS: Symptomatic three vessel coronary
artery disease
HISTORY OF PRESENT ILLNESS: This is a 71-year-old female
with a history of heavy smoking and insulin-dependent
diabetes mellitus for 25 years, with known coronary artery
disease since [**2147**], managed medically, who presented with
increasing symptoms on minimal exertion. The patient
underwent a cardiac catheterization on [**6-26**], which
demonstrated severe triple vessel disease with 50% stenosis
of the left main and an ejection fraction of 45%, no mitral
regurgitation. She was referred for possible surgical
correction.
PAST MEDICAL HISTORY: Significant for insulin-dependent
diabetes mellitus, coronary artery disease, achalasia.
PAST SURGICAL HISTORY: Significant for esophageal
perforation, left thoracotomy, and right total knee
replacement.
PHYSICAL EXAMINATION: She was a pleasant lady, in no
apparent distress. On neck examination, she had no jugular
venous pressure, no bruits. The lungs were clear to
auscultation. Her cardiovascular examination was regular
rate and rhythm. Her abdomen was benign. The extremities
showed bounding pulses.
HOSPITAL COURSE: She was admitted on [**7-8**] and underwent a
coronary artery bypass grafting x 5 as follows: Left
internal mammary artery to left anterior descending,
saphenous vein graft to diagonal, saphenous vein graft to
obtuse marginal II, to ramus, saphenous vein graft to
posterior descending artery. The cardiopulmonary bypass time
was 117 minutes, with an aortic cross-clamp time of 99
minutes.
The patient was transferred to the CTICU postoperatively, and
did very well. She was transferred from the CTICU on [**7-9**]
to the floor. By [**7-11**], postoperative day number three, the
patient had all chest tubes removed, and was ambulating
independently, tolerating by mouth well. Her vital signs
were afebrile, with a rate in the 70s to 80s and a stable
blood pressure. Her sternal wound showed no signs of
infection. Her leg incision was healing well.
On postoperative day number three, however, the patient,
while climbing stairs, felt a small tearing sensation within
her left leg, and there was a small dehiscence of one of the
minimally invasive vein harvest sites at the left knee. This
was examined. It was likely secondary to a hematoma that had
developed underneath one of the skin flaps. The hematoma was
evacuated, and the wound was packed with normal saline
wet-to-dry dressing changes.
Aside from this minor postoperative complication, the patient
did excellently, and was discharged on [**7-12**], to home, on
the following medications: Lasix 20 mg by mouth twice a day
for seven days, potassium chloride 20 mEq by mouth twice a
day for seven days, Colace 100 mg by mouth twice a day,
Zantac 150 mg by mouth twice a day, aspirin 81 mg by mouth
once daily, Motrin 400 to 600 mg by mouth every six hours as
needed, Synthroid 200 mcg by mouth once daily, insulin 32
units of NPH subcutaneously every morning and 16 units of
regular subcutaneously every morning, 48 units of NPH
subcutaneously daily at bedtime, and 12 units of regular
subcutaneously after dinner. The patient was also on Vasotec
5 mg by mouth once daily, Verapamil 80 mg by mouth three
times a day, hydrochlorothiazide 25 mg by mouth once daily,
isosorbide 30 mg by mouth three times a day, and Tylenol #3
one to two by mouth every four to six hours as needed for
pain.
The patient was discharged with VNA, normal saline wet-to-dry
dressing changes to the left lower extremity wound twice a
day, on a diabetic diet, with instructions to follow up with
Dr. [**Last Name (STitle) **] in a week, as well as with her primary care
physician. [**Name10 (NameIs) **] patient was stable on discharge.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Name8 (MD) 4720**]
MEDQUIST36
D: [**2155-7-12**] 00:34
T: [**2155-7-12**] 02:04
JOB#: [**Job Number **]
ICD9 Codes: 4111, 9971, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3634
} | Medical Text: Admission Date: [**2125-6-14**] Discharge Date: [**2125-6-29**]
Date of Birth: [**2060-7-29**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Linezolid
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
Fevers and increased WBC
Major Surgical or Invasive Procedure:
Interventional Radiology placed PICC line
History of Present Illness:
64 year old female with two-day vascular surgery ~ 5/808. Has
bovine aortic arch and innominate artery aneurysm. Had bypasses
to all of his great vessels and then covered stent to aorta (
anatomy unclear). Was dc'd to rehab and then represented [**6-14**] to
[**Hospital1 **] with resp distress and infection (multiple possible sources).
Past Medical History:
-- DM2
-- chronic foot ulcers/PVD
-- HTN
-- OA
-- obesity
-- asthma
-- leg pain/neuropathy
-- depression
-- anemia
-- h/o MRSA bacteremia [**11-18**], also septic arthritis treated at
[**Hospital3 **]
.
Right thalamic hemorrhage resulting in a gait disorder and
incontinence of urine, followed by Dr. [**Last Name (STitle) **].
Old CVAs.
Neuropathy, peripheral.
Anxiety and panic disorder.
Status post total abdominal hysterectomy.
Hypercholesterolemia.
Social History:
The patient lives with her daughter [**Name (NI) 2048**] and her three kids
since being d/c'ed from a nursing home last [**Month (only) 205**]. Has seven
children, many grandchildren. Smokes [**1-16**] to 1 pack per day.
Family History:
Brother died of an MI in his 30's, she denies diabetes mellitus
in the family. Cancer in parents (mother died in 40s, father in
80s), at least two siblings, but unsure what kind.
Physical Exam:
Obese AA woman laying in bed, appears to be acutely ill and
older
than staged age.
cta
rrr
abd benign
palp fems, dopp L DP only, dopp R DP/PT
Nuero
Comprehension seems intact.
Able to do months/days forwards but not backwards.
Registration intact but recall 0/3 in 3 min and [**2-17**] with prompt.
Speech is extremely slowed but coherent. Minimal output.
Mood is "OK".
Affect is flat
Pertinent Results:
ON ADMISSION:
[**2125-6-14**] 05:22PM BLOOD WBC-11.8* RBC-2.68* Hgb-7.5* Hct-23.4*
MCV-88 MCH-28.1 MCHC-32.2 RDW-17.3* Plt Ct-287
[**2125-6-14**] 05:22PM BLOOD PT-21.8* PTT-38.9* INR(PT)-2.1*
[**2125-6-14**] 05:22PM BLOOD Glucose-132* UreaN-25* Creat-1.6* Na-142
K-4.2 Cl-109* HCO3-22 AnGap-15
[**2125-6-14**] 05:22PM BLOOD CK(CPK)-348*
[**2125-6-14**] 05:22PM BLOOD CK-MB-2
[**2125-6-14**] 11:00PM BLOOD Mg-2.1
[**2125-6-14**] 08:57PM BLOOD Type-ART pO2-211* pCO2-25* pH-7.45
calTCO2-18* Base XS--4
[**2125-6-14**] 05:28PM BLOOD Lactate-1.7
[**2125-6-14**] 08:57PM BLOOD Glucose-103 Lactate-1.0
[**2125-6-14**] 08:57PM BLOOD O2 Sat-98
[**2125-6-14**] 10:22PM BLOOD freeCa-1.00*
.
ON DISCHARGE:
[**2125-6-28**] 05:26AM BLOOD WBC-10.1 RBC-3.23* Hgb-9.2* Hct-26.9*
MCV-83 MCH-28.5 MCHC-34.2 RDW-18.1* Plt Ct-256
[**2125-6-29**] 08:56AM BLOOD PT-15.9* PTT-33.4 INR(PT)-1.4*
[**2125-6-28**] 05:26AM BLOOD Glucose-79 UreaN-11 Creat-1.1 Na-141
K-4.0 Cl-107 HCO3-24 AnGap-14
[**2125-6-28**] 05:26AM BLOOD CK(CPK)-91
[**2125-6-28**] 05:26AM BLOOD Calcium-8.5 Phos-4.1 Mg-2.2
[**2125-6-14**] 5:22 pm BLOOD CULTURE
STAPH AUREUS COAG +. FINAL SENSITIVITIES.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE SET
ONLY.
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
DAPTOMYCIN------------ S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- S
VANCOMYCIN------------ <=1 S
[**2125-6-20**] 6:44 pm BLOOD CULTURE Source: Line-picc.
ENTEROCOCCUS FAECIUM. FINAL SENSITIVITIES.
ENTEROCOCCUS FAECIUM
|
AMPICILLIN------------ =>32 R
LINEZOLID------------- 2 S
PENICILLIN------------ =>64 R
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ =>32 R
[**2125-6-14**] 7:10 pm URINE Site: CATHETER
PROTEUS MIRABILIS. 10,000-100,000 ORGANISMS/ML..
PROTEUS MIRABILIS
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN--------- 0.5 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- 16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Brief Hospital Course:
Started on broad spectrum AB on admission
Pan CX'd
On first hospital night had resp distress followed PEA arrest
after meds given for intubation. transferd to the SICU. Got 1
min cpr, epi which led to af with rvr, and then dccv for AF.
Echo (reviewed with [**Doctor Last Name **]) showed large anterior mi with
aneurysmal apex. EKG also suggests anterior event in past month
(prwp). Suspect that she decompensated from cariopulmonary
perspective because of this infection and presented for care.
Cardiology consult / ID consult obtained
Pt delined / Cx's taken / Pt delined / blood, urine, surgical
site, cxr
Bronchoscopy performed [**6-15**]
Swnaz ganz placed [**6-16**]
orignal PICC pos for staph coag pos.
proteus UTI
[**6-19**] epi weaned / extubate / transfer to VICU
ID adjusts AB
PT consult / OT consult
heparin started per cardiology for ACAS / DVT upper extremity,
possible catherizationn discusse. Coumadin on hold.
Psych consult / depression.
[**6-21**] cipro dc for UTI
[**6-22**] vanco stopped / daptomycin started
pt with 2 days negative blood cx's / PICC replaced
[**6-26**] foley DC'd
Cardiolgy decides against catherization / to be arranged at
alter date
Id makes final recommendations
Pt stable for DC
Medications on Admission:
vicodin 500, lipitor 20, lopressor 25", aricept 10', celexa 10',
plavix 75'
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff
Inhalation Q6H (every 6 hours).
4. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
INH Inhalation Q6H (every 6 hours).
5. Beclomethasone Dipropionate 80 mcg/Actuation Aerosol Sig: One
(1) INH Inhalation [**Hospital1 **] (2 times a day).
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain.
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): Hold for SBP < 100 or HR < 60.
10. Daptomycin 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours) for 4 weeks: from [**6-15**] /
may DC [**7-29**] Follow labs as on Pg 1.
11. Insulin
Sliding Scale
Fingerstick Q6H
Insulin SC Sliding Scale
Regular
Glucose Insulin Dose
0-60 mg/dL 1 amp D50
61-120 mg/dL 0 Units
121-140 mg/dL 2 Units
141-160 mg/dL 4 Units
161-180 mg/dL 6 Units
181-200 mg/dL 8 Units
201-220 mg/dL 10 Units
221-240 mg/dL 12 Units
241-260 mg/dL 14 Units
261-280 mg/dL 16 Units
281-300 mg/dL 18 Units
> 300 mg/dL Notify M.D.
12. Enoxaparin 120 mg/0.8 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours) for 7 days: DC when INR is greater then 2/
Keep INR [**2-17**].
13. Coumadin 5 mg Tablet Sig: One (1) Tablet PO at bedtime: INR
goal is [**2-17**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary:
Wound infection
PEA arrest after
MI
VRE, MRSA
Secondary:
HTN, PVD, depression, urinary incontinence, DM2, anemia(iron
def), CRI (1.1-1.4), vascular dementia,
Discharge Condition:
Stable
Discharge Instructions:
WOUND CARE:
PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:
Redness in or drainage from your wound(s).
New pain, numbness or discoloration of your lower or upper
extremities (notably on the side of the incision).
Watch for signs and symptoms of infection. These are: a fever
greater than 101 degrees, chills, increased redness, or pus
draining from the incision site. If you experience any of these
or bleeding at the incision site, CALL THE DOCTOR.
Followup Instructions:
Scheduled Appointments :
Provider CAT SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2125-7-12**] 8:45
Please follow with Dr [**Last Name (STitle) 3394**] her office number is [**Telephone/Fax (1) 79526**].
You have an appointment [**7-10**] at 1030 hrs.
Appointments to be made:
Please followup with Dr [**Last Name (STitle) **] at [**Telephone/Fax (1) 2625**]. This
appointment should be in 4 weeks.
Call Dr [**Last Name (STitle) 30977**] office, you should see him in 4 weeks. he can be
reached at, Phone: [**Telephone/Fax (1) 5003**].
Completed by:[**2125-6-29**]
ICD9 Codes: 5990, 3572, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3635
} | Medical Text: Admission Date: [**2124-7-20**] Discharge Date: [**2124-7-28**]
Service: Cardiothoracic
HISTORY OF PRESENT ILLNESS: This is a 79 year old female
with a history of coronary artery disease, status post
myocardial infarction in [**2121**] who presented to an outside
hospital [**7-17**] with complaints of warmth and malaise. She
had been in her usual state of health when these symptoms
occurred which were reminiscent of her prior myocardial
infarction. She also had palpitations and intermittent
shortness of breath. Electrocardiogram then showed ST
depressions in leads 1, V3 through V6 and she was thought to
be in heart failure. CKs were cycled and found to be
negative and she was diuresed but continued to have oxygen
requirements of 4 liters by nasal cannula. She was
transferred to [**Hospital6 256**] for
cardiac catheterization with a diagnosis of unstable angina
on a Heparin drip. Her transthoracic echocardiogram done at
the outside hospital showed an ejection fraction of about 55%
with questionable wall motion abnormalities.
PAST MEDICAL HISTORY:
1. Coronary artery disease, status post myocardial
infarction in [**2121**], no catheterization was done.
2. Hypertension.
3. Hypercholesterolemia.
4. Diabetes mellitus.
5. Peripheral vascular disease.
6. Peptic ulcer disease, status post gastrointestinal bleed
requiring transfusion.
7. Status post bladder suspension. The patient has no known
drug allergies.
MEDICATIONS ON ADMISSION:
1. Heparin drip
2. Nitroglycerin drip
3. Lopressor 25 b.i.d.
4. Norvasc 10 mg q.d.
5. Pravachol 10 mg q.d.
6. Zantac
7. Univasc 7.5 mg q.d.
8. NPH 15 units q AM, 10 units q PM, 5 units of regular q.
PM
FAMILY HISTORY: Mother died at 60 of myocardial infarction,
father with diabetes mellitus.
SOCIAL HISTORY: She stopped tobacco use in [**2114**], 25 pack
year history, occasional alcohol.
PHYSICAL EXAMINATION: Physical examination on admission
revealed vital signs of temperature 97, heartrate 62, blood
pressure 142/64, respiratory rate 22, saturation 94% on 4
liters nasal cannula. General: An elderly female lying
. Head, eyes, ears, nose and throat examination:
Anicteric, no ocular lesion. Neck with jugulovenous
distension about 6 cm, carotids 2+ bilaterally.
Cardiovascular, regular rate and rhythm, II/VI systolic
murmur, no S3 or S4. Lungs, crackles bilaterally. Abdomen
is soft, nontender, nondistended with positive bowel sounds.
Extremities, 2+ dorsalis pedis pulse bilaterally, 1+ edema of
the lower extremities to mid calf. Neurological: Cranial
nerves II through XII intact, alert and oriented times three,
nonfocal.
LABORATORY DATA: White blood count 9.8, hematocrit 31.6,
chemistries reveal sodium 139, potassium 3.9, chloride 103,
carbon dioxide 22, BUN 20, creatinine 1.1, glucose 126. CKs
were 48, troponin 2.1, MB negative. Studies revealed
electrocardiogram results as listed above. Cardiac
catheterization revealed three vessel coronary artery
disease, presumptive left main coronary artery disease,
normal ventricular function, elevated bilateral filling
pressures, severe pulmonary hypertension, severe systemic
systolic hypertension.
HOSPITAL COURSE: The patient was admitted [**2124-7-20**] with
a diagnosis of unstable angina and congestive heart failure
to the Medicine Cardiology Service where she was treated with
Aspirin, beta blockers, ACE inhibitors and Heparin drip. She
was also diuresed with Lasix pending cardiac catheterization.
Cardiac catheterization was performed with results as listed
above. The patient tolerated the procedure well. Based on
these results, it was felt that coronary artery bypass
grafting would be necessary. She was further stabilized and
diuresed with Lasix and continued on Nitroglycerin drip and
Heparin. She was taken to the Operating Room on [**2124-7-24**] where she underwent three vessel coronary artery bypass
graft with saphenous vein grafts to obtuse marginal 1,
posterior left ventricular and left anterior descending
respectively under general endotracheal anesthesia. There
were no intraoperative complications and the patient was
transferred to the Cardiac Recovery Room, intubated, being
atrioventricularly based at 90 per minute. She was extubated
on postoperative day #1 and she was weaned. She was started
on Lopressor, Aspirin and Lasix and transferred to the
regular floor that evening. That evening the patient was
complaining of some increased belching and symptoms that were
similar to her previous myocardial infarction.
Electrocardiogram was obtained which showed no changes. She
was given 1 mg of Morphine. On postoperative day #2 the
patient exhibited some confusion which cleared over the
course of the day. Her narcotics were held. On
postoperative day #3 she went into atrial fibrillation with
rates to 100s. She was given 2 mg of Magnesium Sulfate and 5
mg of Lopressor intravenously. Rate was controlled to the
70s, she was intravenously loaded with Amiodarone after which
she converted to normal sinus rhythm and then was continued
on oral Amiodarone. At this time the patient was in normal
sinus rhythm on p.o. Amiodarone and Lopressor. She is
ambulating with assistance, tolerating a regular diet and is
deemed stable for discharge to a rehabilitation facility for
further physical therapy and cardiopulmonary care.
DISCHARGE DIAGNOSIS:
1. Status post coronary artery bypass graft times three
2. Coronary artery disease, status post myocardial
infarction in [**2121**]
3. Hypertension
4. Hypercholesterolemia
5. Insulin dependent diabetes mellitus
6. Peripheral vascular disease
7. Peptic ulcer disease status post gastrointestinal bleed
8. Status post bladder suspension
DISCHARGE MEDICATIONS:
1. Potassium chloride 20 mEq p.o. q.d. times one week
2. Lopressor 25 mg p.o. q. 12 hours
3. Colace 100 mg p.o. b.i.d.
4. Aspirin 81 mg q.d.
5. Lasix 20 mg q. 12 hours times one week
6. Protonix 40 mg q.d.
7. Reglan 10 mg q. 8 hours
8. Amiodarone 400 mg t.i.d. times 7 days beginning [**7-28**]
and then Amiodarone 400 mg p.o. b.i.d. times 7 days and then
Amiodarone 400 mg p.o. q.d. times 7 days
9. Milk of magnesia 30 cc p.o. q.h.s. prn
10. Dulcolax suppository one p.r. q.d. prn
11. Insulin NPH 5 units q AM, 10 units q. PM
12. Insulin regular 5 units q. PM
13. Insulin sliding scale
14. Tylenol #3 one to two p.o. q. 4 to 6 hours prn
15. Zantac 150 mg p.o. b.i.d.
FO[**Last Name (STitle) 996**]P: The patient is to follow up with her primary care
physician in one to two weeks and to follow up with Dr. [**Last Name (Prefixes) 411**] in clinic in three to four weeks.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 2682**]
MEDQUIST36
D: [**2124-7-28**] 08:17
T: [**2124-7-28**] 09:44
JOB#: [**Job Number 28041**]
ICD9 Codes: 4111, 9971, 4280, 5990, 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3636
} | Medical Text: Admission Date: [**2136-4-11**] Discharge Date: [**2136-4-24**]
Date of Birth: [**2070-10-23**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
CABGx5(Lima>LAD,SVG>OM1,SVG>OM3,SVG>Diag,SVG>RCA)[**4-16**]
History of Present Illness:
65 yo F with URI since [**Month (only) **], presented to OSH [**4-7**] with
wheezing and SOB. Treated with nebs, benzodiazepines and
steroids. Enzymes +, started on lovenox for NSTEMI. Cath on [**4-11**]
showed 3VD and she was transferred for CABG. Also admits to 6
months of increasing DOE and LE edema.
Past Medical History:
right eye macular edema, IDDM, hypothyroid, CAD (RCA p90%, m90%,
dLCX 50%, mLAD 50%)s/p PCI x 2 [**2127**], NSTEMI [**2127**], HTN, bipolar,
?asthma/chronic bronchitis, esophageal stricture s/p dilatation
x 2 (last [**7-23**]), microhematuria s/p cystoscopy with biopsy and
fulgeration [**5-23**], s/p chole, ovarian cyst s/p removal, c-s x 2,
app, T&A, chart says carotid stent however patient denies.
Social History:
retired teacher
never smoked
rare etoh
Family History:
father deceased from MI at age 69
Physical Exam:
HR 71 RR 18 BP 136/64
NAD
HEENT hoarse
Lungs CTAB except expiratory wheeze, dry cough
Heart RRR Abdomen benign, obese, well healed appy/chole/c-s
scars
Extrem warm, trace BLE edema
No varicosities
Pertinent Results:
[**2136-4-22**] 06:50AM BLOOD WBC-16.2* RBC-3.54* Hgb-10.5* Hct-31.8*
MCV-90 MCH-29.6 MCHC-33.0 RDW-16.2* Plt Ct-220
[**2136-4-21**] 06:30AM BLOOD WBC-16.8* RBC-3.28* Hgb-9.9* Hct-28.5*
MCV-87 MCH-30.1 MCHC-34.7 RDW-16.4* Plt Ct-192#
[**2136-4-20**] 03:00AM BLOOD WBC-20.4* RBC-3.22* Hgb-9.5* Hct-28.0*
MCV-87 MCH-29.4 MCHC-34.0 RDW-15.9* Plt Ct-126*
[**2136-4-18**] 04:08AM BLOOD WBC-31.0* RBC-3.45* Hgb-9.9* Hct-29.5*#
MCV-86 MCH-28.7 MCHC-33.6 RDW-14.6 Plt Ct-95*
[**2136-4-22**] 06:50AM BLOOD Plt Ct-220
[**2136-4-18**] 04:08AM BLOOD PT-11.8 PTT-29.7 INR(PT)-1.0
[**2136-4-21**] 06:30AM BLOOD Glucose-69* UreaN-14 Creat-0.7 Na-140
K-4.4 Cl-99 HCO3-30 AnGap-15
CHEST (PA & LAT) [**2136-4-21**] 10:13 AM
CHEST (PA & LAT)
Reason: eval pneumothorax
[**Hospital 93**] MEDICAL CONDITION:
65 year old woman s/p CABG
REASON FOR THIS EXAMINATION:
eval pneumothorax
EXAMINATION: PA and lateral chest.
INDICATION: Right-sided pneumothorax.
PA and lateral views of the chest were obtained [**2136-4-19**] at 10:22
hours and compared with the previous evening's radiograph
performed at 18:42. The small right-sided apical pneumothorax is
not appreciated on the current examination. Tubes and lines are
unchanged. Linear atelectasis at the right base is unchanged.
There is mild increase in the interstitial markings bilaterally
which may represent some developing fluid overload or early
edema.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 77593**]TTE (Complete)
Done [**2136-4-12**] at 1:57:12 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
Division of Cardiothoracic [**Doctor First Name **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2070-10-23**]
Age (years): 65 F Hgt (in): 65
BP (mm Hg): 126/66 Wgt (lb): 208
HR (bpm): 54 BSA (m2): 2.01 m2
Indication: Coronary artery disease
ICD-9 Codes: 414.8
Test Information
Date/Time: [**2136-4-12**] at 13:57 Interpret MD: [**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern4) **],
MD
Test Type: TTE (Complete) Son[**Name (NI) 930**]: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7474**], RDCS
Doppler: Full Doppler and color Doppler Test Location: West Echo
Lab
Contrast: None Tech Quality: Adequate
Tape #: 2008W003-: Machine: Vivid [**7-23**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: 4.0 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 4.8 cm <= 5.2 cm
Left Atrium - Peak Pulm Vein S: 0.4 m/s
Left Atrium - Peak Pulm Vein D: 0.4 m/s
Left Atrium - Peak Pulm Vein A: 0.2 m/s < 0.4 m/s
Right Atrium - Four Chamber Length: 4.7 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 0.9 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.4 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 2.9 cm
Left Ventricle - Fractional Shortening: 0.46 >= 0.29
Left Ventricle - Ejection Fraction: 60% to 70% >= 55%
Left Ventricle - Lateral Peak E': *0.07 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': *0.03 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': 12 < 15
Aorta - Sinus Level: 2.6 cm <= 3.6 cm
Aorta - Ascending: 2.7 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.3 m/sec <= 2.0 m/sec
Mitral Valve - E Wave: 0.6 m/sec
Mitral Valve - A Wave: 0.7 m/sec
Mitral Valve - E/A ratio: 0.86
Mitral Valve - E Wave deceleration time: 230 ms 140-250 ms
TR Gradient (+ RA = PASP): *30 mm Hg <= 25 mm Hg
Findings
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Overall normal LVEF (>55%). No resting LVOT gradient. No VSD.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Normal ascending aorta diameter.
Focal calcifications in ascending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Trace 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.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Normal tricuspid valve supporting structures. Borderline PA
systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR. Normal main PA. No Doppler evidence for
PDA
PERICARDIUM: No pericardial effusion.
Conclusions
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 normal
(LVEF 60-70%); however, the basal segment of the inferior free
wall is hypokinetic. There is no ventricular septal defect.
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. There is borderline pulmonary artery systolic
hypertension. There is no pericardial effusion.
Brief Hospital Course:
She was admitted to cardiac surgery. She was started on a
heparin drip. Carotid duplex showed no carotid stenosis. She was
seen by pulmonology, and CT chest was performed. She was seen by
ENT and she was started on [**Hospital1 **] PPI. She was started on cipro for
a UTI. She was taken to the operating room on [**4-16**] where she
underwent a CABG x 5. She was transferred to the ICU in stable
condition. She was extubated later that same day. She was
transfused. On POD #2 a right chest tube was placed for a
penumothorax. She was started on amiodarone for atrial
fibrillation. She again developed a UTI and was restarted on
cipro. Her urine culture returned resistant to cipro and she was
switched to Bactrim. She did not show any signs of allergy to
Bactrim. She converted to sinus bradycardia and her amio was
dc'd with improvement in her heart rate. She was transferred to
the floor on POD #4. She otherwise did well postoperatively and
was ready for discharge home on POD #6.
Medications on Admission:
avapro 300', synthroid 125', paxil 40', lopressor 25'', vesicare
5', nifedipine 60', nexium 40', pravachol 80, klonopin 1',
trazadone 50', humalog ss, lantus 22, asa
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
4. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily). Tablet(s)
6. VESIcare 5 mg Tablet Sig: One (1) Tablet PO once a day.
7. Nexium 40 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:*0*
8. Pravachol 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
9. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*0*
10. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
12. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
13. Insulin Glargine 100 unit/mL Solution Sig: Twenty Two (22)
units Subcutaneous at bedtime.
Disp:*qs 1 month* Refills:*0*
14. Insulin Lispro 100 unit/mL Solution Sig: sliding scale
Subcutaneous four times a day.
Disp:*qs 1 month* Refills:*0*
15. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 1 weeks.
Disp:*14 Tablet(s)* Refills:*0*
16. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 1
weeks.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] VNA
Discharge Diagnosis:
CAD s/p CABG
right eye macular edema, IDDM, hypothyroid, CAD (RCA p90%, m90%,
dLCX 50%, mLAD 50%)s/p PCI x 2 [**2127**], NSTEMI [**2127**], HTN, bipolar,
?asthma/chronic bronchitis, esophageal stricture s/p dilatation
x 2 (last [**7-23**]), microhematuria s/p cystoscopy with biopsy and
fulgeration [**5-23**], s/p chole, ovarian cyst s/p removal, c-s x 2,
app, T&A, chart says carotid stent however patient denies.
Discharge Condition:
Stable.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions,creams or powders to incisions.
No lifting more than 10 pounds for 10 weeks from surgery.
No driving until follow up with surgeon.
Followup Instructions:
Dr. [**Last Name (STitle) **] 2 weeks
Dr. [**First Name (STitle) 4640**] 2 weeks
Dr. [**Last Name (STitle) **] 4 weeks
With ENT as planned prior to surgery
Completed by:[**2136-4-23**]
ICD9 Codes: 5990, 4019, 412, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3637
} | Medical Text: Admission Date: [**2152-5-19**] Discharge Date: [**2152-5-27**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
slurred speech, confusion, and hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
85 Russian-speaking only woman brought in from NH with confusion
and slurred speech, and hypotension. Her niece called her at the
nursing home this am and she did not answer; later, in the
afternoon ([**5-19**]), she answered the phone but was slurring her
speech and was somewhat disoriented. VNA visited and found she
was disoriented and sent her to the ED, where she was found to
be hypotensive at 65/43 on arrival. She described a night of
nausea, vomiting, and diarrhea. Her slurred speech resolved and
she was AAOx3 after receiving approximately 4 liters of IVF, at
which time SBP 90s with MAP 50s; she also received levofloxacin
and metronidazole empirically as well as dexamethasone 10mg.
.
.
The family was not aware of any hematemesis or melena. There was
no report of fevers and no localizing signs of infection. Pt was
guaiac positive with brown stool in the ED, and so PRBCs hung,
but stopped once Hct came back at 37, and protonix IV. EKG
showed accelerated junctional rhythm with TWI anteriorly,
cardiac enzymes were negative.
Past Medical History:
"mini stroke" in [**2151-11-18**], for which she spent 2 weeks in rehab
and was prescribed coumadin, which she does not take, according
to her niece
- inferior MI (non-Q wave) in [**2138-10-18**] Rx'd with balloon
angioplasty of prox RCA
- s/p R lobectomy
- mitral regurgitation
- dyslipidemia
- HTN
- s/p TAH
Social History:
Lives alone, niece calls daily and VNA visits once/week. former
smoker. No alcohol.
Family History:
NC
Physical Exam:
Tmax: 35.6 ??????C (96 ??????F)
Tcurrent: 35.6 ??????C (96 ??????F)
HR: 80 (80 - 88) bpm
BP: 91/50(61) {80/27(44) - 96/60(65)} mmHg
RR: 22 (11 - 26) insp/min
SpO2: 99%
Height: 61 Inch
General Appearance: Thin
Eyes / Conjunctiva: PERRL, Conjunctiva pale
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: Cervical WNL
Cardiovascular: (S1: Normal), (S2: Normal), S3, (Murmur:
Systolic), soft early systolic murmur at LUSB c/w aortic
sclerosis
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Percussion:
Resonant : ), (Breath Sounds: No(t) Crackles : , Wheezes : )
Abdominal: Soft, No(t) Non-tender, Bowel sounds present, No(t)
Distended
Extremities: Right: Trace, Left: Trace, No(t) Cyanosis, No(t)
Clubbing
Skin: Warm, No(t) Rash:
Neurologic: Responds to: Not assessed, Movement: Not assessed,
Tone: Not assessed
Pertinent Results:
ADMIT labs:[**2152-5-19**] 05:45PM BLOOD WBC-13.4*# RBC-4.45 Hgb-11.9*
Hct-37.0 MCV-83 MCH-26.8* MCHC-32.2 RDW-14.3 Plt Ct-328#
[**2152-5-19**] 05:45PM BLOOD Neuts-62 Bands-22* Lymphs-2* Monos-7
Eos-1 Baso-0 Atyps-1* Metas-5* Myelos-0
[**2152-5-19**] 05:45PM BLOOD PT-14.6* PTT-27.2 INR(PT)-1.3*
[**2152-5-19**] 05:45PM BLOOD Glucose-140* UreaN-39* Creat-1.9*# Na-145
K-4.1 Cl-102 HCO3-23 AnGap-24*
[**2152-5-20**] 04:59AM BLOOD Calcium-7.0* Phos-3.3 Mg-1.4*
====================================================
CT abd/pelvis
IMPRESSION:
1. No evidence of free fluid, or aortic dilatation. Assessment
for aortic dissection is limited on this non-contrast
evaluation.
2. [**Doctor First Name **] appearance to the abdominal mesentery, with multiple
small nodes. This appearance is nonspecific but can be seen with
sclerosing mesenteritis, mesenteric adenitis, but could also be
seen in lymphoma. Followup is recommended, consider 6-12 months.
3. Probable liver hemangiomas, though incompletely characterized
without contrast.
4. Diverticulosis without evidence of diverticulitis.
5. Multiple vertebral body hemangiomas
--------------
CT head
IMPRESSION: No intracranial hemorrhage. Moderate atrophy, and
microangiopathic change as described above.
-----------------
CXR
FINDINGS: Lung volumes are diminished. There is a mild
engorgement of the vascular pedicle and small interlobular
septal lines at the lung bases. These findings suggest overall
mild pulmonary edema. No focal consolidation is seen. There is a
tortuous atherosclerotic aorta. The cardiac silhouette is
enlarged. No effusion or pneumothorax is seen. There is
deformity of the mid portion of the right clavicle and the
lateral portions of upper right ribs presumably from remote
trauma.
IMPRESSION: Mild volume overload with no focal consolidation
==============================================================
[**2152-5-19**] 05:45PM BLOOD WBC-13.4*# RBC-4.45 Hgb-11.9* Hct-37.0
MCV-83 MCH-26.8* MCHC-32.2 RDW-14.3 Plt Ct-328#
[**2152-5-19**] 05:45PM BLOOD Neuts-62 Bands-22* Lymphs-2* Monos-7
Eos-1 Baso-0 Atyps-1* Metas-5* Myelos-0
[**2152-5-19**] 05:45PM BLOOD PT-14.6* PTT-27.2 INR(PT)-1.3*
[**2152-5-19**] 05:45PM BLOOD Glucose-140* UreaN-39* Creat-1.9*# Na-145
K-4.1 Cl-102 HCO3-23 AnGap-24*
[**2152-5-20**] 04:59AM BLOOD Calcium-7.0* Phos-3.3 Mg-1.4*
================================================
[**Last Name (un) **] stim/TSH:
[**2152-5-19**] 05:45PM BLOOD Cortsol-43.9*
[**2152-5-20**] 04:11AM BLOOD Cortsol-30.3*
[**2152-5-20**] 04:59AM BLOOD Cortsol-33.0*
[**2152-5-19**] 05:45PM BLOOD TSH-1.1
Brief Hospital Course:
85 year old Russian speaking woman with 1 day of nausea,
vomiting, and diarrhea, with report of slurred speech and
confusion on day of admit, found to be hypotensive to 60's by
VNA at home
1. Hypotension:
2. Hypovolemia
3. Nausea/Vomiting
4. Diarrhea
5. Dysarthria/Altered mental status: Patient admitted to [**Hospital Unit Name 153**]
for SBP at home by VNA in the 60??????s in the setting of vomiting,
diarrhea, leukocytosis with bandemia, and guaiac positive
stools. Patient underwent aggressive fluid rescucitation in
emergency room and in ICU with normalization of BP. Slurred
speech and altered mental status resolved with improvement of
blood pressure. Head CT negative. Also given cipro/flagyl for
GI complaints, ruled out by cardiac enzymes, appropriate adrenal
response to stimulation, normal TSH, stable hematocrit.
Nausea, vomiting diarrhea have been chronic issue. Patient had
these symptoms for months prior to admission, then they remitted
for about a month, and recurred in the week prior to admission.
Had seen [**Hospital Unit Name **], had negative CT scan and negative
for c. diff x 1 with past few months. CT abdomen on admission
here read as "[**Doctor First Name 9189**] mesentery", non specific finding. In first
two days of admit, no GI symptoms, but then by HD#3 recurrence
of nausea, vomiting, diarrhea. Therefore, ultimately underwent
EGD/colonoscopy after great difficulty with prep, only could
tolerate mag citrate. EGD and [**Last Name (un) **] with gastritis/duodenitis
but revealed no clear etiology of patient's nausea, vomiting,
diarrhea, early satiety.
Biopsies taken at EGD for ? celiac, h. pylori.
TTG/IGA sent given possibility of celiac, pending at discharge.
After EGD/colonoscopy, patient was able to tolerate full diet.
Patient received 6 day course of cipro/flagyl but missed many
doses due to her refusal to comply with pills inspite of
extensive efforts by nursing and staff to explain necessity of
medications.
Blood and urine cultures ultimately negative.
Possible etiologies include viral illness, possible intolerance
to flagyl, H. pylori , celiac.
BIopsy and celiac results should be followed up.
Patient should have CT abdomen within 6 months to ensure
resolution of non specific [**Doctor First Name 9189**] mesentery findings, ?adenitis.
Lymphoma is consideration.
6. Acute renal failure:
7. Hypokalemia:
Renal failure resolved with aggressive hydration.
Aggressive potassium repletion.
8. HTN:
9. CAD:
10. Hyperlipideima
11. TIA's and atrial fibrillation - pt. in atrial fibrillation
here, rate controlled.
On a home regimen of HCTZ and metoprolol, aspirin. had been
started on coumadin at OSH but patient ultimately decided to
discontinue given difficulty with compliance and concern it was
contributing to GI symptoms. Discussed this with neice (health
care proxy) and GI. GI stated OK to restart day after bx. if
indicated (bx at colonoscopy was [**5-25**], restarted warfarin [**5-27**]).
HCP stated that she wants pt. on warfarin to minimize stroke
risk, understands risk of bleeding and ? of N/V/D as side effect
of warfarin. Will monitor for bleeding, side effects, and INR
at rehab.
Restarted metoprolol, aspirin, statin, and warfarin in hospital.
12. Hypophosphatemia: repleted, occured after colonscopy.
Medications on Admission:
Medications at home--pt states she does not take, b/c medicines
are "not good for her"
trazodone 50mg qhs
HCTZ 12.5mg daily
lopressor 12.5mg [**Hospital1 **]
simvastatin 80mg daily
omeprazole 20mg daily
docusate 100mg [**Hospital1 **]
acetaminophen
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
3. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: INR
will need to be checked daily and dose adjusted accordingly by
MD for target INR 2.0 to 3.0 (indication is atrial
fibrillation). Tablet(s)
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
1. Hypotension
2. Hypovolemia
3. Nausea with vomiting
4. Diarrhea
5. Hypokalemia
6. Hypophosphatemia
7. Atrial fibrillation
Discharge Condition:
Stable, afebrile, tolerating PO
Discharge Instructions:
Follow up as below.
All medications as prescribed.
If you have recurrent nausea, vomiting, abdominal pain or
diarrhea, or bleeding in your bowel movements contact your
doctor.
Followup Instructions:
Follow up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **].
Your PCP is [**Name9 (PRE) **] [**Name9 (PRE) 92817**] [**Telephone/Fax (1) 92818**]
Your [**Telephone/Fax (1) **] is Dr. [**Last Name (STitle) 41956**] [**Telephone/Fax (1) 92819**]
You will need to follow up with these doctors [**Name5 (PTitle) **]: management of
your coumadin levels, as well as for the results of the biopsies
obtained on colonoscopy/endoscopy.
ICD9 Codes: 4589, 5849, 4240, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3638
} | Medical Text: Admission Date: [**2153-4-5**] Discharge Date: [**2153-4-10**]
Date of Birth: [**2092-4-12**] Sex: F
Service: MEDICINE
Allergies:
Compazine / Droperidol / Gadolinium-Containing Agents / Demerol
/ Morphine / Haldol
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Mast Cell Degranulation Syndrome Flare
Major Surgical or Invasive Procedure:
none
History of Present Illness:
60 yo F w/ Mast Cell Degranulation Syndrome with multiple admits
for flares most recently discharged [**3-4**] for same. She states
that since the [**3-4**] discharge she was seen at multiple OSH for
flares, and also had a cataract procedure on her eye, which may
have precipitated a flare. She states that last night she began
to have flushing, abdominal cramps, chest pain, SOB, nausea and
diarrhea-similar symptoms as prior flares. Pt states she tried
to take her benadryl and keep up with her known protocol but was
unable to keep her meds down due to N/V. She gave herself 1 dose
of Epi pen 1:1000 0.3mc SCx1. Came into ED for further
evaluation.
.
ED COURSE: Initial VSS Afebrile 98.2 BP 132/86 HR 96 RR 14 96%RA
[X] cxr-neg; [x] ekg-baseline; [x] labs;[x] protocol- 0.3mg Epi
at home, Epi 0.3mg SC x2, 50mg IV Benadryl x2, 80mg Solumedrol
x1, dilaudid 2mgx3, zofran 8mg IV, pepcid 20mg IV x1.
Past Medical History:
-Mast cell degranulation syndrome (MCDS)
*** EMERGENCY PLAN *** (as posted in chart)
administer:
1. Epinephrine 0.3cc of 1/1000 SC and repeat x3 at 5 min
intervals if BP <90 systolic in setting of flare
2. Benadryl 25-50 IV q4 hr for 24-48 hrs
3. Solu-medrol 80mg IV/IM
4. Oxygen by mask or cannula
5. Albuterol nebs q2-4 hr prn
6. Dilaudid 2mg IV q 3hrs or PCA pump
7. Zofran 8mg IV q 12h for 24-48 hrs
PRE-MEDICATION for major/minor procedures:
1. Prednisone 50mg po q24 hrs and 1-2 hours prior to surgery
2. Benadryl 25-50mg 1 hour prior to surgery
3. Ranitidine 150mg 1 hour prior to surgery
-Depression/anxiety
-Bipolar disorder
-MI in [**2147**] after receiving cardiac arrest dose epi instead of
anaphylactic dose epi
-HTN
-Erosive osteoarthritis
-GERD, gastritis and esophagitis on recent EGD [**2151-1-8**]
-Paradoxical Vocal Cord Dysfunction viewed on fiberoptic
laryngoscopy
-Anemia, iron studies c/w AOCD
-Hemorrhoids
-EGD with vegetable bezoar (?[**12-7**])
-Status post hysterectomy and oophorectomy
-h/o MRSA infection (porthacath associated)
-portacath placed [**3-8**] - d/c'd [**2-3**] MRSA infection
-portacath placed [**2151-6-9**]
-MRSA left arm infection; now is cast
.
Social History:
Pt is divorced. Lives alone. She works as an ER tech in
[**Hospital3 **]. No tobacco or EtOH or illicit drugs. Son is
HCP [**Telephone/Fax (1) 21738**]
Family History:
Mother died of MI @ 76, Sister w/ breast cancer and bilateral
mastectomy.
Physical Exam:
VS: 97.2 BP 144/72 HR 103 RR 18 100%RA
GEN: NAD
HEENT: Dry MM, EOMI, PERRL
RESP: CTABL, No crackles/wheezing, speaking in full sentences,
no use of accessory muscles
CV: Reg Nml S1, S2, no M/R/G
ABD: Soft ND, Tender at epigastric region
EXT: no peripheral edema, warm 2+DP pulses b/l
NEURO: A&Ox3, no focal deficits, fluent speech, strength 5/5,
normal sensation
Pertinent Results:
[**2153-4-5**] 08:20PM URINE HOURS-RANDOM
[**2153-4-5**] 08:20PM URINE GR HOLD-HOLD
[**2153-4-5**] 08:20PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.038*
[**2153-4-5**] 08:20PM URINE BLOOD-NEG NITRITE-POS PROTEIN-TR
GLUCOSE-250 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2153-4-5**] 08:20PM URINE RBC-0-2 WBC-[**6-12**]* BACTERIA-MANY
YEAST-NONE EPI-[**6-12**]
[**2153-4-5**] 08:17PM WBC-21.1*# RBC-4.35 HGB-12.2 HCT-37.6 MCV-87
MCH-28.0 MCHC-32.3 RDW-13.3
[**2153-4-5**] 08:17PM PLT COUNT-299
[**2153-4-5**] 02:45PM GLUCOSE-96 UREA N-25* CREAT-0.7 SODIUM-143
POTASSIUM-3.9 CHLORIDE-109* TOTAL CO2-19* ANION GAP-19
[**2153-4-5**] 02:45PM estGFR-Using this
[**2153-4-5**] 02:45PM CK(CPK)-69
[**2153-4-5**] 02:45PM CK-MB-4 cTropnT-<0.01
[**2153-4-5**] 02:45PM CALCIUM-7.4* PHOSPHATE-3.4 MAGNESIUM-2.3
URINE:
> 100,000 GNRs (E. Coli), [**Last Name (un) 36**] to all but Cipro.
[**2153-4-5**] CXR: IMPRESSION: Low lung volumes. No evidence of pna.
Brief Hospital Course:
59 y.o. F with h/o Mast Cell Degranulation Syndrome presented
with typical MCDS symptoms including SOB, chest, abdominal pain,
diarrhea, initially admitted to MICU for close monitoring.
Transferred to floor with normal vital signs after a period of
ICU observation. Now well appearing with less pain today. She
did complain of some dysuria, and was found to have a UTI. She
was treated with Macrodantin and will follow-up with her primary
outpatient physicians.
.
# Mast Cell Degranulation Syndrome: Per her protocol, she was
initially given zofran, dilaudid, solu-medrol, albuterol nebs,
O2 by NC, epinephrine, ativan and benadryl. Episode may also be
c/w narcotic withdrawal as no stridor/wheezing, no clinically
abnormal VS, HD stable. Pt also requesting to eat which would be
inconsistent with acute mast cell degranualation and significant
N/V.
- hold steroids
- continue zofran, ativan, benadryl, anti-histamine, dilaudid as
needed if sx recur
- IVF hydration prn, not currently needed
- continue pain control with dilaudid. Chest pain c/w prior
flares, EKG generally similar to prior, but with ? new lateral
nonspecific ST-T changes. Chest pain has been present x 2-3 days
at this point, and two sets CEs negative (ruled out for MI).
.
# ? narcotic withdrawal: Pt on fentanyl patch, dilaudid 4mg PO
q4-6hr prn takes ~2tabs per day, has not ran out, however
symptoms of flushing, cramps, diarrhea concerning for narcotic
withdrawal as no si of infection.
- continued minimal narcotics as outpatient
- SW c/s for addiction/withdrawal
.
# Urinary Burning: pt with this c/o as of xfer to floor on
[**2153-4-6**]. With very recent foley dc. Will check UA, consider
pyridium and abx if pos.
- UA shows UTI, pt with symptoms. Will rx Macrobid given culture
data
- current urine cx: E. Coli [**Last Name (un) 36**] to all but cipro.
.
# Hypertension: Continue diltiazem.
.
# Depression/anxiety/bipolar: Psych and anxiety issues seemed to
instigate some of her acute flares.
- continue outpatient medications of cymbalta, Adderall, Ativan
prn.
.
# Postmenopausal symptoms: Held premarin while in hospital,
flushing may be c/w postmenopausal hot flashes.
.
# Home Meds: Continued plaquenil.
.
#. FEN: reg diet
.
#. CODE: FULL
#. Dispo: to home with continued stable vitals, good pain
control.
.
Medications on Admission:
1. Gastrocrom 100 mg/5 mL Solution Sig: One Hundred (100) mg PO
every six (6) hours.
2. Diltiazem HCl 180 mg SR daily
3. Premarin 0.3 mg Tablet daily
4. Hydroxyzine HCl 25 mg [**Hospital1 **]
5. Ranitidine HCl 150 mg daily
6. Duloxetine 60 mg Capsule, daily
7. Hydroxychloroquine 200 mg Tablet [**Hospital1 **]
8. Adderall XR 15 mg Capsule, Sust. Release Daily
9. Fexofenadine 180 mg Tablet [**Hospital1 **]
10. Omeprazole 20 mg Capsule, Delayed Release [**Hospital1 **]
11. Zolpidem 10 mg Tablet HS PRN
12. Zofran 8 mg Tablet 8 HRS
13. Zyflo 600 mg Tablet QID
14. Asmanex Twisthaler 220 mcg (120 doses) Aerosol Powdr [**Hospital1 **]
Activated Sig: Two (2) puffs Inhalation twice a day.
15. Dilaudid 4 mg Tablet every 6-8 hours as needed.
16. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: One
(1) Tablet PO Q6H (every 6 hours) as needed.
17. Ativan 0.5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
18. Benadryl 25 mg Capsule PO every 4-6 hours as needed
19. zaditen Sig: One (1) mg twice a day: continue as before.
20. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours) for 5 days--Completed [**2153-3-8**]
Discharge Medications:
1. Diphenhydramine HCl 25 mg Capsule Sig: [**1-3**] Capsules PO Q4H
(every 4 hours) as needed for FLARE.
2. Epinephrine 1 mg/mL Solution Sig: One (1) Injection PRN (as
needed) as needed for FLARE for 1 doses: Epinephrine 1:1000 0.3
mg SC PRN FLARE.
3. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Amphetamine-Dextroamphetamine 5 mg Capsule, Sust. Release 24
hr Sig: Three (3) Capsule, Sust. Release 24 hr PO Daily ().
6. Fexofenadine 60 mg Tablet Sig: Three (3) Tablet PO BID (2
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).
8. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed.
9. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: [**1-3**]
Tablets PO Q6H (every 6 hours) as needed for Migraine.
10. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
13. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO HS (at bedtime).
14. Phenazopyridine 100 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed for dysuria for 3 days.
15. Nitrofurantoin (Macrocryst25%) 100 mg Capsule Sig: One (1)
Capsule PO BID (2 times a day) for 8 days.
Disp:*16 Capsule(s)* Refills:*0*
16. Dilaudid 4 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for pain: take for severe pain not controlled by
over the counter medications .
Disp:*30 Tablet(s)* Refills:*0*
17. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
18. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every [**6-10**]
hours as needed for anxiety.
Discharge Disposition:
Home
Discharge Diagnosis:
1. Mast Cell Degranulation Syndrome, s/p flare
2. Urinary Tract Infection
Discharge Condition:
Good
Discharge Instructions:
Please call your physician or go to the emergency room if you
develop chest pain, shortness of [**Month/Day (3) 1440**], lightheadedness, fever
greater than 101.5 not responsive to tylenol, severe abdominal
pain or distention, persistent nausea or vomiting, severe
diarrhea, inability to eat or drink, or any other symptoms which
are concerning to you.
.
Activity: You may resume your usual activity as tolerated.
.
Diet: You may resume your usual diet.
.
Medications: Resume your usual home medications. Take any new
medications as prescribed. You should take a stool softener with
your pain medication. Your pain medication may make you drowsy,
so please do not drive while taking pain medicine.
Lastly, please continue to abide by your Mast Cell Degranulation
Syndrome Plan:
*** EMERGENCY PLAN *** (as posted in chart)
administer:
1. Epinephrine 0.3cc of 1/1000 SC and repeat x3 at 5 min
intervals if BP <90 systolic in setting of flare
2. Benadryl 25-50 IV q4 hr for 24-48 hrs
3. Solu-medrol 80mg IV/IM
4. Oxygen by mask or cannula
5. Albuterol nebs q2-4 hr prn
6. Dilaudid 2mg q 3hrs
7. Zofran 8mg q 12h for 24-48 hrs
PRE-MEDICATION for major/minor procedures:
1. Prednisone 50mg po q24 hrs and 1-2 hours prior to surgery
2. Benadryl 25-50mg 1 hour prior to surgery
3. Ranitidine 150mg 1 hour prior to surgery
Followup Instructions:
Please follow-up with Dr. [**First Name4 (NamePattern1) 4051**] [**Last Name (NamePattern1) 79**] in [**1-3**] weeks. Call ([**Telephone/Fax (1) 21747**] to arrange an appointment.
Also, please follow up with your primary care physician, [**Last Name (NamePattern4) **].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], after discharge. Please call [**Telephone/Fax (1) 21748**] to
arrange an appointment.
Please keep your previously arranged appointments as listed
below.
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2153-4-24**] 4:00
Provider: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 2226**]
Date/Time:[**2153-6-4**] 1:30
ICD9 Codes: 5990, 4019, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3639
} | Medical Text: Admission Date: [**2188-8-6**] Discharge Date: [**2188-8-23**]
Date of Birth: [**2113-1-28**] Sex: M
Service: CARDIOTHORACIC SURGERY
HISTORY OF THE PRESENT ILLNESS: The patient is a 75-year-old
white male with a history of atrial fibrillation,
hypertension, DVTs and CVAs/TIAs, who was admitted to an
outside hospital on [**2188-8-1**] for dizziness and mental status
changes. The patient had rule out MI and underwent CT scan
of the head which did not reveal any new infarct. However,
the patient was found to be in rapid atrial fibrillation with
nonspecific ST-T changes on EKG. The patient subsequently
was transferred to the [**Hospital6 256**]
for cardiac catheterization which revealed severe left main
disease and two vessel [**Hospital6 **] artery disease with moderate
MR with normal left ventricular function. The patient was
referred to Cardiothoracic Surgery for evaluation for
[**Hospital6 **] artery bypass graft surgery.
The patient denied chest pain, shortness of breath, dyspnea.
PAST MEDICAL HISTORY:
1. Atrial fibrillation.
2. Hypertension.
3. COPD.
4. Status post CVAs/TIAs.
5. Status post DVT, left leg.
6. Mental status changes.
7. Dementia.
8. Right eye macular degeneration.
9. Prostate cancer.
10. [**Hospital6 **] artery disease.
PAST SURGICAL HISTORY:
1. TURP eight years ago.
2. Appendectomy when he was 12 years old.
PREADMISSION MEDICATIONS:
1. Coumadin 6 mg q.d.
2. Aspirin 81 mg q.d.
3. Captopril 25 mg t.i.d.
4. Nitroglycerin paste.
5. Humibid.
6. Diltiazem 180 mg q.d.
7. Lopressor 100 mg b.i.d.
8. Albuterol.
9. Atrovent nebulizers.
10. Heparin.
11. GTT.
ALLERGIES: Penicillin.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: Former smoker, discontinued 30 years ago,
use to smoke two packs per day. Former heavy alcohol
drinker. Now drinks socially. Lives with daughter and
grandchildren in [**Name (NI) 47**].
REVIEW OF SYSTEMS: Neurologic: History of TIAs/CVAs without
visual changes, occasional frontal headaches, positive
dizziness in the past few months. Respiratory: Without
cough or hemoptysis, without recent URIs, without shortness
of breath, without PND. Cardiac: Without chest pain,
without palpitations, without MI history. GI: Normal bowel
movements, without melena, without GI ulcers, without
dysphagia, without GERD. Psychiatry/endocrine: Denied
diabetes, thyroid disease, and bleeding dyscrasias.
Vascular: Without claudication, without vein stripping.
Cardiac catheterization on [**2188-8-6**] showed LMCA 90%, LAD
normal, left circumflex 80%, RCA normal, EF 50%, moderate 2+
MR, left dominant.
LABORATORY/RADIOLOGIC DATA: White count 8.2, hematocrit
41.2, platelets 208,000. Chemistries: 137, 3.3, 104, 25,
14.6, sodium, potassium, chloride, bicarbonate, BUN,
creatinine respectively with a glucose of 141, ALT 16,
amylase 75, total bilirubin 0.8, albumin 3.7. PT 15.5, PTT
34.2, INR 1.6.
Echocardiogram from the outside hospital showed a mild MR [**First Name (Titles) **]
[**Last Name (Titles) **], trace AI, EF 45%, LAE, and positive MAC.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Afebrile
now with stable vital signs. Blood pressure 119/81, heart
rate 62, respiratory rate 18, oxygen saturation 96%.
General: The patient was a well-developed, well-nourished
male in no acute distress, appearing stated age, alert,
somewhat confused, oriented to place, not date. HEENT:
PERRLA, EOMI, positive ...................., positive upper
dentures. Normal buccal mucosa. Neck: Supple, without JVD,
without lymphadenopathy, without bruits noted, without
thyromegaly. Chest: Clear to auscultation bilaterally
without wheezing, rhonchi, or rales. Cardiac: Irregular
normal rate, positive S1, S2, without murmurs or rubs.
Abdomen: Soft, nontender, nondistended, normoactive bowel
sounds. Negative guarding, negative rebound and rigidity,
negative hepatosplenomegaly. Extremities: Warm, without
edema, cyanosis, or clubbing, positive mild varicosities in
the left leg with spider veins bilaterally. Pulses were 2+
in the carotid bilaterally, radial 1+ bilaterally, femoral 2+
bilaterally, DP 1+ bilaterally, PT 2+ bilaterally.
Neurologic: Cranial nerves II through XII were grossly
intact, without significant motor or sensory deficits.
HOSPITAL COURSE: The patient was taken to the Operating Room
on [**2188-8-8**] for the diagnosis of MR [**First Name (Titles) **] [**Last Name (Titles) **] artery
disease and the procedure was [**Last Name (Titles) **] artery bypass grafting
times two vessels with mitral valve annuloplasty with 28 mm
[**Doctor Last Name 405**] band under general anesthesia, LIMA to LAD,
saphenous vein graft to left PDA. The surgeon was Dr. [**First Name (STitle) **]
[**Last Name (Prefixes) **] with assistance of Dr. [**Last Name (STitle) 8420**]. Three tubes
were placed postoperatively, two mediastinal and one left
pleural tube.
The patient was transferred to the unit on epinephrine drip
and Propofol. The patient was weaned off the nitroglycerin
drip on postoperative day number one, continued to be on an
insulin drip and vancomycin perioperatively. Chest tubes
were discontinued on postoperative day number two. The
patient was started on Lopressor 50 b.i.d. on postoperative
day number two, continued to do well. The patient was
transferred to the floor on postoperative day number three
after being given Amiodarone for chronic atrial fibrillation
since ICU stay into the 115-120 range.
On the floor, the patient continued to stay in atrial
fibrillation with rates of 110-120 with bursts of 130-140 at
night and was started on a Diltiazem drip on postoperative
day number four, titrated up to 15 and was started on
Diltiazem p.o. The patient also was confused and would
sundown at night significantly.
Physical Therapy saw the patient throughout the hospital
course and worked with the patient until discharge. The
patient was increased to Diltiazem 180 q.d. and continued to
stay in atrial fibrillation throughout postoperative day
number five and six and had mild sternal wound drainage
starting on postoperative day number six and was started on
levofloxacin for ten days. By discharge, the drainage had
ceased and the wound was clean, dry, and intact. The patient
required a one-to-one sitter and on postoperative day number
seven, Neurology was called to assess the patient's mental
status who recommended Seroquel at night which improved the
patient a bit and Geriatrics was also called for further
evaluation.
The patient continued to be Coumadinized throughout the
hospital course. On [**2188-8-19**], postoperative day number 11,
the patient was cardioverted by electrophysiology into a
sinus bradycardia and the patient remained in sinus
throughout the remainder of the hospital course. The patient
was continued on Amiodarone 400 t.i.d. for two days, 400
b.i.d. for five days which would stop on [**2188-8-25**]
and 400 q.d. for a week with 200 q.d. taper continuing. The
patient was continued to be Coumadinized and Diltiazem was
discontinued and Lopressor was decreased to 25 b.i.d.
The sitter was able to be discontinued and the patient became
more lucid towards the end of the hospital course.
Geriatrics continued to see the patient towards the end of
the hospital course and was following taper of Seroquel. The
patient was to have an INR goal of 2 and INR on [**2188-8-23**], postoperative day number 15, was 2.6. Coumadin was
held on postoperative day number 13 and 14 for INRs of 3.3
and 3.4 respectively. Coumadin, one dose of 2 mg, was to be
given on postoperative day number 15, [**2188-8-23**], in
the p.m. and INR checked frequently for a goal of 2 at [**Hospital3 51126**] Rehabilitation.
The patient was discharged on [**2188-8-23**],
postoperative day number 15, in no acute distress, without
event.
DISCHARGE MEDICATIONS:
1. Colace 100 mg p.o. b.i.d.
2. Folic acid 1 mg tablet p.o. q.d.
3. Thiamine 100 mg tablet p.o. q.d.
4. Albuterol 103-18 microgram aerosol adapter one to two
puffs inhalation q. six hours as needed.
5. Aspirin 81 mg p.o. q.d.
6. Lopressor 50 mg tablet 0.5 p.o. b.i.d.
7. Protonix 40 mg tablet one p.o. q.d.
8. Amiodarone 200 mg tablet one p.o. q.d. after 400 mg
tablet p.o. times seven days, after 400 mg p.o. b.i.d. which
is to end on [**2188-8-25**].
9. Seroquel 50 mg tablet p.o. q.h.s.
DISPOSITION: The patient was discharged to [**Hospital3 15644**]
Rehabilitation.
DISCHARGE DIAGNOSIS:
1. [**Hospital3 **] artery disease.
2. Atrial fibrillation.
3. Hypertension.
4. Chronic obstructive pulmonary disease.
5. Mental status changes.
6. Moderate mitral regurgitation.
7. Status post [**Hospital3 **] artery bypass graft times two
vessels, mitral valve annuloplasty with 28 mm [**Doctor Last Name 405**] band.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: Rehabilitation.
FO[**Last Name (STitle) **]P: The patient was instructed to follow-up with
primary care physician in one to two weeks, cardiologist in
two to three weeks, and Dr. [**Last Name (Prefixes) **] in three to four
weeks.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern4) 7013**]
MEDQUIST36
D: [**2188-8-23**] 10:19
T: [**2188-8-23**] 10:26
JOB#: [**Job Number 51127**]
cc:[**Hospital3 51128**]
ICD9 Codes: 4240, 4111, 496, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3640
} | Medical Text: Admission Date: [**2178-4-14**] Discharge Date: [**2178-4-22**]
Date of Birth: [**2119-12-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest discomfort and exertional dyspnea
Major Surgical or Invasive Procedure:
CABGx4(LIMA->LAD, SVG->PDA, OM2, Diag) [**2178-4-15**]
CAZrdiac Catheterization [**2178-4-14**]
History of Present Illness:
Mr. [**Known lastname 60510**] is a splendid 58 year old gentleman who has recently
developed chest discomfort and dyspnea on exertion. He is
normally able to exercise for 40 minutes or longer without
difficulty. Since [**Month (only) 956**], he describes 2/10 chest pain and an
overall sensation that something is wrong with exercise. He was
seen at [**Hospital3 3583**] on [**2178-4-13**] where a troponin was positive
and EKG changes were noted. Nitroglycerin was given with relief.
He was subsequently transferred to [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1675**] [**Last Name (NamePattern1) **] Medical
center for a cardiac catheterization.
Past Medical History:
S/P Hernia Repair
Nephrolithiasis
Social History:
Denies smoking cigarettes. Former pipe smoker and occassional
cigars. No illicit drug use. Occassional beer or wine. Lives
with wife at home.
Family History:
Non Contributory
Physical Exam:
VITALS: 57 SB, BP: 150/74
NEURO: Alert, no focal deficits, PERRL, Stregth equal
bilaterally
CARDIAC: RRR, no murmur
LUNGS: Scattered rales at bases
ABDOMEN: normoactive bowel sounds, nontender, nondistended
EXTREMITIES: warm, well perfused, no edema, no varicosities
noted
PULSES: 2+ throughout No bruits
Pertinent Results:
[**2178-4-14**] 03:49PM PT-14.6* PTT-113* INR(PT)-1.4
[**2178-4-14**] 03:49PM WBC-4.5 RBC-5.23 HGB-15.9 HCT-45.6 MCV-87
MCH-30.5 MCHC-34.9 RDW-12.7
[**2178-4-14**] 03:49PM ALT(SGPT)-29 AST(SGOT)-24 CK(CPK)-73 ALK
PHOS-86 AMYLASE-55 TOT BILI-0.8
[**2178-4-14**] 03:49PM GLUCOSE-111* UREA N-22* CREAT-0.7 SODIUM-139
POTASSIUM-3.6 CHLORIDE-105 TOTAL CO2-27 ANION GAP-11
[**2178-4-14**] CXR
No acute cardiopulmonary process.
[**2178-4-14**] ECG
Sinus bradycardia. Borderline prolonged QTc interval. Left
ventricular
hypertrophy with ST-T wave abnormalities. The anterolateral ST-T
wave changes suggest in part, ischemia. Clinical correlation is
suggested. No previous tracing available for comparison.
[**2178-4-15**] ECG
Baseline artifact. Probable sinus rhythm, although baseline
artifact makes
assessment difficult. Left ventricular hypertrophy with ST-T
wave
abnormalities. The anterolateral T wave changes suggest in part,
ischemia.
Clinical correlation is suggested. Since the previous tracing of
[**2178-4-15**]
baseline artifact makes comparison difficult.
[**2178-4-14**] Cardiac Catheterization
1. Three vessel coronary artery disease.
2. Moderate and regional systolic ventricular dysfunction.
3. Mild left ventricular diastolic dysfunction.
4. Successful stenting of the proximal LAD with a Drug Eluting
Stent.
Brief Hospital Course:
Mr. [**Known lastname 60510**] was admitted to the [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1675**] [**Last Name (NamePattern1) **] Medical
Center on [**2178-4-13**]. He underwent a cardiac catheterization which
revealed an occluded left anterior descending artery with distal
90% disease, an 80% stenosed circumflex artery, an 80% stenosed
posterior descending artery and an ejection fraction of 35%. The
proximal left anterior descending artery was stented with
success. Plavix and heparin were started. Due to the severity of
his disease, the cardiac surgical service was consulted for
surgical revascularization. Mr. [**Known lastname 60510**] was worked-up in the
usual preoperative manner. On [**2178-4-15**], Mr. [**Known lastname 60510**] was taken to
the operating room where he underwent coronary artery bypass
grafting to four vessels. Postoperatively he was taken to the
cardiac surgical intensive care unit for monitoring. His chest
tube output was noted to be high and Mr. [**Known lastname 60510**] was returned to
the operating room. Bleeding was found coming from a side branch
of the vein graft. Hemostasis was achieved and Mr. [**Known lastname 60510**] was
returned to the intensive care unit for monitoring. On
postoperative day one, Mr. [**Known lastname 60510**] [**Last Name (Titles) 5058**] neurologically intact
and was extubated. Beta blockade was resumed and titrated for
optimal heart rate and blood pressure control. Plavix was
resumed. Later on postoperative day one, Mr. [**Known lastname 60510**] was
transferred to the cardiac surgical step down unit for further
recovery. He was gently diuresed towards his preoperative
weight. The physical therapy service was consulted for
assistance with his postoperative strength and mobility. His
chest tubes and pacing wires were removed per protocol. A small
amount of serous drainage was noted from the inferior aspect of
Mr. [**Known lastname 60511**] sternotomy. Betadine occlusive dressings were
applied and Keflex was started prophylactically. Mr. [**Known lastname 60510**]
continued to make steady progress and was discharged to his home
on postoperative day seven. He will return in 1 week for
evaluation of his sternal wound. Mr. [**Known lastname 60510**] will follow-up with
Dr. [**Last Name (STitle) **], his cardiologist and his primary care physician as
an outpatient.
Medications on Admission:
Norvasc 5mg daily
[**Doctor First Name **] PRN
Aspirin occassionally
Discharge Medications:
1. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for 7
days.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day) as needed.
Disp:*120 Tablet(s)* Refills:*0*
5. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Hydromorphone HCl 2 mg Tablet Sig: 1-2 Tablets PO Q3-4H () as
needed.
Disp:*50 Tablet(s)* Refills:*0*
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
9. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a
day for 10 days.
Disp:*40 Capsule(s)* Refills:*0*
10. Carvedilol 3.125 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
TBA
Discharge Diagnosis:
Coronary artery disease.
Discharge Condition:
Good.
Discharge Instructions:
Follow medications on discharge instructions.
You may not drive for 4 weeks.
You may not lift more than 10 lbs. for 3 months.
You should shower, let water flow over wounds, pat dry with a
towel.
Followup Instructions:
Make an appointment with Dr. [**Last Name (STitle) 30224**] [**Name (STitle) **] for 1-2 weeks.
Make an appointment with Dr. [**Last Name (STitle) 911**] for 2-3 weeks.
Make an appointment with Dr. [**Last Name (STitle) **] for 4 weeks.
Come to [**Hospital Ward Name 121**] 2 between 10AM and 4PM on Fri., [**4-24**] for wound
check.
Completed by:[**2178-4-22**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3641
} | Medical Text: Admission Date: [**2151-10-11**] Discharge Date: [**2151-10-20**]
Date of Birth: [**2091-8-19**] Sex: F
Service: SURGERY
Allergies:
Fentanyl
Attending:[**First Name3 (LF) 5569**]
Chief Complaint:
HBV/HCC here for liver transplant
Major Surgical or Invasive Procedure:
[**2151-10-11**]: orthotopic liver transplant
History of Present Illness:
60 y/o female originally from Rumania with chronic Hepatitis
B infection which was diagnosed in [**2124**]. She had a liver biopsy
in [**2133**] suggestive of cirrhosis. She has been treated with
interferon in the distant past, lamivudine in the more recent
past and is now currently taking tenofavir. MRI in [**2149**] showed
a
nodule in segment VIII which was slowly enlarging from previous
scans and a second subcapsular lesion also in segment VIII which
appeared more stable. Biopsy showed this to be HCC. She had
chemoembolization [**2151-1-8**] and in [**2151-3-8**] she underwent
RFA to lesions in segment VIII and segment VI. This was all
performed at an OSH.
In [**Month (only) 205**] of [**2151**] her case was presented at tumor conference
where
it was decided on a f/u CT torso performed on [**2151-4-22**]
did not show any suspicious lesions or residual disease. Outside
imaging from [**State 1727**] was also reviewed showing low density
lesions in the right anerior and posterior segment of the liver
with no definite arterial enhancement, although there are some
prominent vessels extending up to these lesions and around them.
These lesions are not concerning for HCC and are most likely
sequelae of prior treament.
She was inactivated for two months due to insurance issues and
is
now reactivated as of [**2151-10-4**].
She reports no recent illnesses or sick contacts. [**Name (NI) **] fever,
chills, GI upsets, bowels regular, Some rib/RUQ pain on occasion
but is not constant. She has never undergone paracentesis.
Denies
chest pain or shortness of breath. States she can walk [**1-9**] mile
and does light housework.
.
Past Medical History:
Past Oncologic History:
She was first diagnosed with hepatitis B in [**2124**]. She developed
acute hepatitis B after going to the dentist, had severe
jaundice and was in a coma for three days. She subsequently
developed chronic hepatitis B. She immigrated to the United
States in [**2126**]. She had a biopsy with the diagnosis of cirrhosis
in [**2133**] and was then treated with interferon. She received a
total of six months; however, this was broken into two separate
periods. She had severe depression on interferon and was
hospitalized for five weeks with depression. Two years ago she
had an MRI of her liver and had nodules noted at that time. In
[**5-/2150**], she had increasing right upper quadrant pain and had a
biopsy, which was consistent with HCC. She underwent a
drug-eluting beads chemoembolization on [**2150-10-21**] in
[**Location (un) 24402**], [**State 1727**], and reports she had a repeat CT scan with no
significant changes. On recent imaging, she had three lesions
appreciated with no changes in appearance of the lesions despite
treatment. She was discussed here at our liver tumor
conference, and has also met with Dr. [**Last Name (STitle) 497**] of the transplant
service. Based on her recent meeting, she has been listed for
liver transplantation, currently has a MELD score of 22 with
additional points that have been added due to her hepatocellular
carcinoma.
.
Other Past Medical History:
- Depression - she has been hospitalized for her depression in
the past
- anxiety
- insomnia
- diabetes mellitus
- hypertension
- GERD
- gastritis
- migraines
- history of bronchitis and pneumonia
Social History:
She lives in [**Location 24402**], [**State 1727**] with one of her sons. She does
nursing assistant work, however, is on short-term disability.
Finances are an issue for her. She does not smoke or drink.
She she has had increasing issues with depression and anxiety
since [**50**]/[**2150**].
Family History:
Mother with stomach cancer at age 72. Cousin with stomach
cancer at age 42, uncle with [**Name2 (NI) 499**] cancer at age 69, aunt had
ovarian cancer in her 50s. She has two sons age 27 and 24, who
are both healthy. She does not know the family history in her
father's side of the family.
Physical Exam:
96.5, 72, 143/86, 20, 100% RA, 59.1 kg
General: Looks well, NAD
HEENT: sclera anicteric, MMM, fixed bridges, no dentures, no
lesions, no LAD
Card: RRR, no M/R/G
Lungs: CTA bilaterally
Abd: Soft, tender in RUQ to deep palpation, unable to feel liver
edge, + BS, non-distended but sl bloated
Extr: 2+ DPs, no lower extremity edema, feet with no sores,
states has intermittent neuropathy. Has a podiatrist
Neuro: No asterixis, A+O x 3, no focal deficit
Skin: Warm and dry, no icterus
Pertinent Results:
On Admission [**2151-10-11**]
WBC-6.1 RBC-4.31 Hgb-13.2 Hct-38.8 MCV-90 MCH-30.6 MCHC-33.9
RDW-13.7 Plt Ct-166
PT-13.3 PTT-24.2 INR(PT)-1.1
Glucose-105* UreaN-14 Creat-0.7 Na-137 K-4.1 Cl-100 HCO3-28
AnGap-13
ALT-149* AST-124* AlkPhos-93 TotBili-0.6
Albumin-4.6 Calcium-10.2 Phos-3.4 Mg-1.8
HBsAg-POSITIVE HBsAb-NEGATIVE HBV Viral Load: not detected
.
At Discharge [**2151-10-20**]
WBC-8.9 RBC-3.30* Hgb-10.1* Hct-30.1* MCV-91 MCH-30.5 MCHC-33.4
RDW-16.7* Plt Ct-238
PT-12.0 PTT-20.0* INR(PT)-1.0
Glucose-139* UreaN-21* Creat-0.8 Na-137 K-4.7 Cl-102 HCO3-31
AnGap-9
ALT-257* AST-57* AlkPhos-357* TotBili-1.3
Albumin-3.4* Calcium-8.8 Phos-3.9 Mg-1.6
HBsAg-NEGATIVE HBsAb-POSITIVE Titer > 500
tacroFK-9.9
Brief Hospital Course:
60 y/o female with HBV/ HCC s/p RFA who now presents for liver
transplant. The patient received routine induction
immunosuppression to include PO cellcept, IV solumedrol. Prograf
was started on the evening of POD 1. Additionally due to
Hepatitis B status she received 10,000 units HBIg during the
anhepatic phase. The case was staffed with Dr [**Last Name (STitle) **] and Dr
[**Last Name (STitle) 816**]. At the time of surgery there was no evidence of
extrahepatic spread of disease. When the liver was re-perfused,
several repair sutures were required to achieve hemostasis in
the suprahepatic caval anastomosis. The portal vein anastomosis
was without difficulties. Following arterial anastomosis and the
liver fully re-perfused, there was significant amount of time
required to achieve hemostasis. In total she received 6 liters
of crystalloid, 24 units of FFP, 22 units of packed red blood
cells, 3 units of platelets and 1 unit of cryo. She was
transferred intubated to the SICU in stable condition on no
pressor support.
She remained in the ICU through POD 4 and was extubated on POD
2.
On POD 1, the patient was noted to have approximately 400 cc
blood loss from epistaxis around the NG tube.
Otolaryngology consult was obtained, the NG tube was d/c'd and
the bleeding controlled with merocel and packing which remained
in for 5 days. Per their request unasyn was continued for 5 days
as well. Once removed, there was no further bleeding and the
patient used saline spray to keep the nasal mucose moist.
Patient was having daily HBSAb titers done, POD 1 titer was <
500 so she received 10,000 units HBIg POD1, the following days
through POD 5 the titer was > 500 and she received 5000 units
through POD 5 and then again on POD 7 per protocol.
She will continue outpatient HBIg administration per protocol.
The lateral drain was removed on POD3 and the lateral drain on
POD 6. There was minimal drainage in the tubes.
The AST and ALT peaked on POD 2 and 3 respectively and then
continued to trend down. T bili was 1.3 on discharge. Hematocrit
was stable once the epistaxis was controlled. Kidney function
remained stable and normal throughout.
Incision was C/D/I. Pain management was initially an issue but
PO dilaudid seemed to manage her pain.
Immunosuppresion was managed by daily prograf levels and
appropriate steroid taper.
[**Last Name (un) **] consult was called as initial blood sugar management was
difficult. Towards the end of the hospitalization, her dosing
was cut back and NPH dose dropped as well. She will follow with
[**Last Name (un) **], was taught how to self administer insulin and has
contact numbers with Dr [**Name (NI) 51334**] if problems arise prior to
being seen in clinic.
She was ambulating without difficulty, was tolerating diet
although she did not have good appetite. She had return of bowel
function.
Patient is discharging to home in [**State 1727**] with VNA. Appointments
for HBIg administration have been made as well as clinic visits.
[**Last Name (un) **] appointment still needs to be made.
Medications on Admission:
Citalopram 40 mg daily, Lisinopril 5 mg daily, Lorazepam 1
mg daily, Metformin 500 mg [**Hospital1 **], Prilosec 40 mg daily, Tenofavir
300 mg daily, Sumatriptan 25 mg PRN migraine (last 1 month ago),
zolpidem 5 mg hs, colace 100 mg daily PRN, Senna 8.6 mg [**Hospital1 **] prn
constipation, imodium 2 mg PRN diarrhea
Discharge Medications:
1. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
2. Bactrim 400-80 mg Tablet Sig: One (1) Tablet PO once a day.
3. prednisone 5 mg Tablet Sig: Four (4) Tablet PO once a day:
Follow transplant clinic taper.
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. tenofovir disoproxil fumarate 300 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
7. citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day.
8. Valcyte 450 mg Tablet Sig: Two (2) Tablet PO once a day.
9. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
10. sodium chloride 0.65 % Aerosol, Spray Sig: Two (2) Spray
Nasal QID (4 times a day).
11. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
13. metoprolol tartrate 25 mg Tablet Sig: [**1-9**] Tablet PO BID (2
times a day).
14. NPH insulin human recomb 100 unit/mL Suspension Sig: Ten
(10) units Subcutaneous once a day.
15. insulin aspart 100 unit/mL Solution Sig: per sliding scale
Subcutaneous four times a day: Check blood sugar 4 times daily
at meals and evening.
16. tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours).
17. tacrolimus 1 mg Capsule Sig: One (1) Capsule PO twice a day.
18. sodium polystyrene sulfonate Powder Sig: Four (4) tsp PO
As direct by transplant clinic: Take only upon direction of
transplant clinic.
19. sumatriptan succinate 25 mg Tablet Sig: One (1) Tablet PO as
needed for migraine as needed for headache.
20. zolpidem 5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
21. Multiple Vitamin Tablet Sig: One (1) Tablet PO once a
day.
Discharge Disposition:
Home With Service
Facility:
[**First Name9 (NamePattern2) 70810**] [**Location (un) 24402**]
Discharge Diagnosis:
HBV/HCC now s/p orthotopic liver transplant
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call the transplant clinic at [**Telephone/Fax (1) 673**] for fever,
chills, nausea, vomiting, diarrhea, constipation, increased
abdominal pain, increased abdominal swelling, weight gain or
loss of greater than 3 pounds in a 24 hour period, inability to
take or keep down food, fluids or medications.
Monitor the incision for redness, drainage or bleeding
You will be having labs drawn every Monday and Thursday at Nordx
lab as has been arranged by the transplant clinic.
No heavy lifting
No driving if taking narcotic pain medications
Take all medications as prescribed. You taking some new
medications and are off some of the pre-transplant medications.
PLease review your mediation list carefully.
You are now taking insulin. DO NOT use the metformin at this
time. Monitor your blood sugar 4 times daily and use the scale
given to you by Dr [**Last Name (STitle) 51334**]. You will have follow up with the
[**Hospital **] clinic.
You may shower, no tub baths or swimming
Followup Instructions:
Pheresis Unit [**Hospital1 18**] [**Hospital Ward Name 516**],[**Hospital Ward Name 2104**] Building [**Location (un) 442**].
Tues [**10-26**] at 11:15
[**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2151-10-28**] 1:40
[**Last Name (LF) **],[**First Name3 (LF) 156**] TRANSPLANT SOCIAL WORK Date/Time:[**2151-10-28**] 3:00
Pheresis Unit [**Hospital1 18**] [**Hospital Ward Name 516**],[**Hospital Ward Name 2104**] Building [**Location (un) 442**].
Monday [**11-1**] at 8:15AM,
Pheresis Unit [**Hospital1 18**] [**Hospital Ward Name 516**],[**Hospital Ward Name 2104**] Building [**Location (un) 442**]
Monday [**11-8**] at 9:15AM.
Completed by:[**2151-10-21**]
ICD9 Codes: 5715, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3642
} | Medical Text: Admission Date: [**2100-11-25**] Discharge Date: [**2100-12-14**]
Date of Birth: [**2020-6-25**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
Chest Pain s/p Urologic procedure (see below)
Major Surgical or Invasive Procedure:
[**2100-11-25**]: Cystoscopy, left ureteroscopy, laser lithotripsy, left
ureteral stent placement, and left percutaneous nephrostomy tube
removal.
[**2100-11-26**]: Subtotal abdominal colectomy and damage control
laparotomy.
[**2100-11-27**]: Reopening of recent laparotomy for 2nd-look exploratory
laparotomy, small-bowel resection and temporary closure of
abdomen.
[**2100-11-28**]: Abdominal exploration. Cholecystectomy. [**Doctor Last Name **]
ileostomy. Secondary closure of open abdomen.
History of Present Illness:
Mr. [**Known lastname **] is a 65 year old male with a history two vessel
disease that has been medically managed. On [**11-25**] he went
for Cystoscopy, left ureteroscopy, laser
lithotripsy, left ureteral stent placement, and left
percutaneous nephrostomy tube removal. After the procedure he
reported substernal chest pain that was relieved with
nitroglycerin.
He was given ASA, morphine, and nitro. He had lateral ST
depressions on his ECG. He was started on heparin and nitro gtt
for NSTEMI. CKMB 28, Troponin <0.01.
.
He was transfered to the [**Hospital1 1516**] service for cardiac
catheterization. However given his pain had resolved by early
afternoon, and due to his renal failure (creatinine 2.8 from
unclear baseline), optimization of his renal function was
attempted prior to catheterization. He recieved Mucomyst and
hydration overnight. At 6:15Am he developed acute lower
abdominal pain, different from his typical anginal pain, EKG
showed ST elevations in V1-V4 with slight elevations in II. He
received ASA 325mg and started on integrillin. Troponins peaked
at 2.91. He was taken urgently to the cath lab where he was
found to have multivessel disease. An intra-aortic balloon pump
was placed (30cc) to maintain pt symptom free, but he continued
to have abdominal pain. He was seen by general surgery as
urology was unable to assess the patient right away. Abdominal
pain was thought to be post procedural pain. He presented to
the CCU on a nitro drip. Heparin gtt was not yet started. It
was unclear when integrillin was discontinued, but he was not
running on the floor and medications were confirmed with
interventional fellow at time of arrival.
.
In the CCU pt was complaining of abdominal pain in his lower
quadrants, exam unrevealing for rebound or guarding. He also
had hematuria, but with good urine output. He denies any chest
pain or shortness of breath. He has occasional light
headedness. Again urology was consulted, they recommended a KUB
to confirm stent placement.
.
Upon evaluation of the patient in the cath lab, the patient was
seen to have primarily suprapubic abdominal pain and was seen
not to have a Foley catheter. Foley catheter was placed with
some amelioration of the abdominal pain. The patient was seen
approximately 2 hours later at which point in time his abdominal
pain was somewhat improved, however, at that point in time a
metabolic panel revealed an increasing metabolic acidosis. The
concern for intra-abdominal distal ischemia was entertained.
Because of the patient's very high operative risk, the
Cardiology service was consulted and there was general agreement
that although the patient was a prohibitive operative risk, he
essentially had no chance for survival without abdominal
exploration. The family was so counseled regarding the high
mortality rate and elected to proceed with operative
intervention.
Past Medical History:
OTHER PAST MEDICAL HISTORY:
1. Hypertension
2. THR [**1-/2098**], bilateral total hip replacements, the right in
[**2071**] or [**2072**] at [**Hospital1 18**], the left in [**2080**] at [**Hospital1 18**].
3. DVT after his right primary THR in the early [**2069**]
4. Three brain aneurysm procedures, presumably [**Doctor Last Name **]
aneurysms(clippings performed, one in [**2065**] and two in [**2078**].)
5. Renal insufficiency - basline likely 2.0
6. Hypothyroidism
7. BPH
8. Cataracts (blind in L eye)
9. Hyperlipidemia
Social History:
He is retired, former truck driver, lives with wife in
[**Name (NI) 3494**], and independent in ADLs. Still smokes cigarettes, a
half pack a day for 50 years. He does not drink alcohol.
Denies recreational drug use.
Family History:
No history of MI or CVA
Physical Exam:
deceased
Pertinent Results:
CARDIAC CATH
[**2100-11-26**]:
1. Selective coronary angiography of this right-dominant system
demonstrated 3 vessel coronary artery disease. The LMCA had no
angiographically apparent flow-limiting disease. The LAD had
80-90%
ostial stenosis with 90% ulcerated mid-vessel stenosis. There
was TIMI 3 flow. The LCx had 50-60% mid-vessel stenosis. The
RCA had proximal TO. Faint left-to-left collaterals were
present.
2. Limited resting hemodynamics revealed moderate systemic
sytolic
arterial hypertension
3. IABP was placed pending decision for CABG.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. IABP placed pending CABG decision
3. Moderate systemic systolic arterial hypertension.
Imaging:
[**2100-11-26**] LLE LENI: No evidence of deep vein thrombosis in the left
leg.
[**2100-11-29**] CT head: No evidence of interval hemorrhage or
infarction since the study of [**2099-12-8**]. Extensive
postoperative changes and new evidence of paranasal sinus
inflammation.
[**2100-11-30**] RUQ US:
1. Fluid which contains some low-level echoes is seen within the
gallbladder fossa. This may represent perioperative fluid/blood
or could
represent bile, but cannot be characterized with ultrasound. A
radionuclide scan or MRI with biliary contrast [**Doctor Last Name 360**] could be
performed for further characterization.
2. No biliary dilatation seen.
3. Trace of ascites in the left lower quadrant.
[**2100-12-1**] ECHO:
Left ventricular wall thickness, cavity size, and global
systolic function are normal (LVEF>55%). 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. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
IMPRESSION: Suboptimal image quality. Preserved regional and
global left ventricular systolic function.
[**2100-12-5**] CT chest/abdomen/pelvis:
1. Evidence for acute bleeding event near the exiting ileostomy
loop in the right lower quadrant. Extent suggests areterial
source over venous. Large collection of blood in the right
lower-to-mid abdomen, with a hematocrit level measuring 8.5
(TRV) x 7.4 (AP) x 12.4 (CC). Given the highest density of
hemorrhagic material near the exiting ileostomy loop, this is
suggestive of clot near the anastomosis.
2. Hemorrhagic material within the left renal collecting system
which may be venous in nature and related to patient's elevated
heparin and indwelling stent
[**2100-12-7**] ECHO:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The aortic 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. The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal global and regional biventricular systolic function. Mild
mitral regurgitation.
Path:
Colon, colectomy (A-L):
1. Mucosal and focal mural ischemia involving predominantly
distal colon; proximal terminal ileal and distal colonic margins
viable.
2. Diverticular disease.
3. One unremarkable lymph node.
Small bowel, small bowel resection (A-D):
Mucosal ischemia with patchy transmural acute inflammation,
extending to at least one specimen margin.
Gallbladder (A-B):
Gallbladder with subtotal mucosal denudation and mural chronic
inflammation; no overt ischemia identified.
One unremarkable lymph node.
Brief Hospital Course:
In brief, this is an 80M who underwent laser lithotripsy, left
ureteral stent placement, and nephrostomy tube removal on
[**2100-11-26**]. Post-procedure, he complained of chest pain and was
found to have ST depressions in V4-V6, I, aVL. Chest pain
improved slightly on heparin and nitro gtt, and the patient
underwent a cath which revealed three vessel CAD. An IABP was
placed during this procedure. The patient subsequently developed
progressive worsening abdominal pain and rising lactate to 5.5,
ABG 7.14/38/202. Given concern for low-flow state s/p MI,
patient was taken to the OR for exploratory laparotomy and
subtotal colectomy of infarcted R and L colon/hypoperfused
stomach and small bowel. He was then taken back x2 on [**11-27**] and
[**11-28**] with removal of 18 additional inches of ischemic small
bowel, end ileostomy, cholecystectomy of necrotic gallbladder,
and abdominal closure. He recovered well from these procedures
and was stable enough to move to the floor on [**2100-12-12**]. His
remaining issue was feeding, as he was having high residuals
with tube feeds. This had made it necessary to continue TPN
through a right IJ CVL.
On [**2100-12-13**], however, the patient complained of chest pain and
was found to be hypotensive and hypoxemic. He was transferred
back to the SICU. There he was found not to be having a cardiac
event but likely to be in florid sepsis. He was intubated and
put on broad-spectrum antibiotics. The right IJ central line
did have some purulent discharge, and this had been removed
shortly after admission to the ICU and sent for culture. An
abdominal CT scan did not elucidate a cause for the patient's
condition. Sputum gram stains showed gram positive cocci and
gram negative diplococci. The other cultures are still pending.
He continued to worsen despite maximal pressors and
antibiotics, with dropping pressures and temperatures. Early in
the morning on [**12-14**], his family agreed to make him care measures
only. He passed away several hours later.
His hospital course by systems until the events on [**12-13**] is as
follows:
Neuro: The patient was intermittently agitated and had several
episodes of delirium. Cultures were sent and all are pending or
negative. A CT head was done on [**11-29**], and this showed no ICH.
He was given valium and later seroquel with good result. Valium
was later stopped.
Pulm: The patient was weaned from the ventilator and extubated
[**12-2**] without problems. [**Name (NI) **] was reintubated on [**12-5**] in the
setting of a major bleeding episode. He was weaned again and
re-extubated.
CV: Three vessel disease found on cath. IABP was placed at the
cath on [**2100-11-25**]. It was removed on [**2100-11-29**] without issue. The
patient was on pressors intermittently until [**12-9**]. The etiology
of the hypotension was unclear. The patient was given 1 dose of
5% albumin on [**12-8**] in the thought that he was dry, but this
pushed him into pulmonary edema. This resolved with lasix. A
[**Last Name (un) 18821**] was then placed, which helped to guide fluid
administration. At that point, the patient appeared to be
somewhat intravascularly dry but more importantly vasoplegic.
On [**12-9**], [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 104**] stim test was performed, which was equivocal in
results (21.9/28.0/30.2). Even though his pressors had been
weaned off at this point, the patient was started on three days
of stress dose steroids ([**Date range (1) 58909**]).
The patient underwent three ECHOs. The first, which was on [**11-26**]
before the cardiac cath, showed moderate regional LV systolic
dysfunction with near akinesis of the distal half of the septum
and anterior walls and distal inferior wall. The apex was mildly
diskinetic. The second two ECHOs showed preserved ventricular
function with LVEF > 55%.
The patient is hypertensive and on atenolol at home. The patient
was seen to have ectopy [**12-10**]. Electrolytes were normal. Low
dose lopressor was added as blood pressure permitted on [**12-10**]
with good result.
Regarding CABG, the cardiothoracic team plans to pursue this
when the patient has recovered from this hospitalization.
GI: The patient underwent exploratory laparotomies on [**12-24**],
and [**11-28**]. The right and left colons were found to be necrotic,
as well as a portion of small bowel and the gallbladder. These
were removed. Lactate had trended up to 5.5 preoperatively; it
trended down and normalized after the necrotic bowel was
resected. The last measured lactate was 1.8 on [**2100-12-8**]. The
abdomen was left open initially but closed at the final surgery
on [**2100-11-28**]. An end ileostomy was placed. This is producing gas
and bowel movements appropriately. When the patient was
restarted on a heparin gtt for his cardiac disease, he suffered
hemorrhage at the ileostomy site. The heparin gtt was stopped
with the approval of cardiology, and a red rubber catheter was
placed in the ostomy to keep it open. The ostomy continued to
function well.
The liver was seen to have patchy areas of necrosis/ischemia
intraoperatively, and LFTs were elevated. This was thought to
be due to the liver necrosis, and a RUQ ultrasound ruled out
blockage of the biliary system. The levels were all trending
down until an acute bleeding episode [**2100-12-5**] with resulting
hypotension. This caused a second episode of shock liver with
an increase in liver function tests. ALT/AST/AP/LDH are
currently trending down, but the bilirubin continues to trend
up.
The patient was started on tube feeds appropriately after
surgery but had an episode of emesis. Therefore, the tube feeds
were stopped and TPN started on [**12-2**]. On [**2100-12-10**], he was
restarted on tube feeds through his NGT. He will need to have a
speech and swallow evaluation at the LTAC. He may take POs when
able.
GU: The patient is s/p laser lithotripsy, left ureteral stent
placement, and nephrostomy tube removal on [**2100-11-26**] for a left
ureteral stone. He developed hematuria in the setting of a
heparin gtt but this has since resolved. The stent will be
removed by urology in the clinic. The patient also has a
history of chronic renal insufficiency. His baseline Cr is
unclear, but it is thought to be 2.0. His Cr reached a peak of
3.0 on this hospitalization, thought to be due to ATN? It is
trending down, now 2.3.
There was a concern for phimosis [**11-30**], but the foreskin was able
to be pulled down. Urology recommended elevation and bacitracin
to the area of the foley.
Heme: Received 2 units PRBC [**11-26**] after the first exploratory
laparotomy, 2 units PRBC [**11-27**] after the second exploratory
laparotomy, and 1 unit of platelets and 1 unit PRBCs [**11-28**] after
the third exploratory laparotomy. Heparin gtt was restarted on
[**11-29**] and was to be continued for 1 month per cardiology
recommendations. There was [**Last Name **] problem until [**12-5**], when the
patient became acutely hypotensive to the 70s and Hct dropped
from 26.8 to 19.8. He was found to have a significant
intra-abdominal bleed from the ileostomy site. The heparin gtt
was stopped, and the patient was transfused 6 RBCs, 3 FFP, and 2
platelets with stable hct thereafter. On [**12-8**], the patient was
restarted on SQH. Cardiology agreed that the patient should not
be more aggressively anticoagulated.
ID: The patient was initially put on vancomycin, cipro, and
zosyn postoperatively. The patient was pancultured for episodes
of delirium and again for one fever of 101.6 on [**12-6**]. Cultures
are all no growth to date. Antibiotics were stopped on [**12-3**].
Endocrine: The patient was maintained on synthroid for his
hypothyroidism. He was also started on 3 days of stress dose
steroids on [**12-10**] for an equivocal [**Last Name (un) 104**] stim test.
On [**12-13**], the patient acutely worsened and was reintubated,
advanced to maximal pressors, and restarted on broad-spectrum
antibiotics. This did not halt the progression of likely
sepsis, and he was made CMO on [**12-14**]. He passed away later that
morning as described above.
Medications on Admission:
ATENOLOL 25 mg by mouth daily
CIPROFLOXACIN 500 mg by mouth twice daily
FLUTICASONE 50 mcg Spray, Suspension 2 puffs(s) intranasal twice
daily
IBUPROFEN 800 mg by mouth every eight hours as needed for pain
ISOSORBIDE MONONITRATE 30 mg Sustained Release by mouth twice a
day
LEVOTHYROXINE [SYNTHROID] 125 mcg by mouth daily
NITROGLYCERIN [NITROSTAT] 0.3 mg Sublingual EVERY 5 MINUTES AS
NEEDED
OMEPRAZOLE EC 20 mg by mouth daily
POLYETHYLENE GLYCOL 17 gram by mouth once daily
SIMVASTATIN 20 mg by mouth nightly
TAMSULOSIN [FLOMAX] SR 0.4 mg by mouth daily
ASPIRIN 325 mg by mouth daily
Discharge Medications:
none
Discharge Disposition:
Extended Care
Discharge Diagnosis:
left ureteral stone s/p lithotripsy and stent
bowel ischemia, s/p subtotal colectomy and small bowel resection
infarcted gallbladder s/p cholecystectomy
ischemic liver
Discharge Condition:
deceased
Discharge Instructions:
none
Followup Instructions:
none
ICD9 Codes: 9971, 5849, 2762, 2761, 3051, 4019, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3643
} | Medical Text: Admission Date: [**2116-4-26**] Discharge Date: [**2116-5-3**]
Date of Birth: [**2067-10-28**] Sex: M
Service: MEDICINE
Allergies:
Zidovudine
Attending:[**First Name3 (LF) 3624**]
Chief Complaint:
found down
Major Surgical or Invasive Procedure:
Endoscopy
History of Present Illness:
48M HIV+ on HAART CD4 228, DM on insulin pump, s/p kidney xplant
([**2114**]) on Tacro/Prednisone 5/Bactrim, found down at home after
taking Ativan/narcotics for pain [**2-19**] colonoscopy 4 days ago. Pt
reports that yesterday afternoon he took 3 pills of what he
thought were ativan per his daily routine and sat down to watch
TV as his last memory. Mother called 911 EMS gave narcan pt woke
then vomited reported coffee ground emesis per EMS after he had
ate he ate meatball sub for diner.
Seen initially at [**Hospital1 1562**] where he had Cr 2.7 from 1.8, K 7.1
and trop 0.14 and he recieved Kayexalate 30mg, CaGluc 1 amp, 6U
humulin and Reglan 10mg, Protonix 80mg, and 1L NS + 2 amps
bicarb. CXR there showed multifocal infiltrates by report.
Reported epigastric pain. Guiaic neg. HR 105 and 73/44 at OSH
In ED 98.4 91 111/70 18 96% 2L and remained normotensive. NG
lavage was negative, guaiac + with mix brown stool and BRB.
Review of symptoms:
denies fever, chills,abd pain, chest pain, diaphoresis, black or
bloody stools, nausea, vomiting, suicidal ideation, tylenol
ingestion. Denies headache, rhinorrhea or congestion. Denies
cough, shortness of breath, or wheezing. Denies chest pain,
chest pressure, palpitations, or weakness. Denies nausea,
vomiting, diarrhea, constipation, abdominal pain, or changes in
bowel habits. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
HIV diagnosed in [**2093**], no AIDS defining illness, last CD4 341
DM type I, c/b neuropathy
CVA [**2108**], mild, lateral 3 digits on right hand affected
Hypertension
Pilonidal cyst, abscess drainage
Kidney transplant [**2114**]
Lt 4th metatarsal osteotomy [**2113**]
Social History:
There is a distant smoking in the past. No history of drug use
or alcohol abuse. The patient lives with his mother and is
currently disabled. Single MSM. No pets, previously worked as a
painter.
Family History:
NC
Physical Exam:
Vitals: 100.1, 102, 116/65, 18, 99%RA
General: Alert, orientedx 3, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: distant heart sounds, Regular rate and rhythm, normal S1 +
S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley, no CVA tenderness
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, well healing ulcer on left foot without erythema or
drainage.
Pertinent Results:
Labs on Admission:
[**2116-4-26**] 11:06PM tacroFK-4.9*
[**2116-4-26**] 08:45PM GLUCOSE-483* UREA N-36* CREAT-3.0*#
SODIUM-141 POTASSIUM-5.6* CHLORIDE-101 TOTAL CO2-24 ANION
GAP-22*
[**2116-4-26**] 08:45PM estGFR-Using this
[**2116-4-26**] 08:45PM ALT(SGPT)-29 AST(SGOT)-28 CK(CPK)-852* ALK
PHOS-64 TOT BILI-0.4
[**2116-4-26**] 08:45PM LIPASE-21
[**2116-4-26**] 08:45PM cTropnT-0.08*
[**2116-4-26**] 08:45PM CK-MB-11* MB INDX-1.3
[**2116-4-26**] 08:45PM CALCIUM-8.2* PHOSPHATE-5.4*# MAGNESIUM-1.8
[**2116-4-26**] 08:45PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2116-4-26**] 08:45PM WBC-8.2 RBC-3.70* HGB-13.1* HCT-39.5*
MCV-107*# MCH-35.3* MCHC-33.1 RDW-16.1*
[**2116-4-26**] 08:45PM NEUTS-70 BANDS-1 LYMPHS-22 MONOS-7 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2116-4-26**] 08:45PM HYPOCHROM-OCCASIONAL ANISOCYT-OCCASIONAL
POIKILOCY-OCCASIONAL MACROCYT-2+ MICROCYT-NORMAL
POLYCHROM-OCCASIONAL TEARDROP-OCCASIONAL
[**2116-4-26**] 08:45PM PLT COUNT-188
[**2116-4-26**] 08:45PM PT-12.5 PTT-25.3 INR(PT)-1.1
Labs on Discharge:
[**2116-5-3**] 06:25AM BLOOD WBC-5.2 RBC-3.23* Hgb-11.5* Hct-32.2*
MCV-100* MCH-35.5* MCHC-35.6* RDW-16.4* Plt Ct-192
[**2116-5-3**] 06:25AM BLOOD PT-12.8 PTT-23.3 INR(PT)-1.1
[**2116-5-3**] 06:25AM BLOOD Glucose-190* UreaN-29* Creat-3.0* Na-138
K-3.5 Cl-105 HCO3-25 AnGap-12
[**2116-5-1**] 06:20AM BLOOD ALT-27 AST-21 AlkPhos-57 TotBili-0.5
[**2116-4-30**] 05:40AM BLOOD CK-MB-3 cTropnT-0.10*
[**2116-4-29**] 06:30AM BLOOD cTropnT-0.10*
[**2116-4-27**] 11:24AM BLOOD CK-MB-9 cTropnT-0.14*
[**2116-5-3**] 06:25AM BLOOD Calcium-8.0* Phos-2.2* Mg-1.8
[**2116-5-3**] 06:25AM BLOOD tacroFK-5.8
Microbiology:
[**2116-4-26**] Blood cultures x 2 No growth
[**2116-4-27**] MRSA Screen No MRSA isolated
[**2116-4-27**] Urine Culture No growth
[**2116-4-29**] VIRAL CULTURE: R/O HERPES SIMPLEX VIRUS (Preliminary):
No Herpes simplex (HSV) virus isolated
Imaging:
- ECG Study Date of [**2116-4-27**] 12:47:16 AM
Sinus tachycardia. Low limb lead QRS voltage. Modest ST-T wave
changes.
Findings are non-specific. Since the previous tracing of [**2114-8-1**]
sinus
tachycardia and modest ST-T wave changes are both now present.
- CHEST (PA & LAT) Study Date of [**2116-4-27**] 3:06 AM
IMPRESSION: Cavitating right lower lobe pneumonia.
- RENAL TRANSPLANT U.S. Study Date of [**2116-4-27**] 8:52 AM
IMPRESSION:
1. Increased resistive indices within the transplanted kidney,
which are
elevated compared to [**2114-7-18**] ultrasound.
2. Mild pelvocaliectasis of the transplanted kidney.
- CT CHEST W/O CONTRAST Study Date of [**2116-4-28**] 5:03 PM
IMPRESSION:
1. Multifocal pneumonia. No cavitation or obstruction.
2. A 9-mm upper tracheal nodule contiguous with possible
esophageal mass. I
would suggest a repeat CT scan, after vigorous coughing to clear
the trachea of any debris, utilizing oral contrast [**Doctor Last Name 360**] to
reassess both the trachea and the esophagus.
- ESOPHAGUS Study Date of [**2116-4-30**] 2:47 PM
IMPRESSION:
1. Esophageal dysmotility, as described above.
2. No evidence of esophageal stricture, intraluminal mass, or
mucosal
abnormality.
- EGD [**2116-5-1**]
Procedure: The procedure, indications, preparation and
potential complications were explained to the patient, who
indicated his understanding and signed the corresponding consent
forms. A physical exam was performed. The patient was
administered moderate sedation. The patient was placed in the
left lateral decubitus position and an endoscope was introduced
through the mouth and advanced under direct visualization until
the third part of the duodenum was reached. Careful
visualization of the upper GI tract was performed. The procedure
was not difficult. The patient tolerated the procedure well.
There were no complications.
Findings:
Esophagus: Normal esophagus.
Stomach: Normal stomach.
Duodenum: Normal duodenum.
Brief Hospital Course:
Mr. [**Known lastname 20083**] is a 48yo M with history of HIV and diabetic
nephropathy s/p living-related transplant [**7-25**] who was found
down at home and was found down with improvement after narcan
and found to have acute kidney injury, elevated K that was
treated and hypotension with report of coffee ground emesis.
# Acute kidney injury: The patient normally has a creatinine
around 1.8 s/p living related transplant, but after being found
down had a creatinine of 3, which rose during the course of his
admission initally; he was thought to have ATN secondary to
volume depletion in setting or recent bowel prep as well as
dehydration. His creatinine improved over the course of his
admission with IV fluids back down to 3, but not completely back
to his baseline. He was discharged with a decrease in his
Truvada to 1 tablet every 72 hours secondary to his continued
but improving renal damage.
# GI bleed: Pt guaiac positive in ED likely related to recent
colonoscopy or prior rectal exam at OSH. Concern for UGI bleed
given report of dark emesis, but pt HCT is stable, GI lavage is
neg and he denies abdominal pain, bloody stool, black stool or
lightheadedness. The patient had a table HCT within the hospital
that did not require any blood transfusions. An endoscopy was
performed which was completely normal, without any sign of mass
or bleed.
#Multivocal infiltrate: Multifocal infiltrate found on CXR after
being altered and vomiting with EMS. Initially endorsed low
grade fevers, cough, and brown productive sputum. Was initially
covered with Vanc/cefepime cover for possible aspiration PNA. A
CT of the Chest was shown to be consistent with multifocal
pneumonia, but also incidentally commented on an
esophgeal/tracheal mass. The patient's antibiotics were later
transition to moxifloxacin. He had completed a 7 day course of
antibiotics by the time of his discharge. UPon discharge he was
not short of breath and satting well on room air, as compared to
his initial presentation when he had required 4 L O2.
#Esophageal mass: On CT scan, the patient was noted to have an
esophageal mass with some possible connection to a very small
tracheal infiltrate, concerning for malignancy. A barium swallow
was performed, which only showed some esophageal dysmotility,
but no signs of a mass or fistula. The EGD for presumed UGIB
also did not reveal any signs of mass or fistula. Given the fact
it was presumed the patient had an aspiration event, the
tracheal infiltrate was presumed to be aspirated content from
his aspiration event.
# Hyperglycemia: Pt with insulin pump at home wtih fingersticks
ranging 100-200 usually presenting with hyperglycemia. His
hyperglycemia was though to be secondary to the stress response
of infection. He was controlled in house with SSI, with
recommendations from the [**Last Name (un) **] team. Upon discharge, he was
re-started back on his insulin pump.
# s/p Renal transplant: Renal ultrasound was not thought to
reflect rejection. The patient's tacrolimus level was elevated
in the hospital, and thus his dose was halved to 1.5 mg [**Hospital1 **] from
3 mg [**Hospital1 **], with Tacro levels on discharge in the appropriate
range.
# HIV: on HAART. HAART medication dosing decreased secondary to
known renal dysfunction; upon discharge, he was still taking
less than his usual home dose of Truvada; this will need to be
uptitrated to his normal home dose once his kidneys fully
recover.
# Substance abuse: It came to light during this admission that
the patient had purposefully taken all of the narcotics
prescribed to him post his anoscopy simultaneously in order to
"get high." Social work and psychiatry was consulted; psychiatry
did not find any acute issues, and recommended continuing the
patient's current dosing of psychoactive medication. PCP was
[**Name (NI) 653**], and will help to make arrnagement for further
outpateint psychiatric help.
Medications on Admission:
AMLODIPINE - 5 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily)
AZATHIOPRINE - 50 mg Tablet - 1 Tablet(s) by mouth once a day
EMTRICITABINE-TENOFOVIR [TRUVADA] - 200 mg-300 mg Tablet - 1
Tablet(s) by mouth every day
ETRAVIRINE [INTELENCE] - 100 mg Tablet - 2 Tablet(s) by mouth
twice daily
INSULIN ASPART [NOVOLOG PENFILL] - (Prescribed by Other
Provider) - 100 unit/mL Cartridge -
LORAZEPAM [ATIVAN] - (Prescribed by Other Provider) - 1 mg
Tablet - 2 Tablet(s) by mouth at bedtime
METOCLOPRAMIDE - 10 mg Tablet - 1 Tablet(s) by mouth three times
a day
PANTOPRAZOLE [PROTONIX] - (Prescribed by Other Provider) - 40
mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth daily
PREDNISONE - 5 mg Tablet - 1 Tablet(s) by mouth once a day
RALTEGRAVIR [ISENTRESS] - 400 mg Tablet - 1 Tablet(s) by mouth
twice daily
SULFAMETHOXAZOLE-TRIMETHOPRIM [BACTRIM] - 400 mg-80 mg Tablet -
1 Tablet(s) by mouth once a day
TACROLIMUS - (restarted) - 1 mg Capsule - 2 Capsule(s) by mouth
twice a day
VENLAFAXINE - (Prescribed by Other Provider) - 75 mg Capsule,
Ext Release 24 hr - 1 Capsule(s) by mouth once a day
Discharge Medications:
1. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO DAILY (Daily).
2. etravirine 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
3. azathioprine 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO every twenty-four(24)
hours.
6. tacrolimus 0.5 mg Capsule Sig: Three (3) Capsule PO Q12H
(every 12 hours).
Disp:*180 Capsule(s)* Refills:*2*
7. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. raltegravir 400 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
9. insulin aspart 100 unit/mL Cartridge Sig: 0.85 U Subcutaneous
every hour: via insulin pump, titrate according to your blood
glucose.
10. Truvada 200-300 mg Tablet Sig: One (1) Tablet PO every
seventy-two (72) hours.
11. Outpatient Lab Work
Chem 7, CBC, serum tacrolimus level. Send to Dr. [**Last Name (STitle) **] at
Office Phone:([**Telephone/Fax (1) 3618**], Office Fax:([**Telephone/Fax (1) 12146**]
12. amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Aspiration pneumonia
Acute Tubular necrosis (kidney injury)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 20083**],
You were admitted to the hospital after you had overdosed on
pain medications given to you for your anoscopy and
sigmoidoscopy. You were unconscious and developed a pneumonia
from inhaling some of your stomach contents. You were treated
with antibiotics for seven days.
You also developed kidney failure afterwards, which has since
improved. However, it has not returned back to normal and
because of this the doses of some of your medications have
changed.
On one of your CT scans, there was a concern for an esophageal
mass. You had an endoscopy that showed no problems.
The following changes have been made to your medications:
Tacrolimus - DECREASE to 1.5mg twice daily
Truvada - DECREASE to 1 tablet every 72 hours.
You should RESTART your insulin pump at 0.85U/hour starting 11pm
tonight [**2116-5-3**].
Followup Instructions:
Please make an appointment with Dr. [**Last Name (STitle) **] within the next 2
weeks. His phone number is [**Telephone/Fax (1) 673**].
Also, you should see your primary care doctor, Dr. [**First Name (STitle) 1557**] as
well. Her phone number is [**Telephone/Fax (1) 30782**].
You will need to have your labs checked sometime next week and
sent to Dr. [**Last Name (STitle) **]. You have been given a prescription for
those.
You have the following other appointments scheduled.
Department: PODIATRY
When: FRIDAY [**2116-5-29**] at 1:20 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: TRANSPLANT CENTER
When: MONDAY [**2116-8-17**] at 1 PM
With: [**Name6 (MD) 2105**] [**Name8 (MD) 2106**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**] MD [**MD Number(1) 3629**]
ICD9 Codes: 5070, 5845, 3572, 4019, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3644
} | Medical Text: Admission Date: [**2205-11-13**] Discharge Date: [**2205-11-14**]
Date of Birth: [**2166-7-13**] Sex: M
Service: MEDICINE
Allergies:
Gabapentin / Trazodone / Codeine
Attending:[**First Name3 (LF) 2712**]
Chief Complaint:
AMS, concern for toxic alcohol ingestion
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 27389**] is a 39 year old man with h/o EtOH and
polysubstance abuse, seizure disorder, who was found to be
unresponsive while visiting his partner in the ICU earlier
today.
.
The patient was visiting his partner in the ICU earlier today.
He was awake and conversant in the morning with no acute
complaints. He was noted to be sleeping on the floor, but walked
to the chair by himself when he was awakened. Later in the
afternoon, the patient was noted to still be asleep in the
chair. He was unarousable with verbal stimuli or sternal rub, so
he was taken down to the ED.
.
In the ED, the patient was initially altered, but was otherwise
hemodynamically stable. No urine incontinence or e/o toxidromes.
Labs notable for EtOH 86, Osms 366, anion gap 16, lactate 3.8.
Utox positive for barbs, but Stox and Utox otherwise negative.
Given high serum osmolar gap (60), toxicology was consulted for
concern of toxic alcohol ingestion. Most likely isopropyl
alcohol given osmolar gap with small anion gap (likely due to
lactate) and access to CalStat in the hospital today. However,
given a dose of Fomepizole 15mg/kg IVx1 in the ED for possible
ethylene glycol vs methanol ingestion. Also given Diazepam 10mg
x1 for EtOH withdrawal. EEG following, as the patient is
enrolled in a study for AMS. Vitals prior to transfer: 97.5 103
120/60 22 RA 100%
.
On the floor, the patient is currently hungry and feels like he
is going to withdraw. He is anxious and has some palpitations.
No shortness of breath, chest pain. He denies ingesting anything
today. He has had no PO intake x4 days.
Past Medical History:
* Subdural hematoma ([**2204-4-12**]) from fall
* Alcohol and polysubstance abuse
* Hepatitis C virus infection
* Mood disorder with multiple suicide attempts
* ?PTSD, bipolar/anti-social personality/impulse/rage disorders
* Migraines
* Chronic lower back pain
* MVA s/p chest tube placement in [**2200**]
* Seizure disorder since [**08**] yo, alcohol withdrawal seizures
Social History:
Stays with his girlfriend in [**Name (NI) **].
- Tobacco: +intermittent tobacco use
- Alcohol: 1/5th daily of hard liquour, has been drinking since
9 yo, has h/o DTs and alcohol withdrawal seizures
- Illicits: Past use of cocaine, heroin, opiates,
benzodiazepines documented in [**Name (NI) **], but patient currently denying
any of this.
Family History:
Father was an alcoholic.
Physical Exam:
On admission:
Vitals: T: 95.9 BP: 123/84 P: 99 R: 18 O2: 94%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: diminished breath sounds throughout R>L, no wheezes,
rales, rhonchi
CV: tachycardic, S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: aaox3, CNs [**2-23**] intact, strength and sensation grossly
nl.
.
On discharge:
[**Name (NI) 4650**]
Pt allert and oriented, walking without difficulty, R knee with
large effussion, exam otherwise unchanged
Pertinent Results:
[**2205-11-14**] 06:14AM BLOOD WBC-6.4 RBC-3.68* Hgb-12.2* Hct-36.1*
MCV-98 MCH-33.2* MCHC-34.0 RDW-14.3 Plt Ct-267
[**2205-11-13**] 05:21PM BLOOD WBC-4.4 RBC-4.15* Hgb-13.4* Hct-40.0
MCV-96 MCH-32.2* MCHC-33.5 RDW-14.2 Plt Ct-307
[**2205-11-13**] 05:21PM BLOOD Neuts-53.9 Lymphs-43.4* Monos-0.9*
Eos-1.2 Baso-0.6
[**2205-11-14**] 06:14AM BLOOD Glucose-96 UreaN-5* Creat-0.7 Na-141
K-3.5 Cl-107 HCO3-27 AnGap-11
[**2205-11-13**] 05:21PM BLOOD Glucose-111* UreaN-10 Creat-0.7 Na-140
K-4.2 Cl-103 HCO3-21* AnGap-20
[**2205-11-14**] 06:14AM BLOOD Calcium-8.7 Phos-3.7 Mg-1.7
[**2205-11-13**] 09:07PM BLOOD Albumin-4.5 Calcium-9.3 Phos-4.6* Mg-1.7
[**2205-11-14**] 06:14AM BLOOD Osmolal-325*
[**2205-11-13**] 05:21PM BLOOD Osmolal-366*
[**2205-11-13**] 05:21PM BLOOD ASA-NEG Ethanol-86* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2205-11-13**] 09:12PM BLOOD Type-ART O2 Flow-3 pO2-92 pCO2-38 pH-7.42
calTCO2-25 Base XS-0 Intubat-NOT INTUBA Comment-NASAL [**Last Name (un) 154**]
[**2205-11-13**] 05:31PM BLOOD freeCa-1.10*
[**2205-11-13**] 05:28PM BLOOD ALCOHOL PROFILE-Test pending on discharge
Head CT: IMPRESSION: No acute intracranial process. Atrophy
advanced for age.
Chest xray: No acute intrathoracic process. COPD with stable
right basilar
scarring/chronic atelectasis.
Brief Hospital Course:
Mr. [**Known lastname 27389**] is a 39 year old man with h/o EtOH and
polysubstance abuse, seizure disorder, who was found
unresponsive while visiting his partner in the ICU, admitted
with concern for toxic alcohol ingestion.
.
#. AMS: Patient was unresponsive to verbal stimuli and sternal
rub while in the ICU, but was alert and oriented just several
hours prior. Concern in the ED for toxic ingestion (?isopropyl
alcohol given easy and serum osmolar gap with explained anion
gap), however patient denies ingesting anything today.
Phenobarbital OD also considered (mentioned earlier on day of
admission that he can tolerate 12 pills at a time), however
phenobarb level was not elevated. Patient given Fomepizole x1 in
the ED. No urinary incontinence or tongue biting to suggest
seizure. Infectious etiology unlikely (afebrile, no
leukocytosis, CXR unremarkable). CT head negative for acute
process. Given h/o EtOH withdrawal, pt was monitored closely in
the ED. He was seen by toxicology and treated with CIWA scale
and supportive care. Once MS improved, pt left AMA, alcohol
profile pending on discharge.
.
#. Hypoxia: Patient desat to high 80s on RA while asleep. E/o
atelectasis and COPD on CXR. No e/o acute infection or COPD
exacerbation. Sats improved with improving MS.
.
#. Elevated lactate: Likely [**2-13**] to alcohol use. Improved with
treatment of intoxication.
.
#. EtOH abuse: History of withdrawal and seizures in the past.
Concern for toxic alcohol ingestion in addition to usual EtOH
use. Last drank brandy evening of [**2205-11-12**], unclear if there were
co-ingestions. Pt was treated with CIWA, MV, thiamine, folate.
.
#. Chronic Pain: Not currently c/o pain, sedating meds held.
.
#. Seizure disorder: Less likely to have been seizing this
afternoon, but is at high risk for EtOH withdrawal. Home
phenobarbital was continued.
.
#. R knee effusion: pt c/o pain but refusing US and pt left AMA
before receiving further diagnosis or treatment.
Medications on Admission:
Phenobarbital ?34.2mg PO TID
Klonopin 2mg PO TID
Folate 1mg PO daily
MVI 1tab PO daily
Thiamine 100mg PO daily
Discharge Medications:
1. multivitamin 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. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. phenobarbital 30 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
Disp:*3 Tablet(s)* Refills:*0*
5. Klonopin 2 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*3 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
primary: isopropyl and alcohol withdrawal
Secondary: knee effusion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the ICU for withdrawal. You were treated
with medications to help with your withdrawal symptoms. You
left against medical advice.
.
No changes have been made to your medications. Because you left
against medical advice, we were unable to schedule a follow up
appointment for you. Please follow up with your doctor in [**1-13**]
wks.
Followup Instructions:
Follow up with your doctor in [**1-13**] wks
ICD9 Codes: 2762 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3645
} | Medical Text: Admission Date: [**2130-1-9**] Discharge Date: [**2130-1-20**]
Date of Birth: [**2060-12-5**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Pericardial effusion
Major Surgical or Invasive Procedure:
[**2130-1-11**] Subxiphoid pericardial window
[**2130-1-11**] IVC filter placement
History of Present Illness:
Mr. [**Known lastname **] is a 69 year old gentlemen with medical history
significant for emphysema and is status-post neoadjuvent
chemoradiation and thoracotomy with left upper lobectomy
[**2129-12-20**] for stage IIIA T2N2 squamous cell carcinoma who
returned to [**Hospital1 18**] with complaint of shortness of breath and CXR
findings at his PCP's demonstrating a left lower lobe infiltrate
concerning for pneumonia. At presentation he described 5 days of
progressively worsening dyspnea.
Patient been discharged home with physical therapy services
after his operation and had been progressing well until 5 days
prior to admission when he began noticing increasing dyspnea
while climbing stairs during the 2
days prior to admission he also experience dyspnea while walking
on flat surfaces and with speech. By the morning of present
admission Mr. [**Known lastname **] was requiring 4L of nasal home oxygen.
He was scheduled to see Dr. [**First Name (STitle) **] in clinic [**2130-1-10**] but due to his
continued worsening dyspnea he presented to his PCP at [**Hospital1 2292**] and was noted on CXR to have a left lower lobe
infiltrate with and elevated WBC count to 19 with left shift, as
well as an INR of 8. (Patient had been discharged from the
hospital on a Lovenox bridge to Coumadin for history of left
lower extremity DVT and pulmonary embolism). He was subsequently
sent to the ED at
[**Hospital1 18**] for further care.
At the time of presentation the patient denied chest pain,
pleuritic pain, headaches, dizziness, fever, chills, nausea,
vomiting, changes in bowel or bladder habits, prolonged
bleeding, easy bruising, or changes in weight did endorse
continued decreased appetite. He had recently completed a course
of Levaquin for suspected hospital-acquired pneumonia.
Past Medical History:
Oncology History:
PET CT [**2129-8-10**]: FDG-avid LULlarge 49x40mm lung lesion is seen
highly concerning for lung cancer. There are FDG-avid
prevascular lymph nodes, as follows: 27 x 19 mm and 18x14mm.
There is a prominent lymph node in the left peritracheal area
measuring 18x12mm (not FDG-avid) and non-specific
Bronchoscopy [**2129-8-22**]: obtained tissue for pathology which
revealed invasive squamous cell carcinoma (stage IIIa)
[**2129-9-9**]: left VATS and lymph node biopsy to complete staging work
up. No pleural metastases were noted but there were bulky level
6 lymph nodes, which were positive for metastatic carcinoma on
frozen sections; final pathology showed poorly differentiated
squamous cell carcinoma with extensive necrosis histologically
similar to the prior lung sample.
[**9-/2129**]: Started cisplatin and VP-16 as well as radiotherapy as
neoadjuvant treatment before a definitive surgery
PMH: Emphyzema, bipolar disorder, patello-femoral syndrome,
squamous cell lung carcinoma
Past Surgical History:
Left VATS with biopsy of peri-aortic lymph node [**2129-9-9**]
Left thoracotomy, left upper lobectomy, mediastinal lymph node
dissection, and buttressing of bronchial staple line with
intercostal muscle [**2129-12-20**]
Subxiphoid pericardial window [**2129-1-11**]
Social History:
Lives with wife at home. 75 pack-year smoking history, quit [**2-10**]
yrs ago, drinks 3 glasses of EtOH/week and denies use of illegal
drugs
Family History:
Mother died of pancreatic cancer, father had Parkinsons. No
other history of cancer or blood clotting disorders
Physical Exam:
GENERAL: No acute distress; alert and fully oriented; pleasant
and cooperative
HEENT: Mucous membranes moist and pink; nasal canula in place;
no ocular or nasal discharge; no scleral icterus; no skin
lesions
CARDIAC: Regular rate and rhythm; normal S1 and S2; no
appreciable murmumurs
CHEST: Left thoracotomy incision healing well; no erythema or
induration
PULMONARY: Crackles at lung bases bilaterally; slightly
diminished breath sounds on left side
ABDOMEN: Soft, non-tender, non-distended; no palpable masses; no
rebound or gaurding; healing vertical incision in sub-xiphoid
region
EXTREMITIES: Moderate bilateral lower extremity edema
bilaterally
Pertinent Results:
[**2130-1-9**] 09:48PM PT-150* PTT-72.9* INR(PT)-15.7*
[**2130-1-9**] 09:37PM LACTATE-2.3*
[**2130-1-9**] 08:13PM TYPE-ART PO2-75* PCO2-27* PH-7.49* TOTAL
CO2-21 BASE XS-0
[**2130-1-9**] 07:20PM PT-150* PTT-74.3* INR(PT)-15.7
[**2130-1-9**] 06:52PM LACTATE-3.5*
[**2130-1-9**] 06:45PM GLUCOSE-123* UREA N-33* CREAT-1.3* SODIUM-134
POTASSIUM-5.4* CHLORIDE-99 TOTAL CO2-21* ANION GAP-19
[**2130-1-9**] 06:45PM estGFR-Using this
[**2130-1-9**] 06:45PM WBC-16.5* RBC-3.31* HGB-9.0* HCT-29.3* MCV-89
MCH-27.2 MCHC-30.7* RDW-16.2*
[**2130-1-9**] 06:45PM NEUTS-88.4* LYMPHS-6.7* MONOS-3.4 EOS-1.4
BASOS-0.2
[**2130-1-9**] 06:45PM PLT COUNT-589
RADIOLOGY:
CT CHEST WITH CONTRAST [**2130-1-10**]:
Findings:
A large pericardial effusion, with attenuation characteristics
of bloody or
exudative fluid has developed, impinging on the right atrium and
right
ventricle, suggesting cardiac tamponade.
Severe consolidation in the post-operative left lung, extending
from the
superior segment to the upper regions of the basal segments has
worsened, and
extensive consolidation in the right lung is largely new, in the
anterior
segment of the right upper lobe, the right middle lobe, and the
right lower
lobe, most pronounced in the superior segment.
Brief Hospital Course:
The patient underwent a CT of the chest in the ED which
demonstrated a large pericardial effusion impairing right
ventricular function. He was transported to the cath lab for
pericardialcentesis and approx 875cc of bloody fluid was
successfully drained. The pericardial fluid was sent for
cytology and a drain was left in place. The patient had
improvement in his dyspnea symptoms, however a TTE performed the
following morning was significant for a continued moderate
pericardial effusion that was reported to be echo-dense and
consistent with blood - despite the minimal output from his
pericardial drain. Cytology results of the pericardial fluid
returned negative for malignant cells.
It was decided at that time that the patient would benefit from
a pericardial window procedure. He was appropriately pre-op'ed
and consented, and underwent a sub-xiphoid pericardial window
procedure with placement of IVC filter for DVT prophylaxis (due
to the importance of discontinuation of his anticoagulation due
to his hemopericardium and drastically supra-therapeutic INR).
The patient was transferred to the ICU post-op for close cardiac
monitoring, and a bedside ECHO did not demonstrate any
significant re-accumulation of fluid on post-operative day 1.
However, the patient's ICU course was complicated by a short
bout of V-tach and two short episodes of atrial fibrillation
with rapid ventricular response which resolved spontaneously
without intervention.
By post-operative day 3 the patient was weaned off all pressors,
and by post-operative day 4 he was stable for transfer out of
the ICU and to the floors following removal of his pericardial
drain.
The patient's post-operative course continued to be complicated
by episodes of atrial fibrillation/ectopy with heart rates in
the 120's while ambulating. His Metoprolol was increased to
3-time daily dosing and a Cardiology consult was obtained. Per
the recommendations of the Cardiology team the patient was begun
on Amiodarone: 400mg [**Hospital1 **] loading dose x1 week to be followed by
200mg [**Hospital1 **] x3 weeks and then decreased to maintenance dose of
200mg daily. Additionally, Cardiology recommended ASA 325mg
(daily) alone for anticoagulation due to his risk of bleeding
and the low likelihood that his (presumed temporary)
post-operative atrial fibrillation would pose a risk for
thrombus formation. Of note, the patient was temporarily placed
on a Lasix regimen of 20mg daily for significant bilateral lower
extremity edema, but had two episodes of mild hypotension on
post-operative days 8 and 10 - both of which responded well to
fluid boluses- after which time the Lasix was discontinued.
Mr. [**Known lastname **] did well after initiation of Amiodarone, with
noticeable decrease in the frequency of his arrythmia episodes.
Staples from his incision were removed on post-operative day 9,
and by post-operative 11 it was determined both medically and
surgically appropriate to discharge the patient home with
physical therapy services, following clearance by both the
Cardiology and Physical Therapy teams.
At the time of discharge the patient was ambulating well with
assistance, was tolerating a regular diet, had no active pain
issues, had been afebrile through-out his hospital course, and
was in normal sinus rhythm. He was discharged with plans to
follow-up in Thoracic Surgery clinic in 2 weeks and to follow-up
with Cardiology clinic in [**4-14**] weeks.
Medications on Admission:
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. lithium carbonate 300 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
3. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
5. enoxaparin 100 mg/mL Syringe Sig: One Hundred (100) mg
Subcutaneous Q12H (every 12 hours).
Disp:*14 syringes* Refills:*2*
6. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily) as needed for constipation.
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. amoxicillin-pot clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q8H (every 8 hours): thru [**2130-1-1**].
Disp:*18 Tablet(s)* Refills:*0*
10. Coumadin 5 mg Tablet Sig: One (1) Tablet PO as directed.
Disp:*100 Tablet(s)* Refills:*2*
11. Respiratory Therapy
Oxygen at 1-2 liters per minute vis nasal cannula during any
exertional activity or for shortness of breath
Discharge Medications:
1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
2. nystatin-triamcinolone 100,000-0.1 unit/g-% Cream Sig: One
(1) Appl Topical [**Hospital1 **] (2 times a day) as needed for rash.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. lithium carbonate 300 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
5. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
7. amiodarone 400 mg Tablet Sig: One (1) Tablet PO twice a day
for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
8. amiodarone 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 3 weeks: Please begin on [**2130-1-26**].
Disp:*42 Tablet(s)* Refills:*0*
9. amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
Begin on [**2130-2-16**] after completion of 3-week cours of [**Hospital1 **]
scheduling.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Hemopericardium
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 accumulation of fluid
around your heart that resulted in difficulty breathing, and
subsequently underwent a procedure to evacuate this fluid called
a "pericardial window." Post-operatively you were also noted to
have some changes in the pattern of your heartbeats for which
you were evaluated by the cardiologists and prescribed some new
medications. Currently you are recovering well and ready for
discharge home
* Continue to take your new cardiac medications as prescribed
* Your Warfarin was discontinued during your hospital stay due
to concern of bleeding. Do not resume your Warfarin for at least
4-6 weeks or until instructed to do so by your Cardiologist.
Continue taking Aspirin 325mg daily for anticoagulation
* Continue to use your incentive spirometer 10 times an hour
while awake.
* Check your incisions daily and report any increased redness or
drainage. Cover the area with a gauze pad if it is draining.
* You may continue to need pain medication once you are home but
you can wean it over a few weeks as any lingering discomfort
resolves. Make sure that you have regular bowel movements while
on narcotic pain medications as they are constipating which can
cause more problems. Use a stool softener or gentle laxative to
stay regular.
* No driving while taking narcotic pain medication.
* Take Tylenol 650 mg every 6 hours in between your narcotics.
If your doctor allows you may also take Ibuprofen to help
relieve the pain.
* Continue to stay well hydrated and eat well to heal your
incisions
* Shower daily. Wash incision with mild soap & water, rinse, pat
dry
* No tub bathing, swimming or hot tubs until incision healed
* No lotions or creams to incision site
* Walk 4-5 times a day and gradually increase your activity as
you can tolerate.
Call Dr.[**Name (NI) 5067**] office [**Telephone/Fax (1) 2348**] if you experience:
-Fevers > 101 or chills
-Increased shortness of breath, chest pain, persistent
palpitations, or any other symptoms that concern you
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD Phone:[**0-0-**]
Date/Time:[**2130-1-31**] 9:00
Please call Dr.[**Name (NI) 17720**] office for a follow-up appointment in
[**4-13**] weeks. Phone: [**Telephone/Fax (1) 56771**]. Address: [**Location (un) 2129**],
[**Location (un) 86**], [**Numeric Identifier 718**]
Completed by:[**2130-1-20**]
ICD9 Codes: 4271, 4589, 2930, 9971, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3646
} | Medical Text: Admission Date: [**2125-10-22**] Discharge Date: [**2125-10-31**]
Date of Birth: [**2084-6-22**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8104**]
Chief Complaint:
hypoxic respiratory failure
Major Surgical or Invasive Procedure:
intubation
bronchoscopy
History of Present Illness:
41 F with history of asthma, recently initiated treatment for
atypical pneumonia, now represents to ED for severe pneumonia
and respiratory failure requiring intubation. Patient seen on
[**10-19**] for R sided chest pain, shortness of breath and cough.
Discharged from ED on azithromycin after CXR showing atypical
pneumonia. Normal O2 per ED notes from that visit. Did not
improve at home and represented to ED yesterday evening. Per EMS
report, O2 sat 65% upon their arrival.
.
In the ED, vitals T97.4 P92 BP120/72, 95% NRB. No episodes of
hypotension (SBP>120 during course) but tachy to 110s-120s. 5 L
NS given, also vanc, levoflox, cefepime, bactrim. Tachypneic to
40-50s; intubated (succ/etomidate) with #7.5. TV 400 x26, PEEP 8
70% FiO2 prior to arrival to floor.
Past Medical History:
asthma
depression
ethanol abuse
Social History:
- Has one daughter age 22
- Lives alone on disability for a vague histoy of brain damage
approximately six years ago, which she is not very clear of the
details.
- Smokes half pack per day for 30 years.
- Uses alcohol several times per week, does not know more
specifically. h/o withdrawal.
- Depression, on fluoxetine.
Family History:
non-contributory
Physical Exam:
Tmax: 36.9 ??????C (98.5 ??????F), Tcurrent: 36.9 ??????C (98.5 ??????F), HR: 84 (84
- 92) bpm, BP: 102/68(81) {102/68(81) - 102/68(81)} mmHg, RR: 25
(25 - 27) insp/min, SpO2: 98%, Heart rhythm: SR (Sinus Rhythm),
Height: 65 Inch
Gen Appearance: Well nourished, No acute distress, Overweight /
Obese, on vent
Eyes / Conjunctiva: PERRL, No(t) Pupils dilated
Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG
tube
Lymphatic: Cervical WNL, No cervical adenopathy
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t)
Systolic, No(t) Diastolic), distant
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), Breath Sounds:
Bronchial: No Wheezes, Rhonchorous
Abdominal: Soft, Non-tender, Bowel sounds present, Not
Distended, Obese
Extremities: Right: Absent, Left: Absent
Skin: Not assessed, No Rash: , No Jaundice.
RUE well healed horizontal scars.
Neurologic: Follows simple commands, Responds to: Not assessed,
Movement: Not assessed, Sedated, Tone: Not assessed, follows
commands when not sedated
Pertinent Results:
[**2125-10-21**] 10:30PM BLOOD WBC-15.1* RBC-3.72* Hgb-11.3* Hct-32.7*
MCV-88 MCH-30.4 MCHC-34.5 RDW-14.5 Plt Ct-442*
[**2125-10-30**] 05:43AM BLOOD WBC-19.5* RBC-4.30 Hgb-12.7 Hct-37.5
MCV-87 MCH-29.6 MCHC-33.9 RDW-14.5 Plt Ct-559*
[**2125-10-21**] 10:30PM BLOOD Neuts-84.7* Lymphs-10.8* Monos-3.8
Eos-0.4 Baso-0.2
[**2125-10-21**] 10:30PM BLOOD PT-13.1 PTT-27.4 INR(PT)-1.1
[**2125-10-28**] 03:00AM BLOOD PT-15.0* PTT-25.6 INR(PT)-1.3*
[**2125-10-22**] 05:17AM BLOOD WBC-15.7* Lymph-10* Abs [**Last Name (un) **]-1570 CD3%-80
Abs CD3-1252 CD4%-58 Abs CD4-905 CD8%-22 Abs CD8-342 CD4/CD8-2.7
[**2125-10-21**] 10:30PM BLOOD Glucose-99 UreaN-11 Creat-0.6 Na-138
K-3.6 Cl-103 HCO3-24 AnGap-15
[**2125-10-30**] 05:43AM BLOOD Glucose-179* UreaN-20 Creat-0.7 Na-136
K-4.7 Cl-100 HCO3-26 AnGap-15
[**2125-10-21**] 10:30PM BLOOD ALT-17 AST-34 LD(LDH)-740* CK(CPK)-109
AlkPhos-105 TotBili-0.3
[**2125-10-28**] 03:00AM BLOOD ALT-18 AST-17 LD(LDH)-456* AlkPhos-72
TotBili-0.5
[**2125-10-21**] 10:30PM BLOOD CK-MB-3 cTropnT-<0.01 proBNP-1388*
[**2125-10-22**] 05:17AM BLOOD CK-MB-NotDone cTropnT-0.04*
[**2125-10-22**] 05:17AM BLOOD Calcium-6.7* Phos-2.5* Mg-1.8
[**2125-10-30**] 05:43AM BLOOD Calcium-8.6 Phos-3.1 Mg-2.1
[**2125-10-26**] 03:52AM BLOOD VitB12-807
[**2125-10-27**] 01:53PM BLOOD Ammonia-31
[**2125-10-26**] 03:52AM BLOOD TSH-0.43
[**2125-10-24**] 12:11PM BLOOD ANCA-NEGATIVE B
[**2125-10-30**] 03:30PM BLOOD HIV Ab-PND
[**2125-10-21**] 10:36PM BLOOD Lactate-1.5
[**2125-10-27**] 03:10PM BLOOD Lactate-1.3
[**2125-10-22**] 01:22AM BLOOD Type-ART Rates-0/20 Tidal V-400 PEEP-8 O2
Flow-100 pO2-162* pCO2-57* pH-7.19* calTCO2-23 Base XS--6
-ASSIST/CON Intubat-INTUBATED
[**2125-10-27**] 03:10PM BLOOD Type-ART pO2-77* pCO2-48* pH-7.49*
calTCO2-38* Base XS-11 Intubat-NOT INTUBA
[**2125-10-24**] 03:03PM BLOOD IGE-Test
[**2125-10-24**] 11:39AM BLOOD IGE-Test
[**2125-10-22**] 10:22AM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-
TEST
[**2125-10-22**] 10:22AM BLOOD B-GLUCAN-Test
.
BAL ([**2125-10-22**]): no bacterial growth, no legionella, no
pneumocystis, no fungus, no acid fast bacilli, no respiratory
viruses (adeno, parainfluenza 1, 2, 3, influenza A and B, RSV
Urine ([**2125-10-22**]): negative legionella antigen, negative bacteria
Blood cultures ([**2125-10-22**] and [**2125-10-27**]): negative
Nasopharyngeal aspirate ([**2125-10-23**]): negative for viruses
RPR ([**2125-10-23**]): negative
Catheter tip-IV ([**2125-10-28**]): negative
.
BAL ([**2125-10-22**] am): clear with 12% eosinophils
BAL ([**2125-10-22**] pm): Negative for malignant cells. 35cc prurulent
fluid. no eos.
.
EKG ([**2125-10-21**]): Moderate artifact in lead V1. Probably within
normal limits. Compared to the previous tracing of [**2125-8-28**] no
diagnostic interim change.
.
Imaging:
CXR ([**2125-10-21**]): Bilateral diffuse airspace opacities in a
perihilar distribution, left greater than right. The
differential diagnosis includes viral, atypical, and fungal
etiologies.
.
CXR ([**2125-10-22**]): Severe bilateral airspace opacity suggesting
ARDS or
severe viral infection. Satisfatory placement of ETT.
.
Chest CT w/o contrast ([**2125-10-22**]): 1. Diffuse bilateral alveolar
and interstitial process with a somewhat upper lobe
predilection. The appearance is somewhat nonspecific and
etiologies can include noncardiogenic pulmonary edema (given
normal heart size and lack of pleural effusions, cardiogenic
pulmonary edema is considered less likely), infectious
etiologies such as viral pneumonia or possibly mycoplasma,
eosinophilic pneumonia (particularly given the 12% eosinophils
on original BAL) including acute eosinophilic pneumonia or
Loffler syndrome, or vasculitis. 2. Exophytic soft
tissue-density structure arising from the upper pole of the left
kidney. Ultrasound evaluation is recommended. 3. Nasogastric
tube tip terminating in the esophagus, which per report has been
subsequently advanced.
.
CXR ([**2125-10-26**]): Cardiomegaly is stable. The ET tube is in
standard position. NG tube tip is out of view below the
diaphragm. Right IJ catheter remains in place. There is no
pneumothorax. There are no enlarging pleural effusions.
Bilateral diffuse ground glass opacities are unchanged.
.
Head CT w/o contrast ([**2125-10-26**]): No change since [**2123-6-12**].
No evidence of hemorrhage or infarction.
.
CXR ([**2125-10-27**]): In comparison with the study of [**10-26**], the
patient has taken a somewhat better inspiration. The lungs
remain essentially clear and the tubes remain in place.
.
CXR ([**2125-10-29**]): Interval removal of nasogastric tube and right
internal jugular central venous catheter. Slight rounding of the
cardiac silhouette, which should be followed on subsequent
radiographs.
Brief Hospital Course:
41yoF with history of asthma, EtOH abuse, psych history;
admitted to MICU with respiratory failure requiring intubation
with severe pneumonia on CXR and high O2 requirements.
.
1. Acute eosinophilic pneumonia and respiratory failure:
admitted with hypoxemic respiratory failure, intubated on
hospital D#1, underwent two BALs. CT scans showed bilateral
pulmonary infiltrates, with BAL cell counts showing abundant
eosinophils (prior to steroids), in addition to elevated serum
IgE - both suggestive acute eosinophillic pneumonia. ANCA and
infection workup negative. Patient completed 7-day course of
levofloxacin for possible CAP. Patient was initiated on
steroids upon initial diagnosis of AEP, then down titrated on
[**10-27**] to solumedrol 60 Q12hrs, and on [**10-30**] to prednisone 60mg
on [**10-28**]. Extubation occurred on [**10-26**]. She was initiated on
bactrim given anticipated prolonged steroid course. Patient was
followed by pulmonary consult after transfer to the medicine
floor. She is being discharged on oral prednisone 60mg until
follow up with pulmonology to evaluate her improvement. Likely
she will need several months of prednisone. Due to high blood
sugars (low 300s) after starting prednisone, she will also be
discharged with metformin 500mg PO qday while she is on
steroids.
.
2. Mental status changes: Per daughter, patient has history of
anoxic brain injury as well as peripheral neuropathy due to
alcohol, reportedly lives/functions at home alone. Patient was
extubated on [**10-26**], showed some delerium post-extubation for 36
hours, requiring 2 doses of flumazenil and PO lactulose down NGT
(no labs or signs of liver failure, but empiric for gut
cleansing). Patient's delirium resolved, transferred to floor
with complete awareness and orientation.
.
3. Fever: Had temp to 101 on [**10-27**], no evidence of new
infiltrate on CXR. Urine and blood cultures were negative,
thought [**1-13**] atelectasis given positioning and lethargy at that
time. No recurrence of fevers. Leukocytosis likely secondary to
initiating steroids rather than infectious etiology.
.
4. Coffee ground emesis: Had one episode on [**10-26**] after dry
heaving; likely [**Doctor First Name **] [**Doctor Last Name **] vs. past OGT trauma; had
self-limited course with stable hct.
.
5. Depression: continued on home prozac dose.
.
6. Ethanol abuse: per family, also chronic pancreatitis per
imaging. Last drink thought to be [**10-20**] or [**10-21**]. Was on benzos
during intubation which would have masked any withdrawal; no
symptoms after extubation. Social work saw her while on the
floor.
.
7. Renal cyst: cyst seen on upper pole of left kidney on CT
scan. Follow up ultrasound showed exophytic 2-cm left upper pole
simple cyst.
.
8. HIV status: patient consented and was tested for HIV, given
association of acute eosinophil pneumonia with HIV. Results
pending at time of discharge. Results were negative and patient
was phoned by the medical team with these results.
Medications on Admission:
MVI daily
Prozac 60 mg daily
Zithromax Zpack
Percocet 1-2 tabs TID prn.
Discharge Medications:
1. Fluoxetine 20 mg Capsule Sig: Three (3) Capsule PO DAILY
(Daily).
2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO 3X/WEEK (MO,WE,FR).
Disp:*30 Tablet(s)* Refills:*2*
4. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily): Take three tablets once per day.
Disp:*90 Tablet(s)* Refills:*2*
5. Metformin 500 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Acute eosinophilic pneumonia
steroid induced hyperglycemia
Discharge Condition:
Stable, improved, satting well at rest and with ambulation on
room air
Discharge Instructions:
You were admitted to the hospital with respiratory distress that
required intubation. You had two bronchoscopies, which ruled
out infectious causes for the pneumonia, but did show eosinophil
inflammatory cells, consistent with acute eosinophilic
pneumonia. You recieved antibiotics and are being discharged on
steroids to treat the pneumonia.
.
Please take all your medications. New medications include
Prednisone 60mg daily and Metformin 500mg each morning daily
(take this medicine only as long as you are on prednisone) as
well as Bactrim three times a week for as long as you are on the
prednisone.
.
Please follow up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 19039**]
as instructed below. At the time of discharge, your HIV test
result is still pending. You will get the result at your follow
up pulmonology appointment. If you need to cancel the
appointment, please phone the pulmonology office at
([**Telephone/Fax (1) 3554**] to get your result.
.
Return to the hospital if you have shortness of breath,
worsening cough, or any other concerning symptoms.
Followup Instructions:
Primary Care at [**Hospital **] Clinic: Dr. [**Last Name (STitle) 93374**]. Date/Time: [**2125-11-30**]
8:00. [**Telephone/Fax (1) 15982**].
.
Pulmonology at [**Hospital1 18**]: Dr. [**Last Name (STitle) 2168**]. Date/Time: [**11-7**] 2:40.
[**Telephone/Fax (1) 612**].
ICD9 Codes: 2930, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3647
} | Medical Text: Admission Date: [**2187-6-28**] Discharge Date: [**2187-6-30**]
Date of Birth: [**2117-5-8**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfonamides / Vibramycin
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
Black stools
Major Surgical or Invasive Procedure:
EGD [**2187-6-29**]
History of Present Illness:
Pt is a 70 yo F with bipolar d/o, diet controlled DM, and
Meniere's dz who presented to ED with c/o black, tarry stools.
.
Of note, pt was seen in ED the day prior to admission for
presyncope. She c/o "feeling faint". Her HCT was noted to be
31.4 down from baseline of 38. She was guaiac negative, CE
negative, and CXR negative. She received 2L NS and was sent
home with f/u instructions. Overnight, she noticed black stools
& also developed diarrhea 5-10x, became concerned, and called
her PCP who referred her to the ED today for further evaluation.
She had no other symptoms of lightheadedness, dizziness, no
abdominal pain, no nausea or emesis. She denies prior hx of
dark tarry stools or BRBPR, although reports a hx of hemorroids
which bleed when irritated. She denies any hematochezia, no
hematemesis.
.
ROS: She denied any CP, palpitations, SOB, fevers or chills,
weight loss, night sweats, edema, dysuria, and hematuria. She
does report freq HA from chronic sinusitis and chronic abd. pain
described as crampy for many years ?IBS.
.
ED COURSE: VS T 98.6F; P 76 BP 132/62 RR 18 & O2sats 97% on
RA. Was guaiac negative & NG lavage was negative. Tn T was also
negative. She received 1L NS. GI was consulted; she was T & C
for 4U PRBCs, however did not receive any units in the ED.
Past Medical History:
- BIPOLAR DISORDER
- HYPERLIPIDEMIA
- Meniere's disease
- ?FIBROMYALGIA
- OSTEOPOROSIS
- HYPOTHYROIDISM
- ASTHMA
- Diet controlled DM (last HgbA1c 6.2 [**5-/2187**])
- LEFT NEPHRECTOMY after being hit by a truck (pedestrian vs.
truck)
Social History:
- Denies EtoH, tobacco or illicit drug use
- Currently retired, worked as a teacher, librarian & instructor
- Lives alone with her cat
Family History:
- [**Name (NI) **] CA, father (died @ age 70's) & grandfather
- HTN, DM in Mother
- ?Blood CA in family
Physical Exam:
VS: T 98.6F HR 99 BP 127/70 (84) RR 20 O2sats 100%
General: Elderly lady lying in bed, NAD
HEENT: MMM, oropharynx clear
Heart: RRR, no m/g/r
Lungs: CTA b/l, no rales or rhonchi
Abd: +BS, soft, no masses, vague RUQ pain that is not always
present on palpation; no rebound tenderness
Extremities: Warm to touch, no BLE edema
Skin: No lesions noted
Neuro: AAO x 3, moves all extremities without difficulty no
focal deficits
Pertinent Results:
Admission labs:
[**2187-6-27**] 11:45AM WBC-9.3 RBC-3.62* HGB-11.3* HCT-31.4* MCV-87
MCH-31.3 MCHC-36.0* RDW-13.9
[**2187-6-27**] 11:45AM NEUTS-64.0 LYMPHS-29.9 MONOS-2.7 EOS-2.7
BASOS-0.7
[**2187-6-27**] 11:45AM GLUCOSE-118* UREA N-34* CREAT-0.9 SODIUM-142
POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-29 ANION GAP-12
[**2187-6-27**] 11:45AM CALCIUM-9.4 PHOSPHATE-3.7 MAGNESIUM-2.1
[**2187-6-27**] 11:45AM CK(CPK)-35
[**2187-6-27**] 11:45AM cTropnT-<0.01
[**2187-6-27**] 11:45AM TSH-2.0
[**2187-6-27**] 11:45AM FREE T4-1.2
[**2187-6-27**] 11:45AM PT-12.1 PTT-28.7 INR(PT)-1.0
.
Imaging:
CHEST (PA & LAT) [**2187-6-27**] 4:03 PM
The heart is normal in size. The mediastinal and hilar contour
is normal. The lungs are clear. There is mild scoliosis of the
thoracic spine. There are no pleural effusions. Multiple
surgical clips present in the left upper quadrant are consistent
with the patient's history of nephrectomy. There are mild
degenerative changes of the thoracic spine.
.
ECG Study Date of [**2187-6-27**] 11:50:58 AM
Sinus tachycardia. Modest non-specific low amplitude t wave
changes. Since the previous tracing of [**2186-3-16**] sinus tachycardia
and low amplitude T wave changes are present.
.
EGD report [**2187-6-29**]
Impression: Ulcer in the duodenal bulb
Otherwise normal EGD to second part of the duodenum
Recommendations: Contine [**Hospital1 **] ppi and carafate. Hold aspirin and
fosamax. Check H. pylori antibody and treat if positive.
Follow-up with GI in [**5-18**] weeks.
Brief Hospital Course:
Pt is a 70 yo F with bipolar d/o who presented with melena and
was found to have a nonbleeding ulcer seen on EGD [**2187-6-29**].
.
1. GI Bleed: A single cratered non-bleeding 12-15mm ulcer was
found in the duodenal bulb on EGD. There was no visible vessel
or active bleeding. No biopsies were taken. A H. pylori
antibody is pending. She received 2 units of PRBCs and her HCT
has been stable at 28-30 since. Pt is to continue PPI [**Hospital1 **] and
carafate as outpatient. She was given prescriptions for both.
She was advised to discontinue aspirin and fosamax until she
followed up with her PCP. [**Name10 (NameIs) **] is to follow-up with [**Hospital **] clinic in
[**5-18**] weeks.
.
2. Bipolar d/o: Pt is a patient of psychiatrist Dr. [**First Name8 (NamePattern2) 915**]
[**Last Name (NamePattern1) **], who was notified of pt's prescence in ICU. According
to the patient, she has self d/c'ed Depakote & Lamotrigine and
is currently only on Abilify as outpt, which she has refused
here. Psychiatry evaluated her and recommended restarting
Depakote at 62.5 mg, which the patient agreed to, and risperdal
0.25 mg for anxiety, which the pt refused. Pt was discharged on
her home psych regimen and is scheduled to follow up with Dr.
[**Last Name (STitle) **].
.
3. Diet-controlled DM, last HgbA1C 6.2 last month: Pt was
placed on an insulin sliding scale.
.
4. Hypothyroidism, TSH level appropriate @ 2.0 on admission: Pt
was continued on her home dose of Levoxyl 37.5mcg daily.
.
5. Hyperlipidemia: Pt was continued on home dose of statin.
.
6. Meniere's disease, currently asymptomatic: Pt was continued
on home dose of meclizine.
Medications on Admission:
- Abilify 2 mg PO daily
- Albuterol INH PRN
- Aspirin 650 mg PO daily
- LEVOXYL 25 mcg PO daily
- LOVASTATIN 20 mg on even days & 40 mg on odd days
- MECLIZINE HCL 25mg TID
- Nizoral 2 % Shampoo PRN
- Ibuprofen PRN
Discharge Medications:
1. Levothyroxine 75 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. Meclizine 12.5 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
6. Sucralfate 1 g Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
7. Divalproex 125 mg Tablet, Delayed Release (E.C.) Sig: 0.5
Tablet, Delayed Release (E.C.) PO QHS (once a day (at bedtime)).
8. Risperidone 0.25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
9. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Duodenal ulcer with gastrointestinal bleeding and anemia
requiring blood transfusion.
Discharge Condition:
Stable.
Discharge Instructions:
Please take all medications as prescribed. Please keep all
follow-up appointments. Please notify your primary care
physician or return to the Emergency department if you
experience fevers, chills, abdominal pain, nausea, vomitting,
diarrhea, black sticky stools, dizziness, lightheadedness, or
any symptoms that concern you.
Followup Instructions:
Please follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 572**] within 8 weeks. Please
call ([**Telephone/Fax (1) 2306**] for this appointment.
Please follow up with Dr. [**First Name8 (NamePattern2) 915**] [**Last Name (NamePattern1) **] on [**2187-7-3**] at
11:40am. Please call [**Telephone/Fax (1) 1387**] if questions regarding this
appointment.
ICD9 Codes: 2851, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3648
} | Medical Text: Admission Date: [**2126-10-2**] Discharge Date: [**2126-10-22**]
Date of Birth: [**2126-10-2**] Sex: F
Service: NB
HISTORY: Baby girl [**Known lastname **] was the 990 gram product of a 29
and [**12-25**] week gestation delivered to a 32-year-old G1, P0 mom.
Prenatal screens - O negative, antibody negative, hepatitis
surface antigen negative, RPR nonreactive, rubella immune,
GBS unknown. This pregnancy was complicated by severe
preeclampsia which was treated with magnesium sulfate and
hydralazine. Mother received betamethasone on [**2126-9-30**]. Prenatal ultrasound showed that the infant is in breech
presentation and growth restricted. The infant was delivered
by cesarean section due to presentation. She emerged with
decreased tone and poor respiratory effort and was given
brief positive pressure ventilation with quick response. She
was transferred to the newborn intensive care unit.
PHYSICAL EXAMINATION: Birth weight 990 grams, 10th to 25th
percentile; length 36 cm, 25th percentile; head circumference
26 cm, 25th percentile. The infant was intubated with a 2.5
ET tube. Anterior fontanel open and flat. Red reflex x2. No
cleft lip palate. Regular rate and rhythm. No murmur. Pulses
equal at all times x4. Mild retractions. Good aeration with
ventilator breath. Abdomen soft. No masses palpable. Bowel
sounds present. Normal external premature female infant. Tone
slightly decreased. Moro equal. Anus patent. Extremities with
full range of motion. bilateral red reflex present on d/c exam.
HISTORY OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: [**Known lastname **]
was admitted to the newborn intensive care unit, intubated.
She received a total of 2 doses of Surfactant and weaned to
CPAP within the first 24 hours of age. She remained stable on
CPAP for 1 week at which time she transitioned to room air.
She remains stable on room air at this time. She was started
on caffeine citrate for management of apnea and bradycardia
of prematurity. She continues on caffeine citrate. Her dose
is 7 mg po q day.
CARDIOVASCULAR: On admission to the newborn intensive care
unit the infant was stable. She presented with a murmur.
Echocardiogram was obtained demonstrated a large patent
ductus arteriosus and was treated with indomethacin. A
followup echocardiogram was performed on [**10-5**] and
there was no patent ductus arteriosus. The infant currently
is cardiovascularly stable with an intermittent audible
murmur.
FLUIDS, ELECTROLYTES AND NUTRITION: Birth weight was 990
grams. Discharge weight is 1165g. head circumference 27.5 cm and
length 38 cm. The infant was initially started on 80 cc
per kg per day. Enteral feedings were started on day of life
3. She achieved full enteral feedings on [**10-15**]. She is
currently receiving 150 cc per kg per day of breast milk 28
calories with Beneprotein, tolerating those well. On [**10-19**] she presented with positive guaiac stools. A KUB was
obtained and was within normal limits. She continued to feed and
has not had any recent feeding intolerance.
GASTROINTESTINAL: Peak bilirubin was on day of life 9 of
6.7/0.2. She was treated with phototherapy and this issue has
resolved.
HEMATOLOGY: Hematocrit on admission was 45. She has not
required any blood transfusions. She is currently received
ferrous sulfate supplementation.
INFECTIOUS DISEASE: CBC and blood culture obtained on
admission. CBC was benign and blood cultures remained
negative at 48 hours at which time ampicillin and gentamycin
were discontinued. She has had no further issues with sepsis
during this hospital course. Routine MRSA surface cultures
were obtained and the infant is MRSA colonized. The parents
are aware of this information and the infant has had no
further issues.
NEUROLOGIC: The infant has been appropriate for gestational
age. Head ultrasound was performed on day of life 9 revealing
a left grade 1, repeat on [**10-16**] revealed a resolving
left germinal matrix and a question of left germinal matrix
cyst. Recommended followup head ultrasound during the 3rd week of
[**Month (only) 1096**].
SENSORY: Hearing screen has not been performed but should be
done prior to discharge.
OPHTHALMOLOGY: The infant has not been examined. RR present
bilaterally.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: To [**Hospital3 **].
NAME OF PRIMARY PEDIATRICIAN: Yet to be determined.
CARE RECOMMENDATIONS:
1. Feedings. Continue on 150 cc per kg per day of breast
milk 28 with Beneprotein.
2. Medications: Ferrous sulfate supplementation 0.1 mg po q day,
caffeine citrate 7 mg po q day, VItamin E 5 units po q day, and
Vitamin A for BPD prophylaxis.
3. Car seat position screening has not yet been performed.
4. State newborn screen was sent on [**2126-10-6**] and was
normal. A repeat screen was sent on [**10-18**].
5. Immunizations received: The infant has not received any
immunizations to date.
DISCHARGE DIAGNOSES:
1. Premature infant born at 29 and 2/7 weeks.
2. Extremely low birth weight.
3. Respiratory distress syndrome, resolved
4. Patent ductus arteriosus, resolved
5. Rule out sepsis with antibiotics, resolved
6. Hyperbilirubinemia, resolved
7. Apnea bradycardia of prematurity.
8. MRSA colonization
9. Feeding intolerance, resolved.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 56662**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2126-10-21**] 20:53:57
T: [**2126-10-21**] 23:49:54
Job#: [**Job Number 70090**]
ICD9 Codes: 769, 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3649
} | Medical Text: Admission Date: [**2162-4-8**] Discharge Date: [**2162-4-28**]
Date of Birth: [**2121-12-30**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
[**9-27**] headache
Major Surgical or Invasive Procedure:
[**2162-4-8**]: Left [**Month/Day/Year 5041**] placement
[**2162-4-8**]: Diagnostic Cerebral Angiogram
[**2162-4-9**]: Craniotomy & Mass Resection. Placement of Right [**Month/Day/Year 5041**]
History of Present Illness:
40 yo F awoke from sleep with severe sudden onset headache
followed by emesis. Per her husband she was confused and
screaming in pain. She currently complains of headache,
although confused and unable to obtain other history.
Past Medical History:
None
Social History:
Married, two children, smokes cigarettes and has ETOH
occasionally
Family History:
NC
Physical Exam:
Hunt and [**Doctor Last Name 9381**]: 3 [**Doctor Last Name **]: 4 GCS E: 3 V: 4 Motor 6
O: T: BP: 109/61 HR: 94 R 20 O2Sats 98%
Gen: WD/WN, lethargic.
HEENT: Pupils: 3->2mm bilat EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Lethargic, awakens to voice.
Orientation: Oriented to person, hospital.
Speech slurred with slowed response.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
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.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Not cooperating with formal motor exam, but moves all
extremities symmetrically.
Toes downgoing bilaterally
Pertinent Results:
Cerebral Angiogram:
[**2162-4-8**] Extensive subarachnoid and intraventricular hemorrhage.
Given the predominant location of intracranial hemorrhage in the
cistern of lamina terminalis, the likely potential source of
bleeding is considered anterior communicating artery. However,
no discrete aneurysm formation
[**2162-4-8**] CT Brain - Interval placement of ventricular drain with
slight decrease in ventricular size.
[**2162-4-8**] MRI Brain w/w/o contrast - Abnormal enhancement is seen
in the suprasellar region surrounding the hemorrhage extending
to the sellar region suspicious for a suprasellar mass. Given
the location, there is suspicion for craniopharyngioma. However,
the tumor characteristics are somewhat altered secondary to
hemorrhage and compression.
[**2162-4-9**] - No change in the ventricular or suprasellar
hemorrhage. As noted on the prior study, the suprasellar clot
demonstrates peripheral enhancement which is unchanged.
[**2162-4-9**] CT brain - Postoperative changes related to right
ventriculostomy catheter placement with fluid and air along its
course. Right lateral ventricular blood clot has been evacuated.
The left ventriculostomy catheter is in unchanged position. The
left lateral ventricle is diminished in size compared to
[**2162-4-8**] exam. Heterogeneous suprasellar hemorrhagic mass is
stable in appearance.
[**2162-4-10**] MRI brain - Status post resection of the suprasellar
mass. Blood products are seen with post-surgical changes in the
region. Some residual enhancement is identified surrounding the
blood clot since the previous study. No acute infarcts are seen.
Some restricted diffusion at the margin of surgical cavity
appears to be related to patient's surgical procedure.
[**4-15**] CT brain - stable position of [**Month/Year (2) 5041**] drains bilaterally. No
evidence of hydrocephalus. stable suprasellar hemorrhage
[**4-15**] CT brain - s/p [**Month/Year (2) **] removal. No evidence fo acute
hemorrhage or hydrocephalus
[**4-18**] CTA Chest- Thrombus is present in the left lower lobe
segmental pulmonary arteries. There is no significant evidence
of right heart strain, however, the RV/LV ratio is difficult to
assess as the left ventricle is predominantly in systole during
the examination.
[**4-18**] CT Head- Post-operative changes following right craniotomy
for resection of suprasellar mass. Overlying subgaleal fluid
collection is noted, possibly increased from prior studies.
Hematoma within the suprasellar cistern decreased in size and
conspicuity, compatible with expected evolution of blood
products. No new hemorrhage, edema, or mass effect. No
hydrocephalus.
[**4-19**] LENI's- No evidence of residual DVT in either lower
extremity.
[**4-20**] CT Head: 1. Interval enlargement of the subgaleal fluid
collection overlying the right frontal craniotomy. 2. No
evidence of interval change in the intracranial compartment. No
hydrocephalus.
[**4-22**] CT Head: Stable ventricular size. Decrease in subgaleal
collection as 60cc was reportedly aspirated.
[**4-23**] CT head: slight reaccumulation of subgaleal collection.
stable ventricular size
Brief Hospital Course:
Ms. [**Known lastname 15852**] was intubated in the emergency room for Left frontal
[**Known lastname 5041**] placement. She was taken to angiogram the following day to
evaluate for an underlying vascular lesion. She was started on
Dilantin for seizure prophylaxis.
Angiogram was negative for an AVM or aneurysm. An MRI of the
brain with contrast revealed a small enhancing lesion above the
pituitary gland. During her post angio course patient had
diabetes insipidus on [**2162-4-8**]. Her sodium rapidly increased
from 141 to 157. Her sodium elevated to 162. PT was given
DDAVP and endocrine was consulted for further management. She
continued to have increase urine output, but improved with
DDAVP.
Patient remained intubated and was taken to the operating room
on [**4-9**] for Right frontal craniotomy resection of sella/supra
sellar mass and right [**Month/Year (2) 5041**] placement. Please review dictated
operative report for details. Postoperatively she was started
on Dexamethasone for cerebral edema. She remained intubated
post-op and was transferred to the neuro ICU for further
management. She had a post operative head CT and MRI which
showed partial resection of sellar mass and post operative
changes. There was no evidence infarct or acute hemorrhages.
She was extubated without incident and continued to be monitored
with prn DDAVP for high urine output and elevated Serum Na.
Bilateral [**Month/Year (2) 5041**] wean was begun on [**4-12**]. Pt tolerated it without
elevation of ICPs or increased headache. On 4.26 her [**Month/Year (2) 5041**]'s were
rasied to 20cm of H2O and she toelrated it well until the
mornign of 4.27 when she was ntoed to have leakage around the
[**Month/Year (2) 5041**] site on the right side. A stitch was placed and no further
leakage was noted. A NCHCT was obtained to assess for
hydrocephalus which showed stable ventricular size. Following
this her [**Month/Year (2) 5041**]'s were clamped. She was transitioned to Oral DDAVP
per Endocrine team. Dexamethasone was slowly tapered every
other day to 2mg [**Hospital1 **] .
On [**4-15**] a repeat Head CT showed stable size of lateral
ventricles without evidence of HCP. Thus [**Name2 (NI) 5041**]'s were removed in
routine fashion without incident. Another repeat head CT
deomonstrated no acute hemorrhage or hydrocephalus. She was
transferred to SDU in stable condition for frequent neuro checks
and for monitor UO. Overnight, sodium decreased to 132 and
given concern for SIADH patient was fluid restricted. Endocrine
rec: qid serum sodiums.
On [**4-18**] the patient was neurologically stable but she was
tachycardic to the 140's. This was discussed with endocrine and
IVF bolus was recommended. She was also febrile to 102.1 so a
fever work up was sent. Her u/a was significant for infection so
she was started on a course of cipro and her foley was changed.
She then began putting out excessive amounts of urine and
continued to be tachycardic so a CTA chest was performed which
was positive for PE. At this time she was transferred to the
ICU. Na was noticed to be elevated so she was given a 1L fluid
bolus.
On [**4-19**] she was neurologically stable. LENI's were ordered were
negative for DVT. General Surgery was consulted for IVC Filter
placement.
Repeat Na was trending up (157) so she was started on IVF per
endocrine recs.
On [**4-20**] her serum Na continued to trend up to 160 and her urine
output increased to greater than 300cc/hr for 2 hours. She
responded to an oral dose of DDAVP and her urine output dropped
off. She continued to receive IVF and her Serum Na started to
downtrend. Serum Na, OSM, Urine Na Osm and spec gravity were
followed closely for DDAVP dosing. She underwent placement of a
rightside PICC line. She also underwent placement of an IVC
filter with General Surgery.
On the evening of [**4-19**] it was noted that she had an enlarging
subgaleal collection under the right craniotomy site and so a
head CT was performed that demonstrated communication with the
ventricular system. A followup head CT was obtained on the
morning of [**4-21**] that showed enlargement of the subgaleal
collection. On the evening of [**4-21**] an Left Frontal [**Date Range 5041**] was
attempted but was not successful, likely due to small
ventricular size. Subsequently the subgaleal fluid collection
was aspirated at the bedside, 60cc withdrawn and a headwrap was
placed. Repeat head CT on [**4-22**] demonstrated no increase in
ventricular size but did show residual fluid collection. She
was then followed with serial head CTs. On 5.6 she was deemed
fit for transfer to the SDU. HEr subgaleal collection had
slightly reaccumulated and her neuro status was stable so the
collection was not drained. Also her nutritional intake was
questionable so calorie counts were initiated. She remained
stable in the SDU on [**4-24**] and [**4-25**] and her neuro exam was improved
as well. Her subgaleal collection remained stable if not
slightly decreased without headwrap. Endocrinology continued to
follow and recommended changing her evening dosing of DDAVP to
0.1 and increase her encourages fluid intake to 2 liters daily
in an attempt to wean her off of IV fluids
On the morning of [**4-26**] her mental status continued to improve
however she self-removed her PICC line in the morning. She was
not receiving any medication intravenously and as such the PICC
was not replaced.
Her serum Na continued to improve and the salt tabs were stopped
and fluid restriction was lifted however on [**4-27**] her serum Na
droppped to 131. She was placed on a 1.5 L fluid restriction
and her AM dose of desmopressin was held on [**4-28**]. Her Na
improved to 133 in the morning of [**4-28**]. Her Na needs to be
closely followed over the next several days to ensure that it
normalizes.
At the time of discharge she is tolerating a regular diet,
ambulating with close assist, afebrile with stable vital signs.
Medications on Admission:
none
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain or fever.
2. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
3. insulin regular human 100 unit/mL Solution Sig: Two (2)
Injection ASDIR (AS DIRECTED).
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
7. acetaminophen-codeine 120-12 mg/5 mL Elixir Sig: 12.5-25 MLs
PO Q4H (every 4 hours) as needed for headache or pain.
8. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for Constipation.
9. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
10. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
11. levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
12. desmopressin 0.1 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
13. desmopressin 0.1 mg Tablet Sig: half Tablet PO BREAKFAST
(Breakfast).
14. dextrose 50% in water (D50W) Syringe Sig: One (1)
Intravenous PRN (as needed) as needed for hypoglycemia protocol.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Suprasellar mass
Intraventricular hemorrhage
Obstructive hydrocephalus
diabetes insipidus
hyponatremia
SIADH
Pulmonary Embolus
Discharge Condition:
Level of Consciousness: Alert and interactive.
Mental Status: Confused - always.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed. If your wound closure uses dissolvable sutures,
you must keep that area dry for 10 days.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 2 weeks.
??????You will need a CT scan of the brain without contrast.
- Followup with Endocrinology Dr. [**Last Name (STitle) **] on [**2162-5-11**] at 11:20.
[**Telephone/Fax (1) 1803**].
-You will need frequent Daily Na checks. Please have them faxed
to Dr.[**Name (NI) 56952**] office.
Completed by:[**2162-4-28**]
ICD9 Codes: 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3650
} | Medical Text: Admission Date: [**2164-4-2**] Discharge Date: [**2164-4-8**]
Date of Birth: [**2089-11-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Lipitor
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Tracheobronchomalacia
Major Surgical or Invasive Procedure:
Tracheobronchoplasty via right thoracotomy
History of Present Illness:
The patient is a 74-year-old man who has had a chronic and
severe cough since
[**2162-12-23**]. It is severely limiting to his activities of
daily life, and he has severe dyspnea on exertion. He has had
several bouts of upper respiratory infections treated with
antibiotics. He is unable to clear his secretions readily. Mr.
[**Name13 (STitle) **] had undergone a stent trial with a Y-stent placed on
[**2164-3-6**] and noted that his breathing and cough
improved, however the stent was removed on [**2164-3-14**]. He
was recently admitted to the hospital for treatment of a left
lower lobe pneumonia., treated with antibiotics at home.
Past Medical History:
Hypertension
Hypercholesterolemia
CAD status post MI s/p CABG in [**2157**]
GERD
OSA
Tracheobronchomalacia s/p Y stent placement and removal [**3-14**]
Basal cell carcinoma of the skin
Status post resection
Squamous cell carcinoma of the skin status
post resection
Melanoma status post resection
Prostate cancer diagnosed in [**2147**] status post radical
prostatectomy Diverticular disease s/p colon resection
Cholecystectomy
Inguinal hernia repair multiple times, last time in [**2156**].
Social History:
He is married, retired, used to work in construction, drinks
alcohol socially, used to smoke 20-pack-year quit 15 years ago,
and has been exposed to asbestos.
Family History:
His father died secondary to prostate cancer, mother had
[**Name (NI) 2481**], and brother had lung cancer.
Physical Exam:
VS: T 96.6 BP 125/62 HR 72 RR 16 95% RA
General: well-nourished, well-appearing, speaking in full
sentences with occasional coughing
HEENT: NC/AT, EOMI, OP clear, MMM, anicteric
Neck: supple, no LAD, no carotid bruits
CV: RRR, normal S1/S2, no m/r/g noted
Lungs: scattered rhonchi thorughout with scattered inspiratory
wheezes
Abdomen: soft, NT/ND, normoactive BS, no masses, no rebound or
tenderness.
Ext: warm, no edema
Skin: no rashes, no lesions
Neuro: AAO x3, muscle strength 5/5 in all 4 extremities
Pertinent Results:
[**2164-4-2**] 03:32PM BLOOD WBC-9.7 RBC-3.42* Hgb-11.5* Hct-32.8*
MCV-96 MCH-33.7* MCHC-35.1* RDW-13.4 Plt Ct-250
[**2164-4-2**] 03:32PM BLOOD PT-13.8* PTT-26.3 INR(PT)-1.2*
[**2164-4-2**] 03:32PM BLOOD Glucose-200* UreaN-16 Creat-0.4* Na-138
K-4.5 Cl-105 HCO3-26 AnGap-12
[**2164-4-2**] 03:32PM BLOOD Calcium-8.8 Mg-1.7
[**4-2**] CXR: Left basilar opacity is likely effusion and
atelectasis, though an infectious consolidation cannot be
excluded. Two right-sided chest tubes with no evidence of
pneumothorax. NG tube tip lies within the stomach, though the
tube could be advanced to ensure that the side hole is within
the stomach. Mediastinal and subcutaneous emphysema are
consistent with recent tracheobronchoplasty and chest tube
insertion.
[**4-3**] CXR: Status post removal of right apical chest tube, with
no residual right pneumothorax. Right basilar chest tube is
still in place. Also, status post removal of the nasogastric
tube. Otherwise, unchanged appearance since yesterday
[**4-4**] CXR: There is no pneumothorax after removal of the right
chest tube, given the limitation of patient motion. There are
small bilateral pleural effusions, possibly loculated. The aorta
remains dilated and tortuous. No new consolidations.
[**4-5**] CXR: Moderate right and small left pleural effusions are
unchanged, with apparent loculation of the right effusion
laterally. No pneumothorax is identified. Cardiac and
mediastinal contours are stable
Brief Hospital Course:
Mr. [**Known lastname 24400**] was admitted to the Thoracic Surgery service under
the care of Dr. [**Last Name (STitle) **] on [**2164-4-2**] after undergoing a
tracheobronchoplast for his tracheobronchomalacia. Please refer
to the operative note for details of this procedure.
Postoperatively, he was cared for in the CSRU.
On postoperative day one, his pain was controlled with an
epidural. His chest tube was removed. His [**Doctor Last Name **] drain remained
until POD2. He was noted to be in atrial fibrillation, and was
begun on an amiodarone and a diltiazem drip. The Diltiazem was
stopped. His rhythm had converted to sinus.
On POD3, he was transferred to the [**Wardname 836**] floor unit. His
amiodarone was converted to an oral dose of 400 mg twice a day,
to continue for a total of 7 days, and then taper to a dose of
200 mg daily. On POD4, he was seen by Physical Therapy, who
felt he may be able to go home with services, however, his wife
is currently disabled, and his family felt strongly about his
being placed in a rehabilitation facilty for a short time.
He continued to do well, and was discharged to a rehabilitation
facility on POD6.
Medications on Admission:
Lopressor 50A/25P, Norvasc 5A/2.5P, Isordil 60", Xanax 5/prn,
Citalopram 40', Detrol LA5', Omeprazole 20', Folate 1', Vit E
400', Vit C 500', ASA 81', Albuterol, Pulmoicort, Zetia 10'
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO QAM (once a day
(in the morning)).
3. Amlodipine 5 mg Tablet Sig: 0.5 Tablet PO QPM (once a day (in
the evening)).
4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO QAM
(once a day (in the morning)).
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO QPM
(once a day (in the evening)).
6. Isosorbide Dinitrate 20 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
7. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. Tolterodine 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
9. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
Beginning after 400 [**Hospital1 **] dosing has completed.
10. Amiodarone 400 mg Tablet Sig: One (1) Tablet PO twice a day
for 4 days.
11. Xanax 0.5 mg Tablet Sig: One (1) Tablet PO Q8H PRN as
needed.
12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
13. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. Vitamin E 400 unit Tablet Sig: One (1) Tablet PO once a day.
16. Vitamin C 500 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO once a day.
17. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation every four (4) hours as needed for shortness of
breath or wheezing.
18. Pulmicort Turbuhaler 200 mcg/Inhalation Aerosol Powdr Breath
Activated Sig: Two (2) puffs Inhalation twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 2670**] [**Location (un) 5871**]
Discharge Diagnosis:
Tracheobronchomalacia
Discharge Condition:
Good
Discharge Instructions:
Call Dr.[**Name (NI) 2347**] office at [**Telephone/Fax (1) 170**] if you develop:
--Chest pain
--Shortness of breath
--Difficulty swallowing
--Fever greater than 101.5 F
--Redness or drainage from your incision sites.
No lifting anything greater than 10 pounds for 6 weeks.
Do not drive while taking pain medication.
Followup Instructions:
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 170**] for a follow up
appointment in 2 weeks
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3651
} | Medical Text: Admission Date: [**2126-12-29**] Discharge Date: [**2127-1-1**]
Date of Birth: [**2065-11-22**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Clindamycin / Celery / apple / bees
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
Malfunctioning tracheostomy
Major Surgical or Invasive Procedure:
1. Revision of tracheostomy. Flexible bronchoscopy ([**2126-12-29**])
2. PICC line placement ([**2126-12-30**])
History of Present Illness:
60F w/ hx of COPD, PAH w/ cor pulmonale, right-sided CHF, CKD
s/p tracheostomy on [**12-25**]. She presents from rehab facility with
a few hours of low tidal volume. Over the past several months
she has undergone prolonged course with several hospitalizations
including a recent admission from [**Date range (1) 49798**] for shortness of
breath thought initially to be pneumonia but eventually
attributed to COPD exacerbation as opposed to infection. Due to
respiratory failure she underwent a tracheostomy on [**12-25**]. She
otherwise has denied any fever, chills, headache, cough, chest
pain, abdominal pain, nausea or vomiting.
Past Medical History:
1. Morbid obesity (s/p gastric bypass)
2. Obstructive sleep apnea (noctural BiPAP 18/15, home oxygen
requirement of 3-4L via nasal cannula)
3. Obesity hypoventilation syndrome
4. Severe pulmonary artery hypertension (attributed to OSA)
5. Cor pulmonale (right heart failure attributed to severe
pulmonary hypertension)
6. Asthma
7. Osteoarthritis (bilateral knee involvement)
8. Diastolic heart failure (2D-Echo [**1-/2124**] showing LVEF 70-80%,
PAP 64 mmHg)
9. Chronic kidney disease (stage III-IV, baseline creatinine
1.8-2.2)
10. Rosacea
11. Hypertension
12. Iron deficiency anemia
11. s/p ventral hernia repair with mesh and component separation
([**5-/2119**])
12. s/p gastric bypass surgery ([**2113**])
13. s/p debridement of anterior abdominal wall and complex
repair ([**6-/2119**])
Social History:
Patient lives at home with disability services. She has 2 adult
children. She notes no toabcco use, rare alcohol use currently
but notes a former heavy alcohol history in the distant past.
She denies recreational substance use.
Family History:
Notable for diabetes mellitus in her mother and sister,
hypertension in siblings, mother and throughout the maternal
family as well as kidney disease.
Physical Exam:
On admission:
Vitals: 99.9 88 122/82 12 100% at 60% fio2
GEN: A&O 3, Moving all four extremities
HEENT:NCAT, Anicteric sclera, mucus membranes moist
Neck: Tracheostomy tube in place, site c/d/i with cuff up. no
evidence of subcutaneous emphysema. However most of her Tv is
come out through her mouth. She is only getting Tv of 105 to
150's, while she is set for 400.
CV: RRR no m/r/g
PULM: Clear to auscultation but diminished breath sound at the
bases b/l
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses
Ext: No LE edema, LE warm and well perfused
Pertinent Results:
LABORATORY
On admission:
WBC-10.2 RBC-3.06* Hgb-8.6* Hct-28.9* MCV-95 MCH-28.0 MCHC-29.6*
RDW-16.3* Plt Ct-298
Neuts-88.4* Lymphs-7.3* Monos-3.6 Eos-0.5 Baso-0.1
PT-12.2 PTT-28.3 INR(PT)-1.1
Glucose-159* UreaN-38* Creat-1.1 Na-147* K-3.7 Cl-99 HCO3-40*
AnGap-12
Calcium-7.8* Phos-2.5* Mg-1.7
Glucose-159* UreaN-38* Creat-1.1 Na-147* K-3.7 Cl-99 HCO3-40*
AnGap-12
ART pO2-134* pCO2-63* pH-7.39 calTCO2-40* Base XS-10
On discharge:
WBC-7.1 RBC-2.94* Hgb-8.2* Hct-27.2* MCV-93 MCH-27.8 MCHC-30.1*
RDW-16.8* Plt Ct-267
Glucose-114* UreaN-29* Creat-0.8 Na-148* K-2.8* Cl-111* HCO3-32
AnGap-8
Calcium-6.4* Phos-1.9* Mg-1.5*
IMAGING
CXR, pre-op ([**2126-12-29**]):
1. Tracheostomy cannula above the level of the clavicles within
the upper
trachea but rotated and potentially malpositioned.
2. No acute cardiopulmonary process.
CXR, post-op ([**2126-12-30**]):
A tracheostomy tube is in place, the tip lies approximately 16
mm above the carina. This appears to represent a change in the
tracheostomy tube compared with earlier the same day ([**2126-12-29**] at
9:59 a.m.). The cardiomediastinal silhouette is prominent but
unchanged. Some patchy opacity in the left greater than right
suprahilar regions is unchanged. Some bibasilar atelectasis is
also unchanged. Prominent pulmonary artery is again noted in
this individual with history of pulmonary arterial hypertension.
Left wrist plain films ([**2126-12-30**]):
1. No obvious fracture. If there has been significant trauma and
wrist pain persists, then followup radiographs in [**7-8**] days
could help to assess for resorption about an occult fracture.
2. Widening and ? slight offset at the distal radioulnar joint.
This could represent a post-traumatic finding, though it is of
indeterminate acuity.
3. Possible soft tissue swelling, best assessed by physical
exam.
4. First CMC and triscaphe joint degenerative changes.
Brief Hospital Course:
60F admitted on [**2126-12-29**] for tracheostomy malfunction. The patient
was taken to the operating room and, under direct laryngoscopy,
was found to have a dislodged tracheostomy. The tracheostomy
was replaced with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 295**] tracheostomy piece without
complication. The patient was subsequently admitted to the ICU
for ventilator management and close monitoring.
On hospital day #2 the patient was weaned off the ventilator to
trach collar. Given her poor IV access, a PICC line was placed.
She was transfused 1 unit PRBC for hematocrit 24.7, with
subsequent increase to 29.1. Her anemia was attributed to
anemia of chronic disease given she had no evidence of active
bleeding. Her transfusion was given in conjunction with IV
Lasix to avoid exacerbation of her congestive heart
failure/pulmonary edema. She complained of left wrist pain, for
which plain films were obtained. No fracture was identified.
Given her history of gout, her home allopurinol was restarted
once enteral access was obtained.
On hospital day #3 the patient went to IR for post-pyloric
advancement of a Dobhoff tube. Nutrition was consulted with
recommendations for Replete with fiber tube feedings at a goal
of 55cc/hour. She continued to remain stable from a hemodynamic
and respiratory standpoint and was deemed appropriate for
discharge back to rehab.
Medications on Admission:
- sildenafil 20mg TID
- aspirin 81mg daily
- fluticasone 110mcg inhaled [**Hospital1 **]
- home oxygen 3-4 L/min N/C
- albuterol 90mcg HFA Q6hrs prn wheezing/SOB
- albuterol 2.5mg nebulized Q4hrs prn SOB
- allopurinol 300mg daily
- metolazone 5mg [**Hospital1 **]
- ISS QID
- acetaminophen 500mg Q6hrs prn pain
- ferrous sulfate 300mg daily
- metronidazole 1% gel topically daily
- docusate 100mg [**Hospital1 **]
- bisacodyl 10mg daily
- PEG 17g powder daily
- heparin SQ TID
Discharge Medications:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every four (4) hours.
2. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every six (6) hours.
3. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
4. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO once a day as needed for
constipation.
5. allopurinol 100 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
6. metolazone 5 mg Tablet Sig: One (1) Tablet PO twice a day.
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
8. torsemide 20 mg Tablet Sig: Two (2) Tablet PO twice a day.
9. Roxicet 5-325 mg/5 mL Solution Sig: [**5-8**] ml PO every six (6)
hours as needed for pain.
Disp:*400 ml* Refills:*0*
10. simethicone 40 mg/0.6 mL Drops, Suspension Sig: Eighty (80)
mg PO four times a day as needed for indigestion.
11. phenobarb-hyoscy-atropine-scop 16.2-0.1037 -0.0194 mg/5 mL
Elixir Sig: Five (5) ml PO three times a day.
12. ferrous sulfate 300 mg (60 mg iron)/5 mL Liquid Sig: Five
(5) ml PO once a day.
13. Miralax 17 gram/dose Powder Sig: Seventeen (17) grams PO
once a day.
14. Insulin
Per insulin sliding scale worksheet.
15. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 100**] Rehab
Discharge Diagnosis:
1. Malfunctioning tracheostomy
2. Hypercarbic respiratory failure
3. Acute Kidney Injury
4. Cor pulmonale
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
We appreciated the opportunity to partipate in your care at
[**Hospital1 18**]. As you transition to your extended care facility we
wanted to highlight several ongoing issues with your care:
1. Physical therapy: please work each day with the physical
therapy team. This will increase your strength and improve your
lung function.
2. Abdominal pain: your pain is similar to the chronic pain you
experienced prior to admission. The medical team has contact[**Name (NI) **]
your GI doctor to discuss your hospitalization, but you should
also schedule a follow up appointment with your GI doctor within
the next several weeks to further evaluate and manage your
chronic abdominal
pain.
3. Obstructive sleep apnea: while you are on the vent you will
receive respiratory support while you are both awake and asleep.
When you are weaned from the vent you will need to continue
using your bipap machine while you are asleep. This is very
important as sleep apnea contributes to worsening of your
pulmonary function and heart failure.
4. Rehab course: we believe you are now ready to continue
rehabilitation from your illness at an extended care facility.
Please keep in mind that you were very sick while in the
hospital, and recovery may be prolonged despite not needing to
remain in the hospital at this time. To help guide what types of
things should prompt calling your primary care physician or
returning to the hospital, please refer to the information
listed below.
Followup Instructions:
1. Please follow up with your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3029**] at
the following appointment that has been scheduled for you:
Provider: [**First Name11 (Name Pattern1) 674**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. Date/Time: [**2127-1-14**] 10:20
2. Please follow up with the acute care surgery clinic in 2
weeks. Your appointment is [**2127-1-9**] at 2pm in the [**Hospital Ward Name **]
Office building at [**Hospital1 18**]. You can call [**Telephone/Fax (1) 600**] for any
questions.
3. Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2127-2-3**]
9:50
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
ICD9 Codes: 4168, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3652
} | Medical Text: Admission Date: [**2164-2-27**] Discharge Date: [**2164-3-3**]
Date of Birth: [**2089-6-15**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
74 y/o patient with a hx of hypertension, hyperlipidemia & CVA
[**2158**] (no deficits). He ran out of his medications 3 weeks ago
and he began to feel progressively short of breath. His
shortness of breath progressed to the point where he was only
able to sleep while sitting up as he would otherwise develop
severe orthopnea and PND. He also began to develop productive
cough, also about 3 weeks ago. He was diagnosed with pneumonia
one week ago and was given a prescription for levofloxacin which
he took every other day. He then developed epigastric pain along
with his shortness of breath and he went to [**Hospital3 417**]
Medical Center for further evaluation. He has also been using
cocaine intermittently, last used 1 week ago.
.
He was admitted to [**Hospital3 417**] Medical Center on Friday [**2-24**]
with NSTEMI, CHF and pneumonia and acute renal failure CR 4.4, K
3.3 (repleting with 20meq this AM). Leukocytosis to high 14s and
requiring non-rebreather. (Currently on azithromax 500mg and
rocephin at 1gm). He was treated with lasix, metolazone and
nitro and transferred to the CCU. His CHF was treated
aggressively over weekend with above medications but his CHF
persisted. His echo showed 3+ MR [**First Name (Titles) **] [**Last Name (Titles) **] 20-25%. He was also
maintained on Milrinone drip at -.25mcg/kg/min & Heparin drip at
1000units/hr PTT 63. His troponin was 4.05 yesterday and peaked
at 7.39 today. Previous to transfer to [**Hospital1 18**], he was given 325mg
ASA, 75mg Plavix, 50mg metoprolol. No chest pain, presently, no
respirator distress - sats mid 90s on 3L nc. His VSS on
transfer: BP 137/73, HR 83 SR, w/PVCs RBBB, sats 95% 3L nc.
.
On review of systems, he denies any prior history of deep venous
thrombosis, pulmonary embolism, bleeding at the time of surgery,
myalgias, joint pains, 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,
palpitations, syncope or presyncope. He states his shortness of
breath is much improved but he still has orthopnea and is
requiring supplemental O2.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes (NIDDM), +Dyslipidemia,
+Hypertension
2. CARDIAC HISTORY:
- CABG:
- PERCUTANEOUS CORONARY INTERVENTIONS:
- PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
CHF
CVA [**2161**] - no deficits, received TPA
CRI- baseline creatine 3.0, ?one kidney
? peripheral artery disease- patient states he had surgery 'on
one of the arteries in my leg'
Social History:
Divorced, retired from construction and part-time bartending.
Fairly sedentary (per OSH report). Lives in a trailer where his
daughter, her boyfriend often visit and smoke cigarettes.
Incarcerated 5 years ago and difficulty re-organizing since.
- Tobacco history: former 42 pack-year hx, quit 15 years ago
- ETOH: former heavy drinker, decreased 20 years ago, now
drinks 1-2 beers every other day
- Illicit drugs: active cocaine use, approximately once a week,
remote hx of heroine, marijuana, amphetamines
Family History:
- Mother: unknown
- Father: patient thinks his father had an MI and had a
pacermaker, he died in his 90s
Physical Exam:
GENERAL: disheveled elderly male, NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 7 cm.
CARDIAC: PMI not palpable, RR, normal S1, S2. [**2-5**] soft
holosystolic murmur heard best over apices
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. patient CTAB over
upper/mid lungs, bibasilar crackles
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: 2+ DP, PT; trace ankle edema
Pertinent Results:
Admission ([**2164-2-27**]):
CBC: WBC-10.9 RBC-4.13* Hgb-12.9* Hct-38.0* MCV-92 MCH-31.2
MCHC-33.9 RDW-14.4 Plt Ct-285 Neuts-63.4 Lymphs-30.5 Monos-4.1
Eos-1.5 Baso-0.5
Coags: PT-13.1 PTT-37.5* INR(PT)-1.1
Chem:Glucose-201* UreaN-44* Creat-4.2* Na-136 K-3.9 Cl-95*
HCO3-27 AnGap-18
CE: CK(CPK)-77 CK-MB-5 cTropnT-2.31*
Calcium-8.6 Phos-5.6* Mg-2.5
Other Labs:
Repeat CE ([**2164-2-28**] 03:40AM): CK-MB-5 cTropnT-2.67* BLOOD
CK(CPK)-81
Risk assessment([**2164-2-28**]): %HbA1c-7.5* Triglyc-136 HDL-61
CHOL/HD-3.4 LDL-119
Studies:
TTE ([**2164-2-28**]):
The left atrium is elongated. Left ventricular wall thicknesses
are normal. The left ventricular cavity is severely dilated.
Overall left ventricular systolic function is severely depressed
(LVEF= 15-20 %) secondary to focal akinesis of the inferior and
posterior walls, and severe hypokinesis of the rest of the left
ventricle. Significant papillary muscle dysfunction is present.
The right ventricular free wall thickness is normal. Right
ventricular chamber size is normal. with depressed free wall
contractility. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Moderate to severe
(3+) mitral regurgitation is seen (due to chamber dilatation and
papillary muscle dysfunction). The tricuspid valve leaflets are
mildly thickened. The pulmonary artery systolic pressure could
not be determined. There is no pericardial effusion.
Stress Test ([**2164-3-1**]):
IMPRESSION: No symptoms or ischemic EKG changes with vasodilator
infusion.
Cardiac Perfusion Test ([**2164-3-1**]):
IMPRESSION: No reversible myocardial perfusion defect. Severe
left ventricular enlargement. Calculated LVEF = 19%.
Cardiac MR ([**2164-3-2**]):
Impression:
1. Mildly dilated left ventricular cavity size with severe
global hypokinesis and focal inferior wall thinning and
akinesis. The LVEF and effective forward LVEF were severely
depressed at 21% and 15%, respectively.
2. Normal right ventricular cavity size with mild global free
wall
hypokinesis. The RVEF was mildly reduced at 44%.
3. Normal coronary artery origins. Diffusely diseased RCA
shortly after the origin. Poor image quality precluded further
assessment of the LCA.
4. Severe mitral regurgitation. Mild aortic regurgitation.
Moderate pulmonic regurgitation. Mild tricuspid regurgitation.
5. The indexed diameters of the ascending and descending
thoracic aorta were normal and mildly increased, respectively.
The main pulmonary artery diameter index was normal.
6. A note is made of a tiny (<5mm) left renal cyst. There was
also moderate atherosclerosis of the descending thoracic aorta
Theses findings are suggestive of a cardiomyopathy with at least
some
contribution of CAD.
Discharge Labs ([**2164-3-3**]):
WBC-11.3* RBC-4.65 Hgb-14.7 Hct-42.8 MCV-92 MCH-31.6 MCHC-34.4
RDW-14.0 Plt Ct-320
PT-12.8 INR(PT)-1.1
Glucose-173* UreaN-46* Creat-4.6* Na-135 K-4.2 Cl-92* HCO3-28
AnGap-19
Calcium-10.0 Phos-5.7* Mg-2.9*
Brief Hospital Course:
ID:
Patient is a 74 yo male with hx of HTN, HLD, DMII, CHF admitted
to OSH 4 days ago with shortness of breath, abdominal pain and
cough and found to have NSTEMI, pneumonia and acute on chronic
CHF exacerbation after stopping all medications 3 weeks now
transferred to [**Hospital1 18**] CCU for further management of his CHF.
.
# CAD:
Patient was admitted to OSH with epigastric pain. His work-up
revealed NSTEMI with peak troponin at 7.39 trending down to 2.31
at time of admission to [**Hospital1 18**]. He denied chest pain at
admission. He is not aware of a diagnosis of CAD and he stated
he had never had a catheterization but he had taken nitro for
chest pain in the past. Troponins stayed flat at [**Hospital1 18**]. Pt was
continued on ASA 325mg and Clopidogrel 75mg (loaded already at
OSH) and Atorvastatin 80mg daily. Pt continued on heparin gtt
which had also been started at OSH as well as metoprolol 25mg
[**Hospital1 **]). ECHO showed EF 15-20% with inf/posterior akinesis and
severe hypokinesis of other regions. 3+ MR. [**Name13 (STitle) **] at been 50% last
check per PCP. [**Name10 (NameIs) **] cardiologist [**Name (NI) 653**] and wanted to check
persantine stress to eval if any reversible defect and no
reversible defect was seen. Cardiac MR was also done (see
results section) although it was a technically poor quality
study. Labetalol was uptitrated to 150mg [**Hospital1 **] at time of
discharge with labetalol used as beta-blocker since also has
alpha-blocking characteristics and there was concern that pt
would continue using cocaine in [**Hospital1 3782**] setting and have
unnopposed alpha constriction on pure beta-blocking [**Doctor Last Name 360**]. Since
pt very likely to be pushed over into needing dialysis with
either cardiac cath or cardiac surgery, decision was made to
medically manage and pt discharged to follow-up with [**Doctor Last Name 3782**]
cardiologist Dr. [**Last Name (STitle) 7047**].
.
#Substance Abuse: Patient had been actively using cocaine and
this is certainly contributing to his cardiac disease. He has
continued to use cocaine despite developing worsening SOB,
palpitations and chest pain with active use. He feels very
optimistic about his cocaine use because recently he has been
using less than prior, but seems very reluctant to agree to
never using cocaine again stating his life isn't very good and
cocaine is the only thing that makes [**Last Name (un) **] feel good about life.
Social work was consulted to address this issue and saw the
patient during his hospitalization affirming that he had a very
unsupportive living environment and overall life. It is very
unlikely from the perspective of the medical team that the
patient will refrain from using cocaine although every effort
was made to convey the importance of this step to the patient.
.
# CHF:
Patient was admitted to OSH with severe CHF exacerbation as
evidenced by severe orthopnea, PND and pulm edema on CXR. His
volume status was much improved at arrival to [**Hospital1 **] although he
is mildly overloaded and still unable to lie flat, oxygen
dependent when baseline was no home oxygen. His JVP was not
significantly elevated, he had only trace pedal edema and
bibasilar crackles. CAD portion of disease was managed as above
and ACE-I was held due to renal failure. Pt was diuresed with
lasix to remove additional volume.
.
# [**Last Name (un) **] on CKD:
Patient admitted to OSH with acute on chronic renal failure.
Patient's baseline creatine 3.5, elevated to 4.2 at time of
admission. His [**Last Name (un) **] may be related to poor perfusion in setting
of NSTEMI or may be related to ischemia [**2-1**] cocaine use.
Elevated creatine may be chronic progression of renal disease as
did not improve over several days in the hopsital. An ACE-I was
held as above due to renal failure and decision was made to
postpone either cardiac surgery or cardiac cath due to thought
that this would push pt over the edge to requiring dialysis and
thought that in setting of very poor social stability that this
would lead to a worse prognosis than medical management of his
disease. Pt should talk to his PCP about [**Name Initial (PRE) **] referral to a nearby
nephrologist in order to help manage his kidney disease. He was
instructed to talk to his PCP about this before he was
discharged.
.
#PNEUMONIA patient was also being treated for pneumonia as
diagnosed at OSH. He had already received levofloxacin as an
outpatient (though pt is unclear how many doses he received) and
ceftriaxone at OSH (day 1= [**2164-2-24**]). CXR raised question of
consolidation. Hre received 2 more doses of CTX to complete a 5
day course and then Abx were discontinued.
.
# HTN: Patient's blood pressures were moderately elevated on
admission, but now well controlled with SBPs in 120s.
Beta-blocker changed to labetalol for reasons noted above and
dose uptitrated to 150mg PO BID by time of discharge.
.
# HLD: patient has been on simvastatin 20 mg po daily in the
past for hyperlipidemia but has been off of it for ~3 weeks. He
was started on high dose atorvastatin for the first few days and
then had dose down titrated slightly before discharge.
.
# RHYTHM: sinus rhythm at presentation and pt stayed in sinus
rhythm during admission while monitored on tele. Rate
controlling [**Doctor Last Name 360**] changed as above.
.
# DMII: patient has history of diabetes mellitus type,
previously on pioglitazone at home, but has not taken in >3
weeks. Checked A1C was 7.5. Pt transitioned to very low dose of
glipizide (2.5mg daily) when blood sugars ran high for a few
days in the hospital.
Medications on Admission:
HOME MEDICATIONS: (has not taken in >3 weeks)
- Actos 15 mg po daily
- Furosemide 40 mg po qAM 20 mg po qPM
- Levaquin 750 mg po QOD (started 1 week ago)
- Simvastatin 20 mg po daily
- Metoprolol 25 mg po BID
- Amlodipine 10 mg po daily
.
TRANSFER MEDICATIONS:
325mg ASA, 75mg Plavix, 50mg metoprolol
IV Fluid/Drips: Milrinone 0.25mcg/kg/min; Heparin 1000units/hr;
20meq K
Discharge Medications:
1. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [**1-1**]
Puffs Inhalation Q6H (every 6 hours) as needed for wheezing/sob.
Disp:*1 inhaler* Refills:*2*
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. labetalol 100 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
6. glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Rel 24 hr(s)* Refills:*2*
7. lancets Misc Sig: One (1) box Miscellaneous four times a
day.
Disp:*1 box* Refills:*2*
8. Glucometer
One glucometer
Please use to check your blood sugars at least 3 times each day.
9. Glucose Test Strips
Please use glucose test strips with your glucometer to check
your blood sugars at least three time each day.
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**] & Hospice
Discharge Diagnosis:
Acute Systolic Congestive Heart Failure: unable to start ACE or
[**Last Name (un) **] because of renal failure
Non ST Elevation Myocardial Infarction
Hypertension
Diabetes Mellitus
Acute on chronic kidney injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 87579**], you had a heart attack at home and your heart is now
very weak and unable to pump efficiently. This means that fluid
has built up in your lungs and making it harder for you to
breathe. We gave you lasix to get rid of the fluid and we
started you on new medicines to help your heart beat more
efficiently. You will need to take these new medicines to help
your heart pump better and failing to take them will cause you
to become significantly worse. It is also very important that
you see a kidney doctor (nephrologist) to prevent your kidney
function from worsening so you can avoid needing dialysis for as
long as possible. The three most important thing that you need
to do to prevent rehospitalization or getting much sicker are:
1. Go to all of your doctor's appointments
2. Take all of your medicines every day
3. Avoid salt in your diet, this includes never eating take out
or prepared food.
4. Never use cocaine
.
Weigh yourself every morning, call Dr [**Last Name (STitle) 7047**] if your weight
goes up more than 3 lbs in 1 day or 6 pounds in 3 days. Your
discharge weight is 97.9kg or 176lbs.
.
We made the following changes to your medicines:
1. STOP taking Actos, Levaquin, Metoprolol and amlodipine
2. Start taking furosemide 40mg(lasix) once daily to prevent the
fluid from building up in your lungs
3. Start Glipizide 2.5mg to control your blood sugar
4. Start taking labetolol 150mg to decrease your heart rate and
blood pressure
5. Increase the simvastatin to 40 mg daily
6. Start taking a baby aspirin (81mg) daily, you will need to
take this every day for the rest of your life
7. Take the ipratropium-albuterol inhaler to help with the
wheezes in your lungs.
Followup Instructions:
Name: RING,[**Doctor First Name 569**] L.
Location: [**Hospital1 **] HEALTHCARE - [**Hospital1 **]
Address: ONE PEARL ST, [**Apartment Address(1) 12836**], [**Hospital1 **],[**Numeric Identifier 9647**]
Phone: [**Telephone/Fax (1) 28095**]
****Please call Dr [**Last Name (STitle) **] office on Monday to book an appt within
1 week for follow up of your hospital stay. Please also ask him
for assistance is setting up a nephrology (kidney doctor)
appointment.
Name: [**Last Name (LF) 7047**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital1 **] HEALTHCARE - [**Location (un) 8720**]
Address: 15 [**Doctor Last Name 8721**] BROTHERS WAY,[**Apartment Address(1) 8722**], [**Location 8723**],MA
Phone: [**Telephone/Fax (1) 8725**]
Appt: Friday [**3-23**] at 8am
You will need to be seen by a Nephrologist (kidney doctor). In
order to get you an appointment near where you live, you should
call Dr.[**Name (NI) 30753**] office on Monday to get a referral to a
nephrologist nearby.
ICD9 Codes: 486, 5849, 4280, 2724, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3653
} | Medical Text: Admission Date: [**2131-2-27**] Discharge Date: [**2131-3-1**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4765**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
89 yo W with PMH of HTN, dyslipidemia transferred from OSH after
presenting with severe back pain and severe L-sided CP that woke
her from sleep. Pt was at home with caretaker when she began
complaining of sharp, pleuritic midscapular pain. EMS came, gave
her ASA x 2, and SLNG x1 with resolution of pain. She initially
went to Caritas [**Hospital6 5016**], had 1" nitropaste, more
SLNG, 80po KCL, was found to be hypotensive to 80/46. EKG @ OSH
was rate 100, nml axis, prolonged PR interval, small STE in III.
.
She had CTA at OSH that was notable for Type A aortic
dissection. She was then transferred to [**Hospital1 18**] for further
management.
.
In ED, VS: T:99 HR96 135/85 16 96RA. She was given 10mg x 1,
20mg x1 and 40mg x 1 of IV labetalol without decrease in
systolic bp. Therefore patient was started on labetalol gtt with
good effect. EKG showed prolonged PR intervals, new STE in II,
aVF. Seen by CT surgery who felt patient was not surgical
candidate due to age and multiple medical problems.
.
On review of symptoms, family denies any prior history of
stroke, TIA, deep venous thrombosis, pulmonary embolism,
bleeding at the time of surgery, myalgias, joint pains, cough,
hemoptysis, black stools or red stools. He denies recent fevers,
chills or rigors. He denies exertional buttock or calf pain.
Does report hx of bleeding hemorrhoids. 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:
HTN
Hypercholesterolemia
Dementia
Afib
.
Cardiac Risk Factors: -Diabetes, +Dyslipidemia, +Hypertension
Social History:
NC
Family History:
NC
Physical Exam:
VS: T 99.9, BP 130/80, HR 92, RR 21, O2 97% on RA on labetalol
0.3mg/min gtt
Gen: Elderly female in NAD, resp or otherwise. Oriented x1.
Mood, affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP of 8 cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. + crackles at b/l
bases; No wheezes, or rhonchi.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits. pulses equal in b/l arms
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Pertinent Results:
CXR: IMPRESSION:
1. Tortuous aorta and widened mediastinum is consistent with
type A aortic dissection as seen on outside chest CTA.
2. No evidence of CHF or pleural effusions.
Brief Hospital Course:
89 yo W w PMH of HTN, hyperlipidemia transferred from OSH with
Type A aortic dissection.
.
Mrs [**Last Name (STitle) 76563**] was found to have a Type A dissection confirmed on
CTA at OSH. CXR here with widened mediastinum. CT surgery
evaluated her; she was not a surgical candidate due to age and
comorbidities. She opted for medical management in discussion
with her family. Her code status was DNR/DNI. She was treated
with IV labetalol. On the morning of [**3-1**] she awoke feeling
well, however, she then developed hypotension and afib. She
then became asystolic, and was pronounced dead shortly
thereafter. Her family (daughters) were notified, and arrived
shortly after her death.
.
# Communication: Patient and daughter [**Name (NI) **], cell ([**Telephone/Fax (1) 76564**]
Medications on Admission:
Atenolol 50'
Imdur 30'
Lexapro 20'
Potassium 10'
ASA 81'
Megace 40'
Zocor 10'
Trazodone 50'
Cyclobenzaprine 10'
Senna daily
Colace 100'
MVI
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
Aortic Dissection
Discharge Condition:
Deceased
Discharge Instructions:
NA
Followup Instructions:
NA
ICD9 Codes: 4275, 4019, 2724, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3654
} | Medical Text: Admission Date: [**2113-4-6**] Discharge Date: [**2113-4-10**]
Date of Birth: [**2050-9-6**] Sex: F
Service:
HISTORY OF THE PRESENT ILLNESS: The patient is a 62-year-old
female with a complicated past medical history including
Takayasu arteritis, idiopathic pulmonary fibrosis,
Parkinson's disease, COPD, who presents with a fall at home.
The patient apparently fell at home and as she lives by
herself, the patient called EMS as she had symptoms of
shortness of breath. The patient was unable to provide a
full detailed history as to events surrounding her fall. The
patient had a pulse of 78, blood pressure 136/64,
respirations 24, and was saturating 98% on nonrebreather when
the EMTs found her. She was also complaining of being cold.
She did state that her 02 tank appeared to be broken. The
patient did state that she had head trauma.
In the Emergency Room, the patient's temperature was 95.1,
pulse 100, blood pressure 90/59, respiratory rate 26,
saturating 81%. The patient was given Albuterol nebulizer
treatments, 700 cc of lactated Ringer's, 800 cc of normal
saline, and 2 units of packed red blood cells. There was
some question of an AP pelvis film that could not
conclusively rule out fracture and given that the patient had
a hematocrit of 28.2 at the time of admission, there was
concern that she could have been actively bleeding. Thus,
the patient was given aggressive fluid hydration as well as 2
units of packed red blood cells.
In this setting, she developed flash pulmonary edema and
required intubation. The patient was also given 100 mg of
hydrocortisone IV and 500 mg of levofloxacin as well as 600
mg of clindamycin. Post intubation, the patient had an
arterial blood gas of 7.17, 92, 146. She was then given 80
mg of IV Lasix in the Emergency Room.
The patient was then transferred to the Intensive Care Unit
for further care.
PAST MEDICAL HISTORY:
1. Takayasu arteritis diagnosed in [**2108**] after a syncopal
episode. The patient was found to have nonpalpable radial
pulses. The patient had an MRA which indicated bilateral
subclavian artery stenoses with subclavian steel. The patient
has been treated with chronic steroids. She is normally on 5
mg of prednisone p.o. q.d.
2. Idiopathic pulmonary fibrosis diagnosed in [**2109**]. The
patient had a BAL and lung biopsy in [**2110**] which showed
hemosiderin bleed-in, macrophages, ANCA negative, [**Doctor First Name **]
negative. The patient was treated with CellCept for this.
3. COPD: The patient's last known pulmonary function tests
revealed an FEV1 of 45% and FVC of 63% and baseline 02
saturation of 89-92% on room air. The patient is on home 02
as well as home BIPAP.
4. Type 2 diabetes mellitus (question if steroid-induced).
5. Iron-deficiency anemia: The patient had a normal
colonoscopy in [**2112-8-8**] and has a baseline hematocrit of
28-30.
6. Parkinson's disease: On carbidopa, levodopa.
7. Question of hypothyroidism.
8. T11-12 disk herniation with compression fracture.
9. Osteoporosis.
10. Mitral stenosis.
11. Question of CAD: The patient had an echocardiogram in
[**2111-3-12**] with moderate MR valve area of 0.5, EF 63%
with a MIBI in [**2109-3-11**] that was nondiagnostic per
report at an outside hospital.
12. Anxiety.
13. Chronic pain, primarily in the back.
14. Pulmonary embolus in [**2112-8-8**].
DISCHARGE MEDICATIONS (PER DISCHARGE SUMMARY [**2-10**]):
1. Methadone 5 mg p.o. t.i.d.
2. Percocet 7.5/325 p.o. p.r.n.
3. Alendronate 70 mg q. week.
4. Salmeterol two puffs inhaled b.i.d.
5. Flovent 110 micrograms two puffs b.i.d.
6. Prozac 60 mg p.o. q.d.
7. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 20 mEq p.o. q.d.
8. Prevacid 40 mg p.o. q.d.
9. Calcium carbonate 1,000 mg p.o. t.i.d.
10. NPH 16 units q.a.m.
11. Aricept 5 q.h.s.
12. Sinemet 25/100 two b.i.d.
13. Aspirin 325 mg p.o. q.d.
14. Metoprolol 12.5 mg p.o. b.i.d.
15. Klonopin 1 mg p.o. b.i.d.
16. Lasix 40 mg p.o. q.d.
17. Prednisone 5 mg p.o. q.d.
18. CellCept [**Pager number **] mg p.o. b.i.d.
19. Colace 100 mg p.o. b.i.d.
20. Senna two tablets p.o. b.i.d.
21. Albuterol inhalers p.r.n.
These medications are unknown but were documented on the EMS
sheet.
1. Synthroid.
2. Seroquel.
3. Remeron.
ALLERGIES: Sulfa which causes hives, bananas and shellfish,
unknown reactions.
SOCIAL HISTORY: The patient has a ten pack year history of
tobacco use which she quit in [**2108**]. No history of alcohol
use. She lives alone. The patient's former primary care
physician is [**Last Name (NamePattern4) **]. [**First Name (STitle) **] .................... at
[**Hospital6 1129**]. The patient's current
primary care physician is listed as Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at the
[**Hospital 191**] Clinic, however, he also does not appear to be the
patient's primary care physician at the time. The patient
has a daughter, [**Name (NI) 1356**], and a son, [**Name (NI) **], phone number
[**Telephone/Fax (1) 97040**]. The patient's next of [**Doctor First Name **] is [**Doctor First Name **], phone
number [**Telephone/Fax (1) 97041**].
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
100.6, pulse 97, blood pressure 86/58 by blood pressure cuff
and 116/81 by A line. Ventilatory settings: AC 400, tidal
volume times 22, respiratory rate 50% FI02, saturating 94%.
General: Intubated, sedated, able to mouth words. HEENT:
Moist mucous membranes. No teeth. Pupils small but
reactive. Neck: C-spine collar, supple. Respiratory:
Coarse breath sounds throughout, occasional expiratory
wheezes. Cardiovascular: Tachy/normal S1, S2, II/VI
systolic murmur. Abdomen: Soft, nontender, nondistended.
Extremities: No cyanosis, clubbing, or edema, 1+ DP/PT
bilaterally. Neurological: Tremor.
LABORATORY DATA AT THE TIME OF ADMISSION: White blood cell
count 17.6, hematocrit 28 with a baseline between 28-31,
platelets 417,000, MCV 81. The differential revealed
neutrophils 78%, basophils 0.6%, bands 0, lymphocytes 13%,
monocytes 3%, eosinophils 5%. PT 12.9, INR 1.1, PTT 25.2.
Sodium 134, potassium 5.3, chloride 90, bicarbonate 29, BUN
16, creatinine 1.0, glucose 213. The initial CK was 234.
Troponin less than 0.3.
Urinalysis: Negative.
Chest x-ray: Infiltrates in the left midlung zone, right
upper and middle lobe which were worse compared to prior
study of [**2113-2-15**], consistent with infection versus
asymmetric pulmonary edema.
AP pelvis film: Question of right pubic rami fracture cannot
be excluded.
Noncontrast CT of the chest: Small bilateral effusions, air
space consolidation, mediastinal lymphadenopathy, no
fractures, no evidence of solid organ injury.
Head CT: No change compared to prior.
CT C-spine: No cervical spine fractures.
EKG: Sinus tachy at a rate of 102, axis 30 degrees,
intervals okay, Q wave in lead III.
HOSPITAL COURSE: The patient was admitted to the Intensive
Care Unit secondary to intubation from volume overload after
aggressive fluid resuscitation as well as red blood cell
transfusion.
1. RESPIRATORY: The patient was intubated primarily in the
setting of acute pulmonary edema from volume overload. The
patient was diuresed aggressively with good results,
diuresing approximately 4 liters while in the Intensive Care
Unit. The patient did continue to have diffuse wheezing and
required frequent nebulizer treatments with Albuterol. She
was titrated down to nasal cannula 3 liters, saturating
92-96% given her underlying interstitial pulmonary fibrosis
as well as COPD.
The patient had a repeat chest x-ray on [**2113-3-30**]
which revealed coarse reticular opacities in the bilateral
lungs, no pleural effusions, and marked interval improvement
of her bilateral opacities. The patient's Lasix was held for
one day given that she had diuresed so well. However, the
patient then redeveloped some increasing wheezing and 02
requirement. She was diuresed again with Lasix 40 IV with
good results and repeat chest x-ray revealed good resolution
of her CHF.
The patient was then restarted on her home dose Lasix regimen
of 40 mg p.o. q.d. The patient also had marked improvement
in her wheezing and did not require frequent Albuterol
treatments. The patient subjectively felt dyspnea on
exertion but no shortness of breath at rest.
On [**2113-4-9**], the patient did have another acute episode
of left-sided pleuritic chest pain and shortness of breath.
Given her prior history of pulmonary embolus, there was a low
threshold to evaluate for this. The patient had a CT angio
which was negative for pulmonary embolism. In addition, the
patient was started on a rule out for myocardial infarction.
2. HYPOTENSION: The patient had a history of reported
hypotension by the Emergency Department notes. However,
given the patient's subclavian stenosis and lack of palpable
radial pulses there is the added element of about 15 mmHg
difference between her arterial line measurement as well as
her cuff blood pressure measurement. The patient had good
blood pressure monitoring with an A line which was
discontinued prior to her transfer out of the Intensive Care
Unit.
Subsequently, the patient had blood pressures that ranged
from 90-120 systolic.
3. CARDIOVASCULAR: The patient again with CHF in the
setting of rapid volume resuscitation. The patient had an
echocardiogram that revealed a mildly dilated left atrium and
normal left ventricle with an EF greater than 55%, positive
basal septal hypokinesis, mitral valve mildly thickened,
consistent with rheumatic deformities, fused commissures, and
leaflets tethering, mild mitral stenosis, 1+ mitral
regurgitation, and eccentric jet, mild pulmonary artery
systolic hypertension. There was no evidence for LVH or for
decreased ejection fraction. Thus, the patient likely has
diastolic dysfunction.
The patient was also ruled out for a myocardial infarction
subsequent to her episode of left-sided chest pain. Her
first two sets of cardiac enzymes were negative with CKs of
23 and 18 respectively with negative troponins. There was a
low threshold of suspicion for myocardial infarction and the
patient also has an EKG without abnormalities during the
episode of chest pain.
4. INFECTIOUS DISEASE: The patient was with an elevated
white blood cell count which appears to be somewhat elevated
at baseline given her chronic steroid use. The patient was
initially placed on levo/clinda. However, her lack of teeth
makes anaerobic coverage unnecessary. Therefore, clinda was
discontinued. The patient was then taken off of her
antibiotics given that there was no clear infiltrate or
evidence of pneumonia without any productive sputum or fever.
However, the patient will likely complete a one week course
of Levaquin given that her underlying pulmonary disease makes
interpretation of consolidation or infiltrate difficult and
she does have a persistently elevated white blood cell count.
The patient had blood cultures with no growth and urine
culture with no growth as well.
5. FALLS: The patient is with an unclear etiology of
frequent falls. However, she did have a recent admission
with evaluation for this and this does appear to be a chronic
problems for the past 12 years, probably concomitant
Parkinson's, T12 compression fracture, as well as multiple
medical conditions and the fact that the patient lives alone.
PT consultation was obtained and they recommended
rehabilitation for this patient.
6. NEUROLOGIC: The patient is with a history of Parkinson's
disease. She was continued on her carbidopa, levodopa at the
time of admission.
7. PSYCHIATRY: The patient was continued on her Prozac.
8. ANXIETY: The patient was initially treated with Ativan
p.r.n. However, she states that this has not had good
results. The patient was restarted on her home dose of
Klonopin 1 mg p.o. b.i.d. given her increase in anxiety.
Initially, this was held given that the patient came in with
an unclear mental status and we did not want to add a
long-acting benzodiazepine in that setting.
9. TAKAYASU'S ARTERITIS: The patient was continued on
prednisone 5 mg after receiving stress-dose steroids in the
Intensive Care Unit. The interpretation of her cortisol stim
test is confounded as she is on chronic prednisone which is
essentially normal replacement physiologic dose. Thus,
inappropriate bump in cortisol does not imply that the
patient has adrenal insufficiency on that basis.
10. IPF: The patient was restarted on her CellCept on [**2113-4-10**] for treatment of her IPF. Her chest x-ray revealed
her baseline interstitial pulmonary disease.
11. DISPOSITION: The patient will likely be discharged to a
rehabilitation facility after appropriate screening.
DISCHARGE CONDITION: Stable. The patient is not at her
baseline status as she needs rehabilitation for her
deconditioning.
DISCHARGE DIAGNOSIS:
1. Congestive heart failure secondary to volume overload,
likely diastolic dysfunction.
2. Takayasu's arteritis.
3. Interstitial pulmonary fibrosis.
4. Parkinson's disease.
5. Pneumonia.
MEDICATIONS AT THE TIME OF DISCHARGE: All home dose
medications noted at the beginning of this discharge summary
with the exception of Aricept and metoprolol, with the
addition of levofloxacin.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**], M.D. [**MD Number(1) 736**]
Dictated By:[**Name8 (MD) 231**]
MEDQUIST36
D: [**2113-4-10**] 03:02
T: [**2113-4-10**] 15:31
JOB#: [**Job Number 97042**]
ICD9 Codes: 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3655
} | Medical Text: Admission Date: [**2177-11-29**] Discharge Date: [**2177-12-16**]
Date of Birth: [**2098-2-21**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2078**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
cardiac catheterization
History of Present Illness:
This is a 79yo M with history of hypertension, hyperlipidemia,
PVD who presented with 5/10 nonradiating burning chest pain in
midchest that started at 3 AM on the morning of admision. HE
denies nausea/vomitting/ diaphoresis / dizziness/palpitation.
THe pain did not wake him up from sleep and he noticed it while
he was waking up to get to the bathroom. The pain was not
relieved by mylanta/tums. At baseline, he could only walk a few
hundred feet because of claudication. This has not changed
recently. He did not notice any leg swelling/weight change.
Patient went to [**Hospital 487**] Hospital where he had ST depression in
V4-V6 and noted to have crackles on exam. Chest pain was
relieved by 2SLNTG. patient geiven lasix. trop noted to be 9.37
at OSH(0-0.5) with MB 65.1. IV heparin was started. He was then
transferred to [**Hospital1 18**]. Patient is chest pain free on IV heparin
and integrillin
Past Medical History:
1. CAD??silent MI in the past
2. COPD
3. paroxysmal Afib
4. hypercholesterolemia
5. bilateral CEA about 20y ago
6. PVD s/p angioplasty LLE about 10y ago
7. neck CA s/p XRT 7y ago
Social History:
denies tobacco/ETOH
Family History:
MI in father at 65yo
Physical Exam:
T97.5 BP 90-110/50-60 P68 94% on RA
Gen-very pleasant elderly gentleman, comfortable in no
pain/distress
HEENT-anicteric, oral mucosa moist, neck supple
CVS-regular HS, no murmur, faint heart sound, no pedal edema, no
JVD, carotid bruit on right
ext-femoral pulse 2+ bilaterally, no bruit, DP 1+
bilaterally(diffuicult to find)
resp-mild bibasilar crackles
[**Last Name (un) 103**]-nl BS, NT/ND
neuro-A+Ox3, move all 4 limbs symmetrically, no facial asymmetry
Pertinent Results:
ECG-irregular rate, wandering atrial pacemaker, normal axis and
interval, ST depression in V2-V6 I, II
CXR [**2177-11-28**]-bilateral hazy opacities c/w CHF
[**2177-11-29**] 09:55AM PTT-113.3*
[**2177-12-16**] 07:05AM BLOOD WBC-8.7 RBC-3.75* Hgb-11.1* Hct-32.1*
MCV-86 MCH-29.5 MCHC-34.5 RDW-16.3* Plt Ct-321
[**2177-12-16**] 07:05AM BLOOD Plt Ct-321
[**2177-12-16**] 07:05AM BLOOD Glucose-97 UreaN-87* Creat-3.8* Na-130*
K-3.0* Cl-87* HCO3-36* AnGap-10
[**2177-12-11**] 07:25AM BLOOD LD(LDH)-273*
[**2177-12-5**] 05:36AM BLOOD ALT-18 AST-23 LD(LDH)-322* AlkPhos-68
TotBili-0.5
[**2177-12-3**] 03:59PM BLOOD CK-MB-23* MB Indx-12.9* cTropnT-4.82*
[**2177-12-3**] 05:27AM BLOOD CK-MB-36* MB Indx-13.7* cTropnT-5.10*
[**2177-12-2**] 01:36PM BLOOD CK-MB-98* MB Indx-18.5* cTropnT-3.84*
[**2177-12-16**] 07:05AM BLOOD Calcium-8.5 Phos-4.4 Mg-2.2
[**2177-11-30**] 01:56PM BLOOD calTIBC-270 VitB12-229* Folate-19.2
Ferritn-71 TRF-208
[**2177-11-29**] 06:30AM BLOOD Triglyc-68 HDL-46 CHOL/HD-2.6 LDLcalc-59
[**2177-11-30**] 01:56PM BLOOD TSH-1.4
Brief Hospital Course:
Patient had a NSTEMI on admission. Over the weekend, the
decision had been to watch him since he was chest pain free and
his Cr was rising. However, he eventually developed chest pain,
his troponin peaked at 5.10 with very ischemic looking ECG. He
was initially put on integrillin and heparin. However, his renal
function continues to worsen and the integrillin was then
switched to reapro. He subsequently passed large liquid black
stool. The reapro and heparin was thus discontinued. The renal
function continues to worsen and he also developed flash
pulmonary edema with acute respiratory distress. He was then
transferred to the CCU and aggressively diuresed with natrecor
and achieved a net loss of 3.2L. The flash pulmoary edema was
thought to be caused by his evolving MI. His EF was known to be
35%. He was then transferred to the floor. His oxygen saturation
did not improve despite aggressive diuresis with natrecor and
lasix drip. His CXR showed moderate to large bilateral pleural
effusion. Bilateral thoracentesis was performed and he had a
therapeutic tap about 2L on the right and 1.4 L on the left.
Pleural fluid was consistent with transudative effusion. His
respiratory status improved dramatically since then. His
diuretic regimen was gradually switched to IV and then to oral
medication. He will be discharged on oral lasix 20 [**Hospital1 **]. There is
no plan for cardiac catheterization at this moment. [**Name2 (NI) **] will be
managed medically with aspirin, metoprolol XL, simvastatin and
nitroglycerin.
Patient also has a history of paroxysmal atrial fibrillation. He
was on digoxin, diltiazem and coumadin as outpatient.
However,coumadin was discontinued because of his GI bleed.
Diltiazem and digoxin were discontinued because of the frequent
4s pauses seen on telemetry. On discharge,he was in sinus rhythm
on metoprolol and amiodarone 400 [**Hospital1 **]. Digoxin was not restarted
due to his renal failure. He will have to have a GI workup
before coumadin could be restarted. GI workup will have to be
arranged as outpatient. Meanwhile, he would continue on PPI. He
had recieved a total of 3 units of pack red cells while he was
actively bleeding and since then his hematocrit had been stable.
He was also started on iron pills. Once his EGD/colonoscopy has
been done, he should be restarted on coumadin for stroke
prevention (Afib) with a goal INR of [**2-25**].
His creatinine peaked at 4.1, likely due to decreased perfusion
from worsening CHF in the setting of MI. Renal U/S showed no
hydronephrosis or stone. There was also no cast in urine to
suggest ATN. The creatinine gradually drifted down with
resolution of his CHF status
He will be discharged to rehabilitation with close follow up.
Medications on Admission:
zocor 20 qhs
terazosin 2mg oi qhs
allopurinol 100 [**Hospital1 **]
albuterol 2 puffs qid
digoxin 0.125 po qd
diltiazem 240 qd
HCTZ 12.5 qam
coumadin 5 qd
NKDA
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
3. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
4. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-24**] Sprays Nasal
QID (4 times a day) as needed.
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
6. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
8. Ipratropium Bromide 0.02 % Solution Sig: 1-2 puffs Inhalation
Q6H (every 6 hours) as needed for SOB.
9. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO twice a
day: Please give 200 mg [**Hospital1 **] for two weeks and then change to 200
mg once daily as his maintenance dose.
10. Trazodone HCl 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
11. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR
Sig: 0.5 Tablet Sustained Release 24HR PO DAILY (Daily).
12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
13. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
TID (3 times a day). Tablet(s)
14. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
NSTEMI
acute on chronic renal failure
GI bleed
congestive heart failure
pneumonia
Discharge Condition:
good
Discharge Instructions:
Please follow-up with your primary care doctor in [**2-25**] weeks.
Dr. [**Last Name (STitle) 50167**], [**First Name3 (LF) **] [**Telephone/Fax (1) 50168**]. Fax [**Telephone/Fax (1) 56897**]
Once you have had your colonoscopy and upper endoscopy, you
should be restarted on coumadin if it is safe to do so. Please
check with your primary care doctor prior to restarting this
medication. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 437**], [**Hospital1 18**] Gastroenterology ([**Telephone/Fax (1) 19233**], will call your Rehab and your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 10542**] the follow-up endoscopy and colonoscopy.
Please follow-up with your nephrologist and cardiologist as
scheduled.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D., PH.D.[**MD Number(3) **]: [**Hospital6 29**]
MEDICAL SPECIALTIES Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2178-1-26**] 2:30
Please follow-up with your primary care doctor in [**2-25**] weeks.
Provider: [**Name10 (NameIs) 475**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 474**], M.D. Where: [**Hospital6 29**] CARDIAC
SERVICES Phone:[**Telephone/Fax (1) 1989**] Date/Time:[**2178-2-13**] 1:00
Outpatient EGD/Colonoscopy to be scheduled. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 437**],
[**Hospital1 18**] Gastroenterology ([**Telephone/Fax (1) 8892**], will call your Rehab and
your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] the follow-up endoscopy and
colonoscopy.
ICD9 Codes: 4280, 5849, 5119, 2851, 4254, 5990, 496, 2762, 4240, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3656
} | Medical Text: Admission Date: [**2153-10-23**] Discharge Date: [**2153-10-29**]
Date of Birth: [**2104-5-1**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain, shortness of breath
Major Surgical or Invasive Procedure:
[**2153-10-23**] Coronary Artery Bypass Graft x 2 (LIMA to LAD, SVG to
OM)
History of Present Illness:
49 y/o spanish speaking female with h/o chest discomfort with
shortness of breath. She had a abnormal stress test and was
referred for a cardiac cath. Cath revealed multi-vessel disease
and she was then referred for surgical revascularization.
Past Medical History:
Hypertension, Anxiety
Social History:
Denies tobacco or ETOH use. Spanish speaking. Lives alone.
Family History:
Non-contributory
Physical Exam:
Admission
VS: 75 18 178/85 5'2" 112#
Gen: NAD
Skin: Unremarkable
HEENT: NCAT, EOMI, PERRL
Neck: Supple, FROM -JVD
Chest: CTAB -w/r/r
Heart: RRR -c/r/m/g
Abd: Soft, NT/ND +BS
Ext: Warm, well-perfused -edema
Neuro: A&O x 3, MAE, non-focal
Discharge
T 97.1 BP 102/65 HR 97 RR 18 97% RA 51.4KG
General: spanish speaking, no acute distress
Pulmonary: lungs clear to asucultation bilaterally
Cardiac: tachycardia, normal S1S2. No murmurs, rubs, gallops
appreciated.
Sternal incision: sternum stable. No erythema or drainage.
Abdomen: soft and nontender without rebound or guarding
Extremities: warm with trace edema
Pertinent Results:
[**2153-10-23**] Echo: PREBYPASS: 1. The left atrium is normal in size.
No atrial septal defect or PFO is seen by 2D or color Doppler.
2. There is hypokinesis of the midpapillary anterior segment
with left ventricular systolic dysfunction with 45%. 3. Right
ventricular chamber size and free wall motion are normal. 4. The
ascending, transverse and descending thoracic aorta are normal
in diameter and free of atherosclerotic plaque. 5. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion. 6. The mitral valve leaflets are structurally normal.
Trivial mitral regurgitation is seen. POSTBYPASS: 1. Patient is
on phenylephrine infusion. 2. The anterior midpapillary segment
has improved function, EF is now 60%. 3. Mitral regurgitation is
unchanged.
[**2153-10-23**] 02:21PM WBC-12.5*# RBC-2.59*# HGB-8.2*# HCT-23.0*#
MCV-89 MCH-31.6 MCHC-35.4* RDW-12.5
[**2153-10-23**] 02:21PM PLT COUNT-247
[**2153-10-23**] 02:21PM PT-16.6* PTT-38.2* INR(PT)-1.5*
[**2153-10-23**] 02:21PM GLUCOSE-126* LACTATE-2.6* NA+-135 K+-3.4*
CL--104
[**2153-10-26**] 05:32AM BLOOD WBC-11.5* RBC-2.71* Hgb-9.0* Hct-24.7*
MCV-91 MCH-33.2* MCHC-36.4* RDW-13.6 Plt Ct-220
[**2153-10-26**] 05:32AM BLOOD Plt Ct-220
[**2153-10-26**] 05:32AM BLOOD Glucose-97 UreaN-9 Creat-0.6 Na-135 K-4.0
Cl-101 HCO3-30 AnGap-8
[**Hospital 93**] MEDICAL CONDITION:
49 year old woman with
REASON FOR THIS EXAMINATION:
s/p cabg falling hct, Is there a hemothorax.
Final Report
INDICATION: Status post CABG, decreasing hematocrit. Left
pneumothorax.
COMPARISON: [**2153-10-24**].
PORTABLE CHEST RADIOGRAPH: Right-sided central venous sheath and
mediastinal
wires are in unchanged position. Cardiac and mediastinal
contours appear
unchanged. Increasing bibasilar atelectasis is present. Lung
volumes are
lower compared to prior study. Possible small bilateral pleural
effusions are
identified; however, there is no evidence of large hemothorax.
IMPRESSION: Increasing bibasilar atelectasis. Possible small
bilateral
pleural effusions; however, no evidence of large hemothorax.
[**2153-10-28**] 06:55AM BLOOD WBC-10.1 RBC-3.34* Hgb-10.7* Hct-31.0*
MCV-93 MCH-32.2* MCHC-34.7 RDW-13.7 Plt Ct-404#
[**2153-10-23**] 02:21PM BLOOD WBC-12.5*# RBC-2.59*# Hgb-8.2*#
Hct-23.0*# MCV-89 MCH-31.6 MCHC-35.4* RDW-12.5 Plt Ct-247
[**2153-10-28**] 06:55AM BLOOD Glucose-90 UreaN-8 Creat-0.6 Na-135 K-4.5
Cl-101 HCO3-27 AnGap-12
[**2153-10-24**] 03:08AM BLOOD Glucose-92 UreaN-10 Creat-0.6 Na-136
K-3.4 Cl-106 HCO3-24 AnGap-9
Brief Hospital Course:
Ms. [**Known lastname 78888**] was a same day admit after undergoing pre-operative
evaluation for her cardiac cath on [**10-15**]. On [**10-23**] she was brought
directly to the operating room where she underwent a coronary
artery bypass graft x 2. Please see operative report for
surgical details. Following surgery she was transferred to the
CVICU in stable condition for invasive monitoring. She did well
in the immediate post-op period, was weaned from sedation, awoke
neurologically intact and extubated. She remained
hemodynamicaaly stable and on POD1 was transferred to the step
down floor for continued post-operative care/recovery. Once on
the floor she had an uneventful post-operative course and was
discharged home with visiting nurses on POD 6.
Medications on Admission:
HCTZ 25mg qd, Lisinopril 5mg qd, Aspirin 81mg qd, Vit E, C, and
B, Propanolol 40mg [**Hospital1 **]
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. 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*
4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
Disp:*270 Tablet(s)* Refills:*0*
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
3 days.
Disp:*3 Tablet(s)* Refills:*0*
7. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two
(2) Tablet Sustained Release PO once a day for 3 days.
Disp:*6 Tablet Sustained Release(s)* Refills:*0*
8. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q6H (every 6 hours) as needed.
Disp:*1 1* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x
2(LIMA to LAD, SVG to OM)[**10-23**]
PMH: Hypertension, Anxiety
Discharge Condition:
Good
Discharge Instructions:
shower daily , no baths or swimming
no lotion, creams, or powders on any incision
no driving for one month and until off all narcotics
no lifting greater than 10 pounds for 10 weeks
call for fever greater than 100.5, redness, or drainage of
incisions
take all medications as directed
Followup Instructions:
[**Hospital 409**] clinic in 2 weeks
Dr. [**Last Name (STitle) **] in 4 weeks
Dr. [**First Name (STitle) **] in [**1-24**] weeks
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2153-11-28**]
9:00
Completed by:[**2153-10-29**]
ICD9 Codes: 2851, 4019, 2768 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3657
} | Medical Text: Admission Date: [**2199-1-2**] Discharge Date: [**2199-1-14**]
Date of Birth: [**2143-1-9**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1943**]
Chief Complaint:
Lethargy, severe ulceration of pannus on right side
Major Surgical or Invasive Procedure:
Skin [**First Name3 (LF) **] debridement by plastic surgery service
History of Present Illness:
[**Known firstname 803**] [**Known lastname 60400**] is a 55 year old morbidly obese woman who was
lost to medical care who was taken to [**Hospital3 **] ED when her
son called 911 due to concern over her recent decline in mental
status and mobility. Per son, she had been depressed the last
several months and then bedbound the last 3.5 weeks secondary to
fatigue. She had complained of chronic SOB but no other
localizing symptoms. Her son and sister tried to care for her
and encouraged her to go to ED but she refused secondary to
embarassment. Her son also [**Name2 (NI) 86727**] decreased PO intake the last
several days and confusion on day of admission. They gave her
two weeks to try ambulating on her own but when she remained
bedbound yesterday, called 911. After being removed from her
trailer, she was initially taken to [**Hospital3 **] and noted to
have necrotic pannus ulcers so was transferred to [**Hospital1 18**] for
plastic surgery evaluation for debridement and possible skin
grafts. Prior to transfer, a triple lumen power PICC was placed
and she was given flagyl and unasyn.
In our ED, initial vs were: T 97.1 HR 102 BP 96/40 RR18 SaO2%96.
She was noted to drop her oxygen saturations with movement and
transport so was placed on NRB but sats later 95%RA. She was
seen by plastics and had wounds debrided which were noted to be
foul-smelling but did not appear infected. She was given
morphine 4mg IV x 3 and vancomycin 1g IV. She had an isolated
drop in BP 55/32 with morphine which responded to IVF. ABG drawn
for labs and reportedly mixed venous and arterial and blood cx
drawn. She received 4L NS. VS prior to transfer: 124/62 101 18
100%2L
On the floor, reports fatigue and not feeling well but denies
fevers, chills, N/V/D, abdominal pain, SOB, chest pain.
Past Medical History:
Hypertension
Morbid obesity
Social History:
Lives alone in trailer. Has son [**Name (NI) **]. Denies ETOH use and
quit tobacco 1 year ago. Smoked x 30 years. Used to work in
retail ([**Company **]) but now on disability. Has dog. Her sister
[**Name (NI) **] [**Name (NI) 68224**] ([**Telephone/Fax (1) 86728**]-Home; [**Telephone/Fax (1) 86729**]-Work) is also
involved.
Family History:
None stated.
Physical Exam:
Vitals: T: 124/62 101 18 100%2L
General: Somnolent but arousable, slightly tachypneic and easily
agitated, no acute distress, morbidly obese
HEENT: Sclera anicteric, MM very dry, oropharynx with dried
exudate
Neck: supple, unable to assess JVP
Lungs: Distant breath sounds. Clear to auscultation anteriorly
CV: Regular rate and rhythm, normal S1, fixed split S2, no
murmurs, rubs, gallops
Abdomen: soft, obese, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly.
GU: foley in place
Ext: warm, [**11-24**]+ edema B/L with chronic vensou stasis changes, 1+
pulses, no clubbing, cyanosis
Skin: Right pannus and groin/thigh ulcers with foul smelling,
purulent exudate and erythema; dsg with serosanguinous drainage.
No eschars noted.
Neuro: Somnolent but arousable. Initially not oriented (unsure
where she was and stated month was [**Month (only) **] but later oriented
to [**Location (un) 86**] and year [**2198**]). Perseverating on asking for water and
complaining of thirst. Unable to relate accurate history. MAE.
Normal muscle bulk and tone. CN grossly intact
Exam on transfer to floor:
VSS, afebrile, normotensive
alert, oriented to self, [**Hospital1 18**], month and year, not always day
of week. Not able to relay all the recent events but able to
converse with staff and family, frequently tearful with family
CV and lung exam unchanged
Skin: right pannus and groin thigh ulcers without any obvious
purulence, full thickness ulcers with exposed adipose tissue,
some areas necrotic alternating with pink tissue
Exam on discharge:
Tmax 98.9 BP 139/76 HR 80 RR 20 O2 93%-96% on Room Air
Alert, anxious about transfer to another facility
RRR
CTAB
Abdomen soft and nontender except for tender skin around ulcers
Pannus with large ulceration, no surrounding erythema, no
purulence
G/U: White chunky discharge from vagina (pt denies vaginal
itching)
Pertinent Results:
[**2199-1-2**]
BLOOD WBC-22.0* Hgb-12.8 Hct-41.0 MCV-97 RDW-13.9 Plt Ct-716*
Neuts-81.9* Bands-0 Lymphs-9.3* Monos-8.5 Eos-0.3 Baso-3.2*
Glu-163* UreaN-103* Creat-1.8* Na-130* K-4.7 Cl-94* HCO3-15*
AnGap-26*
ALT-33 AST-59* CK(CPK)-[**2217**]* AlkPhos-86 TotBili-0.6
ALBUMIN 2.3
%HbA1c-6.7* eAG-146*
TSH-0.68
[**2199-1-13**] PT: 26.5 PTT: 73.9 INR: 2.6
[**2199-1-14**] PT-45.4* INR(PT)-4.9*
CXR [**2199-1-3**]:
IMPRESSION: Enlarged left pulmonary artery, of indeterminant
chronicity. If this is a new finding it could reflect recent
pulmonary emboli.No evidence of pneumonia. Findings were
discussed with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at the time of approval.
ECHO [**2199-1-4**]:
The left atrium is mildly dilated. There is moderate symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Left ventricular systolic function is hyperdynamic
(EF 70-80%). The right ventricular free wall is hypertrophied.
The right ventricular cavity is dilated with normal free wall
contractility. The aortic root is moderately dilated at the
sinus level. The aortic valve leaflets are mildly thickened
(?#). There is no aortic valve stenosis. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. There is zt least
moderate pulmonary artery systolic hypertension.
IMPRESSION: Suboptimal image quality. Dilated right ventricle;
moderate (or more) pulmonary hypertension
RUE U/S
IMPRESSION: Extensive right upper extremity deep venous thrombus
extending
from the right subclavian vein to the right axillary and the
duplicated
brachial veins. Occlusive thrombus within the right basilic
vein.
Bilateral LE U/S
IMPRESSION: Nondiagnostic examination of lower extremity veins
due to
patient's body habitus and discomfort during the exam. Normal
color flow
within the right common femoral vein.
Brief Hospital Course:
55 year old female with morbid obesity and hypertension admitted
to [**Hospital Unit Name 153**] with transient hypotension, lethargy and pressure ulcers
now s/p debridement by plastics. Patient transiently hypotensive
in ED after morphine but remainder of SBPs in 110s-120s so
likely related to morphine as well as significant component of
dehydration by labs and exam. After IVF boluses pt remained free
of hypotension for the remainder of stay. Pt ruled out for MI.
PROBLEM LIST:
# Severe ulcerations: See detailed assessment and
recommendations below.
# RUE DVT in the presence of power PICC line, removed on [**1-10**].
Bridged with heparin gtt until INR>2. Coumadin 5mg given daily.
[**1-13**] INR 2.6, [**1-14**] INR 4.9. Coumadin held on [**2199-1-14**].
Recommend trending INR at LTAC and resuming Coumadin when
appropriate for a goal INR [**12-26**].
# Hypokalemia: KCl repleted orally, usually 40 mEq daily.
# Hypophosphatemia: Supplemental Neutrophos
# Vaginal candidiasis: Vaginal discharge noted on exam [**2199-1-14**]:
Patient without complaint for vaginal itching or discomfort.
Given one dose of fluconazole 200mg for candidiasis.
# Pulmonary HTN: seen on Echo, not previously known, pt may have
sleep apnea due to habitus but this has not yet been worked up.
Given that patient has a DVT as well, should consider PE if
condition worsens.
- Will need outpt follow-up sleep study
- Outpatient pulmonary hypertension workup.
# Depression, psychiatric, social situation: psychiatry
consulted for pt's anxiety and depression, started on celexa
which has now been titrated to 20 mg daily. SW for concern
about social situation, concern that she was immobile in home
for prolonged period at home and was not able to seek or obtain
proper care.
# SVT: Pt had an episode of SVT in ICU, reportedly brief run.
Now on metoprolol. Pt has had no further episodes of SVT
# HTN: currently normotensive, on metoprolol (for episode of
SVT)
# Recent acute renal failure: Cr elevated on admission, likely
prerenal +/- rhabo, urine lytes in ICU were consistent with
prerenal. Now resolved after hydration
#Glucose intolerance with mild elevated HgBa1c 6.7. Pt does not
know of a prior history of DM.
# Altered mental status: appeared altered and delirious on
presentation but this has resolved after treatment of infection.
TSH and B12 wnl
# PCP: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] in [**Location (un) **] - she has never seen this physician
but he took over the practice of her prior PCP who retired.
[**Name (NI) 1094**] sister said that Dr. [**First Name (STitle) **] would be willing to assume her
care when she is an outpt
# Communication: Patient, son [**Name (NI) **] [**Telephone/Fax (1) 86730**]. Also
has a sister [**Name (NI) **] [**Name (NI) 68224**] who is involved
([**Telephone/Fax (1) 86728**]-Home, [**Telephone/Fax (1) 86729**]-Work)
# Stage 4 Pressure Ulcers and panniculitis: Patient appears to
have developed severe pressure ulcers from large pannus and
immobility. Unasyn and vancomycin (started on [**2199-1-2**]) given
severe skin findings, leukocytosis and no other obvious source.
Vancomycin was discontinued on [**2199-1-8**] and Unasyn was continued
until further discussion with plastics, at which point it was
decided that she no longer appeared to have active infeciton.
Unasyn discontinued on [**2199-1-10**]. There was some initial concern
for possible deeper penetration of the ulcers, however pt would
be unable to fit in CT scanner and morevoer would not be an
operative candidate for deeper [**Date Range **] debridement in the
operating room. Plastic Surgery performed bedside debridement on
[**1-4**] and [**1-8**], [**1-11**], and [**1-14**].
- Continue foley and rectal tube to maintain clean [**Month/Year (2) **]
- Bowel regimen to maintain functioning rectal tube
- Vitamin C, Zinc
- Pain control with scheduled oxycodone and prn morphine before
dressing changes
- F/u with Plastics as outpatient (many on their team are
familiar with her care including Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **])
Here is the [**Last Name (NamePattern1) **] assessment by Surgery:
[**Last Name (NamePattern1) **] ASSESSMENT on [**2199-1-14**]:
Pannus: full-thickness ulcer: irregular, 30 x 26 cm, 10% black
necrotic tissue, 30 % yellow tissue, 60 % beefy red
granulation,large amount yellow exudate, no odor, edges
irregular
and attached, periwound skin intact, darker pigmentation changes
related to old injury, induration present, no fluctuance.
Right lateral thigh ulcer: full-thickness, irregular 10x14 cm,
80% yellow tissue, 20% beefy red granulation buds present, edges
attached, no odor, small yellow exudate, peri [**Date Range **] skin intact,
dry, no induration or fluctuance.
Proximal right thigh ulcer: 9x7cm, irregular, 90% beefy red
granulation, 10% yellow tissue, small yellow exudate, no odor,
edges attached, peri [**Date Range **] skin, no induration or fluctuance.
Lateral pannus ulcer: two small stage III, 3 x 1 cm, 1 x 0.5 cm,
90% pink, 10% yellow, edges attached, small yellow exudate, no
odor, peri [**Date Range **] intact, no fluctuance.
Perineum: Resolving perineal dermatitis from stooling, and
increase moisture. Much improved.
Patient premedicated with pain medication for sharp debridement
of pannus and right lateral thigh [**Date Range **]. Tolerate procedure
well.
Debridement every other day, much improved since admission to
[**Hospital1 18**].
Mid-pannus: large area of cellulitic skin, which has been marked
with marking pen, skin intact, no induration or fluctuance,
bears
watching.
Intergluteal ulcer: small linear stage II, related to
friction/shearing, stripping of epidermis, bed is pink, edges
macerated, no drainage.
Goals of [**Hospital1 **] care:Prevent Infection, Pressue Redistribution,
Decrease bacterial bio burden [**Hospital1 **] beds, sharp debridement,
healing by secondary intention.
[**Hospital1 **] CARE RECOMMENDATIONS on [**2199-1-14**]:
Pressure relief per pressure ulcer guidelines
Support surface Mighty Air
Lift system for positioning and OOB.
Turn and reposition every 1-2 hours off back
Heels off bed surface at all times Waffles
If OOB, limit sit time to one hour at a time and sit on a
pressure relief cushion Bariatric cushion
Elevate LE's while sitting.
Moisturize B/L LE's and feet [**Hospital1 **] with Aloe Vesta ointment.
Commercial [**Hospital1 **] cleanser all open wounds.
Pat the tissue dry with dry gauze.
D/C 1/4 strength Dakins.
Pannus Ulcer: pack loosely with wet to dry normal saline
Kerlix.
Protect peri [**Hospital1 **] skin with critic-aid antifungal ointment.
Cover with large Soft sorb dressings, and place [**Doctor First Name **] binder
to secure dressing. Dressing change [**Hospital1 **].
Right medial thigh ulcer: Apply no-sting barrier wipe peri
[**Hospital1 **]
skin. Pack loosely with wet to dry normal saline Kerlix
dressing. Cover with Soft sorb dressing, secure with Medipore
tape. Change [**Hospital1 **].
Right lateral thigh ulcer: apply Xeroform dressing to [**Hospital1 **]
bed,
apply no-sting barrier wipe Cavilon to peri [**Hospital1 **] skin, cover
[**Hospital1 **] with 4x4's, soft sorb, and secure with Medipore tape.
Change daily.
Right proximal thigh ulcers: Apply no-sting barrier wipe to
peri
[**Hospital1 **] skin. Apply small amount of DuoDerm [**Hospital1 **] gel to each
[**Hospital1 **] bed. Cover with 4x4 Mepilex dressing. Change every 3rd
day.
Perineum: Cleanse skin with Aloe Vesta foam cleanser. Pat dry.
Apply critic-aid antifungal to area. Re-apply after each 3rd
cleansing.
Intergluteal ulcer: apply critic-aid clear skin barrier
ointment daily, re-apply after each 3rd cleansing.
Separate pannus with large folded sheet, to prevent skin
against skin.
Nutritional consult - albumin 2.3
Support nutrition and hydration.
Notify MD [**First Name (Titles) **] [**Last Name (Titles) **] care nurse [**First Name (Titles) **] [**Last Name (Titles) **] or skin deteriorates.
Medications on Admission:
None
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Potassium & Sodium Phosphates 280-160-250 mg Powder in Packet
Sig: One (1) Powder in Packet PO TID (3 times a day).
6. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
10. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Sodium Hypochlorite 0.5 % Solution Sig: One (1) Appl
Miscellaneous [**Hospital1 **] (2 times a day).
12. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day) as needed for pain.
13. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
14. Morphine 100 mg/4 mL Solution Sig: 4-6 mg Intravenous Q4H
(every 4 hours) as needed for pain >[**7-2**] or [**Month/Year (2) **] care/turning.
15. Outpatient Lab Work
Please check Chem 10, CBC, and INR daily.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] [**Location (un) 1456**]
Discharge Diagnosis:
Stage 4 pressure ulcers - abdominal wall, right groin, right hip
Panniculitis, cellulitis
Morbid obesity
Right upper extremity deep vein thrombosis
Hyperkalemia
Hyperphosphatemia
Hypertension
Vaginal candidiasis
Depression
Pulmonary hypertension
Supraventricular tachycardia
Discharge Condition:
Mental Status: Alert and oriented x 3
Ambulatory status: Bedridden given large body habitus
Tolerating regular diet
Discharge Instructions:
You will be going to a facility which will provide continued
care for your ulcer wounds. Please follow-up with plastics
surgery.
When you are well enough to leave the facility (or if this can
be arranged there), we recommend that you undergo a sleep study
to determine if you might have sleep apnea. We also found you
to have Pulmonary Hypertension and this should be re-evaluated
as well.
Followup Instructions:
Your facility will continue to provide appropriate [**Location (un) **] care
and debridement as needed. The facility should also assist you
in arranging a follow-up appointment in plastics surgery clinic
with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 9144**] or one of his associates
You have informed us that your prior PCP has retired but that
his colleague Dr. [**First Name (STitle) **] would be willing to be your new PCP.
[**Name10 (NameIs) 357**] schedule an appointment with him when you have left the
facility:
[**First Name11 (Name Pattern1) 4768**] [**Last Name (NamePattern1) 86731**], M.D.
[**Location (un) 86732**], [**Numeric Identifier 73722**]
([**Telephone/Fax (1) 86733**]
ICD9 Codes: 5849, 2762, 2761, 2930, 4019, 4168, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3658
} | Medical Text: Admission Date: [**2115-6-13**] Discharge Date: [**2115-6-18**]
Date of Birth: [**2059-7-10**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Respiratory distress
Major Surgical or Invasive Procedure:
Intubation/extubation
Chest tube placement
History of Present Illness:
History of Present Illness: 55 y/o male with COPD (not on home
oxygen) and EtOH cirrhosis who came to [**Hospital3 3583**] 2 weeks
ago with a report of increased shortness of breath. He was
diagnosed with LLL pneumonia, left pleural effusion, and small
nodule in the RLL. Pulmonary was consulted and recommended a
thoracentesis and bronchoscopy. He declined these procedures. He
was discharged on PO levofloxacin.
.
He completed 5 days of therapy, but then developed cough,
worsening sputum production, and increasing dyspnea. He had a
repeat CT scan of the chest which confirmed dramatic progression
of disease when compared to prior CT scan of [**5-29**]. There was a
large loculated pleural effusion on the left c/w possible
empyema. There is extensive atelectasis in the residual left
lung apex where there are cavitary or emphysematous changes.
Left main stem bronchus is no longer visible and occluded. There
are diffuse infiltrates throughout the R lung and small R
pleural effusion, ascites, cirrhosis, and enlarged spleen.
.
Prior to transfer, patient received vancomycin and zosyn, and
flagyl.
.
Vitals on transfer were: HR 64, BP 138/72, 92% on 50% FIO2.
.
On the floor, patient reports that he is mildly uncomfortable
with breathing. He denies fevers. Reports cough with greenish
phlegm. Denies chest pain.
.
Review of systems:
(+) Per HPI. Also reports 8 lb weight loss in 1 mo.
Past Medical History:
-EtOH cirrhosis
-COPD
-HTN
Social History:
married. Resides in a single family home. Currently retired.
Denies tobacco, EtOH, or illicts currently.
- Tobacco: 40 pack year history of smoking, quit 2 weeks ago.
- Alcohol: quit 6years ago
- Illicits: denies
Family History:
Father and mother passed away in their 50s from cancer
Physical Exam:
Physical Exam on Admission:
Vitals: T: 95.9 BP: 114/70 P: 86 R: 24 O2: 93% on 50% ventimask
General: Alert, pleasant, oriented, mild respiratory distress
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: no tracheal shift, significantly diminished air movement
at left lung, dullness to percussion, rhonchi and crackles at
left side. Right side with more air movement, but intermittent
rhonchi and decreased BS at base.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
LABS ON ADMISSION
WBC-22.9* RBC-4.07* Hgb-12.0* Hct-35.3* Plt Ct-69*
Neuts-96* Bands-0 Lymphs-0 Monos-4 Eos-0 Baso-0 Atyps-0 Metas-0
Myelos-0
PT-15.8* PTT-32.6 INR(PT)-1.4*
Glucose-80 UreaN-19 Creat-0.7 Na-128* K-4.7 Cl-93* HCO3-24
AnGap-16
-27 AST-62* LD(LDH)-691* AlkPhos-203* TotBili-2.1*
Albumin-2.6* Calcium-10.2 Phos-2.9 Mg-2.3 Iron-39*
calTIBC-282 Ferritn-482* TRF-217
ART pO2-60* pCO2-39 pH-7.47* calTCO2-29 Base XS-4 Intubat-NOT
INTUBA
CXR [**2115-6-13**]
Current study demonstrates complete opacification of the left
hemithorax with minimal lucency noted at the left apex. These
findings are highly concerning for a combination of large
pleural effusion and atelectasis giving the absence of the right
mediastinal shift. Central obstruction with significant
atelectasis are suspected. On the right, there is small amount
of pleural effusion, partially imaged and potentially loculated
(note is made that the right costophrenic angle was not included
in the field of view). In addition, there is right lower lobe
opacity as well as vascular prominence and questionable right
upper lobe opacities. Although the vascular engorgement may be
physiologic, reflecting the constriction of the vascularity in
the left hemithorax, it can represent volume overload
CT CHEST W/ CONTRAST IMPRESSION:
1. Moderate residual hydropneumothorax with split pleura sign
suggesting
empyema, which could be confirmed by examination of pleural
fluid characteristics.
2. Left apical cavitary lesion with an intraluminal rounded
opacity suggests mycetoma or semi-invasive aspergillus.
3. Complete collapse of the left lower lobe bronchus and
expanded left lower lobe with low attenuation suggests drowned
lung.
4. Right lower lobe consolidative peribronchobronchovascular
mass with
vascular attenuation and associated right hilar adenopathy
concerning for
neoplasm or aggressive fungal infection. Bronchoscopy should be
considered. Otherwise, CT follow up after treatment of acute
symptoms is recommended.
5. Multiple lytic bone lesions in the sternum, scapula and
vertebral bodies may represent multiple myeloma versus
metastatic disease.
6. Diffuse ground-glass opacity in the bilateral upper lobes
could be related to multifocal infection or aspiration.
7. Small nonhemorrhagic right pleural effusion and pericardial
effusion.
8. Cirrhosis and at least small to moderate ascites.
Brief Hospital Course:
53yo male with COPD and EtOH cirrhosis presenting with worsening
SOB and loculated pleural effusion concerning for empyema from
OSH.
# Hypoxemic respiratory failure: On presentation patient's
respiratory distress appeared to be related to the OSH diagnosed
pneumonia and likely parapneumonic effusion or empyema. CXR
showed nearly complete white-out of the L lung and OSH CT chest
showed large loculated pleural effusion on the left with
extensive atelectasis in the residual left lung apex, and
occluded left mainstem bronchus.
He was started on vancomycin, cefepime, and flagyl as he has not
improved with levofloxacin monotherapy from OSH and considered
he may have anaerobic infection.
The patients COPD seemed to play a minimal role in his
respiratory distress. There was no evidence of chronic CO2
retention per review of ABG or chemistry. Interventional
Pulmonary performed a thoracentesis. And patient showed
symptomatic improvement. Cytology revealed very abnormal cells
concerning for malignancy but cell block was required for
definite diagnosis. He also had a CT Chest which showed RLL
consolidative mass with right hilar adenopathy concerning for
neoplasm, a consolidation of the LLL with complete collapse of
the LLL bronchus, and multiple lytic bone lesions in the
sternum, scapula and vertebral bodies which suggested a
metastatic process.
Patient was maintaining adequate oxygenation on a venti mask. On
HD2 patient became tachypnic and tachycardic and required
intubation. The family was informed of the high likelihood the
patient had metastatic lung cancer and the dismal prognosis.
They stated that his wishes would be consistent with being made
CMO. However, they wanted family members to have the opportunity
to come and visit with him. On HD4 patient was noted to have
cyanotic right foot, bleeding from IV sites and lab work
consistent with a diagnosis of DIC. On HD5 his family was able
to come see him and he was made CMO. He was pronounced dead at
5:35pm on [**2115-6-18**].
Medications on Admission:
-aldactone 25 mg daily
-potassium chloride
-metoprolol 25 mg daily
-lasix 40 mg daily
-albuterol 2 puffs qid prn
Discharge Medications:
N/a
Discharge Disposition:
Expired
Discharge Diagnosis:
Respiratory failure from suspected lung cancer
Discharge Condition:
Expired
Discharge Instructions:
N/a
Followup Instructions:
N/a
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2115-6-18**]
ICD9 Codes: 486, 2761, 5849, 5119, 496, 2875, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3659
} | Medical Text: Admission Date: [**2104-1-2**] Discharge Date: [**2104-1-18**]
Service: CARDIOTHORACIC
CHIEF COMPLAINT: Dyspnea on exertion.
HISTORY OF PRESENT ILLNESS: This is a pleasant 82 year-old
man with coronary artery disease status post myocardial
infarction 26 years ago and a cerebrovascular accident in
[**3-/2102**] without any residual symptoms who presented to CT
Surgery clinic one week prior to admission with complaints of
increased fatigue and dyspnea on exertion accompanied by some
chest tightness over the past six months. In [**2103-11-7**] an
exercise tolerance test was significant for moderate
reversible defect of the apical and basilar lateral walls and
severe reversible inferior wall filling defect. A cardiac
catheterization from [**2103-12-14**] revealed a left main coronary
artery stenosis of 70%, 70% stenosis of the main left
anterior descending coronary artery with an 80% lesion in the
major diagonal and 100% occlusion of the right coronary
artery. Mild disease within the left circumflex. In
addition the catheterization revealed an ejection fraction of
approximately 23%, which confirmed a prior echocardiogram
from [**3-/2102**], which showed an ejection fraction of 25%, but
otherwise not showing any significant valvular problems.
PAST MEDICAL HISTORY:
1. Coronary artery disease status post myocardial infarction
26 years ago.
2. Status post cerebrovascular accident 2/[**2102**].
3. Umbilical hernia.
He has no hypertension, no increased cholesterol and no
diabetes.
PAST SURGICAL HISTORY: Tonsillectomy.
MEDICATIONS AT HOME:
1. Lasix 81 mg a day.
2. Lasix 10 mg once a day.
3. Zestril 5 mg in the morning and 2.5 mg in the evening.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: He use to be an accountant. He never smoked
cigarettes. He never drank. He lives with his wife in
[**Name (NI) **] who is restricted to a wheel chair. In addition,
he played competitive hockey and tennis until his mid 70s.
REVIEW OF SYSTEMS: General feeling of fatigue and shortness
of breath. He does report having worsening vision and he has
vision. He does have some chest tightness on exertion and
occasional dry cough. He has normal bowel movements with no
bright red blood per rectum. No dysphagia. He does have
increased urinary frequency. No arthritis. No claudication.
No neurological or psychiatric problems.
PHYSICAL EXAMINATION: He is afebrile weighing 240 pounds.
Heart rate of 60. Blood pressure 140/80. Well developed
male in no acute distress. Head and neck his mucous
membranes are moist with no JVD, or lymphadenopathy. He does
have bilateral carotid bruits. Chest is clear to
auscultation bilaterally. Heart regular rate and rhythm with
some skipped beats. S1 and S2. No murmurs. Abdomen is
obese with an obvious umbilical hernia, soft, nontender,
nondistended. Extremities are warm with slight lower
extremity edema and some slight lower extremity color changes
of his legs. Pulses are 2+ and equal bilaterally.
Neurological examination he is grossly intact. No motor or
sensory deficits.
HOSPITAL COURSE: This man is noted to have three vessel
coronary artery disease and he was scheduled for an elective
coronary artery bypass graft on [**2104-1-2**]. A further
preoperative workup before this was a carotid ultrasound,
which revealed an 80 to 90% stenosis of the right internal
carotid artery and on the left a 40% internal carotid artery
stenosis. After he was appropriately consented he came to
[**Hospital1 69**] for his elective
coronary artery bypass graft procedure on [**2104-1-2**]. Once
consent was confirmed and the patient was identified he was
brought to the Operating Room for a coronary artery bypass
graft. Please refer to the previously dictated operative
note of [**2104-1-2**] by Dr. [**Last Name (STitle) 1537**]. In brief a four vessel
bypass was performed. The left internal mammary coronary
artery was brought down to the left anterior descending
coronary artery and saphenous vein grafts were connected via
the aorta to the posterior descending coronary artery, obtuse
marginal one and diagonal number two. He was on
cardiopulmonary bypass for 130 minutes and the aorta was
cross clamped for 118 minutes. He was sent intubated to the
Intensive Care Unit on Propofol and Levophed drips and
otherwise in very good condition.
Postoperatively in the Intensive Care Unit the patient's
issues revolved around extubation. He was extubated on the
morning of postoperative day one without complication. He
also required hemodynamic monitoring and blood pressure
stabilization with Levophed for the first couple of days. In
addition, he was also significantly agitated throughout his
Intensive Care Unit stay and required several doses of Haldol
to calm him. His last major Intensive Care Unit issue was
recurrent rapid atrial fibrillation, which was treated
initially with Lopressor to control his rate and with an
Amiodarone drip and then po Amiodarone. He tolerated this
well and returned to [**Location 213**] sinus rhythm. On postoperative
day five the patient was transferred to the floor in good
condition, although he was still in a somewhat confused
state. Over the next few days he remained confused and a
neurological consult was obtained to ascertain whether or not
there could be some pathology for his continued confusion.
An MR of the head was obtaiend on [**2104-1-8**], which revealed
several watershed infarcts that were described as acute in
age with an age of no more then one week. These
perioperative strokes were to old to be treated and managed
basically conservatively. His symptoms at this time included
dysarthria, confusion and those were his major issues.
Following identification of having a stroke the patient was
put on swallowing precautions. He was fed Enterally with
Dobbhoff tube feeds for several days. He received a swallow
study on [**2104-1-14**], which revealed that the patient could
swallow and was not an aspiration risk. He was brought back
to a regular pureed diet. His postoperative course was
otherwise unremarkable except for a urinary tract infection
and some urinary retention, which occurred on [**1-14**] and [**1-15**].
E-coli eventually grew out in the urine culture and he was
treated with Levofloxacin. He intermittently needed a Foley
catheter for his urinary retention. Finally the patient did
require a sitter for most of his floor stay until
approximately two days prior to discharge when the patient
was noted to be coherent enough to not become overly
agitated. On this day he is being discharged to [**Hospital **]
rehab facility on [**2104-1-18**] in good condition.
DISCHARGE DIAGNOSES:
1. Coronary artery disease status post myocardial
infarction. Status post coronary artery bypass graft.
2. Postoperative delirium.
3. Postoperative atelectasis.
4. Postoperative pneumothorax.
5. Perioperative stroke.
6. Atrial fibrillation.
7. Urinary tract infection.
8. Acute renal failure.
9. Benign prostatic hypertrophy.
10. Umbilical hernia.
DISCHARGE MEDICATIONS:
1. Lopressor 150 mg po b.i.d.
2. Warfarin 1 mg po q.d. to maintain an INR fro 1.5 to 2.0.
3. Levofloxacin 500 mg po q.d. for one week.
4. Aspirin 81 mg po q.d.
5. Zantac 150 mg po b.i.d.
6. Tylenol 650 mg po q 4 as needed for fever or pain.
7. Atrovent and Albuterol nebulizer treatments q 6.
8. Colace 100 mg po b.i.d.
9. Dulcolax 10 mg pr b.i.d. prn constipation.
10. Milk of Magnesia 30 milliliters po q.h.s. prn
constipation.
11. Haldol 2 mg intravenously t.i.d. prn agitation.
12. Zofran 2 to 4 mg every 6 hours prn nausea.
13. Sliding scale insulin.
FOLLOW UP: Follow up with Dr. [**Last Name (STitle) 1537**] his cardiologist in one
to two weeks and Dr. [**Last Name (STitle) 1537**] CT surgeon in about one month.
Please follow up with his primary care physician.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 45152**]
MEDQUIST36
D: [**2104-1-18**] 09:08
T: [**2104-1-18**] 09:11
JOB#: [**Job Number 98481**]
ICD9 Codes: 5990, 5180, 5849, 4271 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3660
} | Medical Text: Admission Date: [**2132-8-19**] Discharge Date: [**2132-8-25**]
Date of Birth: [**2066-4-25**] Sex: M
Service: MEDICINE
Allergies:
Coumadin
Attending:[**Last Name (NamePattern1) 1171**]
Chief Complaint:
Left leg and scrotal swelling
Major Surgical or Invasive Procedure:
pericardial drain placement, [**2132-8-19**]
History of Present Illness:
66 initially presenting with left leg and scrotal swelling.
Referred in by PCP for concern for ARF vs IVC clot. Of note is
s/p LKR on [**2132-7-10**]. Has noted increased fluid retention over
the past few weeks with an approximately 13lb weight gain,
swelling in abd, scrotum and LE. Denies recent viral illness,
fevers, new medications, chest pain, foamy urine, rash. Does
have mild DOE, climbing a steep [**Doctor Last Name **] in front of his house
slightly more difficult that prior. No PND or orthopnea. No
confusion, blurred vision/double vision, numbness, tingling or
weakness. Had hyponatremia 120 on initial labs, normal cr.
States his wife thinks he drinks to much water, reports drinking
~1 gallon water per day.
Slight transaminitis noted on initial labs. CTV done to eval for
thrombosis, not ideal timing of contrast to establish presence
of IVC clot, incidentally a large pericardial effusion, free
fluid in abdomen and pleural effusions were found. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 679**]
concerned about tamponade, requesting ICU admission. Initial VS
in triage 96.5 100 132/93 20 100% RA. BP noted to be trending
down in ed to high 90s. Cards consulted in ED. TTE without
tamponade physiology, large RA/RV, raised ? of PE. Pt underwent
CTA which was negative for PE or aortic dissecction but showed
persistent pericardial effusion and b/l pleural effusions.
Given a total 1 1L NS in ED.
Past Medical History:
Benign lesion removed from his right breast [**2125**]
s/p 3 knee surgeries, LTR [**2132-7-20**]
Normal stress test in [**2127**]
HL (His LDL was over 150 before medication)
Pre-malignant skin lesions
Tendonitis (he is on disability from the
military due to the tendonitis)
HTN
Social History:
Retired IRS attorney. Now runs own business as CPA/tax lawyer.
Lives with wife. 2 grown children. [**Country 3992**] veteran. No h/o
incarceration or known TB exposures. No IVDU. Very distant
smoking history. 2 glasses wine/day.
Family History:
He has a strong family history of coronary artery disease.
Father d. fatal MI age 51.
Physical Exam:
Vitals: T:95.5 BP:128/99 P: 95 R: 13 SaO2: 99% Ra
General: Awake, alert, NAD, pleasant, appropriate, cooperative.
HEENT: NCAT, PERRL, EOMI, no scleral icterus, MMM, no lesions
noted in OP
Neck: supple, no significant JVD or carotid bruits appreciated
Pulmonary: Lungs CTA bilaterally, no wheezes, ronchi or rales
Cardiac: RR, nl S1 S2, no murmurs, rubs or gallops appreciated
Abdomen: soft, NT, ND, normoactive bowel sounds, no masses or
organomegaly noted
Extremities: No edema, 2+ radial, DP pulses b/l
Lymphatics: No cervical, supraclavicular, axillary or inguinal
lymphadenopathy noted
Skin: no rashes or lesions noted.
Neurologic: Alert, oriented x 3. Able to relate history without
difficulty. Cranial nerves II-XII intact. Normal bulk, strength
and tone throughout. No abnormal movements noted. No deficits to
light touch throughout. No nystagmus, dysarthria, intention or
action tremor. 2+ biceps, triceps, brachioradialis, patellar
reflexes and 2+ ankle jerks bilaterally. Plantar response was
flexor bilaterally.
Pertinent Results:
[**2132-8-18**] 03:00PM WBC-7.5 RBC-4.20* HGB-12.3* HCT-38.7* MCV-92
MCH-29.3 MCHC-31.8 RDW-14.1
[**2132-8-18**] 03:00PM NEUTS-72.1* LYMPHS-18.1 MONOS-9.0 EOS-0.3
BASOS-0.4
[**2132-8-18**] 03:00PM GLUCOSE-133* UREA N-24* CREAT-1.1 SODIUM-120*
POTASSIUM-4.6 CHLORIDE-83* TOTAL CO2-26 ANION GAP-16
[**2132-8-19**] 12:43PM TSH-1.4
[**2132-8-19**] 07:24AM ALT(SGPT)-136* AST(SGOT)-71* LD(LDH)-256*
CK(CPK)-96 ALK PHOS-174* TOT BILI-1.1
[**2132-8-19**] 07:24AM CK-MB-NotDone cTropnT-<0.01
[**2132-8-19**] 07:24AM [**Doctor First Name **]-POSITIVE TITER-1:40 [**Last Name (un) **]
[**2132-8-19**] 07:24AM NEUTS-67.0 LYMPHS-21.4 MONOS-9.7 EOS-1.6
BASOS-0.2
[**2132-8-19**] 07:24AM PT-16.1* PTT-29.2 INR(PT)-1.4*
.
CT ABDOMEN/PELVIS IMPRESSION: 1. Large pericardial effusion,
with apparent mass effect and tamponade on the heart. The
impaired venous return results in hepatic congestion and likely
affected the timing for IVC evaluation. 2. Anasarca, with
moderate-sized bilateral pleural effusions, large amount of free
fluid throughout the abdomen and pelvis, and edema within the
soft tissues. 3. Heterogeneous enhancement pattern of the liver,
likely reflecting congestion related to increased venous
pressures. 4. Assessment for IVC thrombosis is limited due to
suboptimal opacification of the venous system.
.
ECHO ON ADMISSION [**2132-8-19**]: The left atrium is normal in size.
The estimated right atrial pressure is 10-20mmHg. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Overall left ventricular systolic function is
normal (LVEF>55%). The right ventricular cavity is dilated with
normal free wall contractility. There is abnormal septal
motion/position consistent with right ventricular
pressure/volume overload. The aortic valve leaflets are mildly
thickened. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Trivial mitral regurgitation is
seen. Tricuspid regurgitation is present but cannot be
quantified. There is a moderate sized pericardial effusion.
There are no echocardiographic signs of tamponade.
Echocardiographic signs of tamponade may be absent in the
presence of elevated right sided pressures.
.
CARDIAC CATH/Pericardiocentesis [**2132-8-19**]: 1. Resting hemodynamics
was measured at baseline and after pericardiocentesis. Right
sided filling pressures were elevated at baseline (RVEDP 19mmHg,
mean RA 21mmHg) and remained elevated post-pericardiocentesis
(RVEDP 22 mmHg). Left sided filling pressures were mildly
elevated with mean PCWP of 20mmHg at baseline and 19mmHg
post-procedure. Intrapericardial pressure was reduced from
13mmHg to -4mmHg post-pericardiocentesis. Calculated cardiac
index was 2.5 and 2.4 L/min/m2 pre- and post-pericardiocentesis.
There was inspiratory decline in systolic arterial pressure from
140 to 126mmHg pre-pericardiocentesis consistent with pulsus
paradoxus. This persisted after pericardiocentesis (141 to
126mmHg). 2 . Pericardiocentesis was performed via a subxiphoid
approach and 210 cc of serosanguinous fluid was removed and sent
for laboratory analyses. A pericardial drain was left in-situ. A
post-procedure transthoracic echocardiogram was performed and
demonstrated no residual pericardial effusion. FINAL DIAGNOSIS:
1. Pericardial effusion with mild hemodynamic compromise and
early
tamponade physiology. 2. Elevated left and right sided filling
pressures and pulsus paradoxus unchanged
post-pericardiocentesis.
.
CTA [**2132-8-19**]: 1. No evidence of pulmonary embolism. 2. Persistent
moderate-sized bilateral pleural effusions and large pericardial
effusion with possible mass effect on the heart. 3. Retained
contrast within the kidneys after prior IV contrast
administration - findings suggestive of ATN.
.
[**Last Name (un) **] DUP EXTEXT BIL (MAP/DVT) [**2132-8-19**]: No evidence of DVT in
bilateral lower extremity.
.
KNEE (2 VIEWS) LEFT [**2132-8-23**]: Comparison is made to the prior
study from [**2124-11-2**]. No more recent radiographs are
available here at this institution for comparison. The patient
is status post left total knee arthroplasty. There are no signs
for hardware-related complications or periprosthetic fracture.
There is a prominent knee joint effusion.
.
CXR [**2132-8-21**]: Increasing opacification at the left base
consistent with effusion and atelectasis.
.
ECHO ON DISCHARGE [**2132-8-25**]: The left atrium is mildly dilated.
Left ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). The right ventricular
cavity is dilated There is abnormal septal motion/position. The
aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Physiologic mitral
regurgitation is seen (within normal limits). The pulmonary
artery systolic pressure could not be determined. There is a
small pericardial effusion. There are no echocardiographic signs
of tamponade. No right atrial diastolic collapse is seen. No
right ventricular diastolic collapse is seen. IMPRESSION: Small
pericardial effusion without evidence of tamponade. Dilated
right ventricle with depressed systolic function.
Brief Hospital Course:
66 year old with pericardial effusion, anasarca, and mildly
elevated LFTs. Hemmoragic pericardial effusion, s/p drainage on
[**2132-8-19**].
.
## Pericardial effusion/Anasarca: Later on the day of admission,
there was a concern that the patient might be developing early
tamponade physiology and consequently pericardiocentesis was
performed in the cath lab. Effusion was hemorrhagic, exudative
based only on LDHeff/LDHserum. Patient did not have recent chest
pain, therefore [**Last Name (un) 21160**]??????s unlikely. TB and lyme tests negative.
TSH WNL; PPD negative. [**First Name8 (NamePattern2) 6**] [**Doctor First Name **] showed a speckled patter at 1:40.
Gram stain of effusion was negative for microorganisms, however
one culture bottle grew coag negative staph. The pt was briefly
treated for this with a dose of vancomycin before it was
determined that this likely represented contaminant. Anaerobic
culture returned gram positive rods - consistent with
corynebacterium and propionibacterium. ID felt most likely
containment as these species do not cause pericarditis. No
history of recent viral illness. Concerned for malignancy. Lymph
nodes found on CT chest, no nodules/masses on CT chest or
abdomen with contrast. Colonoscopy in [**2129**] and [**2124**] with no
polyps. Had FNA breast in [**2128**]. Pathology report was abnormal,
however patient states mass was benign. No masses or enlarged
nodes on exam. Per primary care notes being treated for
pre-malignant skin lesions. Prostate screening up to date.
Unknown etiology of pericarditis. Following drainage, the pt's
urine output increased significantly and his edema was noted to
diminish. Was treated with Naproxen initially, discharged on
Mobic 7.5 mg [**Hospital1 **] for 10 days duration. Discharged on 20 mg po
Lasix for 3 days for diuresis. Pulsus 4 on discharge. ECHO on
discharge demonstrated resolved pericardial effusion, however
right ventricular cavity is dilated with abnormal septal
motion/position. Patient to have cardiac MR to investigate
constrictive cardiac pathology and follow-up with cardiology as
an outpatient.
.
## Hyponatremia: The pt has a low FeNA on urine lytes prior to
IVF, suggesting functional hypovolemic hyponatremia in setting
of poor cardiac output. With fluids and then tapping of his
pericardial effusion, his serum sodium slowly corrected. Patient
to have his Na checked in one week with follow-up.
.
## s/p LKR: The pt's surgery was done at NEBH. Dr. [**Last Name (STitle) 44068**] is the
surgeon. Several days into his hospital stay, the pt's left knee
was noted to be slightly warmer than his right. Both the [**Hospital1 18**]
Ortho Service and the pt's private orthopedist were consulted
and felt that this was normal post-operatively and unlikely to
represent infection.
.
## HTN: The pt's antihypertensives were held in the setting of
his effusion. At discharge, his HCTZ was not restarted given his
significant hyponatremia at admission. His Benicar was also held
until follow-up at his primary care appointment. SBP was stable
on the floor.
.
# Elevated LFTs: Trending down, most likely related to
congestion. ALT > AST. Hep B and C serologies pending.
Medications on Admission:
HCTZ 12.5mg daily
Benicar 40mg daily
Lipitor 10mg daily
Ferrous gluconate 325mg daily
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Mobic 7.5 mg Tablet Sig: One (1) Tablet PO twice a day for 10
days.
Disp:*20 Tablet(s)* Refills:*0*
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day for 14 days.
Disp:*14 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
4. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 3
days.
Disp:*3 Tablet(s)* Refills:*0*
5. Outpatient Lab Work
Please have a Chem-7 (Na, K, Cl, BiCarb, BUN, Creatinine) drawn
at your appointment with Dr. [**First Name (STitle) 679**] on [**9-3**] 9:30. We would
like to check your sodium level.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
- Hemorrhagic pericardial effusion
Secondary diagnoses:
- Anasarca
- Status-post left knee replacement
Discharge Condition:
Ambulating with stable vitals.
Discharge Instructions:
You were admitted for fluid surrounding your heart (pleural
effusion) and additional fluid in your stomach and legs. This
could be pericarditis related to a virus or unknown etiology. We
did some tests that can cause these symptoms - all were with in
normal limits. You were negative for lyme, TB, bacteria. You had
a procdure called a pericardiocentesis which drained the fluid
around your heart. Before discharge you had a follow up ECHO
which demonstrated only a small effusion remaining. We would
like to follow up with cardiology and your primary care doctor.
.
We have made the following changes to your medication:
1) We have stopped your blood pressure medications,
Hydrachlorothiazide (HCTZ) 12.5 mg and Benicar. Discuss with Dr.
[**First Name (STitle) 679**] whether this should be re-started.
2) Started Lasix 20 mg for 3 days duration
3) Started Mobic 7.5 mg twice a day for 10 days until follow-up
with Dr. [**First Name (STitle) 679**]
4) Please have your labs checked at your follow-up appointment
with Dr. [**First Name (STitle) 679**] on [**9-3**]. Your sodium was mildly decreased on
admission and we would like to check it.
Otherwise please take your medications as perscribed.
.
Please attend all your follow up appointments.
.
Return to the ER if your experience shortness of breath, chest
pain, worsening fluid accumalation, bleeding or other concerning
symptoms.
Followup Instructions:
Please attend the following appointments:
1) Cardiology: [**Name6 (MD) **] [**Last Name (NamePattern4) 6559**], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2132-9-16**] 2:20 [**Hospital6 29**], [**Location (un) **]
2) Primary Care: Dr. [**First Name (STitle) 679**], Wednesday [**9-3**] at 9:30 am,
please come early and have your labs drawn. His office number is
([**Telephone/Fax (1) 103752**] if you need to contact him.
3) Schedule an ECHO in [**1-2**] weeks for follow-up. To schedule an
ECHO call [**Telephone/Fax (1) 62**]. Dr.[**Name (NI) 16937**] office can also schedule the
ECHO.
4) We are scheduling a Cardiac MR for you. They will contact you
with an appointment time. If you do not hear from them in a week
please call [**Telephone/Fax (1) 9559**].
Completed by:[**2132-8-27**]
ICD9 Codes: 5119, 2761, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3661
} | Medical Text: Admission Date: [**2106-2-1**] Discharge Date: [**2106-2-17**]
Service: MEDICINE
Allergies:
Depakote
Attending:[**First Name3 (LF) 9853**]
Chief Complaint:
Dehydration, Acute Renal Failure, Severe Hypernatremia,
Hypokalemia
Major Surgical or Invasive Procedure:
PEG placement
PICC placement
History of Present Illness:
[**Age over 90 **] year old female with moderate-severe dementia, recent very
complicated hospital course from [**Date range (1) 98904**], during which
time she was intubated [**Date range (2) 98905**], with aspiration
pneumonia, ventilator-associated pneumonia, and tension
pneumothorax (from line-placement), septic shock requiring
pressors, thrombocytopenia, and acute renal failure. Pt now
presents to [**Hospital1 18**] for concern for failure to thrive with
refusing all po intake with sodium i nthe high 160's.
Per [**Hospital1 1501**] records, the patient had been refusing po intake for
several days. Her daughter called [**Name (NI) 1501**] and told them that she
wanted the patient to be brought to the hospital for admission.
In the ED, patient received NS @ 125 cc/hr, IV KCl 40 meq.
Patient is demented and is unable to provide history.
On arrival to the floor, the patient had a calculated 5L free
water deficit along with dehydration. This was attempted to be
corrected on the floor, however her sodium was rechecked and was
175, so she was moved to the ICU for further therapy. In the
ICU, her sodium was slowly corrected with renal consultation, to
the low 150's, and she was transferred back to the floor.
Serial sodium levels were checked, with plan for slow resolution
at a rate of [**3-16**] per day. As the patient still is taking low PO,
split fluids were started with both NS and D5W drips to allow
seperate titration.
Past Medical History:
# moderate to severe dementia
# Osteoporosis
# Chronic Diastolic Heart failure
# mild-moderate systolic pulmonary hypertension
# history of depression
# Malnutrition - moderate to severe, likely secondary to
dementia
Hospitalization [**1-18**]:
# Hx Respiratory Failure attributed to aspiration pneumonia
necessitating artificial ventilation, vasopressors, and broad
spectrum antibiotics. Septic Shock with thrombocytopenia
possibly related to consumption.
# Left Lower Lobe collapse/partial collapse s/p bronchoscopy
# Tension Pneumothorax on Right s/p central line insertion, s/p
chest tube placement for nearly 2 weeks. Significant
subcutaneous emphysema, resolving
# Ventilator associated pneumonia - MRSA and pan-sensitive
Klebsiella pneumonia cultured from sputum
# Acute renal failure - resolved
# Hx Atrial Fibrillation with rapid ventricular response, on
amiodarone since [**2105-12-12**]
Social History:
(per chart review)
Ms. [**Known lastname 98899**] [**Last Name (Titles) 546**] at [**Hospital1 599**] of [**Location (un) 55**]. She was married
many years ago and never had any children.
FUNCTIONAL STATUS: She at baseline is minimally oriented and
interactive according to staff ([**Name (NI) **], PT at [**Hospital1 599**] in
conversation [**2106-1-18**]). Prior to her first ICU admission this
fall, she was able to transfer with a two person assist. Now
requires a [**Doctor Last Name 2598**] lift to transfer her.
Family History:
(from chart review) Mother died of old age in her late 90's.
Physical Exam:
VS: 96.5, 115/58, 75, 20, 100%
GEN: severely cachectic elderly female, non-verbal. Eyes open,
responds to voice. Appears uncomfortable.
HEENT: eomi, perrl, MM dry.
Neck: No LAD.
RESP: CTA B. No WRR. Fair resp effort with only fair AE. BS
symmetric.
CV: RRR. No mrg.
ABD: +BS. Soft, NT/ND.
Ext: No CEE.
Neuro: severe dementia.
Skin: no areas of skin break-down noted. No decubitus ulcers.
Pertinent Results:
[**2106-2-5**] 06:55AM BLOOD WBC-8.2 RBC-2.84* Hgb-9.0* Hct-27.3*
MCV-96 MCH-31.6 MCHC-32.9 RDW-16.5* Plt Ct-179#
[**2106-2-3**] 05:14AM BLOOD WBC-7.0 RBC-3.03* Hgb-9.8* Hct-30.4*
MCV-100* MCH-32.5* MCHC-32.4 RDW-16.9* Plt Ct-363
[**2106-2-2**] 05:25AM BLOOD WBC-6.7 RBC-3.29* Hgb-10.4* Hct-33.7*
MCV-102* MCH-31.6 MCHC-30.8* RDW-16.5* Plt Ct-368
[**2106-2-1**] 09:32PM BLOOD WBC-7.1 RBC-3.49*# Hgb-11.5*# Hct-35.3*#
MCV-101* MCH-32.9* MCHC-32.5 RDW-17.1* Plt Ct-333
[**2106-2-5**] 06:55AM BLOOD Glucose-102 UreaN-11 Creat-0.6 Na-150*
K-3.0* Cl-116* HCO3-26 AnGap-11
[**2106-2-4**] 07:20PM BLOOD UreaN-13 Creat-0.7 Na-150*
[**2106-2-4**] 12:25PM BLOOD UreaN-11 Creat-0.6 Na-146* K-3.9 Cl-110*
[**2106-2-4**] 05:36AM BLOOD Glucose-99 UreaN-13 Creat-0.7 Na-152*
K-4.2 Cl-118* HCO3-26 AnGap-12
[**2106-2-4**] 12:25AM BLOOD Glucose-104 UreaN-13 Creat-0.6 Na-149*
K-4.1 Cl-113* HCO3-25 AnGap-15
[**2106-2-3**] 05:35PM BLOOD Glucose-166* UreaN-15 Creat-0.7 Na-153*
K-4.5 Cl-118* HCO3-25 AnGap-15
[**2106-2-3**] 11:47AM BLOOD Glucose-168* UreaN-16 Creat-0.7 Na-159*
K-3.4 Cl-120* HCO3-27 AnGap-15
[**2106-2-3**] 05:14AM BLOOD Glucose-133* UreaN-20 Creat-0.9 Na-165*
K-3.6 Cl-127* HCO3-30 AnGap-12
[**2106-2-3**] 12:03AM BLOOD Glucose-142* UreaN-23* Creat-0.9 Na-164*
K-3.1* Cl-127* HCO3-29 AnGap-11
[**2106-2-2**] 05:34PM BLOOD Glucose-221* UreaN-26* Creat-0.9 Na-166*
K-3.3 Cl-127* HCO3-30 AnGap-12
[**2106-2-2**] 12:02PM BLOOD Glucose-154* UreaN-29* Creat-0.9 Na-171*
K-3.0* Cl-127* HCO3-29 AnGap-18
[**2106-2-2**] 05:25AM BLOOD Glucose-102 UreaN-32* Creat-0.9 Na-175*
K-3.4 Cl-130* HCO3-28 AnGap-20
[**2106-2-1**] 09:32PM BLOOD Glucose-94 UreaN-30* Creat-0.9 Na-168*
K-2.8* Cl-123* HCO3-29 AnGap-19
[**2106-2-5**] 06:55AM BLOOD Albumin-2.8* Calcium-7.8* Phos-2.7 Mg-2.0
[**2106-2-2**] 05:25AM BLOOD Osmolal-359*
[**2106-2-2**] 08:21AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.020
[**2106-2-2**] 08:21AM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-40 Bilirub-SM Urobiln-2* pH-5.5 Leuks-TR
[**2106-2-2**] 8:21 am URINE Source: CVS.
**FINAL REPORT [**2106-2-3**]**
URINE CULTURE (Final [**2106-2-3**]): NO GROWTH.
ECG Study Date of [**2106-2-1**] 10:53:24 PM
Baseline artifact
Sinus rhythm
Probable QT interval prolonged although is difficult to measure
Findings are nonspecific but clinical correlation is suggested
for possible in part drug/metabolic/electrolyte effect
Since previous tracing of [**2105-12-8**], atrial fibrillation absent
and findings as outlined now present
Intervals Axes
Rate PR QRS QT/QTc P QRS T
82 158 90 422/460 94 -18 -132
CHEST (PA & LAT) Study Date of [**2106-2-1**] 10:31 PM
IMPRESSION: No evidence of pneumonia.
Brief Hospital Course:
This is a [**Age over 90 **] yo female with severe dementia with poor functional
status, multiple medical problems with multiple recent
hospitalizations including recent ICU stay with intubation,
sepsis, pressors, etc, now presented with severe dehydration,
poor po intake, hypernatremia, and failure to thrive.
#. Severe Hypernatremia, Dehydration, Acute Renal Failure,
Failure to thrive: The pt was admitted with a sodium up to 175
on admission. She was treated with D5W and then D5W plus NS
until sodium normalized. She was followed by renal while she was
here. Creatinine was also up to 0.9 from 0.5 on admission, which
also resolved after IV fluids. Per OMR, the pts HCP [**Name (NI) **]
[**Name (NI) 1445**] has had a number of discussions with prior hospitalists
including Dr. [**Last Name (STitle) **] and Dr. [**First Name (STitle) **] regarding feeding tube
placement. Dr. [**Last Name (STitle) 98906**] of gerontology was consulted to see this
patient, and in his discussion with pts HCP, it was decided that
although feeding tube placement would not prevent aspiration, it
would prevent recurrent admissions for dehydration. The
hospitalist caring for the pt also discussed plan with pts HCP,
who did wish to pursue feeding tube placement. She understood
the risk of continued or increased aspiration and lack of
prolonging life. It was also decided to continue to allow pt to
eat as HCP feels joy of eating is very important to pt, even at
risk for recurrent aspiration PNA. Prior to feeding tube
placement, PPN was initiated. Surgery was consulted initially
but wanted to place a J tube under general anesthesia. Case was
discussed with GI and IR, and decision was made to place PEG by
IR under light conscious sedation. PEG was placed on [**2106-2-8**],
and tubefeedings were initiated 24 hours later.
# Aspiration: the patient has been admitted twice prior to this
admission in the past 1.5 months for aspiration PNA x2 requiring
intubation and pressors. As per above, feeding tube placement
was decided upon not to prevent aspiration (as the HCP wants the
pt to continue to be able to enjoy eating), but for
nutritional/hydration purposes. The HCP is aware of the
continued risk of recurrent aspiration PNA with eating.
# Fever/Leukocytosis/C diff Colitis/UTI: Pt febrile to 102
overnight of [**2-10**]. Found to have C diff +stool, +UA. WBC
elevated to 23 up from 8 the day prior. CXR showed no PNA. She
was started on cipro/flagyl on [**2-11**] and WBC as well as fever
curve trended down. Her urine culture eventually grew out E.
coli ESBL and Cipro was changed to meropenem on [**2106-2-14**]. A PICC
line was placed to complete a 10-day course of meropenem (last
day [**2-24**]); she will need to continue Flagyl for another week
beyond that (last day [**3-3**]).
# Anemia of chronic disease, hematocrit drop: Pts hct trended
down from 35 on admission to 28, and then 24.8 prior to
discharge. Her baseline hct is in fact 22-25 per prior records
here. Given her Na was 175 on admission and pt was receiving
continuous fluids, PPN, and tubefeeds while here, this hct drop
was in all likelihood just dilutional. Given PEG was done day
prior to hct drop from 28 to 24.8, stools was guaiaced and were
brown grossly guaiac positive. In discussion with IR, one would
likely expect some guaiac positive stools after PEG incision
made in stomach. Pts hct was monitored and she was transfused 1
U PRBC for hct of 22 and mild hypotension (SBP low 90s). She
thereafter maintained a Hct of 25-28.
# Hypokalemia
- repleted multiple times in house
# Alzheimer's Dementia: Continued memantine
#. Chronic Diastolic Congestive Heart Failure, moderate
pulmonary artery hypertension: Continued heart rate control with
amiodarone
#. Atrial Fibrillation: continued amiodarone.
#. Papules on right cheekbone: appear to be whiteheads, no sign
of infection. Would continue to observe at rehab.
ADVANCE DIRECTIVES:
Health Care Proxy = [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 98901**]
CODE STATUS = FULL CODE
Medications on Admission:
1. Heparin (Porcine) 5,000 unit/mL Solution [**Telephone/Fax (1) **]: 5000 (5000)
units Injection TID (3 times a day).
2. Acetaminophen 500 mg Tablet [**Telephone/Fax (1) **]: Two (2) Tablet PO TID (3
times a day) as needed for pain.
3. Amiodarone 200 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO DAILY
(Daily).
4. Memantine 10 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO qam.
5. Memantine 5 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO at bedtime.
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Telephone/Fax (1) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
7. Senna 8.6 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO BID (2 times a
day) as needed.
8. Docusate Sodium 50 mg/5 mL Liquid [**Telephone/Fax (1) **]: Five (5) mL PO BID (2
times a day).
9. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Telephone/Fax (1) **]: Two (2)
Tablet PO DAILY (Daily).
10. Bactrim DS 1 tab po bid; started [**1-26**]; although not taking
most medications currently
Discharge Medications:
1. Amiodarone 200 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY
(Daily).
2. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Year (2) **]: 5000 (5000)
Units Injection twice a day.
3. Memantine 5 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO qAM ().
4. Memantine 5 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO qHS ().
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Month/Year (2) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
6. Senna 8.6 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO BID (2 times a
day) as needed.
7. Calcium 600 + D(3) 600 mg(1,500mg) -200 unit Tablet [**Month/Year (2) **]: One
(1) Tablet PO at bedtime.
8. Acetaminophen 325 mg Tablet [**Month/Year (2) **]: 1-2 Tablets PO Q6H (every 6
hours) as needed.
9. Camphor-Menthol 0.5-0.5 % Lotion [**Month/Year (2) **]: One (1) Appl Topical
TID (3 times a day) as needed.
10. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
11. Meropenem 500 mg Recon Soln [**Last Name (STitle) **]: One (1) Recon Soln
Intravenous Q8H (every 8 hours) for 1 weeks: last day [**2-24**].
12. Metronidazole 500 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO Q8H
(every 8 hours) for 2 weeks: last day [**3-3**].
13. Senna 8.6 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO HS (at bedtime).
14. Heparin, Porcine (PF) 10 unit/mL Syringe [**Month/Year (2) **]: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
Severe Hypernatremia
Moderate Malnutrition
Atrial Fibrillation
Alzheimer's Dementia
Chronic Diastolic CHF
Hypokalemia
Discharge Condition:
Good, stable, tolerating tube feeds
Discharge Instructions:
You were placed in the ICU due to the very high level of sodium
in your blood. You were given IV fluids and your sodium level
normalized. A feeding tube was placed in your stomach. You will
receive food and fluids through this, as well as your
medications. You can continue to eat by mouth as well.
During your hospitalization you were found to have an infection
in your intestines (C. difficile) as well as a urinary tract
infection (E. coli ESBL). You will require IV antibiotics to
complete a 10-day course and continue oral antibiotics for a
week beyond that.
Call your doctor or return to the ER for shortness of breath,
chest pain, fevers, abdominal pain, difficulty with your feeding
tube, or any other concerns.
Followup Instructions:
Follow up with your PCP [**Name9 (PRE) **],[**Name9 (PRE) **] [**Telephone/Fax (1) 76366**] as
required
ICD9 Codes: 2760, 5849, 2930, 5990, 4280, 4168, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3662
} | Medical Text: Admission Date: [**2137-9-27**] Discharge Date: [**2137-10-22**]
Date of Birth: [**2081-6-15**] Sex: F
Service: MEDICINE
Allergies:
Tums
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Fever of 100.5 and confusion.
Major Surgical or Invasive Procedure:
Paracentesis
Placement of lines
CPR
History of Present Illness:
Mrs. [**Known lastname 1968**] is a 56 year-old woman with a history of HCV and
autoimmune heptatis with a baseline MELD score of 32 and
previous admissions for hepatic encephalopathy, who was brought
into the [**Hospital1 18**] ED at the urging of her visting nurse this
morning. Her visiting nurse, who sees her twice a week to check
her weight, temperature, and blood pressure, noticed today that
her temperature was 100.5 and that she seemed "not herself". She
advised Mrs. [**Known lastname 1968**] to seek medical attention.
.
Mrs. [**Known lastname 1968**] acknowledges that at baseline she has some
"confusion" due to her hepatitis, and sometimes "doesn't think
clearly". She states that over the last few days she has felt
more confused than normal, but was unable to provide any
specifics on why she thought she had been more confused. Per her
daughter, her current affect, slow speech, and confusion are
near or at her baseline level, but her confusion is easily
exacerbated if she does not take her lactulose every three
hours.
.
In the ED, her initial vitals were T 101 HR 99 BP 113/40 RR 18
O2 sat 98 on room air. Her physical exam was notable for a mild
abdominal fluid wave, and she was noted to be "slow speaking".
An initial work up for her fever was begun, which inlcuded an
rapid influenza antigen test, and broad spectrum antibiotics to
cover both possible meningitis (given her confusion) and
spontaneous bacterial peritonits. An LP was not obatined to rule
out meningitis given her high INR (4.0). A head CT and chest
X-ray were read as normal, and an abdominal US showed no
baseline change from recent imaging.
.
On reveiw of systems, she denies any chest pain, shortness of
breath, dizziness, nausea, vomiting, change in bowel habits or
urine habits (of note, she states that her urine has been "dark
colored" for several years). She did endorse of feeling of
abdominal pain, which she states starts in her abdomen and
radiates down to both feet bilaterally, and which she first
noted in the ED.
Past Medical History:
1) HCV and autoimmune hepatitis leading to cirrhosis c/b:
-encephalopathy
-ascites, LE edema
-nonocclusive portal vein thrombosis for which she takes
Coumadin
-grade 1 varices in the lower third of the esophagus ([**11/2135**])
2) Left breast cancer dx [**2129**] s/p mastectomy and reconstruction,
with local recurrence s/p excision and XRT without recurrence on
Femara
3) Type 2 diabetes mellitus, on insulin x 30 years, last A1c 6.7
[**6-30**]
4)Hypertension
5) Chronic renal failure, baseline creatinine 1.6-1.8
6) CAD - cath [**5-29**] showed LAD mild diffuse dz
7) History of sarcoid
8) Osteopenia with borderline osteoporosis in spine and hip
9) Gastroesophageal reflux disease
10) Thickened rectal mucosal folds consistent with proctitis
diagnosed on last colonoscopy [**12/2133**]
11) Reactive airway disease with seasonal symptoms
Social History:
Divorced. Lives alone in [**Location (un) 4398**] in [**Location (un) 86**]. Daughter and
grandson live nearby in [**Name (NI) **]. Daughter works at [**University/College 5130**]
[**Location (un) **] and has been involved in care, although patient lives
independently and is competent in all ADLs and IADLs. She denies
tobacco, alcohol, or illicit drug use.
Family History:
Sister with type 2 diabetes and breast cancer, half-sister with
breast cancer.
Physical Exam:
On admission:
Physical Exam:
Vs: T 97.7 92 112/52 16 99%RA
General: Awake, lying in bed comfortably, in no apparent
distress.
HEENT: No thyromegaly, lymphadenopathy. Moist mucous membranes.
Scleral icteri.
Chest: Lungs CTAB, no wheezes, murmrs, rhonchi.
Cardiac: Normal S1/S2, no rubs, murmurs, gallops
Abdomen: Distended. Horizontal midline scar below umbilicus from
breast reconstruction surgery. No tenderness to palpation or
palpable masses, bowel sounds positive in all four quadrants. No
fluid wave apprecaited. Liver and spleen not palpable. Active
bowel sounds.
Extremities: No cyanosis, clubbing, or edema. DP/TA palapable
bilterally. Decreased pigmentation and excorcations on anterior
surface of lower extremities bilaterally.
Skin: Scattered nevi throughout.
Neurology:
Mental status: Awake, alert, appropriately interactive. Mini
mental status exam was 28/30, with only deficits poor attention
(was able to say months of the year backwards with great
difficulty and several mistakes).
Cranial Nerves: Cranial nerves II-XII intact. Several beats of
nystamus on right lateral gaze.
Sensation: Intact to touch, propriocetion throughout.
Motor: Strength 5 throughout in all four extremities. No
asterxisi or pronator drift.
Coordiantion: Finger-nose-finger intact, [**Doctor First Name **] intact.
Gait: not assessed.
.
Pertinent Results:
[**2137-9-27**] (Admission)
WBC-8.8# RBC-2.86* HGB-8.2* HCT-26.1* PLT 77
NEUTS-75.1* LYMPHS-18.7 MONOS-5.6 EOS-0.3 BASOS-0.2
GLUCOSE-134* UREA N-29* CREAT-2.6* SODIUM-134 POTASSIUM-4.2
CHLORIDE-102 TOTAL CO2-25 ANION GAP-11
ALT(SGPT)-59* AST(SGOT)-120* ALK PHOS-85 TOT BILI-10.1*
LIPASE-49
ALBUMIN-1.9*
LACTATE-2.8*
AMMONIA-32
PT-38.1* PTT-50.2* INR(PT)-4.0*
[**2137-10-14**] (Day of transfer to MICU):
[**2137-10-14**] 04:59AM BLOOD WBC-6.4 RBC-2.54* Hgb-7.6* Hct-24.5*
MCV-97 MCH-29.8 MCHC-30.8* RDW-23.0* Plt Ct-92*
[**2137-10-14**] 04:59AM BLOOD PT-55.3* PTT-63.0* INR(PT)-6.2*
[**2137-10-14**] 04:59AM BLOOD Fibrino-106*
[**2137-10-14**] 04:59AM BLOOD Glucose-199* UreaN-51* Creat-1.5* Na-150*
K-4.4 Cl-116* HCO3-28 AnGap-10
[**2137-10-14**] 04:59AM BLOOD ALT-32 AST-80* LD(LDH)-400* CK(CPK)-128
AlkPhos-68 TotBili-24.0*
[**2137-10-14**] 04:59AM BLOOD Albumin-3.9 Calcium-10.1 Phos-2.9 Mg-3.1*
STUDIES:
-[**2137-10-13**] U/S: 1. No DVT in the right upper extremity. 2. No
evidence of pseudoaneurysm or hematoma at the site of puncture
of the radial artery. 3. Subcutenous edema within the right arm
-[**2137-10-12**] KUB (Prelim read): No findings of bowel obstruction,
slightly prominent loops of large bowel suggestive of probable
ileus
-[**2137-10-11**] ECG: Sinus rhythm. Low limb lead voltage. Compared to
the previous tracing of [**2137-9-27**] the limb lead voltage is less
prominent. The rate has slowed. Otherwise, no diagnostic interim
change.
MICRO:
-DIRECT INFLUENZA A ANTIGEN TEST (Final [**2137-9-27**]): Negative
-DIRECT INFLUENZA B ANTIGEN TEST (Final [**2137-9-27**]): Negative
-UCx ([**2137-10-5**]): STAPHYLOCOCCUS, COAGULASE NEGATIVE
| ENTEROCOCCUS SP.
| |
AMPICILLIN------------ =>32 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
LINEZOLID------------- 2 S
NITROFURANTOIN-------- <=16 S 128 R
OXACILLIN------------- =>4 R
TETRACYCLINE---------- =>16 R =>16 R
VANCOMYCIN------------ 2 S =>32 R
-BCx ([**2137-10-6**]): no growth
-UCx ([**2137-10-7**]): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), C/w
SKIN AND/OR GENITAL CONTAMINATION.
-UCx ([**2137-10-10**]): <10,000 organisms/ml
-BCx ([**2137-10-10**]): Pending x 2
Brief Hospital Course:
MEDICINE SERVICE COURSE:
56 year-old woman with a history of HCV and autoimmune hepatatis
with a baseline MELD score of 32, on liver and kidney [**Month/Day/Year **]
list and previous admissions for hepatic encephalopathy, who was
admitted on [**9-27**] for fever and altered mental status. Her VNA
found her to be confused on the day of admission, with a T of
100.5.
.
The patient was initially treated with ceftriaxone empirically
for SBP from [**9-27**] to [**10-1**]. She has completed a 2nd course of
ceftriaxone and 1 course of Vancomycin empirically for SBP on
[**10-7**] to [**10-14**]. She has not had a documented fever during her
nearly 3 week hospital stay.
.
She has had some mild vaginal bleeding during her
hospitalization. She has received 2u PRBCs early in her
hospitalization, and then again 2 units [**10-16**].
.
She triggered evening of [**10-12**] for altered mental status.
Started on empiric linezolid for VRE in urine. This was stopped
on [**10-14**]. KUB performed for abdominal distension, though no SBO.
On [**10-15**] with AMS, her lactulose was increased to 60mg po q3h
and transferred to the ICU for further management.
.
In the MICU, the patient had her INR corrected and had a LIJ
placed and dobhoff placed on [**2137-10-16**]. Diagnostic paracentesis
was negative. FT placed. Mental status improved slightly.
.
She was transferred back to the floor and noted to have slurred
speech and tangential thoughts. She denies pain, SOB, nausea,
HA, cough. States she has chills and dry mouth.
##################
[**Doctor Last Name 3271**]-[**First Name4 (NamePattern1) 679**] [**Last Name (NamePattern1) 4869**]
Upon transfer to the Hepatorenal service, the patient was alert,
awake, and oriented to name, place, and time. She was treated
for the following issues:
ESLD: The patient was intermittently encephalopathic during her
admission, especially when she was not given her lactulose
strictly Q3 hrs. She was also continued on rifaximin. Her MELD
scores were generally above 40 though had improved to 35 on the
day of transfer, in the setting of an acute improvement in her
creatinine. Her bilirubin had climbed to 24.0 on day of
transfer. Her INR was consistently elevated, and she required
occasional doses of FFP to reverse her INR when she developed
low-grade bleeding from the corner of her mouth and lips. She
also had regular vaginal spotting nightly, though no frank
hemorrhage. Her fibrinogen was also occasionally found to be
<100, and was given several units of cryoprecipitate. OB/Gyn saw
the patient for a potential endometrial biopsy as part of the
pre-[**Last Name (NamePattern1) **] evaluation, though the risks of the procedure
were thought to outweigh the pre-test probability of finding any
malignancy, especially given the patient's chronic femara
(believed to be protective against endometrial malignancy). Her
ascites worsened steadily, and she had tenderness to
palpation/percussion. She had no respiratory compromise, and had
consistently excellent oxygen saturation. Diagnostic
paracentesis was not performed given high INR and risk of
bleeding. She was instead given a seven day course of empiric
ceftriaxone. Her diuretics were held for the duration of her
time on the hepatorenal service, given her acute kidney injury.
# Right wrist hematoma: The patient triggered for altered mental
status on the evening of [**10-12**]. She had an ABG performed, and
subsequently developed a hematoma. Her hand was felt to be cold
and plastic/hand surgery was consulted. They did not believe she
had compartment syndrome, and her U/S was negative for DVT or
pseudoaneurysm. She was followed with serial hand
sensation/strength exams.
# Angioedema: On [**10-10**] the patient was found to have periorbital
and lip/face edema, concerning for angioedema. She was given
benadryl and IV steroids. She did not have any respiratory
compromise. The precipitant was unclear, and was ultimately
believed to be a lidoderm patch that she had received 2 days
prior, for abdominal pain. After discontinuing the lidoderm, the
patient did not have further episodes of angioedema.
# UTI: The patient's urine culture on [**10-5**] grew coag negative
staph and enterococcus. She completed seven day course of
vancomycin. Subsequent urine cultures were negative. Linezolid
was started for the patient's [**10-12**] trigger (altered MS), given
the culture data. The linezolid was discontinued on [**10-14**].
# Anemia: The patient had a generally stable hematocrit and did
not require frequent blood transfusions. She had guaiac positive
stool on [**10-14**]. She was continued on her regular dose of
erythropoeitin, and her aspirin and warfarin (for portal vein
thrombosis) were held. She had low-grade vaginal and
oropharyngeal bleeding, as above. She was also continued on
daily PO vitamin K, and was given 5 mg of IV vitamin K on day of
transfer to MICU, in anticipation of IR-guided line placement
and paracentesis.
# Acute on Chronic Kidney Injury: The patient's creatinine level
was 2.6 on admission. It peaked at 3.1 on [**9-29**]. She was placed
on octreotide and midodrine, and received daily doses of IV
albumin. Her creatinine improved to 1.5 on day of transfer to
the MICU, but her midodrine regimen was occasionally interrupted
secondary to hypertension. Her albumin infusions were stopped
when the patient became hypertensive and volume overloaded. Her
urine output was low, but unreliably measured, and frequently
mixed in with loose stools. She had a foley placed on day of
transfer to the MICU.
# Hypernatremia: Her sodium levels trended up to 150 on day of
transfer to the MICU, which may have contributed to her mental
status. She was started on a D5W fluid infusion.
# Diabetes Mellitus: As the patient's blood sugars generally
trended downward, her home basal glargine was steadily decreased
from her home basal 35 units QHS, to avoid hypoglycemic
episodes. On the day of transfer to the MICU, her glargine was
written for 25 units QHS. She was written for a low-protein,
diabetic diet.
# History of Breast Cancer: The patient was continued on her
home dose of letrozole. She has a history of lymphedema in her
left arm, and blood draws were avoided in the left arm.
# Access: The patient had an EJ line placed in her right neck,
and also had a peripheral IV placed on her right arm. At the
time of transfer to the MICU, there was a plan in place for the
patient to receive vitamin K via the IV, and have her
coagulation studies checked overnight, with FFP/cryoprecipitate
given as needed to reduce her INR to <2.0. Angio and ultrasound
were contact[**Name (NI) **] to arrange central venous line vs PICC placement
and diagnostic/therapeutic paracentesis on the morning of [**10-15**].
At the time of transfer, the interventional radiologists were
planning to perform both procedures at 8:00 on [**10-15**].
####################
MICU GREEN COURSE
On the floor, she was noted to be more confused and oozing blood
from venous access sites, mouth and vagina. There was no blood
in rectal tube. Her abd was noted to be more distended. KUB
showed distention of the stomach and colon w/o air-fluid levels.
.
She was transferred to the MICU and NGT is placed which
aspirates blood. She is intubated and a cordis is placed for
rapid resucitation. She became hypotense to SBP 67. She was
given 3U PRBCs, 4U FFP, 1U cryo and started on dopamine drip.
CVP was noted to be elevated to 30s and heart was enlarged on
CXR so stat echo was ordered and showed no effusion but PASP
40-48 with a normal LVEF. She had EGD by GI which showed diffuse
oozing in the stomach which had stopped.
.
On [**10-18**], she continued to bleed. She was aggressively
transfused with FFP/cryp/PRBC/plt with goals Hct > 25, fib >
100, plt > 50, INR < 2. A Cordis and A-line were placed. Her
CT Abdomen showed moderate to large amount of ascites. No bowel
obstruction and no free air. Her bladder pressures were
monitored with plan to para for > 30. ENT scoped and packed
nares.
On [**10-19**], a temp femoral line placed by renal and CVVH started.
She received 3 U blood, 2 FFP, 1 PLT. Smear reviewed by heme:
some schistocytes c/w light degree of DIC.
On [**10-20**], ENT again packed bilateral nares. She received total
7u FFP, 1u PRBCs. SQ methylnaltrexone was given for trace
stool. Her abd was more distended, with bladder pressure
overnight 21. KUB showed ground glass ascites, less distended
stomach air bubble, no signs of free air or obstruction. Her
lactate was trending upwards into 8s; unclear etiology at this
point, but probably bowel related vs. secondary to liver disease
and inability to clear lactate.
On [**10-21**], she continued to have escilating pressor requirements.
She began to develop NSVT with associated blood pressure drops.
She was started on amiodorone and given lidocaine boluses. Her
NSVT normalized for a few hours. She was then found to be in
pulseless VT. She had return of spontaneos circulation with DC
cardioversion. She continued to go into and out of VT. In
discussion with the family, she was made DNR/DNI. Pressors were
continued but no further shocks were given. Her blood pressure
slowly declined and she passed away in no apparent distress at 6
AM on [**10-22**].
Medications on Admission:
CHOLESTYRAMINE-SUCROSE - 4 gram Packet - [**Hospital1 **]
CLOTRIMAZOLE - 10 mg Troche - Five times daily
EPOETIN ALFA [EPOGEN] - 4,000 unit/mL Solution - 8000 units
qweek
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - 50,000 unit - twice
weekly
FUROSEMIDE - 20 mg Tablet - QDD
GLUCAGON (HUMAN RECOMBINANT) [GLUCAGON EMERGENCY] - 1 mg Kit
INSULIN GLARGINE [LANTUS] - 35 U at bedtime
INSULIN LISPRO [HUMALOG] - Sliding scale at breakfast, lunch,
dinner
LACTULOSE - 10 gram/15 mL Solution - 2 TBS(s) by mouth Q3hours
LETROZOLE [FEMARA] - 2.5 mg Tablet - QD
OMEPRAZOLE [PRILOSEC] - 20 mg Capsule, QD
RIFAXIMIN [XIFAXAN] - 200 mg [**Hospital1 **]
SPIRONOLACTONE - 50 mg Tablet - [**Hospital1 **]
URSODIOL - 500 mg Tablet - [**Hospital1 **]
WARFARIN [COUMADIN] - 1 mg QD
ASPIRIN [ASPIRIN [**Hospital1 **]] - 81 mg Tablet QD
CALCIUM CITRATE-VITAMIN D3 [CITRACAL + D] - 500 mg-400 unit [**Hospital1 **]
CAMPHOR-MENTHOL [SARNA ANTI-ITCH] - 0.5 %-0.5 % Lotion - [**Hospital1 **] PRN
INSULIN SYRINGE-NEEDLE U-100 [BD INSULIN SYRINGE] - 28 gauge
MULTIVITAMIN - Tablet - 1 Tablet(s) by mouth daily
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Cardiopulmonary arrest
Cardiogenic shock
Septic shock
Diffuse bleeding with hypovolemic shock
Liver failure
Renal failure
Discharge Condition:
Deceased
Discharge Instructions:
N/A
[**Hospital1 **] Instructions:
N/A
Completed by:[**2137-10-29**]
ICD9 Codes: 5849, 5856, 0389, 5990, 5715 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3663
} | Medical Text: Admission Date: [**2190-4-13**] Discharge Date:
Date of Birth: [**2129-9-17**] Sex: F
Service: MEDICINE
This discharge summary will span the dates from admission
[**2190-4-13**], to [**2190-5-2**].
HISTORY OF PRESENT ILLNESS: The patient is a 60 year old
female who was sent to the Emergency Department secondary to
delta MS from a nursing home. She was noted to have
lethargy, decreased oxygen saturation in the low 80s. In the
Emergency Department, the patient was suctioned with
increased secretions and the saturation improved on a 40%
tracheostomy mask. Prior to this presentation, the patient
had had multiple complicated admissions, including from
[**2190-2-27**], to [**2190-3-3**], for hepatic artery stenosis, status
post dilatation and stent, complicated by acute renal failure
and multiple multiresistant organisms. The patient then was
admitted from [**2190-3-12**], to [**2190-4-9**], with elevated alkaline
phosphatase of unknown origin, episode of [**Year/Month/Day **]/sepsis
from a urinary tract infection and pneumonia requiring a
Medical Intensive Care Unit transfer, questionable dystonic
reaction to Phenergan, and intermittent left bundle branch
block with troponin leak, and intermittent delirium, pyloric
tube placed for feeding and diarrhea. In the Emergency
Department, the patient denied chest pain, abdominal pain,
fever, chills or sweats. She complained of shortness of
breath and needing suctioning. The shortness of breath
improved after suctioning. The patient also complained of
buttocks pain. In the Emergency Department, the patient
received Ceftazidime and Azithromycin. The patient was
unable to give significant history but nodded and shook her
head appropriately to questioning.
PAST MEDICAL HISTORY:
1. Recent admission [**2190-3-12**], to [**2190-4-9**], increased
alkaline phosphatase, sepsis, Medical Intensive Care Unit
transfer for delta MS [**First Name (Titles) **] [**Last Name (Titles) **].
2. Hepatitis C virus, status post liver transplant in
[**2189-1-31**], and redo transplant in [**2189-2-28**], after
hepatic artery stenosis, status post stent.
3. History of respiratory failure, status post tracheostomy.
4. Diabetes mellitus.
5. Hypertension.
6. Chronic renal insufficiency secondary to
immunosuppressive toxicity.
7. Chronic right pleural effusion.
8. Chronic anasarca.
9. Tricuspid regurgitation.
10. Depression.
11. History of VRE.
12. History of spontaneous bacterial peritonitis.
13. History of Clostridium difficile.
14. Pyloric tube placed.
15. Chronic obstructive pulmonary disease.
16. Gastroparesis.
17. Decubitus ulcers.
18. Anemia.
19. History of polysubstance abuse.
ALLERGIES: No known drug allergies.
MEDICATIONS ON TRANSFER:
1. Promote 45 cc/hour.
2. Plavix 75 mg once daily.
3. CellCept [**Pager number **] mg four times a day.
4. Aspirin 325 mg once daily.
5. Prevacid 30 mg once daily.
6. Paxil 20 mg once daily.
7. Vitamin C 500 mg twice a day.
8. Zinc 220 once daily.
9. Oxycodone 10 mg p.o. q4hours p.r.n.
10. Ativan 0.5 mg p.r.n.
11. Bactrim 400/80 once daily.
12. Lopressor 12.5 mg twice a day.
13. Albuterol and Atrovent nebulizers q6hours.
14. Reglan 10 mg three times a day.
15. Lasix 20 mg once daily.
16. Ursodiol 300 mg three times a day.
17. Nystatin Powder.
18. Prograf 0.5 mg twice a day.
19. Loperamide 2 mg four times a day.
PHYSICAL EXAMINATION: Admission vital signs revealed
temperature 98.6, pulse 90, blood pressure 127/76,
respiratory rate 30, oxygen saturation 100% on 40%
tracheostomy mask. In general, the patient nodded and shook
her head appropriately, appeared tired, oriented to the
hospital. Head, eyes, ears, nose and throat - The left pupil
is slightly larger than the right, bilaterally reactive.
Mucous membranes are moist. Tracheostomy was in place. The
heart was tachycardic without murmurs. The lungs revealed
decreased breath sounds one half way up on the right. The
abdomen was soft, nontender, no masses, no definite ascites.
Extremities - large pitting edema, warm. Sacral decubitus
was noted to be large but did not appear infected.
LABORATORY DATA: White blood cell count was 12.3, hematocrit
29.0, platelet count 639,000. INR 1.1. Sodium 140,
potassium 4.9, chloride 101, bicarbonate 30, blood urea
nitrogen 28, creatinine 1.0, glucose 118. ALT 21, AST 42,
LDH 242, alkaline phosphatase 1016, total bilirubin 0.6,
amylase 43, troponin 0.29, CK 14, albumin 3.0. Urinalysis
showed greater than 30 white blood cells with many bacteria.
Electrocardiogram showed sinus rhythm at 119, Q waves in V1
through V3, Q wave in III, T wave inversion in V4, biphasic T
waves in V2 and V3, flat T wave in aVL.
Chest x-ray showed a right PICC, postpyloric tube into the
duodenum, right sided pleural effusion, no changes.
HOSPITAL COURSE:
1. Pulmonary - On hospital day one, the patient had another
episode of acute hypoxia requiring transfer to the Intensive
Care Unit. The patient spent one night in the Intensive Care
Unit where she responded to frequent suctioning and nebulizer
treatments. The patient's sputum culture grew out
multiresistant Klebsiella and pseudomonas. It was felt that
these organisms were likely colonizers rather than
representing infection. However, early in her hospital stay,
the patient was having frequent episodes of desaturation and
she was started on Zosyn for possible pneumonia. As the
patient responded to suctioning and quickly improved her
oxygen saturation, it was felt that mucous plugging was the
most likely cause for hypoxia. She was treated with a seven
day course of Zosyn although it was felt that the said
organisms were more likely colonizers than infection. She
was also diuresed for some mild congestive heart failure but
the ultimate cause of her hypoxia was felt to be due to
inability to clear her secretions. She required frequent
suctioning and saline washes to try to reduce the viscosity
of the secretions. At the time of this dictation, the
patient has been stable from her pulmonary status, although
still requiring frequent respiratory therapy and suctioning.
In terms of her tracheostomy tube, it was noted that the
patient was unable to speak with her Passy-Muir valve in
place and it was wondered if there may be some upper airway
stenoses causing increased resistance. ENT was consulted and
noted no anatomical problem with the upper airway. Combined
effort between Speech and Swallow, ENT and Transplant
Surgery, it was felt that the patient would benefit from
slowly reducing the size of her tracheostomy and trying to
wean her off the tracheostomy. However, she continued to
have frank aspiration and therefore this was not a viable
option at this time. Additionally, the patient continued to
have problems clearing her own secretions as mentioned above
and thus a smaller diameter tracheostomy would increase the
difficulty with these secretions. Her tracheostomy was
changed by ENT to a #6 Shiley cuffed as it was felt that a
noncuff would increase the risks for aspiration events. The
patient continued to be too weak to speak with her Passy-Muir
valve and it was felt that the valve should not be used until
she demonstrated improvement in her strength, decreased her
aspiration and we were able to clear her secretions more
effectively.
2. Diarrhea - The patient continued to have profuse watery
diarrhea. It was unclear what the etiology was. The type of
tube feed was changed on a number of occasions to see if an
alimentary formula would improve the diarrhea, however, there
was not much change. Stool lytes were done, which showed
evidence of an osmotic diarrhea. The patient's CellCept was
titrated off thinking that that may be causing the diarrhea.
She was treated symptomatically with Loperamide and Tincture
of Opium. Ultimately, the diarrhea was resolved with the
stopping of the tube feeds altogether and changing to TPN for
nutrition. Additionally, Ursodiol was stopped and
Cholestyramine was started and this may have also contributed
to the resolution of the diarrhea.
3. Sacral decubitus - The patient with a large sacral
decubitus ulcer which was cared for by the wound care team
and then plastic surgery was consulted who did a bedside
debridement. The patient had considerable pain from this
ulcer and was treated with Oxycodone. There were frequent
wet to dry dressings performed. Initially, the diarrhea
complicated the matter as it was very difficult to keep the
wound area clean. However, once the diarrhea was under
control, this was less of a problem. There was a question of
whether this ulcer could have led to sacral osteomyelitis.
At the time of this dictation, that diagnosis was not
pursued.
4. Cardiology - The patient was noted to have episodes of
tachy/brady with heart rate going up into the 100 teens and
down into the 30s to 40s in a junctional pattern. Cardiology
was consulted. They felt that this was likely secondary to
her overall status and felt that there was nothing that could
be done at this point, that she was not a candidate for a
pacer and that this may improve as her overall health
improved. The patient's beta blocker was held for this
reason. There was no evidence that the patient became
symptomatic during these episodes of bradycardia.
5. Hypertension - The patient was hypertensive throughout
her stay and her ace inhibitor was slowly titrated up with a
close eye on her blood urea nitrogen and creatinine given her
history of acute renal failure, especially in the setting of
the Prograf use which was thought to be the likely culprit
during her last admission.
6. Liver - Her alkaline phosphatase remained approximately
where it had been, ranging between 800 and 1000. Again,
there was no clear etiology for this laboratory value. There
was a question of some form of rejection, although this was
never substantiated. The patient's immunosuppressives were
adjusted. As mentioned above, the CellCept was titrated off
and the Prograf was titrated up in its place. Imuran was
started as well.
7. Nutrition - The patient initially was fed with tube feeds
through a postpyloric nasogastric tube. This nasogastric
tube unfortunately fell out and a regular nasogastric tube
was placed. As mentioned above, due to the diarrhea, the
tube feeds were turned off and the patient was given
nutrition through TPN in its place. The patient remained NPO
due to her risk of aspiration.
8. Depression - The patient appeared extremely depressed and
at times appeared ready to give up on getting better. She
was on Paxil for depression although this was likely not
helping very much. A family meeting was held to discuss the
patient's code status and level of care desired, however, the
patient's family members did not attend. The patient
expressed her desire to continue with aggressive care and
remain full code.
9. Anemia - The patient's hematocrit slowly titrated down
throughout her stay. There were no signs of gastrointestinal
bleed although this could not necessarily be excluded. It
was felt to be due to blood draws and anemia of chronic
disease. She was treated with Epogen and transfused one unit
of packed red blood cells.
The remainder of this discharge summary as well as the
discharge diagnoses and medications will be dictated as part
of an addendum to this summary.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], M.D. [**MD Number(2) 22654**]
Dictated By:[**Name8 (MD) 13747**]
MEDQUIST36
D: [**2190-5-2**] 08:46
T: [**2190-5-2**] 10:58
JOB#: [**Job Number 44033**]
ICD9 Codes: 0389, 5119, 5990, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3664
} | Medical Text: Admission Date: [**2184-7-12**] Discharge Date: [**2184-7-15**]
Date of Birth: [**2113-4-2**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Lisinopril / Morphine
Attending:[**First Name3 (LF) 8587**]
Chief Complaint:
s/p fall with right ankle injury
Major Surgical or Invasive Procedure:
[**2184-7-12**]: I+D right ankle fracture
[**2184-7-12**]: ORIF right ankle fracture
History of Present Illness:
72 year old female, s/p fall with twisting injury to right ankle
Past Medical History:
CAD s/p MI x 3
CABG in 96
Cardiac Arrest During cath in [**8-20**]
AAA repair
Hypertension
Hypertension
Hyperlipidemia
Ruptured Appendix s/p partial colectomy
GI Bleed (large Vol on anticoagulation) colonoscopy found to
have Diverticulosis and Melanosis of entire colon
Social History:
Lives w Daughter
no tobacco
no etoh
Family History:
MI/death father at 61
Physical Exam:
Upon discharge:
AVSS
NAD
A+O
CTA b/l
RRR
S/NT/ND/+BS
RLE: bivalve in place c/d/i
incision c/d/i
wiggles toes
SILT
brisk cap refill
Pertinent Results:
[**2184-7-12**] 07:09PM GLUCOSE-128* UREA N-13 CREAT-0.7 SODIUM-141
POTASSIUM-4.4 CHLORIDE-109* TOTAL CO2-21* ANION GAP-15
[**2184-7-12**] 07:09PM CK(CPK)-131
[**2184-7-12**] 07:09PM CK-MB-5 cTropnT-<0.01
[**2184-7-12**] 07:09PM WBC-11.4* RBC-3.98* HGB-11.8* HCT-34.9*
MCV-88 MCH-29.7 MCHC-34.0 RDW-15.8*
[**2184-7-12**] 07:09PM PLT COUNT-243
[**2184-7-12**] 05:57PM TYPE-ART PO2-160* PCO2-38 PH-7.37 TOTAL
CO2-23 BASE XS--2 INTUBATED-INTUBATED VENT-CONTROLLED
[**2184-7-12**] 05:57PM GLUCOSE-136* LACTATE-1.6 NA+-139 K+-4.1
CL--107
[**2184-7-12**] 05:57PM HGB-11.7* calcHCT-35
[**2184-7-12**] 05:57PM freeCa-1.16
[**2184-7-12**] 02:00PM GLUCOSE-156* UREA N-16 CREAT-0.8 SODIUM-141
POTASSIUM-4.1 CHLORIDE-108 TOTAL CO2-20* ANION GAP-17
[**2184-7-12**] 02:00PM WBC-11.2*# RBC-4.16* HGB-12.3 HCT-36.2 MCV-87
MCH-29.6 MCHC-33.9 RDW-15.8*
[**2184-7-12**] 02:00PM NEUTS-87.6* LYMPHS-9.0* MONOS-3.0 EOS-0.2
BASOS-0.2
[**2184-7-12**] 02:00PM PLT COUNT-280
ANKLE (AP, MORTISE & LAT) RIGHT [**2184-7-12**] 1:23 PM
ANKLE (AP, MORTISE & LAT) RIGH
Reason: eval fx, disloctn
[**Hospital 93**] MEDICAL CONDITION:
71 year old woman with R tib fib fx
REASON FOR THIS EXAMINATION:
eval fx, disloctn
HISTORY: Right tibiofibular fracture.
RIGHT ANKLE, FOUR VIEWS: There is a fracture/dislocation of the
tibiotalar joint, including that of the medial and lateral
malleolus. The posterior malleolus appears to be intact as does
the talus. There is gas within the medial soft tissues. There is
lateral soft tissue irregularity, which appears to be open
communication to the skin surface. There are multiple fracture
fragments seen within the distal fibula.
Brief Hospital Course:
The patient was brought to the operating room on [**2184-7-12**] for I+D
and ORIF of her right ankle. See operative note for details.
She tolerated the procedure well. She was extubated and brought
to the recovery room in stable condition. Once stbale in the
PACU she was transferred to the floor. On the floor she did
well. She was evaluated by physical therapy and progressed
well. She was placed in a bivalve cast on POD#2. Her labs and
vitals remained stable. Her pain was well-controlled. Her
hospital course was otherwise without incident. She is being
discharged today in stable condition.
Medications on Admission:
Fosamax
Lasix
Aricep
Protonix
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
4. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
5. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours) for 4 weeks.
7. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) as needed for itching.
10. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-19**]
Drops Ophthalmic PRN (as needed).
11. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
12. Hydromorphone 2 mg/mL Syringe Sig: One (1) Injection Q6H
(every 6 hours) as needed.
13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
15. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
16. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Right open ankle fracture
Discharge Condition:
Stable
Stable
Discharge Instructions:
Please do not bear weight on your right foot. Use
crutches/walker for ambulation.
Please keep incision clean and dry. Dry sterile dressing daily
as needed under bivalve cast. If you notice any increased
redness, swelling, drainage, temperature >101.4, or shortness of
Take all medications as prescribed. You may continue any normal
home medications.
Please follow up as below. Call with any questions.
Physical Therapy:
Activity: Activity as tolerated
Right lower extremity: Non weight bearing
Treatments Frequency:
Keep wound clean and dry. Apply a dry sterile dressing as
needed. Bicalve cast at all times.
Call your doctor if you have any increased swelling, pain,
redness or temp >101.4.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] at the BIMCD orthopedic
clinic in 2 weeks. Call [**Telephone/Fax (1) **] to make an appointment.
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name12 (NameIs) **] OB/GYN Date/Time:[**2184-8-5**] 2:00
Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2184-8-27**] 11:20
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] & DR. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2184-8-27**] 11:40
Completed by:[**2184-7-15**]
ICD9 Codes: 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3665
} | Medical Text: Admission Date: [**2124-3-15**] Discharge Date: [**2124-3-21**]
Date of Birth: [**2055-1-24**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Aspirin / lisinopril / Wellbutrin / Seroquel
Attending:[**Doctor First Name 6807**]
Chief Complaint:
Palpitations during hemodialysis
Major Surgical or Invasive Procedure:
Radioablation (via right femoral access)
Hemodialysis
History of Present Illness:
69F with history of SVT/AT s/p ablation [**3-2**], CAD s/p two BMS in
LAD ([**9-26**]), depressed EF 35% ([**9-/2123**]), ESRD (HD M/W/F), who was
admited after developing palpitations during hemodialysis this
morning. She was able to complete the dialysis. She denies chest
pain, SOB, or lightheadedness during the episode. No
syncope/presyncope. She has a long history of becoming
tachycardic during HD; admitted at [**Hospital1 18**] last [**Month (only) **]. She
continues to breakthrough despite pharmacologic therapy with
metoprolol, and failed amiodarone. She undewent ablation by Dr.
[**First Name (STitle) **] on [**2124-3-2**].
.
She had been discharged yesterday from [**Hospital 882**] hospital after
admission for SOB and was found to have pulmonary edema. She
uses 2 pillows/day and wakes up SOB [**2-18**]/week. She has not
noticed any changes in her functional status recently. She lives
with her husband and is able to perform ADL.
.
In the ED, VS were T-98.2, P-130, BP-98/65, RR-16, 96% on RA;
triggerred for tachycardia. Received 500cc NS bolus. Labs
remarkable for troponin of 0.18 in the setting of ARF.
Past Medical History:
-Paroxysmal SVT/AT
-CAD; NSTEMI ([**9-26**]) BMS to LAD, RCA 100% occluded
-chronic systolic HF, LVEF 35%
-DM2
-Hypertension
-Hyperlipidemia
-CVA (residual R weakness and intermittent R facial droop)
-PAD
-ESRD on HD 3x/week: anuric, on HD for >5y
-Sleep apnea (not using CPAP)
-Seizure disorder since [**3-/2123**] on Keppra: one seizure per pt
-depression with psychosis
-GERD with gastric ulcer causing UGI [**3-/2123**]
-Cervical Disk disease
-Syncope and collapse
-diabetic retinopathy
-gout
-anemia
-carotid artery stenosis
-thyroid cancer (vastly fluctuating TSH)
.
PSHx:
-bariatric surgery
-cholecystectomy
-C section x3
-LUE braciocephalic AV fistula last angioplasty [**11-25**]
Social History:
Married, lives with husband. 2 sons, [**Name (NI) **] and [**Name (NI) 74998**] (HCP).
Able to perform ADL.
-Tobacco history: denies
-ETOH: denies
-Illicit drugs: denies
Family History:
No family history of early MI, arrhythmias, cardiomyopathies, or
sudden cardiac death. Mother died in her 70's of cancer. Father
was killed.
Physical Exam:
ADMISSION EXAM:
VS: T-98.3 P-128 BP-107/70 97% Sat on RA
GENERAL: Thin, pleasant elderly woman in NAD. Lethargic. Alert
and Oriented x3. Mood-appropriate. Affect-flat.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Mucous membrane
moist.
NECK: Supple with JVP of 8cm. Carotid bruits L>R. +Hepatojugular
reflex
CARDIAC: PMI nondisplaced, tachy, normal S1, S2. Difficult to
appreciate murmurs due to heart-rate. No rubs or thrills.
LUNGS: Unlabored, no accessory muscle use. Crackles in mid-lower
lung fields b/l. No wheezes or rhonchi. Scoliosis.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. [**Name (NI) 104848**] bruit over L brachiocephalic
fistula.
SKIN: Xerosis. No stasis dermatitis or ulcers.
PULSES: 1+ carotid, 1+ brachial, 1+ DP and PT.
NEURO: CN 2-12 grossly intact, motor strength and sensation
grossly intact bilaterally. 3/5 strength symmetric. No facial
droop or dysarthria.
.
DISCHARGE EXAM:
VS. 98.3 BP 109/58 (95-125/50-60) HR 87 18 100/RA fasting FS 111
Wt 55.4 kg
GENERAL: well-appearing elderly female sitting up in chair,
pleasant, alert and conversational, NAD.
NECK: supple, JVP 7 cm. Carotid bruits L>R.
CARDIAC: normal S1, S2. high-pitched holosystolic [**Name (NI) 9413**] best
@LUSB
LUNGS: prominent sternum/clavicle. respirations unlabored, no
accessory muscle use. bibasilar crackles, no wheezes or rhonchi.
Scoliosis.
ABDOMEN: Soft, NTND.
Pulse: palpable R femoral bruit (decreased from yesterday's
exam). warm, well-perfused RLE and LLE, warm feet, palpable
distal pulses, no edema
NEURO: AOX3, face symmetric, speech fluent but slow, moves all
extremities spontaneously
Pertinent Results:
ADMISSION LABS:
[**2124-3-15**] Glucose-109* UreaN-22* Creat-4.1*# Na-140 K-5.4* Cl-96
HCO3-32 AnGap-17 Calcium-9.3 Phos-3.4 Mg-2.0
[**2124-3-15**] WBC-4.6 RBC-3.16* Hgb-10.8* Hct-33.3* MCV-105*#
MCH-34.0* MCHC-32.3 RDW-13.7 Plt Ct-182 Neuts-74.5* Lymphs-15.2*
Monos-5.0 Eos-2.0 Baso-3.3*
.
DISCHARGE LABS
03/06/12Glucose-103* UreaN-48* Creat-6.7*# Na-139 K-3.9 Cl-96
HCO3-26 AnGap-21* Calcium-8.9 Phos-3.4 Mg-1.9
[**2124-3-21**] WBC-5.0 RBC-2.91* Hgb-9.8* Hct-29.9* MCV-103*
MCH-33.8* MCHC-33.0 RDW-14.9 Plt Ct-146*
.
OTHER PERTINENT LABS
[**2124-3-16**] TSH-2.5
.
IMAGING
CXR ([**2124-3-15**]):
FINDINGS: Single frontal view of the chest was obtained. There
are low lung
volumes, accentuate the bronchovascular markings. Fullness of
the hila and
mild perihilar opacities may relate to mild fluid overload
and/or crowding of vessels. No definite focal consolidation is
seen. No large pleural effusion or pneumothorax. Cardiac and
mediastinal silhouettes are grossly stable.
IMPRESSION: Low lung volumes with possible mild fluid overload.
Consider
repeat with better inspiration when patient able.
.
EKG
[**2124-3-15**]: HR 120, atrial tachycardia, Nl axis, normal interval,
nl R wave progression, no ST-changes.
[**2124-3-19**]: NSR 84
.
Microbiology:
[**2-/2041**] Blood culture (FINAL): NO growth
MRSA screen: NO MRSA isolated
.
[**3-17**] TTE
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 severely
depressed (LVEF= 20 %) secondary to extensive apical akinesis
and severe hypokinesis of the rest of the left ventricle with
the exception of the basal posterior and lateral walls, which
are relatively preserved. [Intrinsic left ventricular systolic
function is likely more depressed given the severity of valvular
regurgitation.] A left ventricular apical mass/thrombus cannot
be excluded with certainty. Tissue Doppler imaging suggests an
increased left ventricular filling pressure (PCWP>18mmHg). The
right ventricular free wall thickness is normal. The right
ventricular cavity is dilated with depressed free wall
contractility. [Intrinsic right ventricular systolic function is
likely more depressed given the severity of tricuspid
regurgitation.] The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. There is severe
mitral annular calcification. Severe (4+) mitral regurgitation
is seen. The tricuspid valve leaflets are mildly thickened.
Severe [4+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. [In the setting of at
least moderate to severe tricuspid regurgitation, the estimated
pulmonary artery systolic pressure may be underestimated due to
a very high right atrial pressure.] There is no pericardial
effusion.
Compared with the findings of the prior study (images reviewed)
of [**2123-10-7**], there has been marked further
deterioration of left ventricular contractile function as well
as marked increased in mitral and tricuspid regurgitation.
.
[**3-19**] R FEMORAL ULTRASOUND
FINDINGS: Focused vascular ultrasound of the right groin, the
common femoral artery and vein was performed with [**Doctor Last Name 352**]-scale,
color Doppler, and spectral analysis. Findings are concerning
for an AV fistula between the right common femoral artery and
vein, just proximal to the greater saphenous vein takeoff, where
there is turbulent, mixed broad waveform and suggestion of
connection between the two vessels. No evidence of
pseudoaneurysm is seen. No evidence of hematoma is seen in the
right groin.
IMPRESSION: Findings concerning for AV fistula between the right
common
femoral artery and vein. No evidence of pseudoaneurysm.
Brief Hospital Course:
69F with HX SVT, ESRD, CAD, PAD, and sCHF p/w symptomatic atrial
tachycardia to the 130s during outpatient dialysis; admitted for
management of this chronic problem, previously refractory to
pharmacologic therapy and a 1st ablation attempt on [**2124-3-2**];
during this admission she underwent a 2nd ablation attempt which
was not wholly successful (some intermittent Atach episodes
thereafter), and which was c/b a post-procedure R femoral AVF.
.
# ATRIAL TACHYCARDIA
Admitted from HD w/atrial tachycardia, a chronic intermittent
issues. Usually asymptomatic; now symptomatic w/lightheadedness
at HD. Admission EKG here documented atrial tachycardia to the
130s, no ischemic changes. Hemodynamically stable and
asymptomatic despite HR intermittently to the 130s. Underwent
successful ablation here on [**2124-3-16**], after which she was in NSR
for >24h. However, she did flip into atrial tachycardia
intermittently thereafter, with HR max 120s - episodes
self-resolved, occurred primarily during HD, and were
asymptomatic. Attempts to increase beta-blockade beyond Toprol
75mg PO QD were limited by BP. Patient will see Dr. [**First Name (STitle) **]
(electrophysiologist) in outpatient follow-up in ~1 week to
discuss any possible future intervenion. In the interim, at home
and at HD, her inpatient cardiologist felt comfortable
tolerating asymptomatic atrial tachycardia to the 120s-130s.
We note that on [**3-16**], post-procedure recovery was initially
complicated by anaesthesia-induced hypotension (requiring
overnight ICU obs) and later by the slow development of a R
femoral AVF (documented by ultrasound, see results). For the R
femoral AVF, vascular surgery consult service evaluated her
daily and recommended conservative management vascular surgery
f/u in 4 weeks. Expect spontaneous resolution.
.
# CHRONIC SYSTOLIC HEART FAILURE, LVEF 20%
TTE during this admission demonstrated LVEF 20%, MR 4+ TR 4+,
all worse than prior. MR [**First Name (Titles) 9413**] [**Last Name (Titles) **] on exam. Ischemic vs.
tachycardia-induced cardiomyopathy suspected as underlying
cause. She was euvolemic during admission; volume/BP control
primarily via BB and dialysis. Imdur was stopped due to relative
hypotension (SBP 90s-110s). Metoprolol dose increased to Toprol
75 mg QD. We note hx lisinopril allergy; considered started [**First Name8 (NamePattern2) **]
[**Last Name (un) **] but deferred this for outpatient f/u in setting of
borderline BPs.
.
# ORTHOSTATIC HYPOTENSION
Patient's BP fell to 75/palp when working w/PT on [**3-20**]. Family
confirmed that she suffers from lightheadedness when she first
rises to stand, especially after watching television (she like
Westerns). Imdur had already been stopped prior to this PT eval;
BB was subsequently lowered from Toprol 100 QD to 75 QD (further
decrease thought inappropriate given need to control atrial
tachycardia). She worked with PT twice more and was instructed
on techniques to decrease orthostatic symptoms and prevent
falls. Outpatient PT arranged at discharge.
.
# DM2
Patient has known DM2, not on either oral hypoglycemics or
insulin. Insulin needs here ranged from 8-12U/day. Discussed
initiating insulin w/pt, but she refused. [**Month (only) 116**] require ongoing BS
evaluation/discussion of therapeutic options as an outpatient.
.
INACTIVE ISSUES
.
# CAD
Patient w/ significant 2V CAD (LAD stented w/BMS x2, RCA
occluded 100% on [**9-/2123**] cath). EKGs negative for evidence of
restenosis or ischemic changes. No chest pain or dyspnea.
Continued Plavix and ASA 81mg.
.
# CHRONIC ANEMIA
Chronic; family confirms that she receives Epo at outpatient HD.
Denies h/o melena or GI bleeding. Hct remained stable ~30.
.
# ESRD:
Longstanding, on qMWF schedule. No difficulty w/LUE AV fistula
access. Atrial tachycardia episodes occurred primarily during HD
sessions, were asymptomatic and self-resolved within minutes.
See above for cardiology plan re: any future asymptomatic ATach
during HD.
.
# Hx Hypothyroidism s/p thyroidectomy
TSH wnl at admission. Continued home dose of synthroid.
.
# Hx HLD
Continued home statin.
.
# Hx Seizure disorder
One seizure in the past per patient. Continued home Keppra. No
seizure activity observed.
.
TRANSITIONAL ISSUES
1. EP to reassess for possible future repeat ablation attempt
2. DM2 - Pt refused discussion of insulin, had 8-12U/day insulin
requirement. [**Month (only) 116**] need further discussion/education about risks
of continuing with dietary control and without any medical
management.
3. Worsening sCHF (35%->20%). Suspected declining LVEF due to
tachycardia-induced crdiomyopathy [**2-17**] long-standing Atrial
Tachycardia. Suggest repeat TTE in [**4-21**] mos to reassess LVEF, MR
and TR once rate better controlled.
4. Follow-up HR, BP, orthostatic VS. Toprol dose increased to
75mg po DAILY, imdur stopped.
5. Follow-up logistics of outpatient PT, recommended by
inpatient PT consult
6. Monitor exam for changes in R femoral AVF (vascular surgery
f/u arranged)
6.
Medications on Admission:
1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Tablet(s)
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
4. aripiprazole 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
5. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
6. calcium acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
7. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO ONCE
(Once) for 1 doses.
9. levothyroxine 100 mcg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
10. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
11. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
14. senna 8.6 mg Tablet Sig: 1-2 Tablets PO DAILY (Daily).
15. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
16. metoprolol succinate 50mg po qday
Discharge Medications:
1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. aripiprazole 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
4. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
5. calcium acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
6. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. levothyroxine 100 mcg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
9. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
10. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
13. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
15. Toprol XL 25 mg Tablet Extended Release 24 hr Sig: Three (3)
Tablet Extended Release 24 hr PO once a day.
Disp:*90 Tablet Extended Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
1. Atrial tachycardia
2. Coronary artery disease
3. Depressed ejection fraction
4. End-stage renal disease
5. Hypothyroidism
6. Type 2 Diabetes
7. Hypertension
8. Sleep Apnea
9. Seizure disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. [**Known lastname **],
.
It was a pleasure taking care of you when you were admitted for
rapid heart rate during dialysis similar to the episodes you
have experienced in the past.
.
During this hospital stay, you underwent an ablation procedure.
The procedure was successful - you developed occasional rapid
rates but eventually returned to [**Location 213**] sinus rhythm. Dr. [**First Name (STitle) **]
will see you in follow-up to discuss whether you might need
another ablation procedure if you develop rapid heartrate again.
We noticed that you were lightheaded and had slightly low blood
pressures when you first stand up, especially on dialysis days.
You worked with a physical therapist here who gave
recommendation about standing up slowly to avoid lightheadedness
and falls. We also adjusted your medications to minimize
symptoms.
You had elevated blood sugars here, to >300 on more than 1
occassion. On average, you received 12 units of insulin/day to
control your blood sugar. You did not want to start diabetes
medications. You should discuss this further with your PCP, [**Name10 (NameIs) 3**]
you should be taking medication to control high blood sugar at
home.
The following changes were made to your medications:
CHANGED METOPROLOL FORMULATION:
START TAKING TOPROL XL 75 MG PER DAY (EXTENDED RELEASE). DON'T
TAKE YOUR OLD METOPROLOL/LOPRESSOR PILLS.
STOP TAKING IMDUR
Review your medication list with your PCP and cardiologist at
your next appointment. Please keep your follow-up appointments
as scheduled below.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] M.
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 3530**]
Appointment: Tuesday [**2124-3-28**] 11:00am
Name: Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **]
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2258**]
Appointment: Friday [**2124-3-31**] 1:10pm
Department: VASCULAR SURGERY
When: WEDNESDAY [**2124-4-19**] at 2:45 PM [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: VASCULAR SURGERY
When: WEDNESDAY [**2124-4-19**] at 3:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD [**Telephone/Fax (1) 2625**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital1 641**]
Address: [**Street Address(2) 34126**] [**Location 1268**], [**Numeric Identifier 3883**]
Phone: [**Telephone/Fax (1) 38275**]
Appointment: Thursday [**2124-4-27**] 2:10pm
*You did have an appointment scheduled for tomorrow which has
been cancelled. If you have any questions or concerns please
call the office.
ICD9 Codes: 5856, 4254, 2724, 412, 4280, 4240 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3666
} | Medical Text: Admission Date: [**2140-2-16**] Discharge Date: [**2140-2-27**]
Date of Birth: [**2060-6-21**] Sex: F
Service: NEUROLOGY
Allergies:
Haldol / Seroquel
Attending:[**First Name3 (LF) 4583**]
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a 79 year old woman with a history of narcolepsy
with cataplexy and NPH s/p VPS in [**2137**] who presented s/p fall.
The patient fell in her bathroom on Tues [**2-16**]. She hit her head
on the toilet, but did not lose consciousness. She crawled to
the living room, where a nurse found her. She was originally
admitted to [**Hospital3 17921**] Center, where a CT scan showed a
1cm right frontal subdural bleed. She was transferred from CMC
to [**Hospital1 18**]. On arrival to the ED, she had vitals T97.4 BP 120/74
HR 74 R 16 O2 98% RA. Exam was deferred because the patient was
"uncooperative." A repeat head CT showed that the SDH had not
increased in size, there was no new hemorrhage and the VPS shunt
was in place.
Past Medical History:
1. Narcolepsy w/cataplexy, as above
2. NPH s/p VP shunt in [**2137**] (@OSH) -- last shunt series was in
[**9-/2139**], unremarkable, and NCHCT at that time showed decompressed
ventricular system (albeit with no prior images for comparison)
3. s/p lumbar spine fusion complicated by MRSA bacteremia,
requiring R-knee hardware removal and replacement; chronic
Bactrim Tx since that time.
4. s/p bilateral knee replacements and repeat of R-knee after
MRSA-bacteremia in [**2132**]-[**2133**]
5. Frequent, recurrent UTIs
6. h/o chest pain with + cardiac stress in [**2139**] (details unknown
to me at this time -- no echo or vessel/stress data in OMR...
ECGs appear benign here and patient has been asx and HDS here)
7. s/p Thyroid ablation, Thyroid nodules, being monitored
8. s/p cholecystectomy
9. Osteoarthritis
10. chronic spastic bladder (Vesicare recently d/c'd)
11. chronic mild dysphagia (cause = ?) on mech soft diet and
thin
liquids. also, pt has only upper dentures
Social History:
Originally from [**Location (un) **], [**State 3914**]. Retired; from various retail
jobs
in the past. Lived in [**State 108**] for 20 years before moving
up to [**State 2748**] in mid-[**2128**] and then [**Hospital1 1501**] here in [**Month (only) **].
Remote smoking Hx (quit 50y ago). Does not drink EtOH. Denies
h/o
EtOH or substance abuse.
Family History:
Daughter - mitral valve disease. Maternal GM with
ateriosclerosis. Breast Ca in Sister. Arthritis in siblings.
Physical Exam:
ADMISSION EXAM
98.0 114/71 59 18 96%RA.
MS: A&OX3. She is fluent with normal prosody. She did not
participate in memory recall or attention questions.
Cranial Nerves:
CNI: Not tested.
CNII: L pupil 3mm-->2mm. R pupil 3mm-->2mm. Visual fields full
to
confrontation.
CNIII, IV, VI: Extraocular movements intact. No nystagmus.
V: Sensitive to light touch in V1,2 and 3 distributions. Able to
clench jaw.
VII: No facial droop. Able to smile without asymmetry. Unable to
overcome eye closure bilaterally.
VIII: Able to hear finger-rub bilaterally.
IX, X: Able to elevate palate. Gag reflex not tested.
[**Doctor First Name 81**]: SCM and shoulder shrug are full strength bilaterally.
XII: Tongue protrudes midline.
Motor: Normal bulk, tone throughout. No adventitious movements
noted. No pronator drift.
[Delt] [Bic] [Tri] [ECR] [IO] [IP] [Quad] [Ham] [TA] [Gas]
[[**Last Name (un) 938**]]
[C5] [C5] [C7] [C6] [T1] [L2] [L3] [L5] [L4] [S1] [L5]
L 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5
-Sensory: Sensitive to light touch and pinprick sensation in
bilateral upper and lower extremities.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 3 3 3 1 1
R 3 3 3 1 1
Plantar response was flexor on L and R.
Coordination: Able to perform finger-to-nose bilaterally. Slowed
cadence on L rapid finger movements; right rapid finger
movements
were normal.
DISCHARGE EXAM:
97.9 97.0 131/57 61 18
MS: A&OX month/date, but not to place, hospital. Can attend to
the examiner. Perserverates on "thank you" but can answer some
questions appropriately. Follows most commands.
Motor: Normal bulk, tone throughout. No adventitious movements
noted. No pronator drift.
[Delt] [Bic] [Tri] [ECR] [IO] [IP] [Quad] [Ham] [TA] [Gas]
[[**Last Name (un) 938**]]
[C5] [C5] [C7] [C6] [T1] [L2] [L3] [L5] [L4] [S1] [L5]
L 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5
-Sensory: Sensitive to light touch in bilateral upper and lower
extremities.
- Coordination: Able to perform finger-to-nose bilaterally.
Pertinent Results:
Cardiovascular Report ECG Study Date of [**2140-2-16**] 2:09:40 PM
Sinus rhythm. Diffuse modest ST-T wave changes which are
non-specific.
Compared to the previous tracing of [**2139-9-27**] there are modest
inferior
ST-T wave changes which are more pronounced.
Read by: [**Last Name (LF) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10592**]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
89 192 84 384/434 55 44 24
_____________________________
Radiology Report CT C-SPINE W/O CONTRAST Study Date of [**2140-2-16**]
2:06 PM
IMPRESSION:
1. Moderate degenerative changes.
2. No evidence for fracture.
3. Findings at the lung apices suggesting pulmonary vascular
congestion.
4. Heterogeneous thyroid probably reflecting nodules which could
be examined in more detail by ultrasound if clinically
indicated.
_______________________________
Radiology Report HIP 1 VIEW Study Date of [**2140-2-16**] 10:36 PM
CONCLUSION:
No good evidence of acute fracture.
_______________________________
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2140-2-17**]
6:56 AM IMPRESSION:
1. No gross change in the size of the right frontal subdural
hematoma or its mild mass effect.
2. No new focus of hemorrhage.
3. Stable prominence of the ventricles with a ventriculostomy
catheter in
unchanged position.
[**2140-2-16**] 02:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
[**2140-2-16**] 02:40PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2140-2-16**] 02:40PM PT-11.9 PTT-32.1 INR(PT)-1.1
[**2140-2-16**] 02:40PM PLT COUNT-232
[**2140-2-16**] 02:40PM NEUTS-80.1* LYMPHS-16.1* MONOS-3.2 EOS-0.6
BASOS-0.1
[**2140-2-16**] 02:40PM WBC-6.8 RBC-3.61* HGB-10.8* HCT-32.4* MCV-90#
MCH-30.0 MCHC-33.4 RDW-12.6
[**2140-2-16**] 02:40PM CALCIUM-9.2 PHOSPHATE-3.1 MAGNESIUM-2.0
[**2140-2-16**] 02:40PM CK-MB-2
[**2140-2-16**] 02:40PM cTropnT-<0.01
[**2140-2-16**] 02:40PM CK(CPK)-30
[**2140-2-16**] 02:40PM estGFR-Using this
[**2140-2-16**] 02:40PM GLUCOSE-96 UREA N-28* CREAT-0.9 SODIUM-138
POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-29 ANION GAP-11
[**2140-2-16**] 04:02PM PLT COUNT-230
TSH 3.8, FT4 0.99, CRP 31.8, ESR 58
[**2-16**] Urine Cx negative
[**2-22**] Urine Cx
[**2140-2-22**] 2:07 pm URINE Site: NOT SPECIFIED
[**Doctor Last Name **] TOP HOLD # 61549F [**2-22**] 2:07PM.
**FINAL REPORT [**2140-2-25**]**
URINE CULTURE (Final [**2140-2-25**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
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
_________________________________________________________
ESCHERICHIA COLI
|
AMIKACIN-------------- <=2 S
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- =>16 R
Brief Hospital Course:
79yoF with a history of narcolepsy with cataplexy and NPH s/p
VPS in [**2137**] who presented s/p fall with SDH diagnosed on head CT
[**2-16**].
[] Subdural Hemorrhage. On [**2-16**], patient was admitted to the
SICU and monitored overnight. A repeat Head CT was done on the
morning of [**2-17**] which showed that the SDH had not increased in
size, there was no new hemorrhage and the VPS shunt was in
place. No focal deficits were identified on serial neuro exams.
She was started on Dilantin 100 mg TID. On [**2-17**], the patient was
transferred to the step-down unit. She remained neurologically
intact. Physical therapy consult was initiated and patient was
able to be OOB with assistance. On [**2-18**], the Dilantin level was
1.8 and the patient was transitioned to Keppra 500mg po BID. On
[**2-21**], the patient was transferred to inpatient neurology for
further management. She has no further seizures. Levetiracetam,
despite its possible behavioral effects, was thought to be the
best choice (other than phenytoin) for prevention of seizures
from intracranial hemorrhage.
[] Narcolepsy. Per daughter, the patient's narcolepsy appears to
be worse in the hospital. She was having more episodes of
cataplexy and falling asleep more frequently. On [**2-22**], the
patient's neurologist Dr. [**Last Name (STitle) **] was [**Name (NI) 653**], and he asked
that her Venlafaxine be changed from [**Hospital1 **] dosing to once daily
(in the morning) as previously prescribed. After much
discussion, her prior medication of Xyrem will likely be
restarted as an outpatient (3.75 at bedtime and 3.75 grams [**3-20**]
hours later). If that is the case, her Olanzapine will need to
be stopped, and her Venlafaxine and Sertraline will need to be
readdressed as to their utility. She will follow-up with Dr.
[**Last Name (STitle) **] after discharge.
***Once XYREM is restarted, please contact Dr. [**Last Name (STitle) **] at
[**Telephone/Fax (1) 6856**] to determine what other medications should be
discontinued. DO NOT ADMINISTER OLANZAPINE (ZYPREXA) IF XYREM IS
RESTARTED.***
[] Combativeness/Aggression. On [**2-17**] and [**2-18**], the patient was
agitated and combative, requiring restraints on both nights. She
had not been written for olanzapine as she previously was
prescribed. She was found to have received twice her normal dose
of Zyprexa in the previous day. The patient was returned to her
home (QHS) dose of the medication on [**2-19**]. Her mental status
improved. She has been alert and oriented x3 and intermittently
x2 since then. She has been off restraints for more than 24
hours and has been much calmer after treatment of her UTI and
correction of her medications.
[] Chest pain. On [**2-20**], the patient reported brief chest pain
and several gagging episodes associated with coughing but no
frank vomiting. EKG was normal. Cardiac enzymes x2 were normal.
CXR showed atelectasis. The transient chest pain associated with
gagging episode was attributed to GERD, and famotidine was
started empirically. Due to potential anticholinergic effects,
Geriatrics recommeded changing to an alternate medication.
Calcium carbonate was used instead.
twice daily
[] Right arm pain. On [**2-19**] the patient complained of right
elbow pain which was diffuse and more painful with movement. A
right elbow xray was ordered and appeared grossly normal.
[] UTI. The patient has a history of recurrent UTIs. She had a
normal UA and UCx on admission but was subsequently
catheterized. The second urinary culture grew E.coli resistant
to TMP-SMX and Ciprofloxacin but sensitive to Ceftriaxone. She
has been afebrile and denies any symptoms. She was treated with
Cefpodoxime 200 mg [**Hospital1 **] x 7 days.
PENDING STUDIES:
TRANSITIONAL CARE ISSUES:
[ ] ***XYREM - Once XYREM is restarted, please DO NOT ADMINISTER
OLANZAPINE. Contact Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 6856**] if any
questions
] Anti-convulsant - She will remain on prophylactic
Levetiracetam at the discretion of Dr. [**Last Name (STitle) **]. This will
likely not need to be an indefinite treatment. Please consider
obtaining an outpatient EEG.
[ ] Hypothyroidism - The patient's TSH was 3.8 but not above the
upper limit of normal. Consider checking a TSH level as an
outpatient.
[ ] GERD. The patient was placed on Calcium carbonate
empirically for treatment of suspected reflux/GERD which
manifested as spitting up and burning substernal pain while
eating.
[ ] Antipsychotics - The patient should not be given too much
olanzapine as this can be oversedating. Avoid giving olanzapine
during the day. The QHS dose appears to be working well with
maintaining her sleep wake cycle and minimizing agitation. If
XYREM is restarted, STOP Olanzapine.
[ ] Venlafaxine - This should be given during the morning; she
was prescribed for twice daily dosing at her prior facility
which may have contributed to insomnia and sundowning.
[ ] Recurrent UTIs - Consider checking a urinalysis if she
develops significant behavioral changes as she often has
behavioral changes triggered by urinary tract infections. Her
last UA in the hospital was equivocal but the urine culture grew
>100,000 E.coli. Macrobid may not be a good choice for
prevention of UTIs as it may precipitate renal failure. Please
complete the treatment of her UTI with Cefpodoxime.
[] Aspiration risk - She can fall asleep while eating, which
contributes to her episodes of gagging/spitting up. She should
be under full aspiration precautions.
[] Blood pressure control - Her goal SBP is <160 because of her
subdural hemorrhage. We started her on Norvasc 2.5 once daily in
the hospital in addition to her metoprolol 25 mg [**Hospital1 **].
Medications on Admission:
1. venlafaxine 37.5 mg Capsule, Ext Release 24 hr Sig: Three (3)
Capsule, Ext Release 24 hr PO DAILY (Daily).
2. sertraline 50 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
3. clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)).
4. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: Two (2)
Tablet PO BID (2 times a day).
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain or fever>101F.
11. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. cefpodoxime 100 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 5 days: Course to finish on [**1-3**].
13. donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
14. Zyprexa 2.5 mg Tablet Sig: 0.5 Tablet PO twice a day as
needed for agitation.
Discharge Medications:
1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. doxycycline hyclate 100 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily): for MRSA prophylaxis.
Disp:*30 Capsule(s)* Refills:*2*
5. donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours) as needed for pain or fever > 101.5.
9. olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
10. venlafaxine 150 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day: in the morning.
Disp:*30 Tablet Extended Rel 24 hr(s)* Refills:*2*
11. sertraline 50 mg Tablet Sig: Three (3) Tablet PO at bedtime.
12. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
Take only if systolic blood pressure >160.
Disp:*30 Tablet(s)* Refills:*2*
13. docusate sodium 100 mg Tablet Sig: One (1) Tablet PO twice a
day.
14. cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours) for 6 days: for treatment of E.coli UTI.
Disp:*24 Tablet(s)* Refills:*0*
15. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
Disp:*60 Tablet, Chewable(s)* Refills:*2*
16. Xyrem 500 mg/mL Solution Sig: 3.75 mg PO twice nightly:
administer 3.75 mg by mouth at bedtime and 3.75 mg by mouth [**3-20**]
hours later.
Disp:*2 weeks* Refills:*0*
17. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
Arbors House
Discharge Diagnosis:
Primary Diagnosis: Right Frontal Subdural Hemorrhage, Urinary
Tract Infection
Secondary Diagnosis: Cataplexy, Narcolepsy, Normal Pressure
Hydrocephalus, Dementia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Neurologic: Awake, alert, oriented to place, hospital, time.
Speech fluent and answers most questions appropriately.
Otherwise nonfocal.
Discharge Instructions:
Mrs. [**Known lastname 90667**] was hospitalized after a traumatic fall and was
found to have a SUBDURAL HEMORRHAGE (right frontal). She was
admitted to the Neurosurgery service initially for management of
the subdural hemorrhage. She was later transferred to Neurology
for titration of her medications. The following changes were
made to her medications to address the risk of seizures from her
subdural hemorrhage and also address her narcolepsy and
behavioral issues:
1. She was started on LEVETIRACETAM 500 MG twice daily for
prevention of seizures from her subdural hemorrhage. She was
initially started on Phenytoin which was not an effective option
for her. These two medications have the best evidence for
preventing seizures from intracranial hemorrhages.
2. Her VENLAFAXINE XR was changed to 150 MG every morning. This
was prescribed twice daily prior to her admission, but it may be
worsening insomnia and night time agitation. Thus, at this time,
she should only receive this in the morning as previously
prescribed by Dr. [**Last Name (STitle) **].
3. She should take OLANZAPINE 2.5 MG at night to help with sleep
and night-time agitation. Doses of this medication should be
avoided during the day if possible. She may not need this
medication in the long term.
4. She may take DOXYCYCLINE HYCLATE 100 MG each day for MRSA
prophylaxis. Please discontinue if felt to be not indicated.
5. We are starting her on AMLODIPINE 2.5 MG per day to help
attenuate her blood pressure. Her goal SBP should be below 160
due to the subdural hemorrhage, but please avoid hypotension
(SBP < 100).
6. She was prescribed CEFPODOXIME 200 MG twice daily for a total
of 7 days for treatment of an E.coli UTI (complicated, possibly
related to urinary catheter).
7. She may restart XYREM at 3.75 mg twice per night (at bedtime
and 3-4 hours later). Once this medication is restarted, please
contact Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 6856**] to determine what other
medications should be discontinued. DO NOT ADMINISTER OLANZAPINE
IF XYREM IS RESTARTED.
She may take her other medications as previously prescribed and
listed on this worksheet.
Please place strict aspiration precautions and monitor her while
eating as she may have narcolepsy episodes while eating.
She should see Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **] as scheduled. Please
call Dr.[**Name (NI) 9034**] office as listed below to have a Neurosurgery
followup appointment scheduled. Please arrange for a time for
Mrs. [**Known lastname 90667**] to see her primary care physician and have
further followup on her thyroid as an outpatient.
It was a pleasure providing Mrs. [**Known lastname 90667**] with care during this
hospitalization.
Followup Instructions:
SLEEP NEUROLOGY Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) **] & [**Doctor Last Name **]
Phone:[**Telephone/Fax (1) 6856**]
Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) **] & [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 6856**]
Date/Time:[**2140-3-8**] 4:45
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
COGNITIVE NEUROLOGY Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 658**], M.D.
Phone:[**Telephone/Fax (1) 1690**] Date/Time: [**2140-3-15**] 8:30, [**Hospital1 **]
Building: Ks [**Hospital Ward Name 860**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
NEUROSURGERY - Please call ([**Telephone/Fax (1) 88**] to schedule an
appointment with Dr. [**Last Name (STitle) **], to be seen in [**4-22**] 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.
PRIMARY CARE - Please follow up with your primary care physician
[**Last Name (NamePattern4) **] [**2-20**] weeks regarding findings on your CT Neck which was
consistent with Heterogeneous thyroid probably reflecting
nodules which could be examined in more detail by ultrasound if
clinically indicated.
ICD9 Codes: 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3667
} | Medical Text: Admission Date: [**2119-3-20**] Discharge Date: [**2119-3-27**]
Date of Birth: [**2033-10-3**] Sex: M
Service: MEDICINE
Allergies:
Bactrim DS
Attending:[**First Name3 (LF) 1943**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Thoracentesis [**3-22**]
Bronchoscopy with biopsy [**3-23**]
History of Present Illness:
This is an 85-year old gentleman with 6 months of dyspnea and
recent diagnosis of likely right upper lung primary cancer with
diffuse mets, and recent thoracentesis diagnostic on the right,
who is presenting with worsening dyspnea 24 hours after a
thoracentesis. He has a 15 pack year smoking history (quit 20
years ago) presenting with worsening shortness of breath and
cough for the past few months. He explains that he has had
worsening dyspnea with exertion for the past few months which
has now progressed to shortness of breath even at rest. He has
also noticed a worsening cough during this time. No hemoptysis
but occassionally lightly brown tinged sputum. He denies any
chest pain, fevers or chills. He reports a mild lost of weight
and with decreased appetite over the past few months.
A chest x-ray on [**2119-3-14**] showed two large pulmonary masses in the
right upper lobe (6.7 x 5.9 and 3.9 x 2.6 cm) as well as several
additional nodular opacities in both lower lobes. A subsequent
CT showed stage IV lung cancer with right upper lobe primary,
satellite nodules, bibasilar metastases, and bilateral effusions
right greater than left.
He was seen by IP on [**3-16**] who performed a right-sided ultrasound
guided thoracentesis removing 1250 cc of fluid. He initially
felt better however in the last few days he started having
worsening shortness of breath and difficulty lying flat. No
chest pain and no fever.
On arrival to the ED his initial VS were 97.8 140/52 60 24 sat
92% on room air. A chest x-ray showed worsening pleural
effusions. He was sent for a CTA to rule out a PE. He was given
1L NS prior to the CTA. Per report during the CTA, while lying
flat and receiving the contrast, he became more acutely short of
breath with increasingly labored breathing, tachypneic to 30,
and desaturating to 86% on 3L NC. Expiratory wheezes and
crackles bilaterally were appreciated. He was given duonebs,
40mg IV lasix, and started on a nitro drip at 0.42 mcg/kg/min. 1
SL NTG was also given. An EKG showed atrial flutter with 4:1
conduction but no ischemic changes. He was subsequently
saturating 80% on FM and so was started on BiPAP, a foley was
placed, and he was admitted to the ICU.
Vital signs at the time of transfer were hr 57 bp 135/55 80% on
FM, 99%/BiPAP.
On arrival to the MICU the patient appeared to be in no acute
distress and was breathing comfortably with sats of 93% on 5L
NC.
Past Medical History:
Diabetes mellitus type 2
Hypertension
Hypercholesteremia
Difficulty with swallowing
Coronary artery disease
Congestive heart failure
Peripheral vascular disease
Chronic venous insufficiency in the legs
Urinary incontinence
Gout
Osteoarthritis
Chronic kidney disease
Retinal detachment
Past Surgical History:
S/p right hernia repair
S/p cataract removal
S/p thyroid adenoma excision
S/p TURP
S/p tonsilectomy
Repair of Zenker's diverticulm
Social History:
Tobacco: 15 pack years, quit 20 years ago
Alcohol: None and none in the past
Occupation: Lives with son, daughter and wife. Retired doctor [**First Name (Titles) **] [**Last Name (Titles) 24809**]l surgery.
Family History:
No lung cancer or congenital lung diseases
Father: Died of old age (70s) but had a history of a colectomy
of unknown reason
Mother: Deceased age 57 unknown reasons.
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: 85 145/106 rr 23 sat 93%/5L NC
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: diminished breath sounds on right, bibasilar crackles
left > right, no wheeze, dullness to percussion over right upper
fields
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
GU: foley in place
Ext: 1+ edema, warm, well perfused, 2+ pulses, no clubbingm or
cyanosis
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
DISCHARGE PHYSICAL EXAM
VS: Afebrile, O2 sat 90-93% on room air at rest; 88% on room air
while ambulating, weight 171#
GEN: NAD
CHEST: Symmetric breath sounds, but with bibasilar rales
CV: RRR
Pertinent Results:
ADMISSION LABS
[**2119-3-20**] 04:53AM BLOOD WBC-8.0 RBC-4.48* Hgb-12.0* Hct-40.2
MCV-90 MCH-26.9* MCHC-29.9* RDW-15.7* Plt Ct-226
[**2119-3-20**] 04:53AM BLOOD Neuts-76.3* Lymphs-10.9* Monos-5.5
Eos-6.9* Baso-0.5
[**2119-3-20**] 04:53AM BLOOD PT-11.1 PTT-32.8 INR(PT)-1.0
[**2119-3-20**] 04:53AM BLOOD Glucose-141* UreaN-32* Creat-1.3* Na-139
K-4.8 Cl-104 HCO3-25 AnGap-15
[**2119-3-20**] 04:53AM BLOOD proBNP-2434*
[**2119-3-20**] 04:53AM BLOOD cTropnT-0.02*
[**2119-3-20**] 12:43PM BLOOD CK-MB-2 cTropnT-<0.01
[**2119-3-20**] 04:15PM BLOOD CK-MB-2 cTropnT-0.01
[**2119-3-20**] 12:43PM BLOOD CK(CPK)-25*
[**2119-3-20**] 04:15PM BLOOD CK(CPK)-31*
[**2119-3-20**] 04:15PM BLOOD Calcium-8.2* Phos-3.6 Mg-2.1
[**2119-3-20**] 08:37AM BLOOD Lactate-0.8
DISCHARGE LABS
[**2119-3-26**] 09:18AM BLOOD WBC-8.8 RBC-4.39* Hgb-12.1* Hct-38.9*
MCV-89 MCH-27.5 MCHC-31.0 RDW-16.2* Plt Ct-215
[**2119-3-26**] 09:18AM BLOOD Glucose-158* UreaN-45* Creat-1.5* Na-137
K-3.9 Cl-100 HCO3-28 AnGap-13
[**2119-3-26**] 09:18AM BLOOD Calcium-8.7 Phos-3.3 Mg-2.1
MICROBIOLOGY
[**2119-3-20**] Blood Culture: No growth
IMAGING
[**2119-3-20**] ECG: Atrial flutter with 4:1 block or this may be
consistent with atrial tachycardia with 4:1 block. Non-specific
septal and inferior ST-T wave changes. Compared to the previous
tracing of [**2118-11-3**] findings are similar
[**2119-3-20**] CHEST (PA & LAT): Known right upper lobe lung mass, and
multiple bibasilar pulmonary nodules, redemonstrated. CHF. Mild
increase in the moderate right pleural effusion, and stable left
pleural effusion.
[**2119-3-20**] CTA CHEST W&W/O C&RECONS, NON-CORONARY: Metastatic lung
cancer, with a right upper lobe primary mass and multiple
satellite metastatic nodules in both lungs, not significantly
changed since the earlier study of [**2119-3-14**]. Moderate right and
small left pleural effusion, have slightly enlarged since
[**2119-3-14**], especially given the fact that the patient underwent a
right thoracentesis in the interim. Increasing bibasilar
atelectasis. No acute pulmonary embolism or thoracic aortic
pathology.
[**2119-3-20**] CT HEAD W/O CONTRAST: No acute intracranial pathology.
Moderate-to-severe involutional changes and small vessel
ischemic disease. No evidence of metastatic disease. Please note
that a non-enhanced MRI
study would be more sensitive for metastatic disease.
[**2119-3-21**] TTE: The left atrium is moderately dilated. The right
atrium is moderately dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). The estimated
cardiac index is normal (>=2.5L/min/m2). The diameters of aorta
at the sinus, ascending and arch levels are normal. The
descending thoracic aorta is mildly dilated. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve leaflets are structurally normal. There is no
mitral valve prolapse. Moderate (2+) mitral regurgitation is
seen. There is mild pulmonary artery systolic hypertension.
There is a very small pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Moderatemitral regurgitation. Mild pulmonary artery systolic
hypertension.
Compared with the prior study (images reviewed) of [**2113-11-17**], the
severity of mitral regurgitation has increased.
CLINICAL IMPLICATIONS:
The patient has moderate mitral regurgitation. Based on [**2112**]
ACC/AHA Valvular Heart Disease Guidelines, a follow-up
echocardiogram is suggested in 1 year.
[**2119-3-21**] CHEST (PORTABLE AP): There continues to be a large
opacity overlying the right upper lung which is the known mass.
Lung volumes are otherwise low. There is a right-sided pleural
effusion as well as a more focal area which correlates to the
multiple masses on the chest CT from one day prior.
Cardiomediastinal silhouette is stable in size.
Brief Hospital Course:
85 year old retired dentist presenting with worsening shortness
of breath and right sided pleural effusion in the setting of
likely new malignancy.
#. Recurrent Pleural Effusion and Acute on Chronic dCHF
exacerbation: Pt appeared [**12-15**] to volume overload in the setting
of a worsening pleural effusion. Moderate right pleural
effusions persisted despite recent thoracentesis prior to this
admission. Pleural fluid was negative for malignant cells.
Breathing dramatically improved with diuresis. Pt ruled out for
MI via enzymes. He was restarted on home Lasix 40. Repeat echo
(last [**2113**]) showed LVEF 55% and was largely unchanged other than
that the severity of mitral regurgitation increased. He was
transferred to the floor, and underwent IP guided thoracentesis
of 900cc fluid with placement of pleural catheter to gravity
drainage. Fluid studies as above and indicate transudate (still
possible with malignant effusions) He will receive continued
diuresis with oral lasix and transition to IV lasix if he has
continued hypoxia. Patient and family advised to weigh patient
daily. Pt Cr bumped to 1.9 and came down to 1.5 following the
folding of lasix for a day and then decreasing back to his home
dose of 40mg daily.
# Adencocarcinoma of the Lung: Pleural fluid was negative for
malignant cells, but CT was suggestive of metastatic disease. He
underwent bronchoscopic lung biopsy on [**3-23**] with lymph node bx
confirming adenoCA. Assumed to be lung primary. Brushing still
pending on discharge. [**Hospital **] clinic appointment to be arranged
as outpatient. Patient will ask PCP for assistance if he has
not heard from [**Hospital **] clinic by the time of his first
follow-up visit with PCP.
CHRONIC ISSUES:
#. Hypertension: BP initially controlled in ICU with a nitro
drip. Losartan was stopped because he was normotensive on a
metoprolol, hydralazine, ace-I. His amlodipine dose was
reduced.
#. DM: Insulin sliding scale
#. Hypothyroidism: No TSH in records here. Continued home dose
and defer to outpatient for further management.
Transitional Issues:
Goals of care discussion was had with patient, family and
attendings. The patient and family are aware that he has lung
cancer and that it will likely be the cause of his death. He
states that he is not interested in pursuing any type of care
that would be too invasive or involved including surgery,
chemotherapy, or radiation. He is open to speaking to an
oncologist regarding his prognosis and treatment options. The
option for hospice care was introduced to the patient and that
he should ask his PCP to help him get more information regarding
this type of care if it fits his stated goals of care. The
patient's goals of care are most consistent with DNR/DNI and he
and his family agreed.
Medications on Admission:
Lasix 40mg PO BID
Hydralazine 25mg PO QID
Allopurinol 200mg PO daily
Amlodipine 10mg PO daily
Losartan 50mg PO daily
Levothyroxine 100mcg PO daily
Nitroglycerin 6.5mg ER PO TID
Metoprolol 25mg PO BID
Quinapril 40mg PO daily
Simvastatin 20mg daily
Aspirin 325mg daily
Fluticasone 50mcg spray 1 nasally each daily
Vitamin D3
Vitamin B12
Tylenol #3
Ferrous Sulfate 325mg daily
Guiafenesin
Hexavitamin
Humalin R sliding scale
NPH insulin 20 units qAM 26 units QHS
Discharge Medications:
1. allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. quinapril 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. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day:
This dose is reduced from 40 mg twice daily.
9. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
This is reduced from 10 mg daily.
10. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain.
11. fluticasone 50 mcg/actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
12. hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
13. NPH insulin human recomb 100 unit/mL Suspension Sig: Ten
(10) units Subcutaneous twice a day: Previously 20 units in the
morning and 26 units in the evening.
14. oxygen
Diagnosis: Lung cancer, ICD-9 code: 162.9
2-3 liters continuous pulse dose for portability.
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
- lung cancer, adenocarcinoma
- pleural effusion
- acute on chronic diastolic CHF
- diabetes type 2 controlled, uncomplicated
- acute kidney injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were hospitalized due to shortness of breath from pleural
effusions and CHF along with masses in the chest that on
preliminary report appear to be adenocarcinoma. You had drainage
of pleural fluid and a bronchoscopic biopsy.
OTHER INSTRUCTIONS:
It is important to weight yourself each day. Your discharge
weight was 171-pounds. If you should gain more than 3 pounds
from that weight, you are likely reaccumulating fluid in your
chest and may need to have your diuretic doses increased.
Please call your doctor if you have more than 3 pound weight
gain (or loss). It is helpful to minimize sodium (salt) intake
to minimize fluid retention or reaccumulation.
You may want to also explore the option of enrolling in Hospice
Care services at your next appointment with your primary care
physician [**Name Initial (PRE) 648**].
MEDICATION CHANGES:
1. DOSE REDUCTION: Amlodipine (Norvasc) 5 mg daily (previously
10 mg daily)
2. DOSE REDUCTION: Furosemide (Lasix) 40 mg daily (previously 40
mg twice daily)
3. DOSE REDUCTION: NPH Insulin 10 units twice daily (previously
20 units in the morning and 26 units in the evening)
4. STOP: Losartan
Followup Instructions:
Department: GERONTOLOGY
When: THURSDAY [**2119-3-30**] at 9:30 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 719**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
ICD9 Codes: 5119, 5849, 4280, 5859, 4240, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3668
} | Medical Text: Admission Date: [**2140-4-23**] Discharge Date: [**2140-5-4**]
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
Fevers/rigors.
Major Surgical or Invasive Procedure:
Colonoscopy
Endoscopic ultrasound with biospy
PICC placement
History of Present Illness:
Ms. [**Known lastname 426**] is an 85 year-old woman with a history of CAD
recently noted abdominal mass who presents with fevers/rigors
and bandemia.
.
Over the last few weeks leading up to admission, she has been
experiencing mid-abdominal pain, radiating to the left flank.
It lasts throughout the day is not increased by eating though
there is associated vomiting and is worsened with coughing.
.
Was seen by Dr. [**Last Name (STitle) 1940**] on [**4-14**] who felt that the pain might be
seconodary to diverticulitis. CT abdomen without contrast was
then performed on [**4-20**] showing a large 9.5 x 7.5 x 6.0-cm
heterogeneous left upper abdominal mass.
.
On the morning of admission, was noted to have rigors/shaking
chills. Also felt nauseated and fatigued. She presented to the
ED for further care.
.
In the ED, initial vitals included T 100.9, HR 76, BP 145/61 and
SaO2 96%. CXR and UA were negative. Given possible GI source,
empiric zosyn was given. Noted to be transiently hypotensive to
80s and recieved a total of 4 liters of IVF with improvement in
lactate 4.0-->2.2-->1.8. Also spiked to 102.
.
ROS:
(+) 4lb weight loss over months; due to "poor appetite"
(-) night sweats
(-) chest pain, shortness of breath, palpatations
(+) diarrhea after oral constrast for CT abd
(+) nausea, occasional vomiting
(+) BRBPR after oral constrast for CT abd
(+) arthritis
Past Medical History:
1. Coronary artery disease with history of angioplasty in
[**State 108**] one year ago
2. Mitral valve prolapse
3. Atrial fibrillation
4. Hyperlipemia
5. Hypertension
6. Chronic kidney disease (SCr 2.1 in [**3-17**])
7. Hypothyroidism? (TSH 10 in [**3-17**])
8. Anemia (HCT 30.7 in [**3-17**])
Social History:
She is a widow and lives alone. Prevsiously smoked (30
pack-years) and rarely drinks a small amount of wine.
Family History:
Father had a GI tumor, primary unknown. Daughter with breast
cancer. Another daughter with ovarian carcinoma. Granddaughter
with celiac disease. No family history of inflammatory bowel
disease.
Physical Exam:
VITALS: afebrile, satting well on room air, normotensive
GEN: Well-appearing, lying in bed in no distress.
HEENT: PERRL; MMM; JVP just above clavicle while lying flat
CV: Regular. Split S2. No murmurs.
PULM: Clear bilaterally without wheeze/rales.
ABD: Soft. Non-tender throughout. No palpable masses.
EXT: Warm. No edema. Dopplerable pulses.
NEURO: Alert, oriented to person, "[**Hospital1 18**]" and "[**4-23**]". Able
to relate recent events well.
Pertinent Results:
[**2140-4-23**] 01:50PM BLOOD WBC-7.1 RBC-3.85* Hgb-10.5* Hct-32.4*
MCV-84 MCH-27.4 MCHC-32.6 RDW-14.8 Plt Ct-393
[**2140-4-23**] 01:50PM BLOOD Neuts-73* Bands-23* Lymphs-2* Monos-0
Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-0
[**2140-4-23**] 01:50PM BLOOD PT-36.3* PTT-29.2 INR(PT)-3.9*
[**2140-4-23**] 01:50PM BLOOD Glucose-93 UreaN-32* Creat-2.0* Na-141
K-4.4 Cl-103 HCO3-21* AnGap-21
[**2140-4-23**] 01:50PM BLOOD ALT-55* AST-59* AlkPhos-106 TotBili-0.3
[**2140-4-23**] 01:50PM BLOOD Lipase-596*
[**2140-4-24**] 01:30AM BLOOD Lipase-268*
[**2140-4-24**] 03:49PM BLOOD CK-MB-9 cTropnT-0.04*
[**2140-4-24**] 10:08PM BLOOD CK-MB-6 cTropnT-0.05*
[**2140-4-23**] 01:50PM BLOOD Albumin-3.8 Calcium-9.2 Phos-3.6 Mg-1.7
[**2140-4-24**] 01:30AM BLOOD Hapto-65
[**2140-4-23**] 01:49PM BLOOD Glucose-95 Lactate-4.0* Na-138 K-5.8*
Cl-100 calHCO3-23
[**2140-4-23**] 04:50PM BLOOD Lactate-1.8
.
CT ABD ([**2140-4-20**]):
1. Large 9.5 x 7.5 x 6.0-cm heterogeneous left upper abdominal
mass with areas of low and high density suggesting hemorrhage.
Underlying tumor is suspected, however, not fully assessed
without IV contrast. Origin of mass is not clear, but not likely
adrenal, renal or gastric in origin. Given mass effect on the
colon, retroperitoneal mass such as pancreatic hemorrhagic tumor
or hemorrhagic pseudocyst arising from the pancreatic tail is
considered, although no findings of acute pancreatitis are seen.
Exophytic splenic or colonic mass are also considered, although
less likely.
2. Large amount of stool proximal to the compressed splenic
flexure.
3. Colonic diverticulosis without evidence of diverticulitis.
4. Several hypoattenuating foci in the liver are incompletely
characterized.
5. Cholelithiasis.
.
CXR (5/16/0): No consolidation or edema is evident. Mild
prominence of the right hilum is evident. There is a tortuous
atherosclerotic aorta. The cardiac silhouette is borderline
enlarged with incidental note made of mitral annulus
calcification. No effusion or pneumothorax is noted. The
visualized osseous structures are osteopenic.
.
RUQ U/S ([**2140-4-23**]): Panc duct dilated but panc not well
visualized; if pncreatitis suspected coorelate with labs GB
appears distended with cholelithiasis but no GB wall thickening,
fluid or CDB dilatation
.
CT abd:
IMPRESSION:
1. No free air in the abdomen.
2. Interval decrease of splenic flexure mass. Corroboration with
the
colonoscopy report would be helpful. The reported drainage of
pus after
biopsy at the depressions site suggests a fluid component of
this mass. This could represent an abscess or hematoma from
possibly prior colonic
infection/inflammation, especially given the sigmoid
diverticulosis. 3.
Unchanged appearance of pancreatic head mass, with abrupt ending
of the
dilated pancreatic duct. Please refer to the recent MRCP for
better
characterization.
4. Sludge-filled gallbladder without evidence of acute
cholecystitis.
5. New small left pleural effusion.
Repeat CT:
CT ABDOMEN WITHOUT AND WITH IV CONTRAST:
Again seen in the left upper quadrant is a heterogeneous lesion
centered at the pancreatic tail/splenic hilum/splenic flexure.
This lesion is centrally hypoattenuating (28 [**Doctor Last Name **]) and was
previously characterized as containing blood products on the
prior MRCP dated [**2140-4-25**]. This lesion has decreased in size
when compared to the prior CT scan dated [**2140-4-20**] perhaps
secondary to decompression after biopsy of the splenic flexure
at colonoscopy as there is a description of purulent material
emanating from the colonic biopsy site. This lesion currently
measures 4.6 cm TV x 2.6 cm AP x 2.6 cm CC. While this mass
lesion abuts the splenic artery, there is no evidence of splenic
artery encasement or thrombosis.
Pancreatic Tumor Table:
I: Pancreatic tumor present: Yes.
a) Location: Pancreatic head.
b) Size: 2.1 cm TV x 2.5 cm AP x 3.1 cm CC.
c) Enhancement relative to pancreas: [**Name (NI) **].
d) Confined to pancreas with clear fat planes (duodenum and IVC
do not
apply): Yes.
e) Remaining pancreas: Fluid-attenuating lesion (blood products)
centered at the pancreatic tail as described above. Pancreatic
duct dilation measuring up to 5mm.
II. Adenopathy present: No.
III. Metastatic disease, definitely present: No.
IV: Ascites/peripancreatic fluid: No evidence of ascites.
Pancreatic Vascular Table:
I: Vascular Tumor Involvement: No.
a) Celiac involvement: No.
b) SMA involvement: No.
c) SMV involvement and percent encasement: No.
d) Less than 1 cm SMV between tumor and first major SMV branch:
Yes,
approximately 5 mm.
e) Portal vein involvement: No.
g) Splenic vein involvement: No.
h) Splenic artery involvement and distance from tumor to celiac
artery
bifurcation: No, approximately 3.3 cm.
II: Thrombosis, any vessel: No.
III: Aberrant Anatomy: No.
Stable hypoattenuating lesions are seen in the liver measuring
up to 6 mm
which were characterized as hepatic cysts on the prior MRCP
dated [**2140-4-25**]. No evidence of intra- or extra- hepatic bile duct
dilation. Sludge and gallstones layer dependently in the
gallbladder.
Adrenal glands are unchanged. As previously described, the right
kidney is
smaller than the left kidney. Hypoattenuating lesions are seen
in the kidneys bilaterally, likely representing renal cysts. The
largest of these lesions is in the lower pole of the left kidney
and measures approximately 3.3 cm. Atherosclerotic disease is
seen in the proximal abdominal aorta which is normal in course
and caliber. Note is made of colonic diverticulosis.
IMPRESSION:
1. Interval decrease in the heterogeneous centrally
hypoattenuating lesion
centered at the pancreatic tail/splenic hilum/splenic flexure in
the left
upper quadrant. Differential diagnosis for this lesion is
unchanged and
includes pancreatic pseudocyst, gastrointestinal stromal tumor,
and
metastasis. Although the splenic artery courses adjacent to this
region,
there is no evidence of splenic artery thrombosis, encasement,
or
pseudoaneurysm.
2. In the pancreatic head, there is a 2.1 cm TV x 2.5 cm AP x
3.1 cm CC
[**Month/Day/Year 71062**] mass which is causing pancreatic duct dilation to
approximately
5 mm. This finding is consistent with the patient's biopsy
proven pancreatic
head adenocarcinoma. No evidence of vascular involvement
3. Interval improvement in the right pleural effusion.
Persistent small left pleural effusion with associated posterior
left lower lobe
atelectasis/consolidation.
4. Left lower lobe pulmonary node measuring 6 mm. A followup CT
scan of the thorax in 3 months is recommended.
5. Cholelithiasis and gallbladder sludge.
6. Multiple hypoattenuating liver lesions which were
demonstrated to
represent hepatic cysts on the prior MRCP dated [**2140-4-25**].
7. Colonic diverticulosis.
.
Blood Culture, Routine (Final [**2140-4-26**]):
ESCHERICHIA COLI. FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 8 S
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 16 I
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- 2 S
.
MRSA screen positive.
Brief Hospital Course:
Assessment and Plan:
Patient is a 85 year old female with history of newly noted
abdominal mass, now being admitted with sepsis.
# Pancreatic adenocarcinoma: This was noted incidentially on a
CT scan. Patient underwent a EUS with biopsy. The results of
the biopsy were consistent with adenocarcinoma. Surgery was
consulted and is planning to do a Whipple procedure on [**5-19**].
Anesthesia was consulted for pre-operative clearance. The
patient will be seen in the geriatrics clinic the week prior to
surgery for pre-operative risk reduction. Her cardiologist was
also involved in her risk assesment. She will be receiving
follow up at [**Hospital3 328**].
.
# Splenic flecture/pancreatic tail mass, likely diverticular
abscess: This mass was unable to be biopsied on colonoscopy.
Based on the imaging it seems that it was not actually attached
to the colon. Given the patients recent likely history of
diverticulitis this was thought to be an infected fluid
collection or abscess. She was treated with IV antibiotics
(Zosyn, then ceftriaxone and flagyl) and will continue on them
until seen by ID as an outpatient. Repeat scans showed that the
mass was decreasing in size. IR was involved initially but felt
that the location of the fluid collection was at a high risk to
drain and given the fact that she was clinically stable it was
better to continue antibiotic treatment without drainiage. ID
and surgery agreed.
.
# Diverticulitis: There was a small outpouching seen on
colonoscopy that was not at the splenic flecture. This was
probed with the biopsy forcepts and immediatly opened up with
some pus and blood. This was sampled and came back as
non-specific inflamamtory chages. This was thought to be a
small diverticula that was clogged and had some reactive
changes.
#. Acute diastolic CHF exacerbation, with acute respiratory
failure: Patient has a history of heart failure. She is not on
oxygen at baseline. In the setting of getting fluid and FFP she
defeloped some pulmonary edema and required diuresis. She the
remained stable on room air. Her home dose of lasix was
continued.
#. E coli Sepsis: Cultures grew GNR (E. Coli) in blood concern
for GI source. No pyuria to suggest urinary tract infection.
Initially treated with Zosyn and patient improved. She did not
require pressors. It was felt that the likely etiology is what
is thought to be intra-abominal abscess based on improvement of
mass on repeat CT and recent history of likely diverticulitis.
She will require a prolonged course of IV antibiotics
(ceftriaxone) and flagyl and will continue these until ID
followup; ID assisted with management during her stay.
.
#. Atrial fibrillation: Anticoagulation held in the setting of
biopsy. Discussed with outpatient cardiologist about her
anticoagulation. She does not have any coronary stents in. It
was agreed that she would continue on lovenox from now until the
evening before surgery. After her surgery she will re-start her
prior anticoagulation. Continued amioradone with good rate
control. Her anticoagulation was changed to lovenox per above.
She remained rate controlled in the hospital.
.
#. Acute blood loss Anemia, lower GI bleeding: At baseline upon
presentation; after 4 liters of IVF, decreased to nadir of 22.8,
followed by one unit of pRBCs. GI source is possible as noted
to have BRBPR with bowel movement soon after arrival to MICU;
the large abdominal mass may also represent hematoma. Hemolysis
labs unrevealing. Her anemia was stable for several days prior
to discharge.
.
.
#. Pancreatitis. Has elevated lipase though exam is not
overwhelming and CT does not show clear evidence of
pancreatitis. Likely related to ductal dilation from pancreatic
head mass.
.
#. Transaminitis. Not severe and seen previosly. [**Month (only) 116**] be
related to statin or hypothyroidism. Patient also with stable
liver cyst per CT.
.
#. Chronic kidney disease. This remained at baseline. She was
given mucomist and sodium bicarbonate prior to receiving
contrast.
.
#. Elevated TSH. No prior diagnosis of hypothyroisism; is on
amiodarone so at increased risk for thyroid dysfunction. T4 is
WNL. [**Month (only) 116**] be sick euthyroid syndrome. She should have repeat TFTs
as an outpatient.
.
#. Coronary artery disease. No stents, continued statin/zetia.
Plavix and aspirin were held for her planned surgery, after
discussion with her cardiologist .
.
#. Hyperlipidemia: Continued statin/zetia
.
#. Left Lower Lobe nodule noted on CT scan. Will need follow up
scan as outpatient.
.
#. Code: FULL
Medications on Admission:
1. Plavix 75 mg daily
2. Coumadin 1 mg
3. Simvastatin 5 mg daily
4. Zetia 10 mg daily
5. Lisinopril 2.5 mg daily
6. Amiodarine 100 mg daily
7. Lasix 20 mg daily
8. Betaxolol 10 mg
9. Keflex (for UTI supression)
10. Vitamins
11. Metamucil
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
6. CeftriaXONE 2 gm IV Q24H
7. Betaxolol 10 mg Tablet Sig: One (1) Tablet PO QD () as needed
for HTN.
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous
[**Hospital1 **] (2 times a day).
10. 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.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 2436**] Nursing Center - [**Hospital1 2436**]
Discharge Diagnosis:
Sepsis - gram negative
intra-abdominal abscess
pancreatic cancer - newly diagnosed
Discharge Condition:
Stable for rehab.
Discharge Instructions:
You were admitted to the hospital with fevers and chills. You
were found to have bacteria in your blood and needed to go to
the intensive care unit for close monitoring. A CT scan found
an incidental mass in the pancreas and a second mass in the
abdomen. We had to stop your coumadin before we could do
biospies. You had a GI procedure with biospies. The pancreatic
mass is a type of cancer called adenocarcinoma. This will need
to be followed closely and discuss with an oncologist. You will
be having surgery for this mass on [**5-19**] br Dr. [**Last Name (STitle) **].
The second mass was not seen on the colonoscopy. It was
followed with CT scans and because it was getting better it was
probably an infection. You will need to continue IV antibiotics
until you meet with the ID doctors as [**Name5 (PTitle) **] outpatient.
Medication changes:
Ceftriaxone 2g IV q24
Flagyl 500mg q8
Stop Aspirin, Plavix and coumadin
Start Lovenox 60mg injection twice a day until after your
surgery.
Please return to the hospital or call your doctor if you have
temperature greater than 101, shortness of breath, worsening
difficulty with swallowing, chest pain, abdominal pain,
diarrhea, or any other symptoms that you are concerned about.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2140-5-20**] 10:00
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 13171**], MD Phone:[**Telephone/Fax (1) 719**]
Date/Time:[**2140-5-13**] 2:30
CALL FOR FOLLOW-UP with Dr. [**Last Name (STitle) **] - general surgery; ([**Telephone/Fax (1) 15807**] In [**12-11**] weeks
ICD9 Codes: 2851, 4240, 2724, 5859, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3669
} | Medical Text: Admission Date: [**2104-4-23**] Discharge Date: [**2104-5-2**]
Service: MEDICINE
Allergies:
Aspirin
Attending:[**Doctor First Name 1402**]
Chief Complaint:
Increased oxygen requirement, volume overload
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pt is an 87 yo man w/ h/o CAD s/p CABG (LIMA-D1,SVG-LAD,
SVG-Ramus;SVG--OM;SVG--PDA), Afib ( on warfarin), diet
controlled DM, CHF (EF 35%) who presents with 1 week of volume
overload from his nursing home. Pt has baseline CHF who is on 3L
O2 at baseline, on 40mg IV lasix [**Hospital1 **] at baseline. Over past
week, has noted increased volume overload, increased O2
requirement to 5L NC. He has been more edematous. He denies any
recent fevers, chills, chest pains, cough, or sputum production.
The only change in his medication has been increasing doses of
lasix. Today, attempted diuresis with lasix 40mg PO x 1,
followed by 80mg IV x1, followed by 100mg IV x 1, followed by
metolazone. UOP on these interventions only 200cc, so patient
sent to ED.
.
On presentation to [**Name (NI) **], pt was afebrile, RR 18, O2 sat 100% on
NRB. Exam notable for mild resp distress, elevated JVP, crackles
on exam. Lactate noted to be 2.5. ABG: 7.44/35/112. EKG: V
paced, unchanged. CXR shows fluid overload. He was treated with
metolazone 5mg PO then lasix 200mg IV with 200cc UOP. Patient
admitted to CCU for further management.
.
Currently, he feels quite well. He reports decreased SOB and has
been weaned to 5L NC. He is alert and interactive. He denies any
chest pain, abdominal pain, shortness of breath at rest. At
night, he uses 1 pillow to sleep.
Past Medical History:
1. CAD s/p CABG in [**2089**]
2. CHF, last ECHO w/EF 30%
3. Atrial fibrillation
4. s/p ICD in [**7-27**]; upgrade to BiV/ICD in [**7-28**]; generator change
in [**2-28**]; device and lead extraction on [**2104-2-4**] for MRSA
bacteremia and temporary pacemaker on [**2104-2-4**]
5. History of idiopathic intrinsic lung disease
- on 3L O2 at home
6. Type 2 DM, diet controlled
7. BPH
8. Hx of GI bleed
9. Hypothyroidism
10. Right ear melanoma s/p exicision
Social History:
Used to deliver milk for job. Lives by himself but son is in
same house, widower, retired. Denies tobacco past or present,
previous moderate EtOH use, no IVDU.
Family History:
Per [**Name (NI) **] father with TB
Mom died of AMI age 70s
Brother died of AMI age 70s
Physical Exam:
VS: T 97.7 BP 97/54 HR 81 RR 17 O2 98% 5L
Gen: AAO to person, place, time, month, situation. interactive,
NAD, comfortable
HEENT: NCAT, anicteric, PERRLA, MM mildly dry
Cards: JVP 15cm, PMI at 6th intercostal space, RRR nl S1S2 II/VI
holosystolic murmur loudest at apex, no thrills. no S3S4
Chest: sternotomy scar well healed. pacer site without erythema.
steri strips in place without purulent drainage.
Resp: nonlabored. no accessory muscle usage. rales 1/3 up
bilaterally with scattered rhonchi. soft wheezes.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits. no rebound
Ext: deep pitting edema bilaterally upper and lower. symmetric.
no cyanosis, clubbing
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
.
Pulses:
Right: Carotid 2+ Femoral 2+ Popliteal 1+ DP 1+ PT 1+
Left: Carotid 2+ Femoral 2+ Popliteal 1+ DP 1+ PT 1+
Pertinent Results:
Admission labs:
133 99 37
-------------< 124
4.6 22 1.7
CK: 25 - 16 - 22
MB: Notdone
Trop: 0.02 - 0.02 - 0.03
Ca: 8.8 Mg: 2.3 P: 3.6
ALT: 11 AP: 89 Tbili: 0.6 Alb: 3.5
AST: 19 LDH: Dbili: TProt: 6.8
[**Doctor First Name **]: 89 Lip:
.
9.7
12.8 >----< 357
30
N:81 Band:1 L:9 M:8 E:1 Bas:0
.
[**4-23**] admission CXR: Examination very limited secondary to
patient motion. Mild pulmonary edema with associated pleural
effusions is likely present and reflective of congestive heart
failure. Unchanged appearance of opacity within the lingula.
Repeat radiography may be helpful
.
[**4-23**]: ECG: Ventricular paced rhythm with ventricular premature
complex
Ventricular couplets
.
Trends/dispo labs:
[**2104-4-30**] Glucose-107* UreaN-46* Creat-1.7* Na-127* K-4.2 Cl-88*
HCO3-31
[**2104-4-30**] WBC-7.7 RBC-3.52* Hgb-9.2* Hct-28.6* Plt Ct-312
[**2104-4-29**] PT-26.7* PTT-44.2* INR(PT)-2.7*
Iron 13, TIBC 355, Folate 15, Ferritin 13
TSH 6.4
FT4 1.2
.
Micro:
C diff pos
blood cx NGTD
Brief Hospital Course:
87 yo man w/ h/o CAD s/p CABG, Afib s/p BiV pacer, DM, CHF (EF
35%) who presented with 1 week volume overload, increased O2
requirement. Hospital course by problem:
.
#) Cardiac Pump/Goals of care: Pt w/ h/o CHF, EF 35% on last
ECHO in [**3-1**], also moderate MR and mod-severe TR, RV moderately
dilated, presented w/ apparent CHF exacerbation with increased
volume overload, increased O2 requirement, no response to
increased lasix at NH. We treated him in the CCU with
aggressive diuresis. He required a lasix gtt (up to 20/h) and
metolazone. He diuresed >12L but still had persistent O2
requirement and inability to ambulate without significant
dyspnea. We also added spironolactone temporarily. Given his
end stage CHF and poor functional capacity, we discussed his
prognosis with the patient and family. The patient very much
wanted to go home. He had an understanding of the severity of
his disease. He requested to go home with hospice care to focus
on comfort. Per his request, we left the foley in place. He
was discharged on lasix 40-60 mg daily to be titrated to a goal
of 1-2L negative per day of diuresis. If fluid overload
worsens, he will likely develop worsening O2 requirement. Given
the goals of hospice and comfort, we have prescribed ativan and
morphine to be administered if patient is exhibiting signs of
respiratory distress.
.
# Respiratory: as above. Patient also has an underlying
interstitial lung disease (PFTs with restrictive pattern) which
likely worsened his symptoms. We treated with albuterol and
atrovent nebs which made some change in his resp status. He is
discharged on these medications.
.
# CAD: continued carvedilol. no ASA given allergy. CE neg. no
chest pain
.
# Rhythm: hx of AFib w/ slow ventricular response, s/p
pacer/AICD placement. He was VPaced. After the family meeting,
we had the ICD turned off to congruence with the goals of care.
We also stopped the amio, digoxin, and coumadin.
.
# ID: Patient had C diff and came in on flagyl. we completed
>14 day course and d/c'd this medication prior to discharge.
.
# Chronic renal failure. Baseline creatinine 1.4. He was
slightly worsened with diuresis.
.
# Iron Deficiency Anemia: profound iron deficiency. Hct stable.
Discharged on iron. We felt that administration of blood would
likely precipitate pulmonary edema.
.
# Code: DNR/DNI. Comfort measures, per d/w patient and HCP
.
# Contact: [**Name (NI) **] is HCP named [**Name (NI) **]: [**Telephone/Fax (1) 94177**].
.
# Dispo status: Patient largely bedridden. Can pivot with
assistance but with significant exertion. He has bibasilar
crackles and remains on 6L O2. His mood is generally well and
he is looking forward to going home.
Medications on Admission:
Amiodarone 200mg daily
carvedilol 6.25mg [**Hospital1 **]
B12 100mcg daily
Digoxin 0.0625 every other day MWF
finasteride 5mg daily
advair 250/50 [**Hospital1 **]
lasix 40mg IV BID
ISS
levothyroxine 25mcg daily
flagyl 500mg TID
MVI
Pantoprazole 40mg daily
simvastatin 20mg daily
tamsulosin 0.4mg qhs
warfarin 2.5mg daily
tylenol prn
albuterol nebs
atrovent nebs
ambien 2.5mg qhs
nystatin topically prn
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain, or temp>101.
2. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation every four (4) hours as needed for shortness of
breath or wheezing.
Disp:*1 inhaler* Refills:*1*
3. Atrovent HFA 17 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation every six (6) hours.
Disp:*1 inhaler* Refills:*1*
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
Disp:*20 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. Docusate Sodium 50 mg/5 mL Liquid Sig: [**4-3**] ml PO BID (2
times a day).
Disp:*200 ml* Refills:*2*
7. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
8. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*30 Tablet(s)* Refills:*0*
11. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*2*
12. Morphine Concentrate 5 mg/0.25 mL Solution Sig: 5-10 mg PO
every four (4) hours as needed for shortness of breath or
wheezing.
Disp:*200 ml* Refills:*0*
13. Ativan 0.5 mg Tablet Sig: 0.5-1.0 mg (liquid formulation) PO
every four (4) hours: please provide the liquid formulation per
hospice.
Disp:*40 mg (in liquid formulation)* Refills:*0*
14. Iron 325 (65) mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
15. Lasix 20 mg Tablet Sig: 2-3 Tablets PO once a day: please
aim for 1-2L negative per day fluid status.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **]
Discharge Diagnosis:
Primary:
- decompensated CHF
- atrial fibrillation s/p AICD/pacer (AICD turned OFF)
- c diff colitis
- iron deficiency anemia
Secondary:
- s/p MRSA bacteremia and pseudomonas UTI in [**1-2**]
- hx CAD s/p CABG in [**2089**]
- BPH
- DMII
- hx of GI bleed on asa
- hypothyroidism
- hyperlipidemia
Discharge Condition:
comfortable
Discharge Instructions:
You were admitted with a CHF exacerbation. We treated you in
the cardiac intensive care unit and removed a significant amount
of fluid. You felt symptomatically improved. We met with you
and your family and, with the assistance of hospice home care,
have discharged you to home.
Please take your medications as instructed. Please contact your
PCP with any questions.
Followup Instructions:
please contact your PCP to discuss followup plans
ICD9 Codes: 4280, 5859, 5849, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3670
} | Medical Text: Admission Date: [**2191-8-25**] Discharge Date: [**2191-9-5**]
Service: VSU
HISTORY OF PRESENT ILLNESS: Briefly, this is a [**Age over 90 **]-year-old
male who lives in a nursing home who came to the ER after
being noted to have a black toe at his nursing home. He was
unsure as to how long, but it was mentioned that it might
have been a few days. He did not complain of any pain and
was noted to feel cold on inspection at the nursing home. He
denied any history of trauma. He was nonambulatory, but
denied any resting pain. No fevers, chills, nausea or
vomiting, and no prior vascular surgery.
PAST MEDICAL HISTORY: Atrial fibrillation.
Prostate cancer.
Chronic renal insufficiency secondary to hypertension.
Renal failure.
Dementia.
PAST SURGICAL HISTORY: Status post pacemaker.
Status post TURP.
Status post aortic repair.
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Lasix 40 mg po once daily.
2. Procrit 0.4 ml q Monday.
3. Atenolol 25 mg po once daily.
4. Isosorbide dinitrate 10 mg tid.
5. Coumadin 4 mg po once daily.
6. Nephrocaps 4 mg tid.
7. KCL 40 mEq po once daily.
8. Multivitamin once daily.
9. Methylphenidate 10 mg po bid.
PHYSICAL EXAM: He was afebrile with stable vitals. He was a
poor historian, but age-appropriate. His heart was
irregular. His lungs were clear. His abdomen was soft,
nontender, nondistended. His extremities were cool. He had
a biphasic DP. Femorals and popliteals were palpable. On
the left, he had a monophasic dopplerable DP and a monophasic
PT. His femoral and popliteals were palpable. His first and
second toes were black and necrotic with dry gangrene.
LABS: Remarkable for a BUN and creatinine of 114 and 6.8,
and his white count was 10.8 with a normal diff. His urine
was normal.
HOSPITAL COURSE: The patient was admitted to the medical
service for management of his elevated creatinine. He was
started on antibiotics, and he ultimately grew out MSSA and
was continued on oxacillin. After maximization of fluids and
renal consult, it was decided that the patient would
ultimately likely need dialysis down the road, and the plan
was to proceed with an angiogram to evaluate his left lower
extremity. Angiogram was done which showed significant
disease of his popliteal and tibioperoneal trunk with
reconstitution distally. Vein mapping was done, and it was
found that the patient had adequate left greater saphenous
vein. It was decided that the patient would undergo bypass
graft after complete optimization. The family was aware of
all of these plans and decided to proceed with his surgery.
The patient was taken to the operating room on [**2191-9-1**] for
a left popliteal-PT bypass graft with reversed saphenous
vein. Please see the operative report for further details.
The patient was transferred to the Vascular Intensive Care
Unit, and postoperatively he did well. He was extubated. A
Swan was placed intraoperatively and was kept in place. He
continued to do well and was began on diuresis shortly after
his operation. He Swan was kept in through his hospital
stay, and his PA pressures were elevated. However, he had no
symptomatology of increased pulmonary hypertension. He was
started on heparin for his graft, as well as for his
coumadinization, and he was restarted on his Coumadin.
On postoperative day 4, he was doing well. His Swan was
removed. He was therapeutic on his Coumadin, and it was
planned that the patient would return to his nursing home.
It was decided that the toes which were necrotic and black
would be allowed to demarcate, and time would be given for
the bypass graft to enhance vascular flow to the region, and
ultimately a decision would be made whether to do toe
amputations versus a TMA. Currently, it is planned that the
patient will return in two weeks time for a planned TMA. The
patient is going to continue on his oxacillin for coverage of
his coag-positive staph aureus which is sensitive, and the
patient was discharged. He was followed throughout his
hospital stay by the renal service, as well as the cardiology
service, which followed in consultation. It was decided that
the patient would return to all of his home medications, and
he would be followed very closely by his nephrologist. The
patient was instructed to follow-up with Dr. [**Last Name (STitle) 1391**] in [**12-10**]
weeks for planned TMA, as well as follow-up with his
nephrologist and his primary care physician for frequent lab
checks. The patient will need his labs checked in
approximately 3-4 days to evaluate his creatinine. The
patient is discharged in stable condition.
DISCHARGE DIAGNOSES: Peripheral vascular disease, status
post bypass graft.
Dry gangrene of his first and second toe, status post bypass
graft.
SECONDARY DIAGNOSES: Renal failure.
Atrial fibrillation.
Chronic renal insufficiency.
Hypertension.
Status post pacemaker.
Status post transurethral resection of prostate.
Status post aortic repair.
DISCHARGE MEDICATIONS:
1. Lasix 40 mg po once daily.
2. Atenolol 25 mg po once daily.
3. Aspirin 325 po once daily.
4. Coumadin dosed intermittently to keep his INR at 2.5.
5. Percocet 1-2 tabs po q 4 h prn.
6. Oxacillin 2 gm po q 6.
7. Colace 100 mg po bid.
He was instructed to continue on all of his home medications,
and instructed to follow-up with Dr. [**Last Name (STitle) 1391**], as well as his
nephrologist, as well as his PCP. [**Name10 (NameIs) **] patient was discharged
in stable condition.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**], [**MD Number(1) 2381**]
Dictated By:[**Doctor Last Name 11225**]
MEDQUIST36
D: [**2191-9-5**] 10:20:17
T: [**2191-9-5**] 10:52:21
Job#: [**Job Number 11226**]
ICD9 Codes: 2762, 2765, 4280, 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3671
} | Medical Text: Admission Date: [**2127-9-7**] Discharge Date: [**2127-9-9**]
Service: MEDICINE
Allergies:
Paxil
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Weakness and slow heart rate.
Major Surgical or Invasive Procedure:
Pacemaker placement.
History of Present Illness:
The patient is a 85 year old male without any significant
cardiac history who had called his primary care provider (PCP)
office last night with complaints of weakness and slow heart
rate of around 40 bpm. He recently had presented to the [**Hospital **] for the seconed time over the past 6 months with
complaints of chest pain. As in his fist presention, during his
most recent hospitalization no abnormalities could be found on
his ECG, ECHO and ETT or CE.
On review of systems, he denies any palpitations, current chest
pain, shortness of breath (SOB), edema, orhtopnea, weight loss,
fever or chills.
Past Medical History:
Hypertension
Anxiety
Insomnia
Question of Cerebral Vascular Accident (CVA)
Social History:
Lives home alone, has a history of 30 years smoking (3 packs per
day), and currently drinks 4 oz of liquor daily. He is widowed
and has one daughter.
Family History:
Noncontributory.
Physical Exam:
Vitals: T 97.7 BP: 111/59 HR: 42 rr: 14 SPO2 99%
General: pleasant male, alert and oriented x 3
HEENT: clear oropharynx, moist mucous membranes, no lymph
adenopathy, no thyromegaly.
Neck: no jugular venous distension.
Heart: bradycardic, 2/6 systolic ejection murmur
Abdomen: soft, nontender, nondistended
Extremities: no edema, 2+ PT bilaterally
Pertinent Results:
Labs on admission:
[**2127-9-7**] 11:14AM WBC-10.1 RBC-4.55* Hgb-14.0 Hct-39.6* MCV-87
MCH-30.8 MCHC-35.4* RDW-13.7 Plt Ct-264
[**2127-9-7**] 11:14AM PT-13.7* PTT-32.3 INR(PT)-1.2*
[**2127-9-7**] 11:14AM Glucose-89 UreaN-21* Creat-1.0 Na-139 K-3.8
Cl-102 HCO3-30 AnGap-11
[**2127-9-7**] 11:14AM CK(CPK)-49
[**2127-9-7**] 11:14AM CK-MB-NotDone cTropnT-<0.01
[**2127-9-7**] 11:14AM Calcium-8.4 Phos-2.7 Mg-2.1
Labs on discharge:
[**2127-9-9**] 05:37AM WBC-11.0 RBC-4.46* Hgb-13.7* Hct-39.0* MCV-87
MCH-30.7 MCHC-35.1* RDW-13.2 Plt Ct-261
[**2127-9-9**] 05:37AM PT-14.0* PTT-29.6 INR(PT)-1.2*
[**2127-9-9**] 05:37AM Glucose-84 UreaN-20 Creat-1.1 Na-137 K-4.1
Cl-100 HCO3-29 AnGap-12
[**2127-9-9**] 05:37AM Calcium-8.8 Phos-3.4 Mg-2.0
ECHO [**2127-9-9**]:
The left atrium and right atrium are normal in cavity size. 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 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.
Physiologic mitral regurgitation is seen (within normal limits).
The pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
IMPRESSION: Normal biventricular cavity sizes with preserved
global biventricular systolic function. No pericardial effusion
identified.
Chest x-ray [**2127-9-7**]:
A right IJ line is present, with pacemaker lead tip overlying
the right ventricle. NO pneumothorax is detected.
The lungs are hyperinflated, consistent with COPD. Heart size is
borderline with left ventricular configuration. The aorta is
mildly unfolded and tortuous. The pulmonary hila are prominent
with a tapered appearance, which may reflect the presence of
pulmonary hypertension. No CHF, focal infiltrate, or effusion is
identified.
Brief Hospital Course:
The patient is a 85 year old male with no history of cardiac
disease presenting with infranodal block in the setting of RBBB.
The etiology of the patient's bradycardia is currently unclear.
It may be related to the patient's extensive drinking history or
possibly a missed silent MI, although per OMR notes, the
patient's prior stress tests and ECHO have been unremarkable.
The patient received a temporary pacemaker wire. He underwent
permanent pacemaker placement on [**Month/Day/Year 766**], [**2127-9-8**].
During the procedure, the patient's blood pressure dropped to
the 40's. The patient never desaturated, and was briefly on
pressors in the lab. He returned to the CCU off pressors. He had
a negative TTE, with no effusion.
# Coronary Artery Disease (CAD)/Ischemia: The patient has no
history of CAD or positive stress test in the past per OMR
records. He has had negative cardiac enzymes here. He was
continued on Aspirin.
# Alcohol abuse: CIWA scale was used. The patient did not
require any benzodiazepines.
# Depression/anxiety: The patient was on a taper of Xanax and
transition to Paxil. He was continued on the taper Xanax (0.25
daily for a week-->0.125 daily for a week-->0.125 qod for a
week). Paxil was also continued.
Medications on Admission:
Alprazolam 0.25 daily prn
Paxil 10 mg
HCTZ 25
Flomax 0.4 mg
Ambien 10 mg prn
Aspirin 325
Vitamin B-12
Discharge Medications:
1. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed.
2. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
3. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
5. Cyanocobalamin 500 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) as needed for PPM implantation for 6 days.
Disp:*24 Capsule(s)* Refills:*0*
7. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Symptommatic bradycardia, status-post pacemaker placement.
Secondary:
Hypertension.
Discharge Condition:
Stable. afebrile.
Discharge Instructions:
You were admitted for bradycardia (slow heart rate) for which
you given a pacemaker. This procedure went well. Please follow
the instructions provided to you for recovery including
refraining from lifting your left arm above your head or lifting
heavy objects as specified by your cardiologist.
Please take your medications as instructed.
Please adhere to your follow-up appointments. They are important
for managing your long-term health.
Please return to the hospital or call your doctor if you have
temperature greater than 101, shortness of breath, worsening
difficulty with swallowing, chest pain, abdominal pain,
diarrhea, or any other symptoms that you are concerned about.
Please refrain from smoking. Information was given to you on
admission regarding smoking cessation and prevention of
relapses.
Followup Instructions:
Please follow up in DEVICE CLINIC on [**2127-9-16**] at 10:30a.m. The
phone number there is [**Telephone/Fax (1) 59**]
Primary Care:
Please follow up with Dr. [**Last Name (STitle) 6481**] on [**Last Name (LF) 766**], [**2130-9-28**]:30am. The office can be reached at [**Telephone/Fax (1) 4775**].
Please follow up with Dr. [**Last Name (STitle) **] on Tues. [**10-14**] at 3pm on
the [**Location (un) 436**] of [**Hospital Ward Name 23**] Building. His office can be reached at
[**Telephone/Fax (1) 62**].
Completed by:[**2127-10-15**]
ICD9 Codes: 4019, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3672
} | Medical Text: Admission Date: [**2122-7-20**] Discharge Date: [**2122-8-4**]
Date of Birth: [**2050-5-1**] Sex: F
Service: SURGERY
Allergies:
Percocet
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
non healing/gangrenous TMA site
Major Surgical or Invasive Procedure:
OPERATIONS:
1. Ultrasound-guided puncture of the left common femoral
artery.
2. Contralateral second-order catheterization of the right
external iliac artery.
3. Abdominal aortogram.
4. Serial arteriogram of the right lower extremity.
Left femoral above-knee popliteal bypass with 6-
mm PTFE graft and left above-knee popliteal to dorsalis pedis
artery bypass with non reversed saphenous vein and
angioscopy.
PROCEDURE: Revision of left transmetatarsal amputation with
primary closure.
History of Present Illness:
72 year old f admitted from Dr.[**Name (NI) 5695**] clinic from her
rehab facility with ischemic left TMA. The TMA is open with
black
eschar consistant with gangrene. Surrounding erythema due to
ischemia, possible infection. Plan for IV ABX, wound care and
angiogram on Wednesday. Patient with recent fall at facility, RT
hip pinning.
Vascular Procedures: right [**Name (NI) 1793**] PTCA [**2121-11-14**], LSFA stent x1,
[**2122-3-25**] PTA of AT, [**2122-3-18**] angioplasty LSFA and peroneal art,
[**2122-4-15**] left TMA
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
Colon cancer s/p right colectomy [**9-9**]
Depression
CVA [**2108**]
Diabetes type II, with neuropathy
Tracheobronchitis [**6-12**]
Small secular aneurysm in aortic arch noted on CT scan [**9-11**]
EF 60-65% on echo from [**6-12**]
severe PVD s/p right [**Name (NI) 1793**] PTCA [**2121-11-14**]
LSFA stent x1
Social History:
SOCIAL HISTORY: lives with husband.
-Tobacco history: denies active smoking, prior 1.5 ppd x 25 yrs
-ETOH: denies
-Illicit drugs: denies
Family History:
FAMILY HISTORY:
Mother with "enlarged heart." Father died from cirrhosis.
Physical Exam:
Physical Exam:
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
Neuro A&OX3
CARDIAC: RRR LUNGS: CTAB anteriorly
ABDOMEN: Soft, NTND.
EXTREMITIES: No c/c/e. Surgical incision C/D/I
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses: B/L fem palp, B/L DP/PT dop
TMA open, black eschar c/w gangrene. Surrounding erythema
RT heel- intact pressure blister
Pertinent Results:
[**2122-8-3**] 11:15AM BLOOD
WBC-8.8 RBC-3.42* Hgb-10.2* Hct-30.1* MCV-88 MCH-29.9 MCHC-34.1
RDW-15.1 Plt Ct-304
[**2122-8-3**] 11:15AM BLOOD
Plt Ct-304
[**2122-7-31**] 03:46AM BLOOD
PT-16.3* PTT-28.4 INR(PT)-1.4*
[**2122-8-4**] 05:35AM BLOOD
Glucose-100 UreaN-16 Creat-0.7 Na-140 K-4.1 Cl-103 HCO3-32
AnGap-9
[**2122-8-4**] 05:35AM BLOOD
Calcium-8.5 Phos-3.4 Mg-2.1
[**2122-7-21**] 11:57AM
URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-SM
[**2122-7-20**] 11:39 am SWAB Source: Left TMA.
GRAM STAIN (Final [**2122-7-20**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS ,
CHAINS, AND CLUSTERS.
WOUND CULTURE (Final [**2122-7-23**]):
STAPH AUREUS COAG +. HEAVY 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.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
ANAEROBIC CULTURE (Final [**2122-7-26**]): NO ANAEROBES ISOLATED.
HIP FILMS:
HISTORY: Right hip pain, to assess for fracture.
FINDINGS: No previous images. There is some metallic fixation
device about
previous intratrochanteric fracture with separation of the
lesser trochanter. Fracture line is still evident. No evidence
of hip dislocation.
Brief Hospital Course:
Ms. [**Known lastname 805**] was admitted to the floor as a direct admit from
clinic on the evening of [**2122-7-20**]. She was started on IV
Vancomycin along with cipro and flagyl.
She was taken to the angio suite on [**2122-7-22**] for angiography of
her left lower extremity. At this time, her peroneal artery and
[**Date Range 1793**] were angioplastied and a stent was placed in the [**Date Range 1793**].
She returned to the floor without complication. On HD 4, she
had noninvasive studies of her lower extremities which showed
severe, diffuse and bilateral arterial disease. Since this
would make healing of a TMA debridement or revision difficult it
was decided to pursue vein mapping studies to assess candidacy
for bypass surgery.
She received vein mapping studies on HD 5 showing patent greater
saphenous veins bilaterally. Also, medicine was consulted
regarding her risk for bypass surgery. The cleared her for
surgery.
Procedure:
Left femoral above-knee popliteal bypass with 6- mm PTFE graft
and left above-knee popliteal to dorsalis pedis artery bypass
with non reversed saphenous vein and
angioscopy.
No complications post op. Once recovered from the BPG, it was
then decided to revise the TMA.
PROCEDURE: Revision of left transmetatarsal amputation with
primary closure.
Pt also c/o r hip pain, films were taken. Fracture seen. Ortho
consult WBAT. no sequele.
Pt also has a coccyx ulcer. Wound care nurse.. Duoderm and
Mepilex dressing. Size of wound unstageable 1.5 L x 0.8 W with
yellow slough, Unstageable. No sequele.
Pt to go to rehab on O bactrim x 14 days.
CX:
STAPH AUREUS COAG +
CLINDAMYCIN-----------<=0.25 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
PT and case management, to Rehab with appropriate followup
ordered.
Medications on Admission:
simvastatin 80QD, ,metoprolol tartrate 50mg [**Hospital1 **], plavix 75mg QD,
lisinopril 40mg QD, metformin 1000mg QD, januvia 100mg daily,
ASA 325mg QD, eye gtts (non formulary/I ordered what we used
during [**Month (only) 116**] admission), coumadin3mg daily, Levemir 20 units QHS
with novulog SS, dilaudid 2-4mg Q4-6 hours, ativan 0.5mg TID prn
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-6**]
Drops Ophthalmic QAM (once a day (in the morning)).
9. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed for pain: prn.
10. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
11. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
12. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
13. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
14. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
16. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
17. Other
Sliding Scale & Fixed Dose
Fingerstick q6hrs
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Novalog
Glucose Insulin Dose
0-70 mg/dL Proceed with hypoglycemia protocol
71-100 mg/dL 0 Units 0 Units 0 Units 0 Units
101-150 mg/dL 2 Units 2 Units 2 Units 0 Units
151-200 mg/dL 4 Units 4 Units 4 Units 2 Units
201-250 mg/dL 6 Units 6 Units 6 Units 4 Units
251-300 mg/dL 8 Units 8 Units 8 Units 4 Units
301-351 mg/dL 10 Units 10 Units 10 Units 4 Units
> 351 mg/dL Notify M.D.
18. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
19. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Vaginal HS
(at bedtime) for 7 days.
20. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for yeast infection.
21. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
22. Warfarin 3 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: INR goal is [**1-7**]. Tablet(s)
23. Bactrim DS 800-160 mg Tablet Sig: One (1) Tablet PO twice a
day for 14 days.
24. Levemir 100 unit/mL Solution Sig: 20 units Subcutaneous at
bedtime: hs.
25. Januvia 100 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Ischemic left transmetatarsal amputation.
Fractured Right Hip
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Post Surgery Wound Care
Overview
Your doctor has placed sutures (stitches) to keep the incision
closed for proper wound healing. Sometimes, sutures need to be
removed in a few weeks. Sometimes, the sutures are all under the
skin and will eventual dissolve on their own and do not need to
be removed.
In either case, please follow these routine wound care
instructions.
If you have steri-strips on your incision (little white paper
tapes), keep them in place until they begin to fall off on their
own. Do not pull the steri-strips off as this could put stress
on the incision line. When the steri-strips start to peel off,
they can be gently washed off.
Please try to keep the incision line clean and dry. You can
shower and gently wash the incision line with soap and water.
Dry the incision area and keep the incision line open to air.
It is not necessary to apply antibiotic ointment, alcohol,
hydrogen peroxide, or a new bandage to the incision line. If
your sutures get caught on your clothing or there is a small
amount of drainage from the incision, you may want to cover it
with small gauze for your own comfort. If so, please use as
little tape as possible to hold the gauze in place as tape can
irritate the skin.
A small amount of drainage from the incision in the first few
days after surgery is not unusual and it will probably resolve
on its own. However, if you should notice bleeding from the
surgical site, apply firm direct pressure for ten minutes. If
the bleeding persists, reapply firm direct pressure for an
additional ten minutes. If the bleeding does not stop after 20
minutes, call our contact phone numbers or go to the nearest
emergency room for assistance.
What to Avoid
Please avoid the following:
Do not submerge the incision line under water for a prolonged
period of time with activities like taking a bath, swimming, or
sitting in a hot tub.
Do not participate in any vigorous activities or exercises that
may put stress on the incision.
Do not take aspirin, ibuprofen, or any other nonsteroidal
anti-inflammatory medication that may cause problems with
bleeding unless instructed by your doctor.
Do not apply perfumes or scented lotions to the sutures as this
may cause irritation.
When to Call the Doctor
Please contact us immediately if you develop:
Fevers, chills, or night sweats
Increasing redness, pain, or pus at the incision
Bleeding that does not stop with firm pressure
Followup Care
If your sutures need to be removed, this is usually done [**12-7**]
weeks after surgery. Even if your sutures will dissolve, the
doctor usually likes to examine the incision while it is
healing. Therefore, you should have been scheduled for a
follow-up appointment in clinic at the time of your discharge
from surgery. As this appointment is very important, please
contact the clinic if you do not have one scheduled or you need
to change the date and/or time.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2122-8-17**] 10:30
Completed by:[**2122-8-4**]
ICD9 Codes: 5180, 2724, 4019, 3572, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3673
} | Medical Text: Admission Date: [**2103-4-20**] Discharge Date: [**2103-4-29**]
Date of Birth: Sex:
Service:
CHIEF COMPLAINT: Back pain.
HISTORY OF PRESENT ILLNESS: This is a 53-year-old male with
a history of nephrolithiasis and known diverticulitis here
for followup who presented back pain and shortness of breath.
The patient was in his usual state of health until
approximately 10 days prior to admission when he started
passing 100 cc to 200 cc of bright red blood per rectum at
home without any abdominal pain. He had several episodes of
near syncopal events at home and called 911. He was admitted
to the Intensive Care Unit at [**Hospital3 3583**].
The patient had several episodes of further bright red blood
per rectum; however, his diet was advanced, and no further
episodes of bleeding were noticed until 10:00 p.m. Again,
the patient had a near syncopal episode in the bathroom with
the passage of painless bright red blood per rectum and was
transfused 2 units of packed red blood cells. The patient
was observed at [**Hospital3 3583**] over the next several days.
No endoscopy or colonoscopy was performed, and the patient
was discharged home on [**2103-4-16**]. Per the patient, his
hematocrit on discharge was 34.6.
On [**2103-4-17**] the patient with sporadic episodes of right-
sided low back pain associated with shortness of breath. The
patient presented to the Emergency Department at [**Hospital1 346**] with back pain and shortness of
breath with oxygen saturations of 75 percent on room air. A
computed tomography scan was performed showing multiple
bilateral pulmonary emboli. At that time, the patient denied
any further episodes of bleeding since discharge from [**Hospital3 6265**].
Rectal examination in the Emergency Department showed dark
brown/guaiac positive stool. The patient denies any history
of black tarry stool, abdominal pain, gastroesophageal reflux
disease, nonsteroidal antiinflammatory drug use, or chest
pain. His hematocrit in the Emergency Department was 33.5.
The patient was started on a heparin drip and transferred to
the Intensive Care Unit for further management.
PAST MEDICAL HISTORY:
1. Diverticulosis.
2. Gastrointestinal bleed in [**2103-4-16**].
3. History of nephrolithiasis.
Hm ah.
MEDICATIONS AT HOME: Aspirin 81 mg (however recently
discontinued).
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: He lives with his wife.
FAMILY HISTORY: Positive for coronary artery disease. No
history of colon cancer. No history of inflammatory bowel
disease.
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed
his temperature was 98.1, his blood pressure was 163/93, his
heart rate was 100, and his oxygen saturation was 98 percent
on 100 percent nonrebreather. Generally, obese. Talking in
full sentences. In no acute distress. Head, eyes, ears,
nose, and throat examination revealed the pupils were equal,
round, and reactive to light. The mucous membranes were
moist. Cardiovascular examination revealed tachycardic first
heart sounds and second heart sounds. There were no murmurs,
rubs, or gallops. The lungs were clear to auscultation
bilaterally. The abdomen was obese, soft, nontender, and
nondistended. There were normal bowel sounds. Extremity
examination revealed right ankle with chronic venous stasis
changes. No lower extremity asymmetry. No calf tenderness.
No Homans' sign. Neurologically, alert and oriented times
three. Cranial nerves II through XII were intact.
PERTINENT LABORATORY VALUES ON PRESENTATION: White blood
cell count was 16.1, his hematocrit was 33.5, and platelets
were 294. Chemistries were within normal limits. D-dimer
was 4919. Prothrombin time was 13. INR was 1.1. Creatine
kinase was 45. Troponin was less than 0.01.
PERTINENT RADIOLOGY-IMAGING: An electrocardiogram showed
sinus tachycardia at 125 beats per minute; otherwise, no
acute changes.
A chest x-ray showed a rounded opacity overlying the third
posterior rib; likely calculous, prominent right hilum. No
evidence of pneumonia or pneumothorax.
A computed tomography angiogram showed areas of tachy
consolidation involving both lower lobes. Impression was
consistent with bilateral pulmonary emboli.
IMPRESSION: A 52-year-old male with recent hospitalization
for diverticulosis/gastrointestinal bleed now here with
subsequent pulmonary emboli secondary to immobilization.
SUMMARY OF HOSPITAL COURSE BY ISSUES-SYSTEMS:
1. PULMONARY EMBOLISM: The patient was continued on a
heparin drip, and ultimately Coumadin therapy was
initiated. Oxygen saturations improved upon initiation of
heparin therapy. Pulmonary emboli thought to be secondary
to immobilization during outside hospital course. The
patient had a 7-day stay at the outside hospital without
any deep venous thrombosis prophylaxis and subsequently
presented with shortness of breath. After further
gastrointestinal procedures performed, the patient was
started on Coumadin, and his INR was therapeutic at the
time of discharge.
1. QUESTIONABLE ASPIRATION PNEUMONIA: The patient's
admission chest x-ray was concerning for possible
aspiration pneumonia versus atelectasis. Vital signs did
not indicate an infections etiology; however, the patient
had evidence of crackles and changes at the lung bases.
The changes were thought to be more consistent with
infarction and atelectasis given new diagnosis of
bilateral pulmonary emboli; however, the patient was given
a 7-day course of levofloxacin. Again, his oxygen
saturations remained stable.
1. GASTROINTESTINAL BLEED: The patient did not have any
workup of gastrointestinal bleeding at the outside
hospital. During this admission, an
esophagogastroduodenoscopy and colonoscopy were performed
showing early questionable early [**Doctor Last Name 15532**] esophagus and
multiple nonbleeding diverticula. The patient was started
on a high-fiber diet. A repeat colonoscopy was
recommended within five to ten years, and a repeat
esophagogastroduodenoscopy was recommended in about two
years to reevaluate GE junction. The patient was continued
on a proton pump inhibitor. Stools remained occult-
blood/guaiac negative, and his hematocrit remained stable
during his hospital course.
1. BACK PAIN: The patient's back pain was controlled with
oxycodone and morphine as well as Tylenol.
1. PROPHYLAXIS: Heparin/Coumadin and a proton pump
inhibitor.
1. CODE STATUS: The patient remained a full code.
CONDITION ON DISCHARGE: Stable with improved oxygenation on
room air. Hematocrit was stable. INR was therapeutic.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSES:
1. Bilateral pulmonary embolism.
2. Diverticulosis.
3. Gastrointestinal bleeding.
4. History of nephrolithiasis.
5. Benign prostatic hypertrophy.
6. Early signs of [**Doctor Last Name 15532**] esophagus.
MEDICATIONS ON DISCHARGE:
1. Protonix 40 mg by mouth once per day.
2. Coumadin 5 mg by mouth once per day.
DISCHARGE INSTRUCTIONS-FOLLOWUP:
1. The patient was to have outpatient laboratory work to
monitor INR.
2. The patient was to follow up with primary care physician
(Dr. [**Last Name (STitle) 49621**] within five to seven days.
3. The patient was to have followup in the [**Hospital 6283**]
Clinic in one to two years for a repeat
esophagogastroduodenoscopy.
4.
The patient was also to see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**4-30**]
,
[**2103**].
DR.[**First Name (STitle) 2416**],[**First Name3 (LF) 2415**] 12-929
Dictated By:[**Name8 (MD) 5978**]
MEDQUIST36
D: [**2103-6-29**] 12:28:49
T: [**2103-6-30**] 13:04:58
Job#: [**Job Number **]
ICD9 Codes: 5070 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3674
} | Medical Text: Admission Date: [**2152-6-11**] Discharge Date: [**2152-7-1**]
Date of Birth: [**2079-8-7**] Sex: M
Service: MED
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
Intubation [**Date range (1) 100821**]
History of Present Illness:
72M [**Hospital3 2558**] resident w/ multiple medical problems now
admitted for a 1 day h/o acute SOB/hypoxia. He was in his usual
state of health until around midnight [**6-11**] when he c/o acute SOB
and chest pressure. His O2 sat was noted to be 89% on RA -> 94%
6L, so he was sent to [**Hospital1 18**] ED for further evaluation. In our
ED his WBC was noted to be elevated at 16 with 9% bands and CXR
with RML consolidation. As a result, he was given 1 dose of
levaquin and erythromycin. Around 6am, he developed substernal
chest pressure in the ED, was given 2mg morphine, and
subsequently became hypoxic to 90% on a NRB resulting in
intubation. ROS on admission were otherwise unremarkable.
Past Medical History:
Recent partial SBO s/p ERCP CBD stent [**2152-5-26**]
Diverticulitis
Chronic diarrhea
Osteoarthritis
Left THR '[**43**]
HTN
CAD s/p MI '[**48**]
Opioid/ETOH abuse
Multiple bowel surgeries, inc sigmoid resection '[**43**] c/b fistula
Lumbar Spinal Stenosis w/ Chronic Back Pain
GERD
1st degree AV Block
Social History:
Lives at [**Hospital3 2558**]
Family History:
unknown
Physical Exam:
VS: T 97.0 (Tm 98.0; last fever=103.8 [**6-11**] early am) BP 152/78
(102-150/60s)
HR 48(48-71) RR 26(18-32) Sats 98% on 40% face tent
I/O: negative 720cc/24hrs; +3.7L for LOS
GEN: cachectic, elderly caucasian male, nontoxic, speaking in
full sentences, A&O x 3, NAD
HEENT: MM sl dry, anicteric, OP clear
NECK: supple, no LAD, no TM
CV: RRR, no R/M/G
LUNGS: [**Month (only) **] at bases bilat, +scatterred ronchi R>L
ABD: soft, ND, NABS, no masses, well-healed surgical scar, mild
diffuse TTP, no rebound or guarding, no HSM
EXT: no edema, no CT, warm, no rashes
NEURO: nonfocal and symmetric
Pertinent Results:
[**2152-6-11**] 03:15PM GLUCOSE-99 UREA N-13 CREAT-0.5 SODIUM-135
POTASSIUM-3.4 CHLORIDE-104 TOTAL CO2-22 CALCIUM-8.3*
PHOSPHATE-3.3 MAGNESIUM-1.8
[**2152-6-11**] 03:15PM WBC-9.3 RBC-3.74* HGB-11.5* HCT-34.1* MCV-91
MCH-30.9 MCHC-33.9 PLT COUNT-306
[**2152-6-11**] 12:58PM LACTATE-3.4*
[**2152-6-11**] 08:30AM ALT(SGPT)-8 AST(SGOT)-13 LD(LDH)-91*
CK(CPK)-16* ALK PHOS-146* AMYLASE-86 TOT BILI-1.3 LIPASE-10
ALBUMIN-2.9*
[**2152-6-11**] 02:52AM PT-13.5* PTT-22.8 INR(PT)-1.2
Studies:
Dobutamine Echo [**2152-6-28**]:
No 2D echocardiographic evidence of inducible ischemia to
achieved
workload. With exercise, a wide comple tachycardia most likely
SVT, developed.
MR Hip [**2152-6-23**]:
Small right sided hip joint effusion with associated severe
degenerative changes, unchanged when compared to [**2152-6-5**].
Limited evaluation of the left hip. Status post left hip
replacement. Fluid near the left hip joint and edema of the
adjacent muscle groups and posterior lateral soft tissues is
unchanged.
CT Abdomen [**2152-6-23**]:
1) Biliary ductal dilatation status post stenting.
2) Failure of left hip prosthesis with superolateral
distraction. Severe degenerative changes of the right hip.
3) No abscess or diverticulitis identified.
EKG [**2152-6-17**]:
Sinus rhythm
Left atrial abnormality
Left axis deviation - consider prior inferior myocardial
infarction and left
anterior fascicular block but baseline artifact makes assessment
difficult
Low limb leads voltage - is nonspecific
QS configuration in leads V1 and V2 - could be in part - ?
positional but
consider also prior anteroseptal myocardial infarction
Clinical correlation is suggested
Since previous tracing of [**2152-6-13**], sinus bradycardia absent and
left axis
deviation now seen
Chest AP Film [**2152-6-11**]:
Significant increase in size of bilateral pleural effusions and
atelectasis of the lower lobes compared to prior film.
Underlying infiltrates cannot be excluded.
Brief Hospital Course:
72M [**Hospital3 2558**] resident admitted for 1 day history of acute
shortness of breath/hypoxia due to pneumonia requring 24hrs of
intubation.
Because he was intubated in the ED for airway protection/hypoxic
respiratory failure, Mr. [**Known lastname **] was initially admitted to the
Medical ICU. His ICU course was notable for transient
hypotension immediately after intubation requiring neosynephrine
for a few hours, negative cardiac enzymes x 3, successful
extubation [**6-12**], a mild transaminitis likely d/t poor
perfusion/hypotension, a failed swallow evaluation [**6-13**], and
new-onset asymptomatic bradycardia since [**6-13**] AM. His sputum
culture came back with moderate MRSA and sparse [**Last Name (LF) **], [**First Name3 (LF) **] as a
result, he was started on a 14 day course of IV Vancomycin via
PICC and PO Levaquin. So his course by problems:
#MRSA Pneumonia - initially intubated x 24hrs for hypoxic
respiratory failure and airway protection. The patient was
extubated the next day without complication. Transferred to the
floor and maintained on a 14 day course of Vancomycin and
Levoquin. The patient remained afebrile but had gradual
elevation of his WBCC and an accompanying bandemia beginning on
[**6-18**]. Further w/u for source had been negative, including blood
cx's, cxr, ua, ct abd/pelvis to r/o abscess, and MRI to evaluate
for septic joint. However on [**6-23**] a urine culture grew out
yeast species. Despite a negative UA, the patient was treated
with a 5d course of fluconazole as it was felt that this was a
possible of his elevated WBCC. The other most likely etiology
is intermittent biliary obstruction, as discussed below.
#Cholecystitis- in [**4-28**] pt was admitted with ascending
cholangitis (was not manifesting any abdominal pain symptoms)
and underwent ERCP stenting of his CBD. Initial plan was for
repeat ERCP to remove additional stones but in discussion with
Dr. [**Last Name (STitle) 957**] of surgery it was felt that the patient would
benefit from open cholecystectomy and subsequent exploration of
the biliary tree as an outpatient elecive procedure. During
admission the patient's tranasminases and bili have remained
normal.
#Bradycardia - During the first 48hrs of admission, telemetry
revealed intermittent bradycardia to 30s-40s, but patient
remained entirely asymptomatic and hemodynamically stable. As a
result, his outpatient metoprolol was reduced by half.
#Intermittent Chest Pain - has been occurring for past few weeks
per patient, but no evidence of EKG changes and was ruled out by
CE x 3 initially. A stress MIBI was attempted, but the patient
could not lay still enough for the procedure. As a result a
dobutamine ECHO was obtained. Mr. [**Known lastname **] developed some NSVT
during the dobutamine infusion (not uncommon per cardiology),
yet his ECHO failed to reveal any ischemic wall motion
abnormalities. Thus, it was thought that he probably does not
have active coronary disease. Nevertheless, he was continued on
his aspirin, beta-blocker, and ACE.
#FEN - despite initial failure, he passed swallow evaluation on
[**6-14**], and tolerated regular soft diet/thin liquids during this
admission. His electrolytes were checked on a daily basis and
repleted as needed.
#Chronic Pain Issues ?????? The patient was taking oxycontin 240mg
TID (!) as an outpatient. We were able to successfully weane
his regimen to 20mg TID at the time of discharge with good
control of his pain.
#L Hip Dislocation/R Hip DJD - patient has had a long,
complicated course with h/o a L septic hip prosthesis that was
removed and replaced at the [**Hospital1 756**] [**2-27**] after 6 weeks of IV
antibiotics. By report, the organism was [**First Name5 (NamePattern1) 564**] [**Last Name (NamePattern1) 563**].
This was not verified by B&W surgical records. An MRI was
obtained of both hips which did not reveal any abscesses or
anything suggestive of osteomyelitis. Orthopedics was consulted
and feel that the patient would benefit from an outpatient
removal of his L hip prosthesis and spacer with an eventual
total R hip replacement. He is to remain completely
nonweight-bearing on his left lower extremity until after his
surgical repair.
#Diarrhea - appears to be chronic in nature. Pt was ruled out
for C.diff. GI followed in consult for the diarrhea. After an
infectious etiology was excluded, the patient was restarted on
his outpatient anti-diarrheals (in discussion with his outpt GI
doc, Dr. [**Last Name (STitle) 79**] with dramatic improvement.
#Proph - the patient was placed on adequate DVT and GI
prophylaxis with fall and MRSA precautions
#Dispo - PT was consulted, and given all his comorbidities and
clinical condition, the patient was deemed most suitable for a
skilled nursing facility. He has been discharged with follow-up
appointments with Dr. [**Last Name (STitle) 79**] (GI), Dr. [**Last Name (STitle) 49469**] (Ortho), and Dr.
[**Last Name (STitle) 957**] (Gen [**Doctor First Name **]). Of note, he will need 3 operations sometime
in the near future: a cholecystectomy and bilateral hip
replacements.
Medications on Admission:
metoprolol 25mg [**Hospital1 **]
hyoscyamine 0.375mg [**Hospital1 **]
cholestyramine 4g qid
loperanite 2mg q4hr
dicyclone 20mg qid
heparin 5000u sq [**Hospital1 **]
oxycontin 240mg tid
valium 2.5mg q12
artificial tears prn
Discharge Medications:
1. Multivitamin Capsule Sig: One (1) Cap PO QD (once a day).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO QD (once a day).
3. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Oxycodone HCl 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4
to 6 hours) as needed for pain.
7. Zinc Oxide-Cod Liver Oil 40 % Ointment Sig: One (1) Appl
Topical PRN (as needed).
8. Simethicone 80 mg Tablet, Chewable Sig: 0.5-1 Tablet,
Chewable PO QID (4 times a day) as needed.
9. Hyoscyamine Sulfate 0.375 mg Capsule, Sust. Release 12HR Sig:
One (1) Capsule, Sust. Release 12HR PO BID (2 times a day).
10. Cholestyramine 4 g Packet Sig: One (1) Packet PO QD (once a
day).
11. Lidocaine HCl 2 % Gel Sig: One (1) Appl Urethral ASDIR (AS
DIRECTED).
12. Dicyclomine HCl 10 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
13. Amitriptyline HCl 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
14. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for to peri area.
15. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
16. Loperamide HCl 2 mg Capsule Sig: Two (2) Capsule PO Q4-6H
(every 4 to 6 hours) as needed for Diarrhea: max 16g/day.
17. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime)
as needed for depression and appetite.
18. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO QD (once a day).
19. Oxycodone HCl 20 mg Tablet Sustained Release 12HR Sig: One
(1) Tablet Sustained Release 12HR PO Q8H (every 8 hours).
Discharge Disposition:
Extended Care
Facility:
Healthbridge
Discharge Diagnosis:
MRSA Pneumonia
Chronic Diarrhea
Asymptomatic Bradycardia
Depression
Displaced L Hip Prosthesis
Intermittent Biliary Obstruction [**12-27**] Numerous Gallstones
Discharge Condition:
stable - tolerating regular diet, afebrile w/ labs stable
Discharge Instructions:
1. Take all your prescribed medications
2. Make sure you go to all your follow-up appointments
3. Keep yourself well-hydrated
4. Call your physician or return to ED for any fevers, chills,
increased SOB, cough, lightheadedness, dizziness, inability to
tolerate food/drink, or anything else that concerns you
Followup Instructions:
1.Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Where: [**Hospital6 29**] MEDICAL
SPECIALTIES Phone:[**Telephone/Fax (1) 1954**] Date/Time:[**2152-7-4**] 1:40
2.Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10486**], MD Where: [**Hospital6 29**]
ORTHOPEDICS Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2152-7-7**] 3:00
3.Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 3628**] SURGICAL ASSOC [**Name11 (NameIs) 3628**]-3A Where: LM [**Hospital Unit Name **] SURGICAL ASSOCIATES Phone:[**Telephone/Fax (1) 3666**]
Date/Time:[**2152-7-14**] 2:00
ICD9 Codes: 4271, 2765, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3675
} | Medical Text: Admission Date: [**2165-12-25**] Discharge Date: [**2166-1-8**]
Date of Birth: [**2084-3-20**] Sex: F
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 4611**]
Chief Complaint:
chest pressure
Major Surgical or Invasive Procedure:
Cardiac cathetherization
History of Present Illness:
[**Known firstname 2127**] [**Known lastname 4612**] is a 81 yo female with a past medical history of
CAD with a 1 vessel CABG (SVG to LAD) in [**2134**] who presents with
chest pressure. She woke up at 8 am with substernal chest
pressure. It was severe initially. She took SL NTG x3 with
relief of CP for a short period of time. The CP radiated to her
right side and eventually down both arms. She reports
diaphoresis, but denied associated nausea, vomiting,
lightheadedness or dizziness. She reports that she has felt
mildly SOB since her recent pneumonia (first diagnosed appox [**6-24**]
weeks ago). She denied worsening dyspnea. Her cough has
improved substantially and is very minimal at this time. She
went to her PCP's office and was found to have a new LBBB and
anterior ST elevations. She was transferred to the ED. She
received Plavix 300mg, Aspirin, boluses of heparin and
integrillin. Code STEMI was called and went to the cath lab.
Cath showed occluded SVG, Native 3vd, occluded proximal LAD.
Wiring the LAD was difficult and there was concern about a
possible dissection. One BMS was placed in the proximal LAD.
Distal LAD is diminutive past 1st septal and diag branches.
She has been hemodynamically stable with HR 60-70s and SBP
120-130s. On the floor, she is currently chest pain free and
feels well.
.
.
On review of systems, she denies any prior history of deep
venous thrombosis, pulmonary embolism, bleeding at the time of
surgery, myalgias, joint pains, cough, hemoptysis, black stools
or red stools. She denies recent fevers, chills or rigors. 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: Pt with MI in [**2134**] and subsequent 1 vessel CABG SVG ->LAD
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
# CVA - small left posterior frontal infarct in [**2164-12-17**]
for which she is on [**1-18**] tab of plavix daily
# hypercholesterolemia.
# small PFO.
# Macular Degereration
Social History:
# Clopidogrel [Plavix] 75 mg Tablet PO Daily
# Ezetimibe-Simvastatin [Vytorin [**11-5**]] 10 mg-20 mg PO daily
# Nifedipine 30 mg SR PO qday
# Nitroglycerin 0.4 mg/hour Patch 24 hr 1 patch once a day
# Nitroglycern sublingual tabs PRN - has not used recently prior
to today
# Propranolol 80 mg Tablet PO once a day
# Multivitamin
.
Family History:
Her father died due to CAD at age 52. Her mother had
stomach cancer and bone cancer.
Physical Exam:
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 8 cm.
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. CTA anteriorly, 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. Femoral sheath in place in right groin.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
Pertinent Results:
EKG: new LBBB with STE in V1 -V3 & V5 that in some leads are
>5mm.
TELEMETRY: NSR 75, few NSVTs.
2D-ECHOCARDIOGRAM: pending
ETT: n/a
.
CARDIAC CATH:
LMCA: 40% distal
LAD: Occluded difficult to cross; was crossed and stented in
proximal LAD. Distal LAD diffuse diseased.
LCX: occluded OM2, 50% LCX
RCA: Occluded
Brief Hospital Course:
[**Known firstname 2127**] [**Known lastname 4612**] is a 81 yo female with a history of CAD who
presented with an STEMI s/p catheterization and was incidentally
found to have multiple pulmonary nodules consistent with
adenocarcinoma.
#. STEMI: Pt presented with an anterior STEMI. Her TIMI risk
score was 7 indicating a 41% risk at 14 days of mortality, new
or recurrent MI, or severe recurrent ischemia requiring urgent
revascularization. Her SVG found to be completely occluded and
a BMS was placed in the proximal LAD. Due to the timing of the
SVG placement over 20 years ago, it was thought that her LAD had
managed to self revascularize and was partially supplied by the
RCA. She was started on routine ACS medications: eptifibatide
for 18 hrs, plavix 75 and aspirin 325mg, metoprolol, captopril,
and atorvastatin. Cardiac enzymes trended down appropriately
with peak Ck and CKMB at 107 and 18.2. There was concern for
acute heart failure from ischemic insult oxygen requirement.
However, she was noted to also have a RLL pneumonia and no
significant pulmonary edema (see below). ECHO showed moderate
to severe regional left ventricular systolic dysfunction with
anterior and anterospetal akinesis and inferior/inferolateral
hypokinesis. Initially, patient was started on coumadin for
ventricular thrombus prophylaxis, but this was subsequantly
discontinued as risk of bleeding outweighed benefit.
# Hypoxia: Upon hospitalization, patient was maintaing
saturations in low 90s on 6L from baseline 92% on RA. CXR
showed RLL pneumonia, and patient was subsequantly started on
ceftriaxone, azithromycin, metronidazole. As the patient had
history recurrent RLL pneumonia, a CT scan was obtained which
showed severe right lower lobe consolidation and extensive, new
diffuse lung nodules with sputum cytology positive for
adenocarcinoma. Hypoxia was initially felt to be a combination
of postobstructive pneumonia and tumor burden from
adenocarcinoma. Antibiotics were changed to vancomycin,
levofloxacin and flagyl of which she completed a 10 day course.
Repeat CT scan showed little interval improvement in right lower
lobe infiltrate. Respiratory status remained tenuous, patient
requiring high flow O2 with 6LNC with desaturations to high 70s
with activity. Prior to discharge O2 requirement was 5L by
nasal cannula. She was breathing comfortably with oxygen
saturation in the low 90s. Likely this will continue to be
necessary for some time. A shovel mask may be used to assist
with oxygenation as needed.
# Lung nodules/ Broncheoalveolar carcinoma: CT scan with diffuse
pulmonary nodules and sputum cytology positive for
adenocarcinoma. Etiology was felt to be primary
bronchioalveolar vs metastatic thyroid dx (prior dx of possible
microfollicular carcinoma) although routine cancer screening was
not up-to-date. A tissue diagnosis was not attained given the
patient's high oxygen requirement and anticoagulation with
plavix/asa in the setting of recent BMS placement. Although
patient did not have imaging of her head, staging based on CT
torso was IIIa with pulmonary nodules in both lung fields
without obvious distal LAD or metastasis. Empiric therapy with
single [**Doctor Last Name 360**] chemotherapy was initiated on [**1-7**] with
Pemetrexed. She tolerated this well. She received
dexamethasone on [**1-8**] to prevent rash.
# Chronic renal insufficiency - Patient with GFR 48.
Medications were renally dosed and renal function was carefully
followed. She was treated prophylactically with mucomyst prior
to and post IV contrast dose. Creatinine remained stable at
1-1.1.
# Hyperkalemia: The patient was mildly hyperkalemic the day
prior to discharge to 5.6 without EKG changes. This responded
promptly to kayexalate. Electrolytes should be checked daily
until stable. If necessary ACEI could be stopped.
# HTN: She was normotensive on ACEI and b-blocker.
Medications on Admission:
# Clopidogrel [Plavix] 75 mg Tablet PO Daily
# Ezetimibe-Simvastatin [Vytorin [**11-5**]] 10 mg-20 mg PO daily
# Nifedipine 30 mg SR PO qday
# Nitroglycerin 0.4 mg/hour Patch 24 hr 1 patch once a day
# Nitroglycern sublingual tabs PRN - has not used recently prior
to today
# Propranolol 80 mg Tablet PO once a day
# Multivitamin
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary:
ST elevation myocardial infarction
Presumed broncheoalveolar carcinoma
Discharge Condition:
stable, with 5L oxygen requirement and O2 Sat in the low 90s
Discharge Instructions:
You were admitted to the hospital for chest pressure and found
to have a heart attack. You had a cardiac catheterization and
had a bare metal stent placed. After this, you had some trouble
breathing and had a scan that showed some nodules in your lungs.
A sputum sample was sent and malignant cells were seen. This
was thought to be broncheoalveolar lung cancer, and you were
treated with one dose of chemotherapy for this. Please
follow-up with Dr. [**Last Name (STitle) 4613**] and [**Doctor Last Name **] to determine if further
treatment will be needed.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
The following changes were made to your medications:
1. You were started on plavix, a medication to thin your blood.
You must take this medication for 1 month to ensure that your
heart stent does not become blocked.
Followup Instructions:
Please follow up with Drs. [**Last Name (STitle) 4613**] and [**Name5 (PTitle) **]. Their office will
be calling [**Hospital1 **] to schedule your appointment. If you do not
hear from them this week please call ([**Telephone/Fax (1) 3280**] to arrange.
We made an appointment with the cardiologist: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **],
MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2166-2-11**] 10:40
Please also call your primary care doctor, Dr. [**Last Name (STitle) 4614**] to
schedule follow up. He may be reached at [**Telephone/Fax (1) 4615**].
Completed by:[**2166-1-9**]
ICD9 Codes: 486, 2761, 2720, 5859, 2767, 4280, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3676
} | Medical Text: Admission Date: [**2178-4-9**] Discharge Date: [**2178-4-10**]
Date of Birth: [**2138-4-9**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
alcohol withdrawal
Major Surgical or Invasive Procedure:
None
History of Present Illness:
40yo male with history of depression, SI, and ETOH was admitted
from the ED with withdrawal.
.
Patient was admitted initially to [**Hospital1 **] for SI, depression,
and alcohol abuse. Patient was doing relatively well until the
day prior to admission when he developed increasing requirements
of lorazepam. He was initially admitted to [**Hospital3 **] Hospital.
roughly 7-10 days he called his wife intoxicated and threatening
suicide and later threatened her with homicide. She called the
police to see him and they then brought him to the hospital for
evaluation of suicidal ideation. After he was medically cleared
at [**Hospital3 **] Hospital, he was transferred to [**Hospital1 **] for
suicidal ideation. On the morning of transfer, he was found by
nursing staff to be agitated and confused, requiring 5mg
haloperidol at 5am. He was tachycardic to 104, hypertensive to
157/117, and tremulous during transport. Upon arrival to the ED,
temp 98, HR 106, BP 157/11, O2 sat 96% on room air. His CIWA was
30 and he was tremulous. He received a total of 15mg IV diazepam
and 2L NS while in the ED. Upon arrival in the [**Hospital Unit Name 153**], he is
sedated and denies pain. He cannot answer when his last drink
was or any other questions.
Past Medical History:
1. Depression
2. ALcohol Abuse
3. h/o Positive PPD with 9 months INH
4. Hyperlipidemia
5. Anxiety
6. Obstructive Sleep Apnea
7. h/o nipple abscess s/p nipple pierces
8. Possible history of NASH
9. GERD
Social History:
- Home: separated from his wife for approximately 1 year, lives
with his mother currently; 2 children; history of physical and
sexual abuse
- Occupation: IT administrator
- EtOH: drinks a fifth to [**12-19**] gallof of vodka or whiskey daily;
last drink was at least [**2178-4-4**]
- Drugs: history of marijuana use
- Tobacco: per previous documentation [**12-19**] PPD
Family History:
unknown
Physical Exam:
On admission
HR 109 / BP 156/100 / RR 25 / 94% RA
Gen: tremulous, sedated but arousable, well nourished
HEENT: Clear OP, MMM
NECK: Supple, No LAD, No JVD
CV: tachycardic but regular rhythm. NL S1, S2. No murmurs, rubs
or gallops
LUNGS: CTA, BS BL, No W/R/C
ABD: overweight, Soft, NT, ND. NL BS. No HSM
EXT: No edema. 2+ DP pulses BL
SKIN: No lesions
NEURO: Appropriate. CN 2-12 grossly intact. Preserved sensation
throughout. 5/5 strength throughout Normal coordination. Could
not complete full neuro exam. Could not answer questions
regarding orientation.
PSYCH: Tremulous and sedated
Pertinent Results:
[**2178-4-9**] 08:50AM BLOOD WBC-9.0 RBC-4.05* Hgb-13.6* Hct-40.2
MCV-99* MCH-33.7* MCHC-33.9 RDW-12.5 Plt Ct-296
[**2178-4-9**] 08:50AM BLOOD Glucose-81 UreaN-19 Creat-1.2 Na-140
K-3.9 Cl-107 HCO3-22 AnGap-15
[**2178-4-9**] 08:50AM BLOOD Albumin-4.2 Calcium-8.7 Phos-4.8* Mg-2.3
[**2178-4-9**] 08:50AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
[**2178-4-9**] 08:50AM BLOOD ALT-184* AST-89* AlkPhos-60 TotBili-0.4
[**2178-4-10**] 04:27AM BLOOD ALT-158* AST-81* AlkPhos-59 TotBili-0.5
[**2178-4-10**] 04:27AM BLOOD ALT-163* AST-77* AlkPhos-61 TotBili-0.5
[**2178-4-9**] 08:50AM BLOOD PT-13.4 PTT-20.8* INR(PT)-1.1
Brief Hospital Course:
40yo male with a history of alcohol abuse, depression,
hyperlipidemia, and presumed NASH was admitted with alcohol
withdrawal.
.
1. Alcohol WithdrawalPatient was admitted to the intensive care
unit with alcohol withdrawal requiring diazepam. His alcohol
withdrawal symptoms have improved markedly since admission, last
requiring diazepam at 11pm on [**4-9**]. Patient does continue to
feel anxious. He received lorazepam 1mg IV x1 this AM and we
restarted him on lorazepam 1mg PO TID which he was taking at
[**Hospital1 **]. He received 5 days of multivitamin, thiamine, and
folate between being at [**Hospital1 **] and being at [**Hospital1 **]. These
medications were discontinued on [**2178-4-10**]. Psychiatry was
consulted to help with placement.
.
2. Depression: The patient has a history of depression, suicidal
ideation, and homicidal requiring psychiatric hospitalization. H
was treated for his alcohol withdrawal and will require
psychiatric hospitalization. Psychiatry was consulted.
.
3. Transmanitis: The patient has elevated ALT and AST in a ratio
consistent with alcohol abuse. Etiology is most likely due to
alcohol abuse in the setting of NASH. He has had a thorough
hepatology evaluation in [**2170**] which was unrevealing for a cause
of his LFT abnormalities. LFTs should be followed up at
[**Hospital1 **].
.
4. GERD: Stable. He was continued on his PPI.
.
5. FEN: The patient is on a regular diet and his eletrolytes
were repleated.
.
6. PPx: PPI, bowel regimen, heparin SC
.
7. CODE: FULL CODE
Medications on Admission:
1. Wellbutrin SR 150mg PO bid
2. Protonix 40mg PO daily
3. Thiamine 100mg daily x 5 days ([**2092-4-3**])
4. Folate 1mg daily x 5 days ([**2092-4-3**])
5. MVI daily ([**2092-4-3**])
6. Lorazepam 1mg PO tid
7. Ibuprofen prn
8. Trazodone 50mg PO qhs prn
9. Hydroxyzine 50mg Po q6h prn anxiety
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO BID (2 times a day).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 8063**]
Discharge Diagnosis:
PRIMARY DIAGNOSES:
1. Alcohol Withdrawal
2. Depression
3. Transaminitis
.
SECONDARY DIAGNOSIS:
1. GERD
Discharge Condition:
Stable. Patient is tolerating oral intake and ambulating.
Discharge Instructions:
You were admitted to the hospital with alcohol withdrawal. You
were treated with medications to help treat your withdrawal
symptoms. Your symptoms are now much improved, and you are being
discharged to a psychiatry facility to treat your depression and
alcohol abuse. While you were in the hospital, your liver
function tests were slightly elevated, which was likely related
to your alcohol use. You are being discharged to [**Hospital1 **].
.
We have made no changes to your medication regimen.
.
Please seek immediate help if you develop symptoms of feeling
anxious, having thoughts about hurting yourself or others,
feeling lightheaded, fevers, shaking chills, night sweats,
headache, abdominal pain, or feeling confused.
Followup Instructions:
Please follow-up with your primary care doctor within 1-2 weeks
of your discharge from the hospital. When you meet with him,
please ask him to check your liver function tests as these were
slightly elevated when you were in the hospital.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2178-4-10**]
ICD9 Codes: 2724, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3677
} | Medical Text: Admission Date: [**2137-8-19**] Discharge Date: [**2137-8-27**]
Date of Birth: [**2056-8-22**] Sex: F
Service: SURGERY
Allergies:
Demerol / Droperidol / Penicillamine / Streptomycin / Ampicillin
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
Lower abdominal pain
Major Surgical or Invasive Procedure:
Exploratory lap with lysis of adhesions [**2137-8-19**]
History of Present Illness:
81 yo female, Russian speaking, with c/o bilateral lower
abdominal pain x3 hours prior to arrival to emergency room;
+nausea, no emesis. Had flatus and a bowel movement earlier
today. Abdominal CT scan revealed + gallstones and ildly dilated
small bowel loops.
Past Medical History:
Atrial fibrillation
Hypercholesterolemia
Gallstones
h/o SBO
s/p Hysterectomy
Hypertension
Gout
Family History:
Noncontributory
Physical Exam:
Upon admission:
T 97.7 HR 56 BP 160/64 O2 Sat 98%
Gen: alert
Cor: RRR
Chest: CTA bilaterally
Abd: soft, slightly distended, TTP LUQ, no rebound
Rectum: guaiac negative, no stool
Extr: no C/C/E
Pertinent Results:
Upon admission:
[**2137-8-19**] 05:52PM GLUCOSE-127* UREA N-25* CREAT-0.9 SODIUM-142
POTASSIUM-3.5 CHLORIDE-105 TOTAL CO2-31 ANION GAP-10
[**2137-8-19**] 05:52PM CALCIUM-7.8* PHOSPHATE-3.5 MAGNESIUM-1.9
[**2137-8-19**] 05:52PM WBC-10.5 RBC-3.62* HGB-10.1* HCT-29.5*
MCV-81* MCH-27.9 MCHC-34.4 RDW-15.2
[**2137-8-19**] 05:52PM PLT COUNT-186
[**2137-8-18**] 11:15PM PLT COUNT-212
[**2137-8-18**] 11:15PM PT-11.9 PTT-28.5 INR(PT)-1.0
CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST
Reason: eval: intraabd path
Field of view: 36 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
80 year old woman with abd pain
REASON FOR THIS EXAMINATION:
eval: intraabd path
CONTRAINDICATIONS for IV CONTRAST: None.
HISTORY: 80-year-old woman with abdominal pain.
COMPARISON: [**2135-9-25**].
IMPRESSION:
1. Dilated mid small bowel loops with a transition to decompress
distal ileum concerning for a partial or early small-bowel
obstruction.
2. Nasogastric tube tip within the esophagus after coiling in
the stomach.
3. Cholelithiasis without evidence of cholecystitis.
CHEST (PORTABLE AP)
Reason: please eval for infiltrates / overload
[**Hospital 93**] MEDICAL CONDITION:
80 yo F s/p SBO OR yesterday for adhesion lysis, poor NGT
output. Now wheezing post some IVF.
REASON FOR THIS EXAMINATION:
please eval for infiltrates / overload
EXAMINATION: AP chest, 6:10 a.m., [**8-21**].
HISTORY: Wheezing.
IMPRESSION: Lateral aspect of the right chest is excluded from
the examination. The remainder of the lungs demonstrates new
moderately severe pulmonary edema and there is also a small left
pleural effusion and superior mediastinal vascular engorgement.
Nasogastric tube can be traced as far as the upper stomach. No
pneumothorax along the imaged pleural surfaces.
Brief Hospital Course:
Patient admitted to the Surgical service under the care of Dr.
[**Last Name (STitle) **]. She was taken to the operating room on [**2137-8-19**] for
exploratory lap and lysis of adhesions. Postoperatively she was
taken to the Surgical ICU. She developed pulmonary edema and was
given Lasix with good diuresis and is being discharged on Lasix
40 mg po BID. Her pain was initially controlled with PCA
Morphine, this was later changed to long acting narcotics (MS
Contin) and Percocet for breakthrough pain. She is tolerating a
regular heart healthy diet and was also placed on an aggressive
bowel regimen.
Physical therapy was consulted and have recommended short term
rehab stay in order to improve overall functional status.
Medications on Admission:
Lipitor
Atenolol
Neurontin
Simethicone
Hydralazine
Lasix
Prilosec
Zoloft
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for pain.
3. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
every six (6) hours as needed for shortness of breath or
wheezing.
4. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours) as needed for shortness of breath or
wheezing.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day): hold for [**Last Name (un) 940**] stools.
6. Polyethylene Glycol 3350 17 g (100%) Packet Sig: One (1)
Packet PO DAILY (Daily): Mix with 8 oz water or juice.
7. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: Two (2) Tablet
PO every four (4) hours as needed for breakthrough pain.
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day): hold for HR <60 and/or SBP <110.
11. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
12. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
13. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection every six (6) hours as needed for per
fingerstick/sliding scale.
14. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily)
as needed for gout.
15. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): Hold for SBP <110.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Partial vs. Early Small Bowel Obstruction
Discharge Condition:
Good
Discharge Instructions:
Return to the Emergency room if you develop fevers, chills,
abdomnal pain, nausea, vomitting and/or any other symptoms that
sre concerning to you.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] in General Surgery Clinic in 1 week,
call [**Telephone/Fax (1) 600**] for an appointment.
Follow up with your Primary Care Doctor (Dr. [**Last Name (STitle) 2450**] after
discharge from rehab.
Completed by:[**2137-9-2**]
ICD9 Codes: 4280, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3678
} | Medical Text: Admission Date: [**2182-12-3**] Discharge Date: [**2182-12-5**]
Date of Birth: [**2148-4-23**] Sex: M
Service: [**Location (un) **]
HISTORY OF PRESENT ILLNESS: Patient is a 34-year-old male
presenting with nausea, vomiting, gastroparesis, and
hypertensive urgency discharged one day prior to this
admission for similar symptoms and complaints. He has had
frequent admissions, from [**11-30**] to [**12-2**] patient was admitted
requiring IV antihypertensives. He was entered into NIH
study for a pseudopheochromocytoma and paroxysms of malignant
hypertension despite his negative workup. He presents with
another bout of nausea, vomiting, blood glucose to the 300,
and reports the same symptoms and circumstances as his prior
admissions.
Currently central access which he has had for four weeks.
Denies any blurred vision, headache. Denies any chest pain.
In the Emergency Department is requiring a labetalol drip.
On presentation, blood pressure was 246/145, which came down
to 124/85 on the labetalol drip.
PAST MEDICAL HISTORY:
1. Type 1 diabetes.
2. Diabetic gastroparesis.
3. Autonomic neuropathy.
4. Chronic renal insufficiency.
5. Mild coronary artery disease.
6. Hypertension.
ALLERGIES: Patient has no known drug allergies.
MEDICATIONS:
1. Lisinopril 10.
2. Nifedipine CR 60.
3. Metoprolol 100 b.i.d.
4. Aspirin 81.
5. Pantoprazole 40.
6. Heparin subQ.
7. Citalopram 20 q.d.
8. Ondansetron.
9. Lorazepam.
10. Glargine 14 units q.h.s.
11. Humalog insulin-sliding scale.
12. Metoclopramide 10 p.o. q.i.d. a.c. and h.s.
13. Clonidine patch.
SOCIAL HISTORY: Patient lives in [**Location 686**]. Denies tobacco
and alcohol use. Currently unemployed secondary to frequent
hospitalizations.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: Temperature 98.5, blood pressure
122/75, heart rate 80, respiratory rate 12, sating 97% on
room air. In general, patient is drowsy, but arousable and
ill appearing African American male. HEENT: Mucous
membranes are dry. Pupils are small, 2 mm on Morphine,
reactive. Extraocular movements are intact. Right lid is
hard to open. Neck is supple. There is a left subclavian in
place with no erythema. Cardiovascular: Tachycardic,
regular rate, S1, S2 with a 1/6 systolic murmur at the right
border. Pulmonary: CTA bilaterally. Abdominal examination:
No bowel sounds are noted. Abdomen is tender to palpation
diffusely. There is no distention, no hepatosplenomegaly
noted. Extremities: No edema is noted, no cyanosis, and no
clubbing. Skin: There are no obvious rashes.
LABORATORIES ON ADMISSION: EKG with normal axes, sinus, ST
elevations, unchanged from prior admissions.
Hematocrit on admission is 35.7, white count 8.1, 62% segs,
24% lymphocytes, 7.4 monocytes, 5.8 eosinophils. Urinalysis:
significant only for 100 glucose, small blood, occasional
bacteria. Blood glucose is notable to be 210. Creatinine
was at its baseline of 1.8 on admission.
HOSPITAL COURSE BY PROBLEM: This 38-year-old African
American male with a long history of type 1 diabetes
complicated by autonomic neuropathy, chronic renal failure,
coronary artery disease, gastroparesis, and malignant
hypertension requiring multiple admissions recently contact[**Name (NI) **]
and connected with NIH for entering into a
pseudopheochromocytoma study.
1. Hypertension: Patient was treated with IV labetalol and
hydralazine in the Emergency Room and closely monitored. He
was transferred to the floor, where he was put on IV doses of
metoprolol as well as IV hydralazine. Placed on telemetry
for monitoring. Patient was transitioned over his hospital
stay to p.o. medications. Blood pressure normalized. There
were no EKG changes. Patient was maintained on his blood
pressure medications and discharged normotensive pressures.
2. Nausea and vomiting resolved: Frequent occurrences of
gastroparesis and autonomic dysfunction may also be related
to his hypertensive CNS symptoms, which was greatly relieved
by a decrease in his blood pressure. Patient is given
metoclopramide and ondansetron, Ativan prn. He was started
on p.o. and was tolerating them well prior to his discharge.
Patient did require IV fluid hydration until p.o. could be
tolerated on the day prior to discharge.
3. Cardiac ischemia: Patient with a history of CAD, MI.
There are no EKG changes. No chest pain during this
admission. Enzymes were not cycled. Patient is already on
aspirin, metoprolol, lisinopril. An echocardiogram on [**11-25**]
showed an EF of 60-65%, mild MR, mild TR, borderline PA
systolic hypertension, moderate left hypertrophy.
4. Anemia: Patient's hematocrit was 35.7 and remained above
the goal of 30 throughout this admission.
5. Chronic renal insufficiency: Patient's creatinine was 1.8
on admission and is baseline.
DISCHARGE CONDITION: Patient was normotensive. Patient was
tolerating p.o. with resolution of nausea and vomiting.
FOLLOW-UP PLANS: Patient had a follow-up plan with his
primary care, [**Doctor First Name **] [**Doctor Last Name **] on [**12-18**] as well as
Dr. [**Last Name (STitle) 18608**].
DISCHARGE MEDICATIONS:
1. Lisinopril 10.
2. Nifedipine 60 q.h.s.
3. Aspirin 81 q.d.
4. Citalopram 20 q.d.
5. Metoclopramide 10 q.i.d. a.c. and h.s.
6. Pantoprazole 40.
7. Insulin.
8. Glargine.
9. Clonidine patch.
10. Metoprolol 100 1.5 tablets p.o. q.d.
[**First Name8 (NamePattern2) **] [**Doctor First Name **], M.D. [**MD Number(1) 19814**]
Dictated By:[**Last Name (NamePattern1) 5713**]
MEDQUIST36
D: [**2182-12-29**] 21:39
T: [**2182-12-31**] 08:18
JOB#: [**Job Number 93213**]
ICD9 Codes: 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3679
} | Medical Text: Admission Date: [**2202-10-11**] Discharge Date: [**2202-10-20**]
Date of Birth: [**2145-7-27**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Mitral and tricuspid regurgitation
Major Surgical or Invasive Procedure:
[**2202-10-11**] - Redo Sternotomy, Mitral valve replacement(27mm St.
[**Male First Name (un) 923**] Mechanical), tricuspid valve Repair(30mm CE Annuloplasty
Ring)
History of Present Illness:
Mrs. [**Known lastname 9996**] is a 57-year-old woman who is five years status
post bovine pericardial aortic valve replacement who presents
with increasing mitral
regurgitation, tricuspid regurgitation and hepatic enlargement.
It was elected to proceed with mitral valve replacement,
tricuspid repair.
Past Medical History:
mitral regurgitation
tricuspid regurgitation
s/p aortic valve replacement
systemic lupus erythematosis
systemic hypertension
pulmonary hypertension
raynaud's disease
s/p cholecystectomy
lupus nephritis
rheumatic heart disease
portal hypertension
anemia
Social History:
Patient is married with one son, denies tobacco, minimal EtOH
Family History:
Grandmother died from a CVA at age 50. Father died at age 70
from complications of diabetes.
Physical Exam:
awake and alert
Lungs- clear
cor-R at 70. crisp cardiac sounds, no murmur
exts- 2- edema legs, not tense
Abdomen- soft, nontender, normoactive bowel sounds
wounds- clean and dry. sternum is stable.
Pertinent Results:
[**2202-10-11**] ECHO
Pre Bypass
The left atrium is elongated. The right atrium is moderately
dilated. No atrial septal defect is seen by 2D or color Doppler.
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The ascending, transverse and descending thoracic aorta are
normal in diameter. There are simple atheroma in the descending
thoracic aorta. A bioprosthetic aortic valve prosthesis is
present. There is mild aortic valve stenosis (area 1.2-1.9cm2).
Mild (1+) aortic regurgitation is seen. There is mild valvular
mitral stenosis (area 1.5-2.0cm2). Moderate to severe (3+)
mitral regurgitation is seen. Severe [4+] tricuspid
regurgitation is seen. There is no pericardial effusion.
Post Bypass
The patient is AV-paced and on an infusion of epinephrine .04
mcg/kg/min.. Left and right ventricular function is preserved.
The aorta is intact. There is [**2-7**]+ tricuspid regurgitation. The
mean gradient of the tricuspid valve was < 5mmHg. The mitral
valve mechanical prosthesis is in good position with a mean
gradient <6mmHg.. There is a mild mitral perivalvular leak.
Remaining exam is unchanged. These findings were communicated
intraoperatively to Dr. [**Last Name (STitle) **].
[**2202-10-19**] 05:30AM BLOOD WBC-14.1* RBC-2.77* Hgb-8.5* Hct-25.4*
MCV-92 MCH-30.8 MCHC-33.5 RDW-16.4* Plt Ct-283
[**2202-10-20**] 10:50AM BLOOD PT-24.7* INR(PT)-2.4*
[**2202-10-18**] 05:25AM BLOOD PT-40.7* PTT-36.2* INR(PT)-4.4*
[**2202-10-18**] 01:35AM BLOOD PT-38.1* PTT-35.9* INR(PT)-4.1*
[**2202-10-17**] 07:00PM BLOOD PT-60.6* PTT-35.9* INR(PT)-7.2*
[**2202-10-17**] 04:58PM BLOOD PT-57.5* PTT-33.6 INR(PT)-6.8*
[**2202-10-17**] 01:00PM BLOOD PT-49.3* PTT-35.9* INR(PT)-5.6*
[**2202-10-17**] 06:35AM BLOOD PT-45.7* PTT-81.8* INR(PT)-5.1*
[**2202-10-16**] 10:04AM BLOOD PT-20.1* PTT-55.1* INR(PT)-1.9*
[**2202-10-16**] 03:45AM BLOOD PT-17.1* PTT-56.5* INR(PT)-1.5*
[**2202-10-15**] 05:50AM BLOOD PT-16.9* PTT-50.2* INR(PT)-1.5*
[**2202-10-14**] 04:33AM BLOOD PT-17.7* PTT-38.3* INR(PT)-1.6*
[**2202-10-14**] 03:08AM BLOOD PT-18.7* PTT-104.1* INR(PT)-1.7*
Brief Hospital Course:
Mrs. [**Known lastname 9996**] was admitted to the [**Hospital1 18**] on [**2202-10-11**] for elective
surgical management of her mitral and triccuspid valve disease.
She was taken directly to the operating room where she underwent
a redo sternotomy with a mitral valve replacement using a 27mm
St. [**Male First Name (un) 923**] mechanical valve and a tricuspid valve
repair/annuloplasty. Please see operative note for details.
Postoperatively she was taken to the intensive care unit for
monitoring. She weaned fro bypass on epinephrine and propafol.
She was AV paced due to underlying complete heart block.Within
24 hours she awoke neurologically intact and was extubated. The
pressor was weaned,however, she remained in heart block with a
ventricular rate in the 30s. On POD 3 she was in sinus rhythm
with first degree block in the 50s and stable. She was
transferred to the floor.
Diuresis was continued, to remove fluid overload that existed
preoperatively as well as secondary to the surgery. She
developed atrial flutter subsequently. The EPS service saw her
and cardioversion was planned. On POD6 her INR was greater than
6 and 2 units of FFP were administered, with a fall of the INR
to 4.
The following day her INR was 3.1 and she received 1mg of
Coumadin. cardioversion with 200jouoles successfully converted
her to SR which persisted at discharge. her INR was 2.4 the day
of discharge and 2 mg of Coumadin was ordered.
Her weight fell with diuresis and edema improved. She remained
stable and felt well. She was ready for discharge and diuretics
will be continued.
Arrangement were made for her follow-up for Coumadin dosing with
her primary care physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) **]. She will take 2mg
[**10-20**] and 16 then have a PT/INR checked on[**10-22**] and talk with
Dr. [**Last Name (STitle) **] for further orders. She is to return in 2 weeks for
staple removal.
Medications on Admission:
lasix 20', plaquenil 200", lisinopril 40', lopressor 100",
diovan 160', ASA 81', ferrex 150", MVI
Discharge Medications:
1. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO twice a day.
Disp:*60 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 2 weeks.
Disp:*28 Capsule(s)* Refills:*0*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
6. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1)
Capsule PO bid ().
Disp:*60 Capsule(s)* Refills:*2*
9. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*1*
10. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain for 4 weeks.
Disp:*50 Tablet(s)* Refills:*0*
11. Warfarin 1 mg Tablet Sig: as directed Tablet PO Once Daily
at 4 PM: [**Name8 (MD) **] MD for instructions as directed.
Disp:*100 Tablet(s)* Refills:*2*
12. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed.
Disp:*30 Tablet(s)* Refills:*0*
13. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
14. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
s/p mitral valve replacement and tricuspid annuloplasty
mitral regurgitation
tricuspid regurgitation
s/p aortic valve replacement
hypertention
Pulmonary hypertension
systemic Lupus erythematosis
H/O Rheumatic heart disease
Raynaud's disease
congestive heart failure
Rheumatoid arthritis
Esophagheal spasm
Lupus nephritis
Anemia
Mild hepatic portal fibrosis
s/p cholecystectomy
Discharge Condition:
good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month or while taking narcotics for pain.
7) Call with any questions or concerns.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**]
Scheduled appointments:
Provider: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 2301**], M.D. Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2202-11-24**] 4:45
Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 2310**], MD Phone:[**Telephone/Fax (1) 2226**]
Date/Time:[**2202-12-9**] 2:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2202-12-21**] 3:30
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**1-6**] weeks and for Coumadin dosing.
Completed by:[**2202-10-20**]
ICD9 Codes: 9971, 2851, 5859, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3680
} | Medical Text: Admission Date: [**2153-9-19**] Discharge Date: [**2153-9-23**]
Date of Birth: [**2153-9-19**] Sex: M
Service: NB
HISTORY OF PRESENT ILLNESS: [**Known lastname 55893**] [**Known lastname 57208**] is the former
2.420 kilogram product of a 33 [**5-18**] week gestation pregnancy
born to a 36-year-old G3, P1 now 2 mother. Prenatal screens
revealed a blood type of O positive, antibody negative,
rubella immune, RPR nonreactive, hepatitis B surface antigen
negative, group beta Streptococcus status unknown. The
pregnancy was complicated by placenta previa with multiple
episodes of vaginal bleeding. The mother was admitted to the
hospital at 25 weeks gestation. She was treated with
betamethasone. The infant was born by cesarean section after
another episode of vaginal bleeding. He emerged from the
breech position with decreased tone and irregular
respirations. He required positive pressure ventilation for
the first 30 seconds of life. His Apgar scores were six at
one minute and eight at five minutes. He was admitted to the
Neonatal Intensive Care Unit for treatment of prematurity.
PHYSICAL EXAMINATION: Upon admission to the Neonatal
Intensive Care Unit, the patient's weight was 2.42 kilograms,
75th percentile. Head circumference 33 cm, 90th percentile.
Length 47 cm, 75th percentile. GENERAL: The patient was a
nondysmorphic preterm infant with mild respiratory distress.
HEENT: Normocephalic. Palate intact. Red reflex deferred.
NECK: Supple. SKIN: Pale with underlying [**Doctor Last Name 352**] hue.
Bruising noted on arms, shoulders, and torso. CHEST:
Pronounced pectus. Shallow respirations. Mild intercostal
retractions. CARDIOVASCULAR: Regular rate and rhythm. No
murmurs. Femoral pulses 2+ bilaterally. ABDOMEN: Soft with
active bowel sounds. No masses or distention. GU: Normal
premature male. Testes palpable in the inguinal canals
bilaterally. The anus was patent. SPINE: Midline and
straight. No sacral dimple. HIPS: Stable. NEUROLOGIC:
Appropriate tone and reflexes.
HOSPITAL COURSE: RESPIRATORY: [**Known lastname 55893**] required intubation
shortly after admission to the Neonatal Intensive Care Unit
for his respiratory distress. He received two doses of
Surfactant. His maximum ventilatory settings were a peak
inspiratory pressure of 24/positive end-expiratory pressure
of 5 and intermittent mandatory ventilatory rate of 20. He
weaned gradually over the first 24 hours of life and was
extubated to nasal cannula 02. He remained in nasal cannula
02 through day of life number two when he weaned to room air.
He has been in room air for 48 hours prior to discharge. At
the time of discharge, he is breathing comfortably with a
respiratory rate of 50-80 times per minute. Oxygen
saturations are greater than 95 percent.
CARDIOVASCULAR: [**Known lastname 55893**] required a normal saline bolus shortly
after admission to the Neonatal Intensive Care Unit for poor
perfusion. This was repeated within a few hours after
delivery. After that time, his perfusion improved
remarkably. He maintained normal heart rates and blood
pressures from the initial episode of hypotension. At the
time of discharge, his heart rate is 140-160 beats per minute
with a recent blood pressure of 75/53 mmHg with a mean
pressure of 66 mmHg. No murmurs have been noted.
FLUIDS, ELECTROLYTES, AND NUTRITION: [**Known lastname 55893**] was initially
n.p.o. and maintained on intravenous fluids. Enteral feeds
were started on day of life one and gradually advanced and
were well tolerated. At the time of discharge, he is taking
140 cc per kilogram per day of breast milk or Similac Special
Care Premature formula. The mother is also breast feeding.
The bulk of his feedings are gavage. Serum electrolytes were
checked on day of life one and two and were within normal
limits. Weight on the date of discharge is 2.315 kilograms
which represents his low weight since birth.
INFECTIOUS DISEASE: Due to the unknown etiology of the
respiratory distress and the unknown group beta Streptococcus
status of the mother, [**Name (NI) 55893**] was evaluated for sepsis at the
time of admission to the Neonatal Intensive Care Unit. A
white blood cell count was 14,300 with a differential of 21
percent polymorphonuclear cells and 0 percent band
neutrophils. A blood culture was obtained prior to starting
intravenous ampicillin and gentamicin. The blood culture was
no growth at 48 hours and the antibiotics were discontinued.
GASTROINTESTINAL: [**Known lastname 55893**] has had serial bilirubins monitored
on day of life one. The total was 6.0/0.2 mg per deciliter
direct. His peak occurred on day of life two with a total of
10.1/0.3 mg per deciliter direct. A bilirubin on the day of
discharge is 9.1/0.2.
HEMATOLOGY: Hematocrit at birth was 46.9 percent. [**Known lastname 55893**] did
not receive any transfusions of blood products.
NEUROLOGY: After his initial depression at birth, [**Known lastname 55893**] has
since demonstrated a normal neurological examination and
there are no neurological concerns at the time of discharge.
SENSORY: Audiology hearing screening has not yet been
performed.
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Transfer to [**Hospital3 3765**] for
level II care.
PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 44696**], [**Hospital **] Medical
Associates, [**Street Address(2) 56428**] [**Location (un) **], [**Numeric Identifier 57209**].
Phone number: [**Telephone/Fax (1) 39136**].
CARE AND RECOMMENDATIONS AT THE TIME OF DISCHARGE: FEEDINGS:
Expressed breast milk or Similac Special Care premature
formula at 140 cc per kilogram per day.
MEDICATIONS: None.
CAR SEAT POSITION SCREENING: Recommended prior to discharge.
STATE NEWBORN SCREEN: Drawn on [**2153-9-22**]. No notification of
abnormal results to date.
IMMUNIZATIONS: None administered to date.
IMMUNIZATIONS RECOMMENDED:
Synagis RSV prophylaxis should be considered from [**Month (only) 359**]
through [**Month (only) 547**] for infants who meet any of the following three
criteria: Born at less than 32 weeks; born between 32 and 35
weeks with two of the following: Daycare during RSV season,
a smoker in the household, neuromuscular disease, airway
abnormalities, or school age siblings; or thirdly with
chronic lung disease.
Influenza immunization is recommended annually in the fall
for all infants once they reach six months of age. Before
this age and for the first 24 months of the child's life,
immunization against influenzae is recommended for household
contacts and out of home caregivers.
DISCHARGE DIAGNOSES: Prematurity at 33 5/7 weeks gestation.
Respiratory distress syndrome secondary to surfactant
deficiency.
Suspicion for sepsis, ruled out.
[**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern1) **], [**MD Number(1) 54604**]
Dictated By:[**Last Name (NamePattern1) 56160**]
MEDQUIST36
D: [**2153-9-23**] 03:08:40
T: [**2153-9-23**] 08:17:53
Job#: [**Job Number 44867**]
ICD9 Codes: 769, 7742, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3681
} | Medical Text: Admission Date: [**2149-3-26**] Discharge Date: [**2149-4-7**]
Date of Birth: [**2083-2-26**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ativan / Metformin / Prednisone
Attending:[**First Name3 (LF) 8104**]
Chief Complaint:
Mental status changes.
Major Surgical or Invasive Procedure:
Femoral line placement (removed [**2149-3-27**])
Intubation
History of Present Illness:
Patient is a 66 yo F with PMHx sig. for asthma, OSA, dCHF, MR,
and bipolar disorder who presents for acute mental status
changes. She had an unwitnessed fall at the [**Location (un) **]
center, found sitting on her buttocks. Per transfer notes, pt
stated that she lost her balance, denied any pain from fall. She
usually ambulated with a walker. At 3PM, she was noted to be
lethargic with occasional jerking movements of both arms. Her
fingers were noted to be cyanotic adn she was placed on O2 2L
NC. O2 sats improved from 90-95%. BP 124/66. HR 102. RR20. Temp
97.9. The nursing home staff felt she was more lethargic than
usual. Family thinks she is slightly off baseline.
Per her sister, she had required intubation three times in the
past for hypoventilation after getting too much oxygen.
In the ED, initial VS were: 98.3 110 136/79 36 98. BS 219. Pt
spiked to T104.8. Exam was sig. for wheezing; pt received
nebulizer treatments. Labs sig. for ARF with creatinine of 1.4
(baseline 0.9), no leukocytosis but mild L shilft. Lactate was
1.6. ABG was 7.44/43/91 on nebulizer. First set of CEs neg.
Lithium level 0.9. U/A suggestived of UTI with >50 WBC, mod
leuk, many bacteria. CXR had suggestion of LLL opacity. CT head
showed no acute intracranial process. CT c-spine showed "severe
degenerative disease with central canal stenosis predispose to
spinal cord injury; consider MR [**First Name (Titles) **] [**Last Name (Titles) **] clinical setting." BCxs
drawn. It was felt she was too tachypneic to safely perform LP.
Pt received ceftriaxone 2 gm for UTI and vanc 1 gm and
levofloxacin 750 mg for pneumonia. During her ED course, SBP
fell to 67/23; levophed was started. Left femoral line placed.
Pt is now on 0.5 of levophed, received 3.4L IVFs.
Past Medical History:
# Asthma
# Obstructive sleep apnea (CPAP 19cm/4L)
# Obesity hypoventilation syndrome
# Restrictive lung disease on spirometry from [**2-23**] with FVC
49%pred, FEV1 57%pred, FEV1/FVC 115%pred
# h/o PNA requiring intubation [**2144**], [**2146**]
# Hypertension
# Diastolic CHF (EF [**5-23**]), 1+ AS
# Mild aortic valve stenosis (area 1.4cm2)
# Mental retardation
# Bipolar disorder (lithium, quetiapine)
# Osteoarthritis
# GERD
# Morbid obesity
Social History:
The patient lives at [**Hospital **] Rehab - [**Location (un) 169**]. She
ambulates with a walker. She denies tobacco, alcohol, or other
drug use.
Family History:
Noncontributory
Physical Exam:
On admission:
Gen: NAD, tachypenic initially, improved after combiven
nebulizers
HEENT: NCAT, MMM, OP clear, no LAD
NECK: Obese neck, no JVD noted
LUNGS: Wheezes and scattered rhonchi at bilateral lung fields
HEART: distant heart sounds, RRR, S1/S2, no m/r/g noted
ABD: +BS, soft, ND/NT
EXT: No BLE edema, 2+ DP pulse
NEURO: Nonfocal, alert and oriented x3, able to name president,
medications.
On discharge:
VSS
regular rate, no mrg
lungs with scattered wheeze and rhonchi but good air movement
abd soft, obese, NTND
Pertinent Results:
Labs on admission:
[**2149-3-26**] 07:35PM BLOOD WBC-8.6 RBC-4.24 Hgb-12.5# Hct-37.6
MCV-89 MCH-29.6 MCHC-33.3 RDW-15.3 Plt Ct-175
[**2149-3-26**] 07:35PM BLOOD Neuts-81.8* Lymphs-12.1* Monos-5.9
Eos-0.1 Baso-0.1
[**2149-3-26**] 07:35PM BLOOD PT-17.3* PTT-29.9 INR(PT)-1.6*
[**2149-3-26**] 07:35PM BLOOD Glucose-192* UreaN-19 Creat-1.4* Na-136
K-4.0 Cl-98 HCO3-29 AnGap-13
[**2149-3-26**] 07:35PM BLOOD ALT-30 AST-21 CK(CPK)-63 AlkPhos-114
TotBili-1.5
[**2149-3-26**] 07:35PM BLOOD CK-MB-NotDone proBNP-622*
[**2149-3-27**] 12:54AM BLOOD Calcium-8.0* Phos-2.8 Mg-1.6
CT head [**2149-3-26**]: No acute intracranial process.
CT c-spine [**2149-3-26**]:
1. No acute fracture or dislocation.
2. Degenerative change at C3-C4 has progressed from [**2145-5-19**].
3. There is stable central canal stenosis from a combination of
reversal of normal lordosis and prominent posterior osteophytes.
This predisposes this patient to spinal cord injury with minor
trauma. In the appropriate clinical context, consider MR for
further characterization.
ECHO [**2149-3-27**]:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets are mildly thickened (?#). There is mild
aortic valve stenosis (area 1.2-1.9cm2). No aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. There
is no mitral valve prolapse. Trivial mitral regurgitation is
seen. There is mild pulmonary artery systolic hypertension.
There is a trivial/physiologic pericardial effusion. There is an
anterior space which most likely represents a fat pad.
Compared with the prior study (images reviewed) of [**2147-9-11**],
the findings are similar with mild aortic stenosis.
DISCHARGE LABS:
[**2149-4-6**] 06:00AM BLOOD WBC-11.4* RBC-3.74* Hgb-10.9* Hct-33.9*
MCV-91 MCH-29.0 MCHC-32.1 RDW-15.3 Plt Ct-339
[**2149-4-6**] 06:00AM BLOOD Glucose-135* UreaN-16 Creat-0.8 Na-140
K-4.6 Cl-101 HCO3-33* AnGap-11
[**2149-4-6**] 06:00AM BLOOD Iron-100
[**2149-3-27**] 12:54AM BLOOD TSH-1.2
Brief Hospital Course:
66 year old female with developmental delay, bipolar disorder
who presents with altered mental status, fever, and hypotension.
Initially required pressors. Treated with iv antibiotics for
sepsis [**1-20**] UTI and [**Location (un) **]-care associated PNA. HCAP course
completed and then treated for UTI with oral medications.
Discharged to nursing home in stable condition on room air.
# Sepsis: [**1-20**] UTI and HCAP. Initially required pressors, but
quickly wenaed off. Treated with vancomycin and zosyn for 8 days
of HCAP coverage and cipro po for a total of 10 days of covereag
for complicated UTI. Both blood and urine cx grew out
pan-sensitive E. coli. Per patient's family, has had several
episodes of sepsis [**1-20**] UTI's. Recommend f/u with PCP to
determine if chronic abx ppx for UTI is indicated.
# Respiratory Failure: [**1-20**] HCAP and COPD exacerbation in the
setting of underlying OSA and obesity hypoventilation syndrome.
Required intubation. Extubated without difficulty. Treated with
abx as above. COPD exacerbation treated with prednisone burst
that was completed prior to discharge. BNP initially was normal
at 500 but climbed to greater than [**2139**] after aggressive fluid
repletion in setting of septic shock. Following stabilization of
her blood pressure, she was diuresed with iv lasix and
eventually transitioned to on home lasix dose. On the floor
patient was stable on room air during the day (baseline sats
88-90% on RA). Should have Bipap at night. Discharged on
nebulizer treatments. Needs close monitoring of respiratory
status at extended care facility. Seroquel was held given
extremely high dose and concern for respiratory suppression.
Recommend f/u with PCP to determine need for pulmonology follow
up and further treatment.
# Anemia: At baseline in low 30's. Stable. Iron studies normal.
Consider out patient work up.
# Acute mental status changes: Likely [**1-20**] sepsis, respiratory
failure. Resolved after abx and steroid treatment as above.
# Bipolar Disorder: Treated with home medications of Lithium,
Haldol, Congentin except for seroquel as above, given concern
for sedation. Haldol 1mg tid with iv prn for agitation was used
in place of seroqual. Can coutinue to uptitrate haldol as
needed after discharge. The covering doctor for the patient's
primary outpatient psychiatrist was [**Month/Day (2) 653**] prior to
discharge.
# Fall: Patient was found down after an unwitnessd fall at
nursing home. Likely in setting of septic shock. Patient had
echo revealing no acute change from prior, showing only mild AS.
# [**Last Name (un) **]: The patient has a baseline Cr of 0.9, which was 1.4 on
admission. Furosemide had initially been held, though this was
restarted to assist in improvement of respiratory status. Her Cr
continued improve over her MICU course.
# Diarrhea: Had several episodes. C. diff was negative. Stool
softeners were stopped on discharge and should be restarted
prudently given pt's recent loose stools.
# Diastolic CHF, mild aortic valve stenosis: Euvolemic.
Continued home lasix, echo showed no change.
# Ppx: Received heparin
# Code: Full
# Communication: HCP sister [**Name (NI) 100314**] [**Name (NI) 3311**] [**Name (NI) 41684**]
[**Telephone/Fax (1) **](h). [**Telephone/Fax (1) **] (c)
Medications on Admission:
Montelukast 10 mg PO DAILY
Folic acid 1 mg daily
Benztropine 1 mg PO QHS
Topamax 25 mg daily
Quetiapine 150mg at QAM, 200mg at 2PM, and 350 PO QHS
Lithium 150 mg tid
Haldol 1 mg tid
Folic Acid 1 mg PO DAILY
Furosemide 40 mg PO DAILY
CPAP 19 cm with 4L O2 QHS
Fluticasone-Salmeterol 250-50 mcg/Dose [**Hospital1 **]
Albuterol Sulfate Nebulization prn
Ipratropium Bromide neb prn
Glipizide 2.5 mg [**Hospital1 **]
Humalog insulin sliding scale
Discharge Medications:
1. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Benztropine 1 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
5. Topiramate 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Lithium Carbonate 150 mg Capsule Sig: One (1) Capsule PO TID
(3 times a day).
7. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): hold for loose stool.
10. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for cough: hold for loose stool.
11. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation: hold for loose stool.
13. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
14. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. Polyethylene Glycol 3350 100 % Powder Sig: [**12-20**] PO DAILY
(Daily) as needed for chest pain: hold for loose stool.
16. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO twice a day.
17. Insulin Lispro 100 unit/mL Insulin Pen Sig: per prior home
sliding scale Subcutaneous qachs.
18. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 2 days: last dose [**2149-4-9**].
19. Haloperidol 5 mg IV Q6H:PRN
Hold for oversedation.
20. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
21. 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.
22. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
23. Albuterol Sulfate 0.63 mg/3 mL Solution for Nebulization
Sig: [**12-20**] nebs Inhalation every four (4) hours as needed for
shortness of breath or wheezing.
24. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation every four (4) hours as needed for shortness of
breath or wheezing.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Livingcenter
Discharge Diagnosis:
Primary:
Septic Shock [**1-20**] UTI
HCAP
Asthma
Bipolar Disorder
.
Secondary:
- Obstructive sleep apnea (CPAP 19cm/4L)
- Obesity hypoventilation syndrome
- Restrictive lung disease on spirometry from [**2-23**] with FVC
49%pred, FEV1 57%pred, FEV1/FVC 115%pred
- h/o PNA requiring intubation [**2144**], [**2146**], [**2148**]
- Hypertension
- Diastolic CHF (EF [**5-23**]), 1+ AS
- Mild aortic valve stenosis (area 1.4cm2)
- Developmental Delay
- Bipolar disorder
- Osteoarthritis
- GERD
- Morbid obesity
- DM
Discharge Condition:
Vitals stable, ambulating at baseline with walker.
Discharge Instructions:
You were admitted with severe infection and sepsis from a
urinary tract infection and additionally, you developed
pneumonia. You have been treated with IV antibiotic for the
pneumonia which you finished prior to discharge. Additionally,
you were treated with a short course of steroids to treat an
asthma exacerbation which you also finished prior to discharge.
You will complete treatment for the urinary tract infection on
oral medication called cipro, to end on [**4-9**].
You have had several significant infections in the past few
years. You should follow up with your primary care physician to
determine if you should be on antibiotics chronically to
suppress urinary infections.
Additionally, you were taken off your seroquel as there was
concern that the very high dose was compromising your
respiratory status. You were started on low dose haldol to
treat your bipolar. Your doctor may increase this as an out
patient.
No other medication changes were made. You should continue all
your other home medications as directed.
You should follow up with your primary care physician to
determine need for cardiology and pulmonary follow up.
If you have shortness of breath, chest pain, pain with
urination, fever, confusion, lightheadedness or dizziness, or
any other concerning symptom, please seek medical care
immediately.
It was a pleasure meeting you and particiapting in your care.
Followup Instructions:
You should follow up with your primary care physician 1-2 weeks
after discharge.
ICD9 Codes: 5990, 5849, 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3682
} | Medical Text: Admission Date: [**2155-1-20**] Discharge Date: [**2155-1-21**]
Date of Birth: [**2129-6-17**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
altered mental status
focal neurological deficit
Major Surgical or Invasive Procedure:
intubation
central line placement
arterial line placement
History of Present Illness:
25 y/o F w/ chrohn's,apendectomy c/b nicked bowel with
colostomy. partial colectomy, h/o infections with open wound,
headache today, received imitrex, then developed confusion and
altered mental status. Pt is afebrile, stares to the right and
does not not cross midline. Pt is complaining about "not
seeing."
.
Two days ago the patient fell and hit her head. This am pt's
family noted pt. to be confused, looking to right, combative.
She complained of a headache and not being able to see, pupils
large dilated and looking to right.
.
In the [**Name (NI) **], pt received ceftrioxone/vancomycin/acyclovir. She was
intubated [**1-4**] apneic episodes and for airway protection and to
help facilitate mri/mrv. The patient was sedated with propofol
and became hypotensive to the 80's. At that point, levophed was
started. In the ED, a right femoral line was placed but did not
flush. An EJ was placed. En route to CT, the patient became
brady to the 50's and went into vtach at 180's, given 2mg mag
and amp of cacl, amio 150 given now on drip. back to sinus. BP
to 60's then improved. She given emergency release blood. A
CTA/CTV of the head and LP were done and pt. was transferred to
the MICU.
.
Upon arrival to the micu, the pt. was hypotensive to the 50's on
levo/neo. She became pulseless and CPR was started. She received
3 rounds of epi, 2 atropine, 1 amp of bicarb, 2 rounds of Ca, 2
rounds mg,
Past Medical History:
Crohn's disease
Migraines
Anxiety, panick disorder
Anorexia
Substance abuse- heroine (intranasal)
Social History:
Hx of substance abuse
Family History:
unknown
Physical Exam:
expired
Pertinent Results:
expired
Brief Hospital Course:
Pt brought to the MICU hypotensive. Exam revealed exposed
bowel. Shortly thereafter, pt went into PEA arrest. She was
able to be successfully resuscitated. Despite aggressive
pressor support, IV fluids, abx, pt remained in refractory shock
and expired.
Medications on Admission:
Zoloft 100mg QD
Clonazepam 1mg TID
Lorazepam 0.5mg QHS prn
Methadone 280mg QD
Usodiol 300mg [**Hospital1 **]
Promethazine 25mg TID
Priolosec 30mg [**Hospital1 **]
Imodium 2mg [**Hospital1 **]
Baclofen prn
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
ICD9 Codes: 0389, 2762, 4271 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3683
} | Medical Text: Admission Date: [**2113-3-9**] Discharge Date: [**2113-3-14**]
Date of Birth: [**2072-6-10**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: This is a 42-year-old female
status post motor vehicle accident. She was an unrestrained
driver without an air bag, who struck a pole. She had been
drinking alcohol prior to the injury. She was brought to the
[**Hospital1 69**] Emergency Room and was
found to have a right sided subdural hematoma and left
subfalcine blood. It was unclear whether or not she had loss
of consciousness at the scene of the accident.
On arrival to the Emergency Room, her [**Location (un) 2611**] coma score was
14.
PAST MEDICAL HISTORY: Unknown other than alcohol abuse.
PAST SURGICAL HISTORY: No past surgical history.
ALLERGIES: No known drug allergies.
MEDICATIONS: Was not on any medications on admission.
PHYSICAL EXAM: Vital signs: Temperature 97.8, blood
pressure 124/72, heart rate 110, 18 for respirations, and 97%
on room air. Lungs were clear. Cardiovascular: Regular,
rate, and rhythm. Abdomen was soft, nondistended.
Extremities were normal. No edema or deformities. HEENT
showed bilateral eye ecchymoses.
ADMISSION LABORATORIES: Hematocrit was 34.3. Sodium was
148, 3.5 for potassium, 106 for chloride, 31 for her bicarb.
NEUROLOGIC EXAMINATION: Patient was awake, alert,
complaining about wanting to sleep, oriented x3 with
prompting. Speech was fluent. Cranial nerves II through XII
were grossly intact. Pupils were 7 to 4 bilaterally. Her
motor exam was [**3-29**] in both upper and lower extremities. Her
reflexes were 1+ throughout. She had no clonus, no
Hoffmann's. She had a slight left pronator drift.
Her head CT showed occipital hematoma present along the
convexity of the right cerebral hemisphere along the falx.
The right hemispheric subdural collection measured
approximately 12 mm in its greatest dimension superiorly
along the right parietal lobe. The hematoma extended along
the right portion of the tentorium.
Patient was admitted to the ICU with a q.1h. neuro checks,
and her systolic blood pressures kept less than 140, and A
line was placed. Patient was kept NPO. Her T spine and CT
of her sinus mandibles and maxillary showed no fracture, and
her laboratories were within normal limits.
On postoperative day, patient was awake and alert. Eyes were
open. Slight decrease in nasolabial fold. EOMs were intact.
No obvious jerk. Her grasps were [**3-29**]. Her IPs are [**3-29**].
Hematocrit did go down from 34.3 to 27.3. Her coags were
within normal limits. She had a repeat head CT on the 16th,
which showed no significant change of the hematomas. She
remained in the ICU with q.1h. neuro checks.
Addiction services saw patient and did make some
recommendations as far as treating with the CIWA protocol and
Ativan q.1h. for per the CIWA protocol. They also
recommended using Valium 10 mg if that was needed. She is
also given numbers to detox facilities at that time.
On [**2113-3-11**], she remained awake, alert, and oriented times
three. She was transferred to the Surgical floor, where she
is tolerating a regular diet, complained of headaches, and
was able to ambulate without assistance. She had a repeat
head CT on that day, which showed a stable appearance of the
right-sided subdural with a small amount of subarachnoid
blood superiorly. She had a large ecchymosis around her
eyes.
She was seen by the Addiction service on [**3-13**], who made some
recommendations to start her on Librium prior to her
discharge, and also again told her about places that she
could seek care for her alcoholism.
On [**3-14**], the patient was seen by Physical Therapy, and she
was cleared safe to be discharged home. She is discharged on
[**2113-3-14**] with the following instructions: If she develops a
headache that is not resolved with the medications that she
is given or becomes nauseated, starts to vomit, or has
increased dizziness, she should call Dr.[**Name (NI) 9224**] office. She
was again told not to drink alcohol, and she can use Librium
for her possible DTs. On her discharge, she had been only
receiving 2 mg of Ativan per day. She stated that she is
going to go back to Alcoholics Anonymous. She also needs to
see her primary care physician regarding [**Name Initial (PRE) **] low sodium. Her
sodium dropped to a low of 129. On discharge, she was up to
132, and she was receiving sodium tablets for that.
FOLLOWUP: She should follow up with Dr. [**Last Name (STitle) 1132**] in one month
and obtain a head CT prior to that appointment. Again, she
should see her primary care physician regarding her sodium.
DISCHARGE MEDICATIONS:
1. Colace 100 mg p.o. b.i.d. She should take that while on
oxycodone.
2. Folic acid 1 mg p.o. q.d.
3. Multivitamins 100 mg p.o. q.d.
4. Thiamine 100 mg p.o. q.d.
5. Sodium chloride tablets take two tablets p.o. q.i.d. until
she follows up with her primary care physician.
6. Librium 25 mg one tablet p.o. t.i.d. for withdrawal.
7. Fioricet one tablet p.o. q.4-6h. as needed, not to exceed
six tablets per day for headache.
8. Oxycodone one tablet p.o. q.4-6h. as needed to take with
the Fioricet.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 23588**]
MEDQUIST36
D: [**2113-3-14**] 18:55
T: [**2113-3-16**] 08:00
JOB#: [**Job Number 26951**]
ICD9 Codes: 2875, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3684
} | Medical Text: Admission Date: [**2153-10-9**] Discharge Date: [**2153-10-12**]
Date of Birth: [**2069-5-3**] Sex: F
Service: MEDICINE
Allergies:
Amlodipine
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Name13 (STitle) 12101**] is an 84 year old lady 6 weeks post CABG recently
discharged home from Rehab returns to the ED with weakness, poor
PO intake and R flank pain.
In the ED, initial vs were: 98.2 76 87/50 14 92% RA. CXR was
obtained.Patient was given Levaquin 750mg IV x1, 1000mL of NS.
Vanc 1g ordered but NOT given.
In the ICU, the patient complains of general tremulousness which
is new, right sided flank pain worse on inspiration, anorexia
and general weakness since leaving [**Hospital3 **] 2 days prior.
She denies cough, fever/chills, chest pain, myalgia, abdominal
pain.
A conversation with the patient's daughter revealed that the
patient returned from [**Hospital3 **] on the 11th. Blood
pressures were stable until 2 days prior associated with
weakness, nausea, poor PO intake, confusion. Confirms R flank
pain, iced intermittently with relief, similar to previous
spinal stenosis. Tremors are new from yesterday and today.
Review of systems:
Peritent positives and negatives per HPI
Denies palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
Chronic Diastolic Congestive Heart Failure
Hypercholesterolemia
Hypertension
Type II Diabetes
Osteoporosis
Glaucoma
Osteoarthritis
Perioperative Atrial fibrillation, not on coumadin
left sided carpal tunnel syndrome with hand numbness
s/p Left knee replacement
s/p Partial hysterectomy
s/p Tonsillectomy
s/p Bladder suspension
s/p Appy
s/p Breast reduction
Social History:
Lives alone, daughter visiting. Ambulates with cane currently.
No history of smoking, no EtoH.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
Vitals: T: BP: 114/94 P: 82 R: 20 O2: 91%
Manually BP repeat 84/40
General: Generally tremulous, Alert, oriented to place, time and
self with some coaching, mentions [**Hospital3 **], no acute
distress;
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Kyphosis. Otherwise clear to ausculation. Tenderness on R
posterior rib cage
CV: S1 & S2 regular without murmur appreciated. Sternal wound
erythematous and dressed.
Abdomen: soft, Right sided tenderness, non-distended, bowel
sounds present, no rebound tenderness or guarding, no
organomegaly
GU: foley in place
Ext: No hip tenderness. warm, well perfused, 1+ pulses, no edema
NEURO: Mental status as above; generally Following commands,
high and low frequency naming intact. Tremulous, CNII-XII intact
to confrontation. Gait deferred. Truncal strength intact. Ext
[**2-25**]. Reflexes deferred due to tremor.
PSYCH: Observed by nursing responding to internal stimuli
Pertinent Results:
Labs on admission:
WBC 11.3 N72 L18.8 M6.9 E1.8 B0.5
Hct 32.4 MCV 92
Plts 517
PT 11.8 PTT 27.1 INR 1.0
Retic 2.8
133 93 45
4.8 26 2.8
Ca 8.8 Mg 2.1 Phos 4.6
ALT 9 AST 30 CK 142 AlkP 66 Tbili 0.5
Lipase 20
CE negative x2
TIBC 157 B12 662 Folate 14.9 Ferritin 243 Transferrin
121
Lactate 1.8
BCx negative to date x2, UCx negative and DFA for flu A/B
negative
[**10-9**] echo:
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity is
unusually small. Left ventricular systolic function is
hyperdynamic (EF>75%). 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 (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. No mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is an
anterior space which most likely represents a fat pad.
IMPRESSION: Mild concentric hypertrophy with small left
ventricular cavity size and hyperdynamic function.
Compared with the prior study (images reviewed) of [**2153-8-23**],
pulmonary artery pressures are lower. The left ventricle is
frankly hyperdynamic and cavity size is smaller.
[**10-9**] lung scan: Match chest X-ray, perfusion, and ventilation
in the right lower lobe, triple match, has an indeterminate
likelihood ratio for pulmonary embolism.
[**10-9**] CT head without contrast: No acute intracranial hemorrhage
or mass effect or obvious major acute infarct.
[**10-9**] CXR: Right lower lobe pneumonia.
[**10-9**] renal u/s:
1. Limited study due to portable technique. No hydronephrosis or
renal
calculi seen.
2. 1-cm simple left renal cyst.
[**10-9**] BLE u/s: No evidence of deep venous thrombosis in
bilateral lower
extremity veins.
DISCHARGE LABS
[**2153-10-12**] 05:20AM BLOOD WBC-7.3 RBC-3.14* Hgb-9.4* Hct-28.2*
MCV-90 MCH-29.8 MCHC-33.1 RDW-15.2 Plt Ct-517*
[**2153-10-12**] 05:20AM BLOOD Glucose-103 UreaN-17 Creat-0.9 Na-143
K-4.1 Cl-109* HCO3-26 AnGap-12
[**2153-10-11**] 06:35AM BLOOD Calcium-8.2* Phos-2.2* Mg-2.3
Brief Hospital Course:
84yoF s/p recent CABG admit to MICU with hypotension and
radiographic evidence of pneumonia
1. Hypotension: Poor PO intake and hypovolemia VS sepsis from
PNA (elevated WBC's and CXR findings). There was some concern
for PE but pt had negative LENI, V/Q scan which was
indeterminate, echo with normal RV, and pt thought to be low
pre-test likelihood for PE. Echo with normal RV, hyperdynamic
EF, but elevated LV filling pressure.
Pt was fluid resuscitated. Got Levaquin in ED and started on
Vanc/Cefepime on MICU admission (Vanc 1g x1 dose on [**10-9**], Vanc
dosing by level due to ARF, and Cefepime started [**10-9**] = day 1),
with plan to start Cipro on the am of [**2153-10-11**] = day 1. Vanc
trough will need to be followed up and Vanc dosed accordingly.
Flu was ruled out with negative DFA. Home antihypertensives
(Metoprolol, Lisinopril, Lasix, Amiodarone) were held. Art line
was placed. By time of call out, pt's bp was in low 100's -
120's and pt was asymptomatic. BP was 156/70 on the floor. The
patient was restarted on home dose of Lisinopril. She can be
restarted on Metoprolol and Lasix prn as an outpatient.
2. HCAP vs HAP: Pt with radiographic evidence of a RLL PNA, HAP
versus HCAP given history with associated right sided pleuritic
pain. She denies cough or fever.
Started on Vanc/Cefepime/Cipro as above. Will need to continue
IV Abx for 14 day course, ending on [**2153-10-23**]. The patient had a
PICC placed for long-term Abx.
3. Delirium with tremulousness: Pt with waxing and [**Doctor Last Name 688**] mental
status in 24 hrs leading up to admission per family report. Also
with new tremor, DDx including new Compazine medication vs
Neurontin overdose in setting of worsening renal fxn [**12-25**] to
hypovolemia from poor PO intake. Compazine was held on
admission. Toxicology was consulted and recommended holding
Neurontin. Infxn was treated as above. Mental status was back to
baseline while the patient was on the medical floor. Compazine
and Neurontin are still being held, but can be restarted as an
outpatient with close monitoring of Cr.
4. Acute on Chronic Renal failure: The patient's Cr was elevated
to 2.8 on admission with a baseline of 1.1-1.2, still elevated
based on her size, weight and age. Pre-renal from poor PO intake
vs ATN from hypoTN. FeUrea was 0.02% consistent with pre-renal
etiology. Pt was fluid resuscitated and Cr trended down to 1.7,
closer to her baseline by time of call out from MICU. Held home
Lisinopril and Lasix while in the MICU. The patient's Cr
improved to 0.9, and she was restarted on Lisinopril prior to
discharge.
5. Anemia: Pt was at pre-operative baseline, but worriesome for
hemoconcentration. Guaiac negative, no signs of bleeding or
hemolysis given normal LFTs, but thrombocytosis concerning.
Normal B12 in [**Month (only) **] and had normal B12 and folate this
admission, normal MCV. Hct slightly down from admission 32.4 -->
27.1 with iron deficiency and labs more consistent with chronic
disease. HCT remained stable and was 28.2 on discharge.
6. Thrombocytosis: The patient's thrombocytosis could be
reactive from bleeding/anemia as above or from infection;
essential or hemoconcentrational. Will likely improve as PNA
improves.
7. s/p CABG: Complicated by postop atrial fibrillation,
currently in Sinus. QTc 438. Elevated Troponin difficult to
interpret given renal failure; CK elevated from hemolysis. Home
Amiodarone was held given hypotension; ASA and statin were
continued. Cardiac [**Doctor First Name **] was consulted out of concern for her
sternal wound but felt this to not be an acute issue or
contributing to her overall clinical picture. Dr. [**Last Name (STitle) 914**] was
consulted regarding the necessity of Amiodarone - since the
patient is now >6 weeks post-op and no longer in afib, the
decision was made to discontinue the Amiodarone. The patient is
in NSR on discharge.
8. Arthritis: Patient with chronic pain. Pt was controlled on
Tylenol PRN. She can continue to take Tramadol for pain control
prn as an outpatient.
9. GERD: Continued Omeprazole
10. Glaucoma: Continued Latanoprost
FEN: No IVF, Vitamin D, regular diet
Prophylaxis: Subutaneous heparin
Access: peripherals
Code: Full (discussed with patient)
Communication: Patient & Daughter [**Known firstname **] [**Last Name (NamePattern1) 805**] ([**Telephone/Fax (1) 12102**])
Medications on Admission:
Alendronate 70mg PO QSunday
Amiodarone 200 mg PO Daily
Furosemide 30mg PO daily
Gabapentin 300mg TID while awake
Latanoprost 0.005 % Drops 1 drop OU QHS
Lisinopril 20mg PO Daily
Metoprolol Tartrate 25mg PO BID
Simvastatin 80mg PO QHS
Tramadol 50mg Q6h PRN Pain
Acetaminophen 325-650mg PO Q4 PRN Pain
Aspirin 81mg PO daily
Calcium Carbonate-Vitamin D3 500 mg (1,250 mg)-400 unit Tablet
PO BID
Omeprazole 20mg PO Daily
Compazine 5-10mg q4 hours PRN Nausea
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Collagenase 250 unit/g Ointment Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
6. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Acetaminophen 160 mg/5 mL Solution Sig: Six [**Age over 90 1230**]y
(650) mg PO Q6H (every 6 hours) as needed for pain.
8. Vancomycin 1,000 mg Recon Soln Sig: One (1) g Intravenous
once a day for 10 days: end [**2153-10-23**].
9. Cefepime 1 gram Recon Soln Sig: One (1) g Intravenous once a
day for 10 days: end [**2153-10-23**].
10. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO every
twelve (12) hours for 10 days: end [**2153-10-23**].
11. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**11-24**] Sprays Nasal
QID (4 times a day) as needed for congestion.
12. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed) as needed for cough.
13. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO BID (2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary Diagnosis
-Pneumonia
-Hypotension
-Acute renal failure
-Altered mental status
Secondary Diagnosis
-Chronic diastolic congestive heart failure
-Anemia
Discharge Condition:
Blood pressure stable, mental status at baseline, afebrile
Discharge Instructions:
You were treated in the hospital for pneumonia. You were found
to have acute renal failure, likely due to poor oral intake for
several days prior to admission. You also came in with mental
status changes and tremors, thought to be due to increased
levels of either Compazine or Neurontin since your kidneys were
not able to clear these drugs properly.
Your mental status has cleared and is now back at baseline. You
have been afebrile and are responding well to the antibiotics.
You had a PICC line placed so that you can receive antibiotics
for the next 2 weeks at rehab.
The following changes were made to your medications:
For your pneumonia:
#. START Vancomycin 1g daily until [**2153-10-23**]
#. START Cefepime 1g daily until [**2153-10-23**]
#. START Ciprofloxacin 500mg every 12 hours until [**2153-10-23**]
Other changes:
#. HOLD Lasix and Metoprolol for now. These can be restarted as
an outpatient if your blood pressure is elevated.
#. HOLD Neurontin and Compazine, as these medications may have
caused altered mental status and tremors while you had renal
failure. You can be restarted on these medications as an
outpatient.
#. DISCONTINUE Amiodarone - your heart is now in a regular
rhythm, so you do not need to continue taking this medication.
If you develop altered mental status, increasing confusion,
shortness of breath, chest pain, productive cough,
lightheadedness, or any other concerning symptoms, please call
your primary care doctor or return to the emergency department.
It was a pleasure meeting you and taking part in your care.
Followup Instructions:
Please follow up with your Cardiothoracic Surgeon:
Provider: [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD
Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2153-10-16**] 1:15
Please follow up with your primary care doctor in 2 weeks.
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Phone: [**Telephone/Fax (1) 7477**]
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
ICD9 Codes: 486, 5849, 2930, 4589, 4280, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3685
} | Medical Text: Admission Date: [**2110-3-13**] Discharge Date:
Date of Birth: [**2110-3-13**] Sex: M
Service: Neonatology
This is an interim discharge summary covering dates from
[**2110-3-13**] through [**2110-3-31**].
HISTORY OF PRESENT ILLNESS: This is a 1735 gm male infant,
triplet #3, born at 30 6/7 weeks gestation to a 29 year old
gravida 4, para now 2, (two deliveries, four children) mom by
intrauterine insemination triplet conception, EDC [**2110-5-16**]. Prenatal screens, blood type 0 positive, antibody
negative, RPR nonreactive, Rubella immune, hepatitis B
surface antigen negative, reportedly Group B Streptococcus
negative. Pregnancy complicated by gestational diabetes.
Mom with question of preterm labor at 23 1/7 weeks with
abdominal cramping and vaginal pressure. She was admitted at
that time and received a complete course of Betamethasone.
On the night of delivery she presented with contractions and
cervical dilatation and was therefore delivered by repeat
cesarean section. Fluid cleared. Infant emerged with
spontaneous cry, required blow-by oxygen and routine care in
the Delivery Room, but was noted to have inconsistent
respiratory effort and poor air entry with increased work of
breathing. Apgars were 8 at one minute and 8 at five minutes
and infant was transported to the Neonatal Intensive Care
Unit on CPAP.
PHYSICAL EXAMINATION: On admission weight was 1735 gm (75th
percentile), head circumference 31 cm (75th to 90th
percentile), length 42.5 cm (50th to 75th percentile). Mean
blood pressure 30. The patient was nondysmorphic with
overall appearance consistent with known gestational age.
Anterior fontanelle open and flat. Red reflex present
bilaterally. Palate intact. Grunting and flaring with deep
sternal retractions and poor air entry. Regular rate and
rhythm without murmur, 2+ femoral pulses including femorals.
Abdomen benign with no hepatosplenomegaly and no masses.
Normal male genitalia for gestational age with testes
palpable, low in canal bilaterally. Normal back and
extremities with hips stable. Slightly decreased tone
throughout. Skin pink but poorly perfused.
HOSPITAL COURSE: (By systems) 1. Cardiovascular -
Cardiovascularly stable throughout admission with normal
blood pressures and no murmur.
2. Respiratory - Was intubated shortly after birth and
received two doses of Surfactant, weaned rapidly on
ventilator settings and was extubated to CPAP on day of life
#1. On day of life #3, the patient developed increased
respiratory distress. Chest x-ray with large right
pneumothorax. The patient was intubated and a chest tube was
placed. The patient subsequently did well, weaning on
ventilator settings and self-extubating on day of life #4 and
placed at this time on nasal cannula oxygen. Chest tube was
put to water-seal on day of life #4 as it had no further
bubbling. Chest x-ray at that time showed a small residual
pneumothorax. The patient did well clinically with the chest
tube on water-seal times 24 hours and chest x-ray unchanged.
Therefore the chest tube was discontinued on day of life #5.
The patient did well in nasal cannula oxygen, 200 cc of flow
with FIO2 weaning to room air by day of life #6. Nasal
cannula flow was gradually weaned and the patient off of
nasal cannula and in room air by day of life #11.
Subsequently breathing comfortably in room air. Was started
on caffeine for apnea of bradycardia of prematurity.
Currently, with very infrequent spells and caffeine was
discontinued.
3. Fluids, electrolytes and nutrition - Initially NPO and on
intravenous fluids, initiated and then held with his
pneumothorax and respiratory decompensation. He was
reinitiated on day of life #4 and advanced without
difficulty. Reached full feeds on day of life #9 and
calories then advanced. Advanced to feeds of breastmilk 26
or PE-26. The patient with rapid weight gain and therefore
on day of life #18 calories were decreased to 24. The
patient was currently on a regimen of 150 cc/kg/day of PE-24
or breastmilk 24, gavaged over 75 minutes for a history of
sips. Weight at birth 1735 gm, weight at time of this
dictation (day of life #18) 2035 gm. Electrolytes monitored
and remained within normal limits.
4. Gastrointestinal - Bilirubin levels monitored.
Phototherapy initiated for hyperbilirubinemia with a peak
bilirubin of 9.2/0.4 on day of life #3. Bilirubin levels
gradually declined. Phototherapy was discontinued on day of
life #10 and a rebound bilirubin was 5.5/0.3.
5. Infectious disease - Complete blood count and blood
culture sent on admission, white count of 10 with 4 polys and
no bands. Infant was started on Ampicillin and Gentamicin.
Complete blood count was repeated secondary to neutropenia on
initial complete blood count. Repeat complete blood count
improved with white count of 6.1 with 50 polys and no bands.
Blood cultures showed no growth at 48 hours and antibiotics
were discontinued. The patient had some eye drainage that
was noted first on day of life #12, was monitored and treated
with warm soaks for several days, however, drainage did not
decrease, was therefore started on Ilotycin ophthalmic
ointment on day of life #15 with some improvement in eye
drainage noted. Continued on Ilotycin at this time. The
patient was noted to be Methicillin-resistant Staphylococcus
aureus positive on routine surveillance cultures and is on
contact precautions, was noted on day of life #18 to have a
left wrist pustule at the site of a prior intravenous line.
This was sent for culture and results are pending at this
time. The patient is not on systemic antibiotic treatment.
6. Hematology - Initial hematocrit was 49.6% with platelet
count of 205, last hematocrit on day of life #1 44.5%.
7. Neurology - Head ultrasound on day of life #7 was normal.
The patient treated with Fentanyl for pain around timing of
his chest tube.
8. Ophthalmology - The patient's eyes have not yet been
examined, due for first examination on [**4-9**].
9. Routine health care maintenance - Initial newborn state
screen sent on day of life #3 revealed an elevated 17 OHP.
Repeat state screen was sent which was normal.
PRIMARY CARE PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 55164**] in [**Hospital1 3597**] [**Location (un) 7498**]. The patient will need a hearing screen prior to
discharge home and a car seat test prior to discharge home.
The patient has not yet received any immunizations.
CONDITION AT TIME OF THIS DICTATION: Stable.
DISCHARGE DIAGNOSIS:
1. Prematurity at 31 weeks gestational age.
2. Triplet gestation.
3. Surfactant deficiency, respiratory distress syndrome.
4. Status post right pneumothorax.
5. Feeding immaturity.
6. Status post hyperbilirubinemia.
7. Status post rule out sepsis.
8. Methicillin-sensitive Staphylococcus aureus colonization.
[**Name6 (MD) **] [**Name8 (MD) 38353**], M.D. [**MD Number(1) 38354**]
Dictated By:[**Last Name (NamePattern1) 50027**]
MEDQUIST36
D: [**2110-4-5**] 10:46
T: [**2110-4-5**] 12:48
JOB#: [**Job Number 55165**]
ICD9 Codes: 769, 7742 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3686
} | Medical Text: Admission Date: [**2117-12-23**] Discharge Date: [**2118-1-1**]
Date of Birth: [**2045-12-14**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2117-12-27**] Coronary artery bypass graft x5: Left internal mammary
artery to left anterior descending artery; and saphenous vein
grafts to right coronary artery, obtuse marginal, ramus and
distal left anterior descending artery
History of Present Illness:
72 year old female with fatigue since waking up then sudden
onset while sleeping of heavy aching non radiating left sided
chest pain followed by shortness of breath and non productive
cough.
Past Medical History:
Hypertension - untreated
Ischemic cardiomyopathy
Social History:
Race: Caucasian
Last Dental Exam: last year
Lives with: alone (widow) - son will be available to help at dc
Occupation: works in deli 32 hours a week
Tobacco: quit 30 years ago
ETOH: denies
Family History:
denies
Physical Exam:
Pulse: 79 Resp: 20 O2 sat: 96 2 l nc
B/P : 151/84
Height: 5'2" Weight: 140 pounds
General: NAD denies chest pain/SOB
Skin: Dry [x] intact [x] right groin with ecchymosis no
hematoma
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur no
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x] no palpable masses
Extremities: Warm [x], well-perfused [x] Edema +1 bilateral LE
Varicosities: None [X]
Neuro: Grossly intact
Pulses:
Femoral Right: +1 Left: +2
DP Right: +1 Left: +1
PT [**Name (NI) 167**]: +1 Left: +1
Radial Right: +2 Left: +2
Carotid Bruit Right: no bruit Left: no bruit
Pertinent Results:
[**2117-12-27**] Echo: Prebypass: No atrial septal defect is seen by 2D or
color Doppler. There is severe regional left ventricular
systolic dysfunction with akinesis of the apex, apical portions
of the inferior , septal and anterior walls. The mid portions of
the anterolateral, inferior septum and anterior septum are also
hypokinetic. Overall left ventricular systolic function is
severely depressed (LVEF= 20 %). Right ventricular chamber size
and free wall motion are normal. There are simple atheroma in
the descending thoracic aorta. The aortic valve leaflets (3) are
mildly thickened 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 no
pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person
of the results on [**12-26**]/210 at 900am.
Post bypass: Patient is in sinus rhythm and receiving an
infusion of phenylephrine and milrinone. LVEF= 35%. RV function
is normal. Trivial mitral regurgitation present. Aorta is intact
post decannulation.
[**2117-12-23**] 07:07PM BLOOD WBC-8.0 RBC-3.53* Hgb-9.9* Hct-30.1*
MCV-85 MCH-28.0 MCHC-32.8 RDW-14.2 Plt Ct-313
[**2117-12-23**] 07:07PM BLOOD PT-11.5 PTT-22.8 INR(PT)-1.0
[**2117-12-23**] 07:07PM BLOOD Glucose-155* UreaN-25* Creat-0.8 Na-139
K-3.9 Cl-104 HCO3-26 AnGap-13
[**2117-12-23**] 07:07PM BLOOD ALT-16 AST-30 LD(LDH)-278* AlkPhos-80
Amylase-50 TotBili-0.3
[**2117-12-24**] 06:10AM BLOOD cTropnT-1.53*
[**2118-1-1**] 08:20AM BLOOD WBC-14.0* RBC-3.58* Hgb-10.4* Hct-31.4*
MCV-88 MCH-29.0 MCHC-33.1 RDW-14.9 Plt Ct-504*#
[**2118-1-1**] 08:20AM BLOOD UreaN-17 Creat-0.8 K-4.0
[**2117-12-30**] 08:50AM BLOOD Glucose-120* UreaN-19 Creat-0.8 Na-135
K-4.2 Cl-98 HCO3-29 AnGap-12
[**2117-12-30**] 08:50AM BLOOD WBC-10.6 RBC-3.14* Hgb-9.2* Hct-26.6*
MCV-85 MCH-29.2 MCHC-34.4 RDW-14.4 Plt Ct-237
Brief Hospital Course:
Ms. [**Known lastname 86423**] was transferred from MWMC on [**12-23**] and pre-op workup
completed. Underwent surgery with Dr. [**First Name (STitle) **] on [**12-27**] and was
transferred to the CVICU in stable condition on titrated
milrinone, phenylephrine and propofol drips. Extubated that
evening. Transferred to the floor on POD #1 to begin increasing
her activity level. Chest tubes and pacing wires removed per
protocol. Amiodarone started for postop A Fib. She did convert
to sinus rhythm prior to discharge. She was gently diuresed
toward her preop weight. Cleared for discharge to rehab on POD #
5.
Medications on Admission:
at home: none
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain.
6. Amiodarone 400 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for arrhythmia: until [**1-6**]; then 400 mg daily
[**Date range (1) 86424**]; then 200 mg daily ongoing .
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. Captopril 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
10. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day
for 2 weeks.
12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 38076**] House - [**Location (un) 47**]
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary artery bypass graft x5
Myocardial Infarction
Acute systolic heart failure
Past medical history
Hypertension - untreated
Ischemic cardiomyopathy
Right femoral hematoma s/p cath
Past Surgical History
Shoulder surgery [**4-27**]
postop A Fib
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with percocet prn
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
[**Hospital1 **] heart center [**Telephone/Fax (2) 6256**]
Dr [**Last Name (STitle) **] (for Dr [**First Name (STitle) **] Thursday [**1-21**] at 9am
Dr [**Last Name (STitle) 1295**] - heart center will call you with appointment
[**Hospital1 **] ambulatory medical clinic [**Telephone/Fax (1) 24107**] appointment
arranged for new PCP [**Name Initial (PRE) **] [**Name10 (NameIs) 3816**] [**2118-1-18**] 230pm - come into
[**Hospital **] hospital entrance and clinic on left
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2118-1-1**]
ICD9 Codes: 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3687
} | Medical Text: Admission Date: [**2158-4-3**] Discharge Date: [**2158-4-5**]
Service: MEDICINE
Allergies:
Morphine
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
Chest Pain / Falls
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
85yo male presenting to ED w/left sided chest pain s/p fall x2
weeks ago. Patient reports multiple falls over last year
(upwards of 5). Patient is usually wheelchair bound at home but
ocacasionally uses walker for ambulation. All of his falls,
including this one occured while using walker. Patient states
that "legs weren't strong enough to hold him" and he fell
striking the left side of his chest. Patient denies any chest
pain, shortness of breath, dizziness, or pre-syncopal symptoms
prior to falling. He states that his current pain is [**8-26**], sharp
and non radiating. He denies LOC w/this fall.
Past Medical History:
1. lumbar radiculopathy with back pain
2. multiple myeloma with 6 cycles of melphagan & steroid.
3. HTN
4. BPH
5. thyroidectomy requiring synthroid
6. ESRD on HD x3/wk
Social History:
He is Russian, married living with his wife. [**Name (NI) **] does not smoke
or drink.
Family History:
Noncontributory
Physical Exam:
T 98.3, P 96, BP 94/52, RR 16, Sat 97% on 2L NC (94% on RA)
GEN: Russian speaking
HEENT: NCAT, No midline Cspine ttp, TMs clear bilat, PERRLA
w/EOMI
NECK: Trach midline
LUNGS: Crackles at bases L>R w/poor inspiratory effort secondary
to pain, ecchymosis @ dialysis site on right anterior chest
CV: [**2-19**] holosystolic murmur, TTP at left axilla w/o obvious
deformity
ABD: Soft, NT/ND, +BS
EXT: 2+ DP pulses, no edema
Pertinent Results:
[**2158-4-3**] 02:30PM PT-17.4* PTT-150* INR(PT)-1.9
[**2158-4-3**] 02:30PM PLT SMR-LOW PLT COUNT-93*
[**2158-4-3**] 02:30PM NEUTS-50 BANDS-38* LYMPHS-5* MONOS-6 EOS-0
BASOS-0 ATYPS-0 METAS-1* MYELOS-0
[**2158-4-3**] 02:30PM WBC-7.2 RBC-2.70* HGB-8.6* HCT-26.8* MCV-99*
MCH-31.8 MCHC-32.0 RDW-16.5*
[**2158-4-3**] 02:30PM GLUCOSE-130* UREA N-60* CREAT-5.5*#
SODIUM-140 POTASSIUM-4.7 CHLORIDE-98 TOTAL CO2-25 ANION GAP-22*
[**2158-4-3**] CXR: AP AND LATERAL VIEWS OF THE CHEST: There is a new
small left pneumothorax. Additionally, there are fractures of
multiple ribs, including the fourth, fifth, and sixth. A pleural
effusion has developed on the left, and there is left lower lobe
atelectasis. The right-sided catheter remains in place in the
superior vena cava/azygos vein.
[**2158-4-3**] Cardiology Report ECG
Normal sinus rhythm. First degree atrio-ventricular conduction
delay. Left axis deviation. Left anterior fascicular block.
Diffuse non-diagnostic
repolarization abnormalities. Compared to the previous tracing
of [**2158-3-6**]
multiple abnormalities as previously described persist without
major change.
Brief Hospital Course:
[**2158-4-3**]: Admit medicine team for eval of frequent falls.
Transfuse for drop in Hct.
[**2158-4-4**]: Incentive spirometry and narcotics to minimize
splinting. Heme/onc consulted given hx of MM/MDS. Code blue
called w/teley showing x2minutes of Vtach, self-resolved
w/patient c/o "pain all over". BP/pulse/O2 stable during code.
Uncertain source of bandemia. Abx started empirically. Trauma
consulted for new abd pain s/p code blue, req CT of abd for
further eval which showed edema in small bowel and colon. Cards
eval felt that prior code blue w/Vtach was actually AFibb
w/aberancy. Central IJ placed for possible swan monitoring, and
better access/fluid resucitation. EP eval w/patient spont
converting back to sinus but w/continued borderline hypotension,
recd initiating amiodarone. Patient transferred to MICU for
closer monitoring, initially ? of change in abd exam, but on
serial abd exams in MICU, no evidence of change/worsening abd
exam. Lactate up to 7.0. Code blue called again at 2300 hrs,
anesthesia intubated. Patient experienced PEA arrest, progressed
into Vtach, was shocked, rcvd bicarb/epi/atropine and finally
settled into a narrow complex rhythm. Patient required
increasing levels of pressors and became bradycardic/refractory
to atropine and was externally paced. His family arrived, the
poor prognosis was discussed with them and they asked to see him
at which time his pressures began to fall and the family chose
to take him off the vent and he was found to have no spontaneous
breaths. The patient was declared dead at 0100 hours.
Medications on Admission:
Levothyroxine 112mcg qd
Pantoprazole 40 qd
Sertraline 100 qd
Colace 100 [**Hospital1 **]
Senna 8.6 [**Hospital1 **]
Sevelamer 800 tid
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
PEA arrest
Rib fractures
Frequent falls
Discharge Condition:
Deceased
Discharge Instructions:
NONE
Followup Instructions:
NONE
ICD9 Codes: 4271, 0389 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3688
} | Medical Text: Admission Date: [**2157-4-9**] Discharge Date: [**2157-4-18**]
Date of Birth: [**2106-1-4**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
vomiting blood clots
Major Surgical or Invasive Procedure:
none
History of Present Illness:
50 yo M with h/o EtOH abuse and HTN who presents with emesis
with blood clots. Pt states he was vomiting for 24 hours before
coming to the ED. States he last consumed EtOH 2 days PTA and
that he drank about a fifth of wine x 2. States he was sleeping
at the [**Hospital3 328**] and vomited again with red clots. Denies CP,
SOB, palpitations, F/C, nausea, BRBPR. No black stools,
constipation, or diarrhea. No dysuria.
Past Medical History:
EtOH abuse
HTN
?pna with empyema?
Social History:
Pt is homeless. Denies IVDA. Smokes 2 packs a day.
Family History:
deferred
Physical Exam:
97 140/92 93 18 97% RA
Gen: in nad. thin, weak, ill-appearing
HEENT: MMM, poor dentition. NCAT. injected sclera.
CV: RRR, no m/r/g
Pulm: CTAB, +R thoracotomy scar
Abd: s/nt/nd, +bs.
Rectal: guiac beg brown stool.
Ext: no c/c/e.
Skin: dry
Neuro: Slightly tremulous. A&O X 3. No flap. Nonfocal.
Brief Hospital Course:
A/P: 50 yo hispanic M with h/o HTN, EtOH abuse a/w emesis with
blood clots.
.
## GI bleed: Pt's hematocrit has been stable while in house and
no further evidence of GI bleeding. Etiology could have been
small [**Doctor First Name 329**] [**Doctor Last Name **] tear vs gastritis. Pt has no evidence of
cirrhosis by physical exam or labs. He was maintained on IV PPI
twice a day and denied any further GI sx's. He will be
discharged on once a day oral protonix. Scope was initially
deferred because of increased risk [**2-16**] his DT's. He was
scheduled for scope on the day of discharge but refused.
.
## EtOH withdrawal: pt states has had DT's in past. Initially
placed in ICU for closer monitoring, where he required large
doses of benzodiazapines for withdrawl (hundreds of milligrams
of valium). He was also started on scheduled haldol, which he
should continue as an outpt. Psych was consulted who agreed
with this plan. Thiamine and folate were continued. He left
the ICU [**4-14**] and tried to leave the hospital twice, each time
requiring Code Purple to be initiated (psych emergency) where he
needed to transiently be restrained to avoid self injury. By
the time of discharge, the pt was no longer withdrawing and not
delerious.
.
## ARF: BUN/Cr ratio indicate likely prerenal. Elevated bicarb
likely [**2-16**] vomiting. Anion gap likely [**2-16**] ARF as well as
starvation ketosis. Renal failure and those associated
abnormalities improved with IVF's and nutritional support. His
K and Mg were aggressively repleted.
.
## Elevated pancreatic enzymes: Lipase/Amylase >2:1 likely
affected by EtOH, however not elevated to a degree sufficient
enough to call true pancreatitis. Likely elevated [**2-16**] vomiting.
Resolved with no sequelae.
.
##HTN: unclear of pt's outpt regimen: started prn hydral for SBP
>160. His htn was attributed to the unopposed sympathetic tone
of alcohol withdrawl.
Medications on Admission:
unknown
Discharge Disposition:
Home
Discharge Diagnosis:
Hematemesis
Alcohol Withdrawl
Discharge Condition:
Stable
Discharge Instructions:
If you have these symptoms, call your doctor or go to the ER:
- vomiting blood
- blood in stool
- dizziness/visual change
- fever/chills
- chest pain/cough
Take all your meds.
Stop drinking alcohol.
Followup Instructions:
Please call your PCP and see him within 2 weeks
Completed by:[**2157-4-18**]
ICD9 Codes: 5789, 5849, 2765, 2875, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3689
} | Medical Text: Admission Date: [**2184-2-10**] Discharge Date: [**2184-2-12**]
Date of Birth: [**2102-2-16**] Sex: F
Service: MEDICINE
Allergies:
Latex / Black Dye / Prevpac
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
bleed
Major Surgical or Invasive Procedure:
Attempted right SFA angiography and stent placement
History of Present Illness:
81yo female with multiple medical problems including CVA in
[**2170**], hypertension, and hyperlipidemia was admitted from the
cath lab with wire perforation and bleeding during peripheral
vascular procedure.
.
She underwent noninvasive imaging studies of her lower
extremities, which demonstrated totally occluded bilateral
superficial femoral arteries. She underwent left SFA stenting at
[**Hospital1 18**] on [**2184-1-20**] and then presented to [**Hospital1 18**] on this day of
admission for right SFA stenting. While in the cath lab, a
catheter was introduced into the left femoral artery and wired
through to the right SFA when a wire perforation occurred in the
right SFA. She developed bleeding into the right thigh. She
developed swelling in her right leg with thigh circumference of
52cm compared to left thigh of 46 cm.
.
On review of systems, she denies any prior history of pulmonary
embolism, bleeding at the time of surgery, myalgias, joint
pains, cough, hemoptysis, black stools or red stools. She denies
recent fevers, chills, or rigors. 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:
PAST MEDICAL HISTORY:
1. CVA in [**2170**]
2. Hypertension
3. Hyperlipidemia
4. S/P bilateral DVT postoperatively to bowel surgery [**2177**]
5. GERD
6. Anxiety
7. Arthritis
.
PAST SURGICAL HISTORY:
1. S/p partial colectomy for adenoma
2. S/P right fifth metatarsal fracture
3. S/P fractured right humerus in [**2181**]
4. PVD s/p left SFA stenting
5. Left ankle surgery, ORIF in [**2152**]
.
Cardiac Risk Factors: Dyslipidemia, Hypertension
Social History:
She does not currently drink alcohol or smoke cigarettes.
Social history is significant for the absence of current tobacco
use.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
VS: HR 65 / BP 141/74 / RR 18 / Pulse ox 100% 2L NC
Gen: WDWN elderly female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple
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: + BS, Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
Ext: No c/c/e. No femoral bruits. Right thigh medially is hard
and tender with ecchymoses.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
.
Pulses:
Right: DP 2+ PT dopplerable
Left: DP 2+ PT dopplerable
Pertinent Results:
Labs
[**2184-2-10**] 05:00PM BLOOD Hgb-11.0* Hct-30.6*
[**2184-2-10**] 07:12PM BLOOD Hct-29.1*
[**2184-2-10**] 11:28PM BLOOD WBC-7.0 RBC-3.01* Hgb-9.6* Hct-27.5*
MCV-91 MCH-31.9 MCHC-34.9 RDW-14.4 Plt Ct-208
[**2184-2-11**] 05:24AM BLOOD WBC-7.0 RBC-3.23* Hgb-10.8* Hct-29.9*
MCV-93 MCH-33.3* MCHC-36.0* RDW-13.9 Plt Ct-224
[**2184-2-11**] 02:26PM BLOOD Hct-27.8*
[**2184-2-10**] 07:12PM BLOOD Glucose-118* UreaN-14 Creat-0.8 Na-141
K-3.6 Cl-106 HCO3-29 AnGap-10
[**2184-2-11**] 05:24AM BLOOD Glucose-92 UreaN-12 Creat-0.8 Na-143
K-3.7 Cl-108 HCO3-29 AnGap-10
[**2184-2-10**] 07:12PM BLOOD Calcium-9.0 Phos-2.9 Mg-1.8
Vascular report
COMMENTS: 1. Access was via 5 F sheath in Left Femoral
artery.
Imaging of the distal aorta was deferred as this had been done 3
weeks
ago showing a small AAA. We crossed over into left External
iliac with
a Omniflush catheter and exchanged for a Straight Glide cath.
2. Limited hemodynamics with BP 126/47. There was a moderate
gradient
from left External iliac to right external iliac sheath with the
right
being about 8mmHG mean greater. This is consistent with mild
left
inflow disease.
3. Imaging of left leg with patent CFA and Profunda. The SFA
had
diffuse distal disease with a 3-4cm occlusion. There was
reconstitution
at Adductor Canal and 3 vessel run off to foot. There was a 90%
left AT
lesion.
4. Given claudication symptoms with good distal runoff we
elected to
proceed to intervention. We exchanged for a 6F [**Last Name (un) **] sheath to
left
CFA. We gave heparin and tried to cross the lesion with
multiple wires
including Angled Glide, Stiff Angled Glide, V-18, and Straight
Glide.
We were unable to cross and angiography revealed a perforation
with
extravasation of dye. At this point further attempts were
aborted. We
gave protamine to reverse anticoagulation. The patient formed a
thigh
hematoma which was treated with manual pressure on the right CFA
and BP
control. She was transferred to CCU for overnight observation.
FINAL DIAGNOSIS:
1. Unsuccessful attempt at right SFA revascularization.
Brief Hospital Course:
81yo female with history of CVA, hypertension, and
hyperlipidemia is admitted to the CCU for monitoring after right
SFA perforation during right SFA stenting procedure.
1. Right SFA Perforation: Patient had evidence of bleeding into
the right thigh related to right SFA perforation. She continues
to have adequate blood flow into her lower extremities with
palpable DP pulses and dopplerable PT pulses bilaterally. HCT
was monitored closely and remained stable between 27-30. She did
not require any transfusions and remained hemodynamically
stable. Thigh ciurcumference was monitored and was initially
53cm and then 47cm on [**2-11**].
2. Hypertension: Patient's blood pressure remained well
controlled. Continued on amlodipine, lopressor, and cozaar at
home doses.
3. Peripheral Vascular Disease: Patient has marked peripheral
vascular disease and has undergone left SFA stent within the
last 30 days. ASA and plavix held on transfer but restarted
since counts were stable. She will follow-up as an outpatient
regarding repeat attempt at right SFA. Continued statin.
Medications on Admission:
1. Amlodipine 5mg daily
2. Nexium 40mg PRN
3. Lopressor 25mg [**Hospital1 **]
4. Ativan 0.5mg prn
5. Cozaar 25mg [**Hospital1 **]
6. Meclizine 12.5mg prn
7. Plavix 75mg daily
8. Simvastatin 60mg daily
9. Vitamin c daily
10. B complex vitamins daily
11. Calcium plus D daily
12. Ferrous sulfate 325mg daily
13. MVI
14. Simethicone PRN
15. Ocean nasal spray
16. Vitamin E 400 IU daily
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day as needed for
heartburn.
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO once a day as
needed for anxiety.
5. Losartan 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Meclizine 12.5 mg Tablet Sig: One (1) Tablet PO once a day as
needed for dizziness.
7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Simvastatin 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
9. Vitamin C 1,000 mg Tablet Sig: One (1) Tablet PO once a day.
10. B Complex Vitamins Tablet Sig: One (1) Tablet PO once a
day.
11. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
12. Vitamin D 400 unit Capsule Sig: Two (2) Capsule PO once a
day.
13. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
14. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed.
16. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY
(Daily).
17. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
1. Peripheral Vascular Disease
.
Secondary Diagnosis:
1. Hypertension
Discharge Condition:
Stable. Patient is tolerating oral intake and has stable vital
signs.
Discharge Instructions:
You were admitted to the hospital for treatment of your blocked
blood vessels in your right leg. During your procedure, you
suffered bleeding complications and the procedure was not
completed. You were monitored very closely in the intensive care
unit and you blood pressure, heart rate, and red blood cell
count remained stable.
.
Aspirin 81mg was added to your medication regimen. You should
continue to take your aspirin and plavix. These medicines are
very important to keep the stent in your right leg open.
.
Please seek immediate medical attention if you develop increased
swelling in your left leg or thigh, back pain, light-headedness,
dizziness, passing out, bloody or black bowel movements, fevers,
shaking chills, or night sweats.
Followup Instructions:
Please follow-up with your cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on
[**2184-3-3**] at 2:30pm.
Please keep all of your previously scheduled appointments. They
are listed below.
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2184-2-18**] 10:00
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2184-3-10**] 4:20
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 13171**], MD Phone:[**Telephone/Fax (1) 719**]
Date/Time:[**2184-4-16**] 2:30
Completed by:[**2184-2-12**]
ICD9 Codes: 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3690
} | Medical Text: Admission Date: [**2110-2-28**] Discharge Date: [**2110-3-5**]
Date of Birth: [**2038-10-25**] Sex: M
Service: CCU
ADMITTING DIAGNOSIS: Torsades.
HISTORY OF THE PRESENT ILLNESS: The patient is a 70-year-old
gentleman who presented from rehabilitation after his AICD
fired three times. The patient complained of fatigue and
buttock pain as well as difficulty sleeping. The patient
denied chest pain and shortness of breath. He did have
low-grade temperatures in the Emergency Department. The
patient had no new paroxysmal nocturnal dyspnea. No
orthopnea. He did have a cough productive of sputum. The
patient denied abdominal pain, dysuria, hematuria. He stated
that his appetite was poor. He denied odynophagia. He
reports dysphagia with solids for many years.
The patient was recently hospitalized for a
presyncopal/syncopal event and shocked. At that time, he had
been started on Amiodarone and was inducible for V tach. At
that time, he underwent placement of a biventricular [**Last Name (LF) **],
[**First Name3 (LF) **] AICD. In the Emergency Department, the patient was noted
to be in torsades. He was started on a lidocaine drip.
PAST MEDICAL HISTORY:
1. Cardiomyopathy: Nonischemic. His ejection fraction was
less than 15% in [**2109-4-8**]. He has 3+ MR, 1+ AR, 2+ TR.
He has biventricular failure.
2. Status post dual-chamber biventricular pacemaker/AICD
placement one week prior to admission.
3. SVC thrombosis.
4. Hypertension.
5. Hypercholesterolemia.
6. Left eye decreased acuity.
MEDICATIONS AT HOME:
1. Coumadin 5 mg p.o. q.d.
2. Lisinopril 5 mg p.o. q.d.
3. Digoxin 0.125 mg p.o. q.o.d.
4. Amiodarone 400 mg p.o. b.i.d.
5. Pravastatin 40 mg p.o. q.d.
6. Aspirin 81 mg p.o. q.d.
7. Prevacid 30 mg p.o. q.d.
ALLERGIES: Penicillin causes rash. Aldactone causes acute
renal failure.
SOCIAL HISTORY: The patient is married. He is retired. He
is a nonsmoker, nondrinker.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
100.8, heart rate 90 and paced, blood pressure 102/60,
respiratory rate 98% on 2 liters, respiratory rate 20.
General: The patient is a chronically ill appearing man. He
was in no apparent distress. HEENT: The extraocular eye
movements were normal. The pupils were equal and reactive to
light bilaterally. There was no scleral icterus. The
oropharynx was normal. Neck: JVD is at 10 cm. There were
no carotid bruits. Lungs: Crackles at the bases
bilaterally. No wheezing. Heart: Regular rate and rhythm
with systolic murmur loudest at the left lower sternal
border. There was a rub at the apex. There was an S3.
There was no S4. Abdomen: There was a negative
hepatojugular reflux. The liver was nonpulsatile. The
abdomen was nontender, nondistended. Extremities: There was
no pedal edema. Peripheral pulses were palpable. There was
no clubbing. There was ecchymosis over the right shoulder
and arm. There was no edema in the left arm. Neurologic:
The patient was alert and oriented times three. There was no
facial droop. The tongue was midline. Cranial nerves were
normal. Strength was [**5-12**] in the upper extremities
bilaterally. Strength in the lower extremities was [**5-12**]. The
toes were downgoing.
LABORATORY DATA: White count 14.5, hematocrit 37, platelets
357,000. INR 2.0. PTT 33. Sodium 136, potassium 4.8,
chloride 99, bicarbonate 26, BUN 20, creatinine 0.8, glucose
88. CK 36. Troponin 0.3. Digoxin 0.6.
The chest x-ray showed an increased effusion on the right and
left side. There was increased retrocardiac infiltrate and
mild diffuse interstitial pattern. The [**Month/Day (1) **] leads were in
place. The AICD was in place.
EKG: There was increased QT interval initiating V tach. The
device was unable to pace at a rhythm. Shock delivered. The
corrected QT interval was greater than 600 milliseconds.
HOSPITAL COURSE: The patient was admitted to the CCU for V
tach/torsades de [**Last Name (un) **].
1. TORSADES: The patient remained hemodynamically stable.
The patient was maintained on his lidocaine drip. His
magnesium and potassium were repleted aggressively to a goal
of magnesium greater than 2.0 and potassium greater than 5.0.
His Amiodarone and digoxin were held.
The patient was seen by the EP Service and a [**Company 1543**]
dual-chamber biventricular ICD was placed. The patient was
maintained on telemetry. The patient was maintained on
mexiletine.
2. INFECTIOUS DISEASE: It was felt that the patient likely
had a pneumonia. His sputum eventually grew out
Staphylococcus. The patient was maintained on levofloxacin
and vancomycin for this. A repeat chest x-ray done on
[**2110-3-3**] showed improving pneumonia.
3. HYPOTENSION: The patient was noted to be hypotensive to
the high 90s during the admission. This was felt to be
secondary to his cardiomyopathy. One of his Lasix doses was
held. The patient was continued on spironolactone and
lisinopril. He was encouraged to take p.o. intake.
DISPOSITION: The patient was seen by Physiotherapy and it
was felt that the patient would benefit from a [**Hospital 3058**]
rehab.
DISCHARGE DIAGNOSIS:
1. Cardiomyopathy.
2. Ventricular tachycardia/torsades de [**Last Name (un) **], status post
biventricular [**Last Name (un) **] and AICD.
3. Superior vena cava thrombosis.
4. Hypotension.
5. Hypercholesterolemia.
6. Decreased acuity of vision in the left eye.
DISCHARGE MEDICATIONS:
1. Magnesium oxide 400 mg p.o. b.i.d.
2. Senna two tablets p.o. b.i.d. p.r.n.
3. Vancomycin 1 gram IV q. 12 h. until [**2110-3-9**].
4. Dulcolax 10 mg p.o./p.r. q.d. p.r.n.
5. Colace 100 mg p.o. b.i.d.
6. Mexiletine 150 mg p.o. q. 12 hours.
7. Spironolactone 25 mg p.o. q.d.
8. Levofloxacin 250 mg p.o. q. 24 hours until [**2110-3-9**].
9. Lisinopril 5 mg p.o. q.d.
10. Protonix 40 mg p.o. q.d.
11. Pravastatin 40 mg p.o. q.d.
12. Aspirin 81 mg p.o. q.d.
DISCHARGE FOLLOW-UP: The patient is being discharged to a
rehabilitation facility. He will continue to be followed by
his primary cardiologist, Dr. [**Last Name (STitle) 911**]. He will also follow-up
in the Device Clinic.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**]
Dictated By:[**Last Name (NamePattern1) 222**]
MEDQUIST36
D: [**2110-3-4**] 03:44
T: [**2110-3-4**] 16:55
JOB#: [**Job Number **]
ICD9 Codes: 4271, 4280, 4254, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3691
} | Medical Text: Admission Date: [**2198-12-7**] Discharge Date: [**2198-12-17**]
Date of Birth: [**2138-6-21**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
60 year old white female s/p CABG [**2198-11-27**] with fever and sternal
wound drainage.
Major Surgical or Invasive Procedure:
Sternal debridement and pectoralis flaps.
History of Present Illness:
This 60 year old white female is s/p CABG on [**2198-11-27**], had an
uncomplicated post op course, and was discharged to home on
[**2198-12-4**]. On [**12-6**] she was readmitted to [**Hospital6 1109**]
with fever, ^WBC, and purulent drainage from her sternal wound.
She was transferred to [**Hospital1 18**] for definitive treatment.
Past Medical History:
s/p CABG [**2198-11-27**]
NIDDM
Arthritis
Anxiety
HTN
Depression
s/p CCY
s/p TAH
s/p tubal ligation
Social History:
Lives with husband.
cigs: none
ETOH: none
Family History:
unremarkable
Physical Exam:
Elderly white female in NAD
Temp: 100 VSS
HEENT: NC/AT, PERLA, EOMI, oropharynx benign
Neck: supple, FROM, no lymphadenopathy or thyromegaly, carotids
2+=bilat. without bruits.
Lungs: Clear to A+P
CV: RRR without R/G/M
Abd: + BS, soft, nontender, without masses or hepatosplenomegaly
Chest: wound w/ purulent drainage, sternum stable.
Neuro: nonfocal
Pertinent Results:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2198-12-17**] 05:50AM 9.6 4.07* 11.8* 36.7 90 29.1 32.2 15.2
735*
BASIC COAGULATION (PT, PTT, PLT, INR) Plt Ct
[**2198-12-17**] 05:50AM 735*
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2198-12-17**] 05:50AM 101 13 0.6 140 4.7 100 31* 14
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2198-12-17**] 05:50AM 8.9 4.7* 1.9
Brief Hospital Course:
The patient was admitted on [**2198-12-7**] and was the wound was
cultured and she was started on Vanco, Gent, and Flagyl. She
was taken to the OR and underwent sternal debridement and
pectoralis flap advancement with the plastic surgery service.
She tolerated the procedure well and was transferred to the CSRU
in stable condition. She was extubated on POD#1 and ID was
consulted. On POD#3 her chest tube was d/c'd and she was
transferred to the the floor. Her wound grew out MRSA and she
was continued on Vancomycin. She continued to progress and had
a PICC placed. She initially had 4 JP drains in and had 2 of
them d/c'd. She needs 6 weeks of IV vanco form the date of her
debridement. She will be seen in Plastic Surgery Clinic in 1
week for evaluation of JP removal.
Medications on Admission:
Percocet [**11-18**] PO q 4-6 hours PRN
Lasix 40 mg PO daily
KCl 20 mEq PO daily
Plavix 75 mg PO daily
Risperidone 1 mg PO qhs
Glipizide 5 mg PO daily
Metformin 500 mh PO daily
ASA 81 mg PO daily
Lopressor 75 mg PO daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
6. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Metformin HCl 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
9. Vancomycin HCl 1000 mg IV Q8H
10. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
11. Risperidone 1 mg Tablet Sig: One (1) Tablet PO at bedtime.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 4480**] [**Hospital 4094**] Hospital - [**Location (un) 1110**]
Discharge Diagnosis:
Sternal wound infection.
Discharge Condition:
Good.
Discharge Instructions:
Follow medications on discharge instructions.
You may not drive for 4 weeks.
You may not lift more than 10 lbs for 3 months.
You should shower, let water flow over wounds, pat dry with a
towel.
Followup Instructions:
Make an appointment with Dr. [**Last Name (STitle) 51717**] when discharged from
rehab.
Make an appointment with Dr. [**Last Name (STitle) **] for 4 [**Telephone/Fax (1) 58913**]
Make an appointment with Plastic Surgery clinic for 1 week for
JP [**Telephone/Fax (1) 58914**]
Completed by:[**2198-12-17**]
ICD9 Codes: 2720, 311, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3692
} | Medical Text: Admission Date: [**2188-4-12**] Discharge Date: [**2188-4-30**]
Date of Birth: [**2110-3-15**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Cephalosporins / Pravachol / Zestril /
Beta-Adrenergic Blocking Agents
Attending:[**First Name3 (LF) 41017**]
Chief Complaint:
Respiratory failure
Major Surgical or Invasive Procedure:
Intubation/extubation
History of Present Illness:
78 y/o M w/complicated med hx who was in his USOH this evening
when his granddaughter found him downstairs confused, gasping
for breath, and "shaking". His daughter ran down there and she
wasn't sure if he was seizing or not. He is on 1-2L home O2 at
baseline, and per the daughter his o2 sat is usually between
90-92%. His O2 sat at that time was in the 70s and per the
daughter he had rales to the apex on the left. She gave him
lasix 40 po and called EMS. When they arrived, he was in
respiratory distress, with bp 190/110, p 135, rr 36, 86% on an
unclear amt of oxygen. His FS was initally 90, the daughter
gave him some glucose tablets, and it went down to 75. EMS gave
him lasix 80 mg iv, an amp of D50 and brought him here. While
en route, he vomited in the ambulance and aspirated.
.
In the ED, he was febrile to 103.8, tachycardic in the
110s-130s, tachypneic in the 30s-40s. He was 84% on NRB and was
intubated. He was started on a nitro gtt and propofol, but
became hypotensive to the 70s/50s and the nitro was
discontinued. He had 825 cc UOP while downstairs. He also
received etomidate 20 mg iv, succinylcholine 120 mg iv, aspirin
600 mg pr, tylenol, and levofloxacin 500 mg iv. Post-intubation
he had no difficulties oxygenating, and he was transferred
upstairs to the MICU.
.
On review of systems with his daughter, he had been in his USOH
earlier today, running errands. Because he is on home O2 and
has a poor pulmonary baseline, he does not walk far, but this
had not been getting worse recently. He did recently finish
Pulmonary Rehab at the [**Hospital1 **] which was not helpful. He had
not c/o chest pain, SOB, cough, weakness, vomiting, or abd pain.
His daughter thinks he has chronic abd pain from his diabetic
neuropathy but that he describes this as nausea, although he
hadn't been vomiting. Of note the pt's wife, who lives at home
with them, has bronchitis and is on abx.
.
Past Medical History:
1. CHF w/EF 20% in [**2183**] (this was prior to cath) - daughter
reports he has worsening LVH
2. CAD s/p RCA stent [**2183**]
3. Lung ca s/p R pneumonectomy [**2180**], s/p chemo, no XRT
4. chronic pancreatitis
5. Type 2 DM on insulin, w/severe neuropathy (?autonomic)
6. gastritis
7. s/p ccy
8. HTN
9. MGUS
10. hx of flash pulmonary edema requiring intubation
Social History:
Retired engineer, worked for NASA and [**Hospital6 **].
Lives at home with his wife, daughter, and daughter's family.
Hx smoking quite a bit but quit 35 yrs ago. Hx asbestos
exposure (worked in shipyards).
Family History:
DM, CAD
Physical Exam:
Tmax: 103.8 (rectal) Tc: 99.8 BP: 90/56 (MAP 67) P: 98
Vent: AC 0.6 450x16 (23) 5 spo2 98% PIP 25 Plat 20
Gen: intubated/sedated, doesn't open eyes to voice or pain but
occasionally wakes up and grimaces
HEENT: anicteric, perrl (2 mm -> 1mm)
Neck: supple, JVD approx 7-8 cm
Lungs: decreased breath sounds on R, diffuse rhonchi on left
CV: tachycardic, regular, no murmurs but diff to appreciate
above lung sounds
Abd: soft, nt/nd. +bs.
Ext: no edema, feet cool, 1+ dp bilaterally
Pertinent Results:
LABS on admission:
WBC 8.4, Hct 38.2, MCV 93, Plt 228
(DIFF: Neuts-79.0* Bands-0 Lymphs-12.3* Monos-5.1 Eos-2.9
Baso-0.8)
PT 13.5, PTT 25.7, INR 1.2
Na 134, K 6.5, Cl 98, HCO3 28, BUN 24, Cr 1.2, Glu 104
Ca 9.0, Phos 2.5, Mg 1.6
.
VBG 7.33/61/35/34
.
[**2188-4-12**] 1:00AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.009
Blood-NEG Nit-NEG Prot-NEG Glu-NEG Ketone-NEG Bilirub-NEG
Urobiln-NEG pH-6.5 Leuks-NEG
.
[**2188-4-11**] 11:40PM CK(CPK)-177* CK-MB-4 cTropnT-0.01
[**2188-4-12**] 07:26AM CK(CPK)-213* CK-MB-7 cTropnT-0.03*
[**2188-4-12**] 02:02PM CK(CPK)-243* CK-MB-7 cTropnT-<0.01
[**2188-4-18**] 04:00AM CK(CPK)-282* CK-MB-2 cTropnT-<0.01
[**2188-4-13**] 03:41AM proBNP-790
[**2188-4-16**] 04:32AM proBNP-216
.
MICRO:
[**4-12**] - blood cx negative
[**4-12**] - sputum cx >25 PMNs, <10 epis, no microorgs, sparse OP
flora
[**4-12**] - urine cx negative
[**4-14**] - urine cx negative
[**4-15**] - blood cx negative
[**4-15**] - urine cx negative
[**4-15**] - sputum cx >25 PMNs and <10 epithelial cells/100X field.
3+ GPC in pairs and clusters. Resp cx + OP flora.
[**4-18**] - blood cx negative
[**4-18**] - urine cx negative
[**4-26**] - RPR pending
.
IMAGING:
[**4-11**] CXR - Near-complete opacification of the right hemithorax
consistent with completed pneumonectomy or collapse of
postoperative right lung, unchanged from studies dating back
[**2182**]. Persistent left lower lobe peribronchial infiltrate
consistent with atelectasis with fibrosis or possibly pneumonia.
.
[**4-11**] CXR - There has been interval placement of an endotracheal
tube approximately 5 cm above the carina. Nasogastric tube is
also seen with tip overlying the stomach. Otherwise, no
significant change is seen from prior study.
.
[**4-11**] EKG -
Sinus tachycardia, rate 138. Since the previous tracing of
[**2184-12-22**] the heart rate is faster. Some technical artifacts are
present. There has been an axis shift to the left. An RSR'
pattern is present in lead V1. The QRS complex is somewhat
widened. No other changes are seen.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
138 128 116 316/396.85 6 -134 15
.
[**4-13**] CXR - Tip of the ETT is in similar position and the NGT
appears to be in the antrum of the stomach. Slight patchiness at
the left lower lung is subtly more dense compared to the prior
study, the remainder of the left lung is clear and unchanged. No
change in pulmonary vascular status. Features of right
pneumonectomy are also unchanged
.
[**4-13**] CXR - The ETT and NGT have been removed. Right
pneumonectomy space is unchanged. There continues to be some
patchiness in the left lower lung but not significantly
different. No change in pulmonary vascular status.
.
[**4-14**] CXR - There has been surgery in the right hemithorax with
rib removal. This may have been the pneumonectomy or lobectomy
with collapse of the remaining right lung present since [**2184**].
Aeration at the left lung base since that time has been poor
probably due to chronic scarring and atelectasis perhaps with
some bronchiectasis. The appearance on the films during this
hospitalization has been stable and not appreciably different
compared to [**2184**]. Rightward mediastinal shift is unchanged. The
heart is not significantly enlarged. ET tube is in standard
placement. Tip of the nasogastric tube is at the pylorus. No
pneumothorax.
.
[**4-14**] CXR - The patient is status post right pneumonectomy with
chronic interstitial markings and scarring involving the left
lung base. There is unchanged rightward shift of the trachea and
mediastinal structures. An endotracheal tube is unchanged in a
standard position. Although, assessment of the right internal
jugular venous catheter is slightly limited secondary to
mediastinal shift, the tip likely terminates in the distal SVC.
No pneumothorax is identified. A nasogastric tube is seen with
its tip in the antrum of the stomach.
.
[**4-14**] ECHO - Suboptimal image quality. The left atrium is mildly
dilated. Left ventricular wall thickness, cavity size, and
systolic function appear normal (LVEF>55%). Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. There is no aortic valve stenosis. The left
ventricular inflow pattern suggests impaired relaxation. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion. Compared with the report of
the prior study (images unavailable for review) of [**2184-10-27**],
the overall LVEF has improved.
.
[**4-15**] CXR - The complete opacification of the right hemithorax
with right mediastinal shifting is unchanged representing most
probably previous pneumonectomy. ET tube is in unchanged
standard position. The NG tube and right internal jugular venous
line are in standard position unchanged. There is a prominent
interstitial marking involving the right lung with perihilar and
lower zone redistribution suggesting congestive heart failure.
The left lung base is out of the film view, the small amount of
left pleural effusion cannot be excluded.
.
[**4-18**] CXR - Poor aeration at the left lung base has been a
chronic feature since [**2183**], somewhat more pronounced throughout
this hospitalization since [**4-11**], suggesting that the findings
are chronic rather than acute. Pulmonary vascular congestion is
present but there is no appreciable edema. Right lung has been
consistently airless since [**2183**], presumably fully resected
following previous lobectomy. Rightward mediastinal shift is
stable. A nasogastric tube ends in the distal stomach, ET tube
in standard placement, and tip of the right jugular line
projects over the SVC. No pneumothorax.
.
[**4-18**] EKG - Initially a sinus beat followed by an atrial
premature complex with initiation of a regular tachycardia of
mechanism uncertain - possoibly AV nodal reentry. Right bundle
branch block. Left anterior fascicular block. Since previous
tracing of same date, tachyarrhythmia present
Intervals Axes
Rate PR QRS QT/QTc P QRS T
157 0 130 312/400.28 0 -68 57
.
[**4-19**] CXR - Patient is status post right pneumonectomy. There is
shift of the mediastinum to the right, unchanged since the prior
chest x-ray. There has been no significant change since the
prior chest x-ray of [**4-18**]. Chronic changes only are
identified.
.
[**4-21**] CXR - Improving aeration within the left lung base.
Otherwise, no significant interval change in appearance of the
chest since the prior study.
.
[**4-23**] CXR - Portable semi-erect AP radiograph of the chest was
reviewed, and compared to previous study of [**2188-4-21**]. The
patient has been extubated. The nasogastric tube has been
removed. The patient has prior right pneumonectomy. The
previously identified left lower lobe aspiration pneumonia has
been improving. There is emphysema in the remaining left lung.
The heart size is not evaluated. There is continued marked
tortuosity of the thoracic aorta. There is a right jugular IV
catheter terminating in the superior vena cava.
.
[**4-24**] VIDEO SPEECH/SWALLOW - Mild oral dysphagia with functional
pharyngeal swallow. No evidence of aspiration.
.
[**4-27**] MRI - There is no evidence of hemorrhage, edema, masses,
mass effect or infarction. The ventricles and sulci are dilated
compatible with the patient's age. There are no diffusion
abnormalities. There is no abnormal enhancement after contrast
administration. There is partial opacification of the mastoid
air cells bilaterally. This may reflect acute or chronic
inflammation. CONCLUSION: Mastoid opacification. The study is
otherwise normal for age.
Brief Hospital Course:
78yo M with MMP who presents with hypoxic respiratory failure
s/p intubation x2, called out to floor for further management.
.
# ICU COURSE: Mr. [**Known lastname 4223**] was found to be in respiratory
distress at home. His family was concerned for either an
aspiration event or flash pulmonary edema (as he has a history
of this in the past), treated him with lasix, and called EMS. On
transfer to the ER, he was hypoxic and hypotensive. He was
intubated in the ED, BP was stabilized with IVF and was
transferred to MICU. He was initially felt to be in respiratory
distress secondary to CHF, so he underwent diuresis and was
extubated the following day. However, he continued to be
tachycardic and tachypneic following extubation and had to be
reintubated on [**4-14**]. A BNP was checked at that time and was 790,
leading the team to think that CHF was less likely, but that
COPD and pneumonia were more likely contributing as the patient
was febrile and had an infiltrate on CXR, as well as wheezing on
exam. TTE also demonstrated an EF of >50% making CHF less likely
(though diastolic failure was still a possibility given his
tachycardia). He was treated with antibiotics (Levo/Vanc) and
eventually extubated successfully on [**4-22**]. He was monitored on
an insulin gtt while in the MICU and was switched over to a RISS
on [**4-23**]. He was given TF while in the MICU, but when he was
extubated, his OGT was pulled out. He changed his code status to
DNR/DNI after being extubated and also told his family he did
not want a feeding tube.
.
Of note, while being monitored on telemetry in the MICU, it was
noted that Mr. [**Known lastname 4223**] had intermittent bursts of SVT, with a
HR as high as 160s for short periods of time. He had an unknown
allergy to b-[**Last Name (LF) 7005**], [**First Name3 (LF) **] the team was originally concerned about
how to best achieve rate control. Since the episodes were
transient, they did not treat immediately w/ rate control.
Cards/EP were consulted and felt that the bursts were SVT,
either atrial tachycardia or AVNRT. Recommendations were made
for rate control w/ bblocker if patient could tolerate it, CCB
or sotalol. B-blockade was started after the patient had 10
minutes of SVT on [**4-18**]. When he has these episodes of
tachycardia, he becomes hypotensive (SBP in the 60s) but is
asymptomatic.
.
Floor Course:
# CV:
1) RHYTHM: As noted above, Mr. [**Known lastname 4223**] was found to have an SVT
while being monitored on telemetry in the MICU. Cardiology/EP
both saw the patient and recommended beta-blockade. He did not
have a repeat episode of prolonged tachycardia after [**4-18**] when
beta-blockade was started, but did continue to have short bursts
of SVT daily, sometimes with activity, but often with rest.
Although cardiology and EP were consulted, it was unclear what
the etiology of his SVT was. He has a history of autonomic
neuropathy which may explain his recurrent SVTs. However with
the concomitant use of albuterol for his presumed COPD flare,
his SVT may have been partially iatrogenic in nature. Albuterol
was switched to xopenex to decrease adrenergic
stimulation/induced tachycardia. Other possible adrenergic
stimulants included PNA, hypoxia, hyperthyroidism or PE. He was
continued on telemetry with good rate control (80s-90s) and his
beta-[**Month/Year (2) 7005**] dose was stable at 37.5 TID for several days prior
to discharge.
.
2) PUMP: Mr. [**Known lastname 4223**] was initially felt to be in CHF. His BNP
was only 790, though, and his TTE demonstrated an improved EF
with mild LA enlargement. It was felt that he likely had
diastolic failure, perhaps from his tachycardia/SVT. On transfer
from the MICU, he appeared euvolemic and we allowed him to
autoregular his fluid status. He was LOS negative 4.5L on
transfer. He was continued on metoprolol, but no ACE was started
given his reported allergy to ACE-i in the past. It is
recommended that after his acute illness resolves that he talk
to his PCP about the possible benefits of retrying an ACE-i or
using [**First Name8 (NamePattern2) **] [**Last Name (un) **].
.
3) COR: He has known CAD from cath in [**2183**] and is s/p RCA stent
x2 for discrete lesions. However, Mr. [**Known lastname 4223**] has been without
any significant troponin leak to suggest ischemia as source of
his respiratory distress. He was continued on a daily asipirin
and beta-blockade, but a statin was not started given his
history of an allergy to pravachol.
.
4) VALVES: Mr. [**Known lastname 4223**] had no obvious murmurs on exam and no
findings on TTE to suggest valvular disease.
..
# DM: Mr. [**Known lastname 4223**] has long standing DM, though his HgbA1C
during his hospitalization was 6.4. It was felt that his
autonomic neuropathy may be due to his DM. For glycemic control,
he had been on an insulin gtt in MICU, but he was transitioned
to a [**Hospital1 **] NPH insulin regimen on the floor, along with a RISS,
with good control of his fingersticks. He was discharged on a
lower dose of insulin than he was taking at home as his FS were
well controlled on this, however this may need to be titrated
back up if his PO intake or FS increase in the future.
..
# AUTONOMIC NEUROPATHY: His autonomic neuropathy was most likely
a consequence of his long standing DM, and it was also felt that
this may be the source of his SVTs. He was on desmopressin,
midodrine and florinef at home. Neurology was consulted and
recommended discontinuing DDAVP, midodrine and florinef given
that he was having more tachycardia and HTN. However, once
discontinuing these medications, he began to have orthostatic
hypotension when working with PT and getting OOB to a chair.
Midodrine was restarted at 5mg PO TID. Per neurology, an MRI was
ordered to evaluate for watershed stroke. MRI showed no evidence
of stroke or encephalopathy. Reglan was also discontinued as it
could be making his symptoms worse. Orthostatics were rechecked
one day prior to discharge on Midodrine and were negative.
..
# COPD: On transfer from the MICU, he was being treated for a
COPD flare. He was receiving albuterol nebulizers, but the
primary team decided to discontinue albuterol as it could be
worsening his tachycardia and instead changed his regimen to
xopenex and ipratroprium nebulizers. He was also continued on
advair. His spiriva was held while he was receiving ipratroprium
nebulizers around the clock. He did well from a respiratory
standpoint and was maintaining sats of 100% on 4L. His oxygen
was weaned down to 3L (his baseline is 2-3L at home). He was
transitioned to prn nebulizers and spiriva was restarted. He was
treated for presumed pneumonia with levofloxacin ([**4-12**] - [**4-18**])
and vancomycin ([**4-18**] - [**4-25**]).
..
# CHRONIC PANCREATITIS: Pain control was with fenatanyl patch
100 Q72 (as his home regimen) and morphine IV PRN for
breatkthrough pain. Creon was restarted once he passed the
speech and swallow exam. Morphine was changed to percocet prn
prior to discharge, to replicate his home regimen.
..
# PSYCH: He was continued on his outpatient doxepin dose.
..
# MGUS: It was felt that his MGUS was not an active issue
currently. We continued to monitor his calcium daily and it
remained within normal range throughout his hospitalization.
.
# FEN: Mr. [**Known lastname 4223**] originally failed the first speech and
swallow exam at the bedside. On [**4-24**], he underwent a video
speech and swallow exam and passed that exam, with only mild
oral dysphagia and no aspirations. His diet was advanced to
ground solids, thin liquids, and aspiration precautions. He
required no further IVF on the flor. His electrolytes were
checked daily and were repleted prn.
.
# PPx: Mr. [**Known lastname 4223**] was given SQ heparin for DVT ppx, PPI for GI
ppx and bowel regimen.
.
# COMM: With daughter [**Name (NI) **] ([**Name2 (NI) **] nurse) and his wife.
.
# CODE: DNR/DNI/No feeding tube. Confirmed with ICU team and
pt's family on [**2188-4-23**].
.
Medications on Admission:
MVT
ASA 325
Vitamin D 50K units q monday
DDAVP 0.1 mg/ml spray daily
Creon caplets 2 tablets tid
Reglan
Protonix
Florinef (daughter gives if bp <130)
Lasix 40 mg daily (daughter gives if bp>170)
Klor-con 20 meq [**Hospital1 **]
Magnesium oxide 400 mg [**Hospital1 **]
Duragesic patch 100 mcg/hr
Advair
Doxepin
spiriva
Percocet prn
Insulin: regular 4 units qam, 6 units qpm; nph 20 units qam, 10
units qpm
B12 shots every 2 months
Discharge Medications:
1. Doxepin 25 mg Capsule Sig: Two (2) Capsule PO BID (2 times a
day).
2. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
3. Amylase-Lipase-Protease 33,200-10,000- 37,500 unit Capsule,
Delayed Release(E.C.) Sig: Two (2) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
4. Pantoprazole 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. Fentanyl 100 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
7. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
8. Levalbuterol HCl 0.63 mg/3 mL Solution Sig: One (1) nebulizer
Inhalation q6hrs () as needed for SOB/wheezing.
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours.
10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
13. Midodrine 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
14. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
15. Insulin Regular Human 100 unit/mL Solution Sig: Varied units
Injection ASDIR (AS DIRECTED): As per sliding scale.
16. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Varied
units Subcutaneous twice a day: 5u QAM, 2u QPM.
17. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO twice a
day.
18. Vitamin B12-Vitamin B1 100-1 mg/mL Solution Sig: Dose
unknown units Intramuscular q 2 months.
19. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) inhaler Inhalation twice a day.
20. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary diagnosis:
# Respiratory failure
# Pneumonia
.
Secondary diagnosis:
# CHF w/EF 20% in [**2183**] (prior to cath) - dtr reports worsening
LVH
# CAD s/p RCA stent [**2183**]
# Lung ca s/p R pneumonectomy [**2180**], s/p chemo, no XRT
# chronic pancreatitis
# Type 2 DM on insulin, w/severe neuropathy (?autonomic)
# gastritis
# s/p ccy
# HTN
# MGUS
# h/o flash pulmonary edema requiring intubation
Discharge Condition:
Good. Afebrile, VSS.
Discharge Instructions:
Please take all your medications as prescribed.
.
Please call your PCP or go to the nearest ER if you develop any
of the following symptoms: fever, chills, shortness of breath,
difficulty breathing, worsening cough, abdominal pain, nausea,
vomiting, diarrhea, difficulty eating or swallowing, or any
other worrisome symptoms.
.
Please keep all your follow-up appointments.
Followup Instructions:
You have a follow-up appointment scheduled with Dr. [**Last Name (STitle) 11679**] on
Thursday, [**5-8**] at 2:00. Please call his office at
[**Telephone/Fax (1) 2394**] with any questions.
Completed by:[**2188-4-30**]
ICD9 Codes: 5070, 5849, 4280, 3572 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3693
} | Medical Text: Admission Date: [**2154-7-9**] Discharge Date: [**2154-7-10**]
Date of Birth: [**2106-8-21**] Sex: M
Service: MEDICINE
Allergies:
NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / gabapentin
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Suspected overdose
Major Surgical or Invasive Procedure:
None
History of Present Illness:
47M with history of hep C, DJD, osteoarthritis presenting in
police custody after reportedly ingesting prepared packets of
heroin or cocaine. Pt regularly injects heroin (2.5g/day) and
cocaine or heroin. He reportedly swallowing 2gm bag of one of
these substances in plasticeal bag. It is unknown exact amount
and if he consumed any cocaine.
Complains of back pain (chronic). No CP/SOB. No abdominal pain,
no n/v/d.
ED Course: pt awake and alert.
- Initial Vitals/Trigger: 99.5 100 138/95 12 100
- EKG: SR 81, normal axis no ST elevat qtc 408
- tox c/s - activated charcoal and whole bowel irrigation
Labs significant for serum tox:negative CBC: unremarkable
chemistry: bicarb 27, no gap.
- transfer vitals: 99.5 100 138/95 12 100% RA
On arrival to the MICU, patient's VS. 145/82, 88, 99% RA, 16,
afebrile. He reports that he believes that he actually consumed
methamphetamine. He complains of chest discomfort and is
concerned that he might rip out his NGT. also felt like his
ears are very warm
Past Medical History:
hep C
DJD
osteoarthritis
Substance abuse disorder
depression/bipolar
Social History:
IVDU, smokes, no etoh. lives in group home
Family History:
NC
Physical Exam:
Vitals: 145/82, 88, 99% RA, 16
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
Pertinent Results:
[**2154-7-9**] 10:00PM GLUCOSE-117* UREA N-17 CREAT-1.2 SODIUM-142
POTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-27 ANION GAP-16
[**2154-7-9**] 10:00PM CK(CPK)-242
[**2154-7-9**] 10:00PM cTropnT-<0.01
[**2154-7-9**] 10:00PM CK-MB-3
[**2154-7-9**] 10:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2154-7-9**] 10:00PM WBC-4.9 RBC-4.77 HGB-13.5* HCT-41.6 MCV-87
MCH-28.3 MCHC-32.5 RDW-14.5
[**2154-7-9**] 10:00PM NEUTS-66.1 LYMPHS-27.2 MONOS-5.5 EOS-0.5
BASOS-0.7
[**2154-7-9**] 10:00PM PLT COUNT-134*
[**2154-7-10**] 01:42AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
Discharge labs
[**2154-7-10**] 02:52AM BLOOD WBC-4.8 RBC-4.59* Hgb-13.0* Hct-39.4*
MCV-86 MCH-28.4 MCHC-33.1 RDW-14.6 Plt Ct-120*
[**2154-7-10**] 02:52AM BLOOD Glucose-108* UreaN-17 Creat-1.2 Na-142
K-3.9 Cl-108 HCO3-23 AnGap-15
[**2154-7-10**] 02:52AM BLOOD ALT-47* AST-40 AlkPhos-62 TotBili-0.2
[**2154-7-10**] 02:52AM BLOOD CK-MB-3 cTropnT-<0.01
Brief Hospital Course:
47M with h/o substance abuse, presents to [**Hospital1 18**] ED in police
custody after reported ingestion of heroin and cocaine vs meth
# Overdose: Patient was given one dose of activated charcoal
(1g/kg) in ED and was given GoLytely until charcoal noted to
pass. Patient did not pass any plastiseal bags, however. Pt did
not have any signs or symptoms of overdose. Patient remained
hemodynamicaly stable. His blood and urine tox screens were
negative. EKG was unremarkable. He is medically cleared to
return to jail under police custody.
# depression: c/w home meds
# Hep C: not currently treated. does not appear to have
stigmata of cirrhosis
Medications on Admission:
Celexa 40
Abilify 10
Wellbutrin 75
Lamictal 75
Discharge Medications:
1. citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day.
2. aripiprazole 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Wellbutrin XL 150 mg Tablet Extended Release 24 hr Sig: 0.5
Tablet Extended Release 24 hr PO once a day.
4. lamotrigine 25 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary: Claimed drug overdose
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr [**Known lastname **],
You were brought here after claiming drug ingestion. Your
toxicologies were negative and you did not have any signs or
symptoms of drug overdose. You are safe to be discharged to
jail.
Followup Instructions:
With PCP at regular follow up
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
ICD9 Codes: 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3694
} | Medical Text: Admission Date: [**2177-11-6**] Discharge Date: [**2177-11-12**]
Date of Birth: [**2105-12-9**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
Chest pain, shortness of breath
Major Surgical or Invasive Procedure:
right ij cordis
a-line
Temporary pacemaker placed and removed
History of Present Illness:
71 year old female with h/o morbid obesity, COPD/asthma, DM,
HTN, CAD s/p PTCA distal LAD ([**2177-7-31**]) with 2 episodes of chest
pain resolved by sublingual NTG x 1 and complaining of
SOB/wheezing. By the time the patient arrived in the ED she had
no complaints of chest pain. Her EKG showed HR in the 40's and
junctional rhythm. She was given aspirin. CXR done and without
pneumonia/pulm edema. She was also in acute renal failure with
K 6.4, Cr 4.0. A Right IJ cordis was placed in the ED and she
was started on dopamine.
.
Patient had a similar presentation in [**9-14**] when she presented in
a junctional rhythm and acute renal failure. It was felt that
she was pre-renal and once fluids were given her renal funtion
improved. The junctional rhythm was felt to be due to
beta-blocker toxicity and also resolved.
.
ROS: difficult to obtain as patient lethargic, but oriented.
Past Medical History:
1. DM- last HgA1c 6.8 in [**4-14**].
2. HTN
3. OSA- uses BiPAP at home 21/17
4. Restrictive/obstructive lung disease; asthma- on home O2-2 L
5. [**Name (NI) **] pt unable to ambulate, uses wheelchair
6. Hyperlipidemia
7. s/p cholecystectomy
8. s/p hysterectomy
9. Chronic back pain
10. CHF with diastolic dysfunction
11. CAD- s/p PTCA to distal LAD [**7-15**]
12. CRI- baseline ~1.4
Social History:
Lives alone in an appartment in [**Location (un) **], divorced. Currently
unemployed, Mass Health/Medicaid. Has an aide that comes every
day to help her with cleaning, dishes, etc. Denies ever
smoking, using Alcohol, or IV drugs.
Family History:
Mother died at age 80yo - had CAD, DM
Father passed away at age 89yo - had CAD
Physical Exam:
Vitals: 96.4F HR 55 112/60 RR 15 97% Bipap: 40%/[**11-13**]
Gen: sleeping, but arousable with bipap on, oriented x 3,
morbidly obese, NAD
HEENT: Pupils large, reactive to light bilaterally, OP clear, MM
sl dry with dentures.
Neck: supple, RIJ cordis
CV: distant S1, S2, regular rate
Pulm: diffuse exp wheezes b/l - Anteriorly
Abd: (+) BS, soft, obese, nontender, no rebound or guarding
Ext: somewhat cool, well-perfused, 1+ pretibial edema b/l
Pertinent Results:
EKG: Junctional bradycardia, HR 46, Nl axis, RBBB
.
[**2177-11-5**] 08:42PM BLOOD WBC-7.8 RBC-3.78* Hgb-9.3* Hct-29.0*
MCV-77* MCH-24.6* MCHC-32.1 RDW-15.3 Plt Ct-203
[**2177-11-5**] 08:42PM BLOOD Neuts-79.3* Lymphs-14.7* Monos-3.7
Eos-2.1 Baso-0.2
[**2177-11-5**] 08:42PM BLOOD PT-12.8 PTT-26.8 INR(PT)-1.1
[**2177-11-5**] 08:42PM BLOOD Glucose-171* UreaN-66* Creat-4.5*#
Na-131* K-6.3* Cl-94* HCO3-23 AnGap-20
[**2177-11-5**] 08:42PM BLOOD ALT-23 AST-22 CK(CPK)-162* AlkPhos-109
Amylase-48 TotBili-0.2
[**2177-11-5**] 08:42PM BLOOD cTropnT-0.07*
[**2177-11-5**] 08:42PM BLOOD CK-MB-PND proBNP-3563*
[**2177-11-6**] 01:30AM BLOOD Type-ART pO2-352* pCO2-51* pH-7.28*
calTCO2-25 Base XS--2 Intubat-NOT INTUBA
[**2177-11-6**] 03:07AM BLOOD Lactate-1.4
[**2177-11-6**] 03:07AM BLOOD freeCa-1.19
.
[**2177-11-5**] CXR: Cardiomegaly is stable given differences in
projection. Perihilar haze is not significantly changed from
previous radiographs and may represent patient's baseline. No
interstitial lines or pulmonary engorgement is identified. No
airspace opacities are present.
.
[**11-8**] Echo: Conclusions:
1. There is moderate symmetric left ventricular hypertrophy. The
left
ventricular cavity size is normal. Due to suboptimal technical
quality, a
focal wall motion abnormality cannot be fully excluded. Overall
left
ventricular systolic function is normal (LVEF>55%).
2. The right ventricular cavity is markedly dilated. There is
severe global right ventricular free wall hypokinesis.
3. The ascending aorta is mildly dilated.
4. The mitral valve leaflets are mildly thickened.
5. There is moderate pulmonary artery systolic hypertension.
6. Compared with the prior study (images reviewed) of [**2177-8-1**],
there is
probably no significant change.
.
[**11-7**] Renal US: IMPRESSION: No hydronephrosis.
.
Brief Hospital Course:
Ms. [**Known lastname **] is a 71 year old female with h/o morbid obesity,
COPD/asthma, diabetes mellitus, HTN, CAD s/p PTCA to distal LAD
([**2177-7-31**]) who presents to the ED with chest pain, SOB.
.
Cardiac: Ms. [**Known lastname **] presented with junctional escape and
hypotension. She has a known history of LAD disease, s/p PTCA
in [**7-15**], EF 60%. In the ED, her BP was 86/51 and HR in the 40s
so she was given glucagon (pt was on metoprolol and CCB),
kayexelate 30 g, dopamine gtt, 2 liters NS, insulin and Ca
gluconate in ED. Beta blockers were held and cardiac enzymes
were cycled. Her troponins were slightly elevated with peak at
0.07, peak CK at 160. Both trended down over the course of the
hospitalization. BNP on admission was elevated at 3563. She
had an elevated CVP which was felt to be secondary to OSA. CXR
was clear without evidence of pulmonary edema and no clinical
signs of CHF. In MICU, SBP 150s and HR 60s. She developed
pulmonary edema which responded to lasix. A temporary pacer
with screw-in lead was put in place by the EP service on [**11-6**]
and the patient was transferred to the CCU. She was put back on
an aspirin and statin. Her lasix was held. The patient was
temporarily pacer dependent. A permanent pacemaker was
considered, however, the patient began pacing on her own and a
permanent pacemaker became unnecessary and the temporary screw
lead was removed on [**11-10**]. The etiology of the patient's sick
sinus and stunned atria was felt to be due to her hyperkalemia
and acute renal failure. A low dose beta blocker was restarted,
however her ACE inhibitor was held and renal artery stenosis was
ruled out with a normal renal US. An MRI was not performed as
the patient is unable to fit in MR machine. She was started on
coumadin for atrial fibrillation and INR will be checked as an
outpatient. Plavix was discontinued. She was followed in the
CCU by her primary cardiologist Dr. [**Last Name (STitle) **]. ACE inhibitor should
be restarted at her first PCP [**Name Initial (PRE) **].
.
ARF: Ms. [**Known lastname **] presented with acute renal failure with a
creatinine of 4.5 (baseline 1.3). A FeNa was calculated and
found to be <1% and FeUrea 12.5%, both indicative of pre-renal
renal failure, however possibly in setting of low cardiac output
from bradycardia. The renal service was consulted in the ED and
felt there was no urgent indication for HD. K was 6.2 on
presentation and 5.5 on recheck. Electrolytes were checked
frequently while the patient was in renal failure and fluids
were given. Potassium normalized and was 3.5 on d/c. A renal
ultrasound was performed which showed no hydronephrosis. The
patient's creatinine normalized prior to discharge. Her ace
inhibitor was held, but will be restarted at first outpatient
f/u visit as above.
.
Pulm: Ms. [**Known lastname **] presented with shortness of breath and
wheezing which could was felt to be secondary to a COPD flare.
She was treated with fluticasone/salmeterol inh, fluticasone
nasal spray and ipratroprium inh. A CXR was clear. She was put
on BiPap per her home regimen.
.
Hypertension: Ms. [**Known lastname **] blood pressure stabilized after
admission and became difficult to control. She was treated with
Isosorbide Dinitrate 10 mg PO TID, Hydralazine HCl 20 mg IV Q6H,
Clonidine HCl 0.2 mg PO BID, and Amlodipine 10 mg PO daily.
.
Diabetes: The patient was on insulin sliding scale with finger
sticks. Glyburide was held.
.
Full Code
Medications on Admission:
Albuterol Sulfate 0.083 % one Neb q4h
Aspirin 325 mg Tablet po qday
Atorvastatin 80 mg po qday
Clopidogrel 75 mg po qday
Metoprolol Tartrate 12.5mg po bid
Lisinopril 20 mg po qday
Glyburide 5 mg po bid
Amitriptyline 50 mg po qhs
Ferrous Sulfate 325mg po qday
Gabapentin 600 mg po tid
Ipratropium Bromide 17 mcg inh qid
Fluticasone-Salmeterol 250-50 [**Hospital1 **]
Fluticasone 50 mcg one spray each nostril qday
Furosemide 40 mg po qday
verapamil SR 240mg po qday
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q48H (every
48 hours).
3. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours).
4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day): One spray in each nostril.
8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
9. Imdur 30 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*
10. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
12. Warfarin 2.5 mg Tablet Sig: Two (2) Tablet PO at bedtime.
Disp:*60 Tablet(s)* Refills:*2*
13. Outpatient Lab Work
INR monitoring twice a week by VNA, goal INR 2.0-3.0, results to
be faxed to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] office (fax # [**Telephone/Fax (1) 14632**], phone
# [**Telephone/Fax (1) 2394**]).
Discharge Disposition:
Home With Service
Facility:
Family Services Association of Greater [**Location (un) 8973**]
Discharge Diagnosis:
Primary:
Bradycardia
Acute renal failure
Right heart failure with pulmonary htn
DM
HTN
OSA- uses BiPAP at home
Asthma- uses O2 at home
CAD s/p LAD PTCA on [**7-15**]
Secondary:
Restrictive lung disease on [**Name (NI) 96801**]
[**Name (NI) **] pt unable to ambulate, uses wheelchair
Hyperlipidemia
Discharge Condition:
Stable. The patient is chest pain free and taking PO. A rehab
facility was recommended by physical therapy, however the
patient refused. She will be discharged home with VNA.
Discharge Instructions:
You were admitted with a slow heart rate and renal failure.
You have been started on a new medication called coumadin for a
heart rhythm called atrial fibrillation. This medication needs
to be taken daily and must be followed in [**Hospital 263**] clinic. The VNA
will be drawing your blood and faxing the results to Dr.[**Name (NI) 5452**]
office until the coumadin clinic takes over monitoring of your
INR.
You had been taking Lisinopril at home. This medication was
held while you were in the hospital because your kidneys weren't
functioning appropriately. You should restart this medication
after seeing your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **].
You are no longer taking Plavix.
Please keep all outpatient appointments.
If you begin to experience any chest pain, shortness of breath,
immediately.
Followup Instructions:
You have the following appointments:
1. [**Doctor Last Name 9894**],NON-FLUORO(B) PAIN MANAGEMENT CENTER Date/Time:[**2177-11-26**]
1:40
2. [**Name6 (MD) 251**] [**Last Name (NamePattern4) 252**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2177-12-4**] 1:45
3. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7059**], M.D. Date/Time:[**2177-12-24**] 4:30
4. Dr. [**Last Name (STitle) **] on [**12-10**], at 12:30 in [**Location (un) **]. [**Telephone/Fax (1) 2394**]
You also need to follow up with the coumadin clinic to have the
level of coumadin in your blood tested. The VNA will draw your
blood twice a week and fax the results to Dr.[**Name (NI) 5452**] office (fax
# [**Telephone/Fax (1) 14632**]) in the meantime.
ICD9 Codes: 5849, 2762, 2767, 4280, 2761, 4589, 5859, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3695
} | Medical Text: Admission Date: [**2109-3-6**] Discharge Date: [**2109-3-19**]
Date of Birth: [**2041-12-10**] Sex: F
Service: NEUROLOGY
Allergies:
Latex
Attending:[**First Name3 (LF) 4583**]
Chief Complaint:
Called by emergency department to
evaluate difficulty breathing in the patient with myasthenia
[**Last Name (un) 2902**].
Major Surgical or Invasive Procedure:
Intubation
Placement of a pheresis line with four sessions of
plasmapheresis
History of Present Illness:
The patient is a 67-year-old
right-handed woman with a past medical history significant for
myasthenia [**Last Name (un) 2902**], diabetes, hypertension, hyperlipidemia, who
is
presenting with four days of worsening dysarthria, dysphagia,
and
respiratory difficulty concerning for a myasthenic crisis.
The patient first noted mild symptoms of difficulty breathing on
Friday night. She reports that this was very mild sensation
that
she was not able to take a full deep breath; however, it was not
very bad and did not trouble her significantly. The patient
noted the following day what she termed flu-like symptoms, which
she described as aching muscles, mild neck pain and mild joint
pain. She indicated that this sensation lasted for most of the
day. She denies having any fevers or chills. There was no
nausea or vomiting or any other symptoms. She did not have any
rhinorrhea or other symptoms concerning of a viral process. The
patient noted on that day (Saturday) that she was having
increasing difficulty chewing her food. She noted that she was
unable to close her jaw fully and felt that her mouth would hang
open. She needed to use her hand to fully help her close her
jaw. This difficulty with chewing got so bad that she was
unable
to eat solid foods and was eating only pureed foods and milk
shakes. The patient was able to use her lips to suck food from
a
straw; however, believes that this ability decreased over the
course of the next two days.
By Sunday she had significant difficulty swallowing any whole
food. If she swallowed whole food she noticed that she would
need to cough and was concerned that she would choke on it. She
was unable to chew very well at all. The patient on Sunday also
started to notice a worsening of her breathing. She again
describes this as an inability to take full deep breaths. She
felt like she was always out of breath and needed to take many
more smaller breaths. The patient also was complaining of some
mild diplopia predominantly in the afternoon. In addition, she
felt that her speech was slurred and abnormal. She felt she was
having difficulty moving her mouth to make the sounds as well as
difficulty with sounds produced by her tongue and pharynx. The
patient believed that her breathing was slightly improved when
she was sitting up as opposed to lying flat. As these symptoms
progressed, she called her neurologist on Tuesday who based on
the worsening of her symptoms, recommended that she go to her
local emergency department. The patient presented to [**Hospital2 **]
[**Hospital3 **] Emergency Room where they evaluated her and then transferred
her to [**Hospital3 **] for further evaluation.
The patient denies significant cough over the last few days.
She
did note that she had an episode of coughing after she was given
a breathing treatment at [**Hospital3 **] Hospital, but does not believe
that there has been any difficulty with coughing during these
last four days. She does have an occasional cough, which she
attributes to long history of smoking, but this is not a daily
event. The patient denies any change in her medication. She
has
been taking her Mestinon reliably; she has been taking it
approximately four to five times a day. She has not recently
changed her dose. The patient denies any recent medication
change of any type. She did not believe she was started on any
antibiotics recently. The patient has had no recent surgeries
or
other particular life stressors.
The patient reports that her myasthenia was diagnosed
approximately two years ago. The symptoms that she noted at the
time of diagnosis was double vision and which worsened in the
afternoon as well as muscle weakness in both her arms and legs
which additionally worsened in the afternoon. She notes that
she
is very good after a night's sleep and reports that she is very
active and energetic in the morning; however, this abates by
early afternoon. The patient is not completely clear of the
workup, she got the diagnosis of myasthenia, but she does
remember getting a multiple blood tests as well as an EMG and
she
has been started on Mestinon for at least two years now. She
did
not remember if she had a trial of steroids but did not believe
so during this interview. The patient reports that she is
well-controlled on Mestinon usually. She will get tired and
feel
fatigued before the next dose; however, the dose usually kicks
in
about 15 minutes and relieves most of her symptoms. She reports
that she will occasionally have diplopia when the dose wears
off.
She has never had a crisis requiring intubation in the past.
She has never had any difficulty with breathing or other
respiratory problems such as asthma.
On neuro ROS, the pt denies headache, loss of vision, she
reports
diplopia, dysarthria, dysphagia. She denies lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. No bowel or bladder
incontinence or retention. Denies difficulty with gait - but
gets
tired easily
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Reports
very rare cough, significant shortness of breath. Denies chest
pain or tightness, palpitations. Denies nausea, vomiting,
diarrhea, constipation or abdominal pain. No recent change in
bowel or bladder habits. No dysuria. Denies rash. She did
have
arthralgias and myalgias last Saturday.
Past Medical History:
- MG - diagnosed about 3 years ago with body weakness, diplopia,
dysarthria, has only been on Mestinon 60 mg QID
- DM
- HTN
- HLD
Social History:
Lives at home with a husband but she indicated that
their relationship was strained. The number that she provided is
not in service. She was intubated before we could get a HCP or
next of [**Doctor First Name **]. She is a long term smoker, smoked 1PPD for 50
years, has cut down to 1/4 pack over last few years. No etoh,
no
drugs
Family History:
No family history of MG or other neurological
diseases. Some DM in the family.
Physical Exam:
Vitals: T:98.6 P:88 R: 28 on my exam, went to 40 before
intubation BP:167/76 SaO2: 95 on 4L
General: Awake, cooperative, tachypneic, feels out of breath,
She
was able to speak in full sentences initially, but then would
have to take breaths every [**2-8**] words. Using accessory muscles,
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: mild expiratory wheezes througout
Cardiac: RRR, nl. S1S2
Abdomen: soft, NT/ND, normoactive bowel sounds
Extremities: No C/C/E bilaterally
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name [**Doctor Last Name 1841**] backward
without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic
errors.
Pt. was able to name both high and low frequency objects. Able
to read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. Pt. was able to
register 3 objects and recall [**2-7**] at 5 minutes. The pt. had
good
knowledge of current events. There was no evidence of apraxia
or
neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Has diplopia on upgaze
after 5 seconds.
V: Facial sensation intact to light touch. Has jaw weakness on
opening jaw, unable to fully close jaw against gravity
VII: No facial droop, mild ptosis of right eyelid, facial
musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically. Has difficulty with
lingual and palatal sounds
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
Can count to 20 on one breath initially
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IP Quad Ham TA Gastroc
L 5- 5- 5- 5- 5 5 5- 5 5 5 5
R 5- 5- 5- 5- 5 5 5- 5 5 5 5
on 10 pumps of deltoid she fatigues to a 4.
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 1 0
R 2 2 2 1 0
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Romberg absent.
Pertinent Results:
Admission Labs:
Blood:
[**2109-3-6**] 07:25PM BLOOD WBC-13.7* RBC-4.71 Hgb-14.6 Hct-42.7
MCV-91 MCH-31.0 MCHC-34.1 RDW-13.9 Plt Ct-272
[**2109-3-6**] 07:25PM BLOOD Neuts-81.8* Lymphs-10.7* Monos-5.9
Eos-1.1 Baso-0.5
[**2109-3-7**] 02:30AM BLOOD PT-12.8 PTT-22.3 INR(PT)-1.1
[**2109-3-12**] 12:55PM BLOOD Fibrino-412*
[**2109-3-6**] 07:25PM BLOOD Glucose-131* UreaN-15 Creat-0.7 Na-142
K-3.8 Cl-103 HCO3-27 AnGap-16
[**2109-3-6**] 07:25PM BLOOD ALT-18 AST-17 AlkPhos-80 TotBili-0.3
[**2109-3-6**] 07:25PM BLOOD Albumin-4.6 Calcium-9.4 Phos-4.0 Mg-2.2
[**2109-3-7**] 02:30AM BLOOD TSH-2.3
[**2109-3-6**] 07:25PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
[**2109-3-6**] 10:42PM BLOOD freeCa-1.23
Urine:
[**2109-3-6**] 07:10PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.019
[**2109-3-6**] 07:10PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2109-3-6**] 07:10PM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE
Epi-<1
[**2109-3-6**] 10:07PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
[**2109-3-11**] 05:15AM URINE Color-Red Appear-Cloudy Sp [**Last Name (un) **]-1.026
[**2109-3-11**] 05:15AM URINE Blood-SM Nitrite-NEG Protein-100
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-4* pH-8.5* Leuks-LG
[**2109-3-11**] 05:15AM URINE RBC-69* WBC-497* Bacteri-MOD Yeast-NONE
Epi-0
Cultures:
[**2109-3-11**] URINE URINE CULTURE-FINAL {PROTEUS
MIRABILIS, ENTEROCOCCUS SP.} INPATIENT
[**2109-3-8**] BRONCHOALVEOLAR LAVAGE GRAM STAIN-FINAL;
RESPIRATORY CULTURE-FINAL INPATIENT
[**2109-3-6**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2109-3-6**] URINE URINE CULTURE-FINAL INPATIENT
[**2109-3-6**] BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY [**Hospital1 **]
Chest X-Ray [**3-13**]
IMPRESSION: AP chest compared to [**3-9**] through 5:
Generalized infiltrative pulmonary abnormality which developed
after [**3-10**] has improved, probably edema either cardiac or
related to drug or blood product administration. Small left
pleural effusion is unchanged and small right pleural effusion
is presumed although not imaged directly. Heart size is normal.
ET tube is in standard placement, nasogastric tube passes below
the diaphragm and out of view, and a right internal jugular line
ends in the upper SVC. No pneumothorax.
Brief Hospital Course:
Mrs. [**Known lastname **] was diagnosed with myasthenia [**Last Name (un) 2902**] as described
above. She had been maintained on Mestinon alone, without prior
immunosuppression or steroid treatment. This time she presented
with severe respiratory compromise, resulting in NIF's less than
-20. She was intubated and maintained on ventilator CPAP support
while plasmapheresis treatment was conducted. She underwent four
sessions of pheresis with clear improvement in strength on
clinical examination and NIF, allowing eventual extubation on
[**2109-3-13**]. Cellcept was started at 500 mg [**Hospital1 **] and Mestinon
restarted at 30 mg QID (half her home dose). The fifth planned
session of plasmapheresis was cancelled. When extubated and
stable she was transferred to the floor service.
While in the ICU, she also developed a UTI with proteus
mirabilis, initially intended as a three day course of
ciprofloxacin. This was changed to Bactrim on [**2109-3-14**], and she
should continue this through [**2109-3-20**].
Given Cellcept, weekly CBC will be necessary.
Dyslipidemia - Low dose statin was continued.
Medications on Admission:
- ASA 81
- Diovan 160mg qd
- Mestinon 60mg QID
- Metformin 500mg [**Hospital1 **]
- Pravastatin 10mg qd
- Lumigan 0.03 % Eye Drops qd qhs
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. pravastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [**12-9**]
Puffs Inhalation Q6H (every 6 hours) as needed for wheeze.
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
6. ibuprofen 100 mg/5 mL Suspension Sig: Four Hundred (400) mg
PO Q6H (every 6 hours) as needed for Headache.
7. Senna Herbal Laxative 12 mg Capsule Sig: One (1) Tablet PO
BID (2 times a day) as needed for constipation.
8. mycophenolate mofetil 500 mg Tablet Sig: One (1) Tablet PO
twice a day.
9. pyridostigmine bromide 60 mg Tablet Sig: 0.5 Tablet PO Q6H
(every 6 hours).
10. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 7 days: Last dose [**2109-3-20**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Hospital3 **] ([**Hospital **]
Hospital of [**Location (un) **] and Islands)
Discharge Diagnosis:
Myasthenia [**Last Name (un) **] flare
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with a myasthenic flare, requiring intubation
and plasma exchange. You improved greatly, and were started on
the immunosuppressant medicine CellCept, which you should
continue. Please continue on this medicine as well as your other
medicines you were taking prior to arrival. Please stop smoking.
Please see your PCP if you need help with this.
Followup Instructions:
Please follow up with your neurologist on the [**Hospital3 **].
Completed by:[**2109-3-16**]
ICD9 Codes: 5990, 5180, 4019, 2724, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3696
} | Medical Text: Admission Date: [**2130-4-6**] Discharge Date: [**2130-4-13**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
confusion, slurred speech
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient is a 86 yo with recent dx of HTN who presents with large
right basal ganglia hemorrhage, intraventricular extension and
dilation of ventricles. Patient was last well at 6:45 pm [**2130-4-6**]
when daughter called him on the phone. The patient was supposed
to meet daughter this AM and failed to show. Daughter went to
patient's home (who lives alone) and found him acting confused,
slow to respond and slurring when he answered the door at 7:45
AM. She denies noting any gait change, weakness, abnormal speech
pattern other than he was slow to answer questions. He was able
to answer questions appropriately not did not initiate
spontaneous conversation. She gave him some food and when
symptoms did not resolve after a couple of hours she took him a
local family clinic. His BP there was 197/90 and CXR, EKG, and
routine labs were nml. He was referred to [**Hospital1 2436**] ER where a
head CT was done and showed right BG hemorrhage with IVH
extenstion. He was then sent to [**Hospital1 18**] ED for further eval. In
ED,
coags nml, plats nml, BPs still high 210/90s requiring
hydralazine and enalprit IV. Repeat Head CT done, pending.
Past Medical History:
HTN-dx with "mild HTN" 6 mo ago
elevated PSA
Social History:
Lives alone, widowed. No smoking, Rare beer with family. No drug
use. Lives alone, drives, shops, cooks independently.
Family History:
-Father and brother both had MIs less <60 y. The brother also
had
a cerebral aneurysm in 60s.
-His son has Afib, HTN.
-Another son has PVCs.
Physical Exam:
O: -Tc: AF BP:154 /61 HR: 77
RR: 20 O2Sat100% RA
Gen: WD/WN, comfortable, NAD.
HEENT: NC/AT. Anicteric. MMM.
Neck: Supple. No masses or LAD. No carotid bruits.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2. soft M
Abd: Soft, NT, ND, +NABS. No rebound or guarding. No HSM.
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Asleep, Awake to voice and alert, cooperative
with
exam, normal affect. Very talkative.
Orientation: Oriented to person, place, and date.
Attention: Able to recite [**Doctor Last Name 1841**] forwards and backwards.
Registration intact.
Recall: [**3-5**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors. No apraxia,
no
neglect. [**Location (un) **] intact.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally. Visual fields are full to confrontation. Optic
not visualized with cataracts.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**6-5**] throughout. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and jp
bilaterally.
Reflexes: 2 plus throughout. Toes down bilaterally.
Coordination: Normal on finger-nose-finger, rapid alternating
movements, heel to shin.
Gait: deferred
Pertinent Results:
[**2130-4-6**] 04:40PM UREA N-18 SODIUM-141 POTASSIUM-4.0
CHLORIDE-104 TOTAL CO2-27 ANION GAP-14
[**2130-4-6**] 04:40PM CK(CPK)-47
[**2130-4-6**] 04:40PM CK-MB-3 cTropnT-<0.01
[**2130-4-6**] 04:30PM GLUCOSE-100 UREA N-19 CREAT-1.3* SODIUM-137
POTASSIUM-7.3* CHLORIDE-102 TOTAL CO2-26 ANION GAP-16
[**2130-4-6**] 04:30PM CALCIUM-9.7 PHOSPHATE-3.3 MAGNESIUM-2.5
[**2130-4-6**] 04:30PM WBC-9.4 RBC-4.68 HGB-14.7 HCT-43.3 MCV-92
MCH-31.5 MCHC-34.1 RDW-13.3
[**2130-4-6**] 04:30PM NEUTS-85.0* LYMPHS-11.3* MONOS-3.2 EOS-0.4
BASOS-0.1
[**2130-4-6**] 04:30PM PT-12.2 PTT-29.8 INR(PT)-1.0
CTH [**2130-4-6**]: Right basal ganglia hemorrhage with extensive
intraventricular blood in the right greater than left lateral
ventricles, extending into the third and fourth ventricles. This
is unchanged from 5 hours ago (OSH study)
Brief Hospital Course:
86M with HA in setting of HTN found to have right basal ganglia
bleed with large amount of intraventricular extension.
Neuro: Pt with stable neurologic exam goal 120-160, MAP <130.
repeat CTH on [**4-7**] stable from previous. Neurosurgery did not
feel EVD placement was warranted at this time pt transferred to
stepdown on [**4-7**]. pt continued to do well with stable CTH and
stable clinical exam.
CV: BPs controlled on prn hydralazine and norvasc in ICU. pt
required increases in norvasc for HTN. On the floor the patient
developped afib with RVR. He required several doses of IV
metoprolol. Ultimately we started him on lopressor 25mg [**Hospital1 **].
-CE negative X 3
Endo: RISS
Medications on Admission:
norvasc 2.5 QD
MVI
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
4. Omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 4444**] Health Care Center
Discharge Diagnosis:
large R basal ganglia hemorrhage
Discharge Condition:
stable, intermittently drowsy so repeat NCHCT done on day of
discharge
Discharge Instructions:
PLEASE MONITOR BP, GOAL SBP <150, WE HAVE INCREASED METOPROLOL
FROM 25 [**Hospital1 **] to 25 TID on [**4-12**]
You have had a large intracerebral hemorrhage extending
intraventricularly, likely from high blood pressure.
Serial head CTs have showed stable mild hydrocephalus.
Please take all your medications as directed and attend all your
follow-up appointments as scheduled.
Please call your PCP or go to the nearest ED if you have any
worsening of your symptoms or any new concerning symptoms,
especially drowsiness, unsteady walking, nausea/vomiting,
headache, visual changes.
Followup Instructions:
You have the following appointment in [**Hospital **] clinic:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2130-6-9**] 10:30
*** Please call [**Telephone/Fax (1) 2574**] prior to this appointment to update
your registration information. ***
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
Completed by:[**2130-4-12**]
ICD9 Codes: 431, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3697
} | Medical Text: Admission Date: [**2147-9-19**] Discharge Date: [**2147-9-25**]
Date of Birth: [**2078-1-13**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Allopurinol
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Burning chest pain.
Major Surgical or Invasive Procedure:
[**2147-9-20**] - Off-pump coronary artery bypass graft x4, left
internal mammary artery to left anterior descending artery and
saphenous vein grafts to the diagonal, obtuse marginal and
posterior descending arteries.
History of Present Illness:
This 69-year-old patient with recent onset epigastric pain was
investigated and was found to have severe triple vessel disease
with positive enzymes and was transferred for urgent coronary
artery bypass grafting. Left ventricular function was well
preserved.
Past Medical History:
Gastroesophageal Reflux Disease, Gout, s/p multiple cysts
removed
Social History:
Lives with wife. Drinks 4 drinks/week of alcohol. Quit smoking
20 years ago.
Family History:
NC
Physical Exam:
SR 84 120/77 18
GEN: NAD lying in bed
NEURO: Nonfocal
HEART: RRR, no m/r/g
LUNGS: CTA
ABD: soft, NT/ND/NABS
EXT: Warm, well perfused, no edema, 2+ pulses, no varicosities.
Pertinent Results:
[**2147-9-21**] ECHO
Pre-procedure: No spontaneous echo contrast is seen in the left
atrial
appendage. Right ventricular systolic function is normal. LV
systolic fxn is moderately depressed, with akinetic apex, and
hypokinesis especially of the inferior, infero-septal and
infero-lateral walls. There are simple atheroma in the ascending
aorta. 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
mildly thickened. No aortic regurgitation is seen. The mitral
valve leaflets are moderately thickened. Mild (1+) mitral
regurgitation is seen. The patient was done "off pump" because
of hematuria.
Post procedure: Biventricular systolic fxn is essentially
unchanged. No AI, trace MR, aorta intact.
[**2147-9-25**] CXR
Improved aeration of lung bases. Still present small left
pleural effusion. No evidence of failure
[**2147-9-19**] 06:52PM BLOOD WBC-7.1 RBC-4.80 Hgb-16.7 Hct-45.6 MCV-95
MCH-34.8* MCHC-36.7* RDW-13.8 Plt Ct-129*
[**2147-9-24**] 05:10AM BLOOD WBC-6.1 RBC-3.28* Hgb-11.3* Hct-32.5*
MCV-99* MCH-34.5* MCHC-34.8 RDW-13.2 Plt Ct-131*
[**2147-9-19**] 06:52PM BLOOD PT-12.6 PTT-32.5 INR(PT)-1.1
[**2147-9-21**] 02:18AM BLOOD PT-12.8 PTT-28.1 INR(PT)-1.1
[**2147-9-19**] 06:52PM BLOOD Glucose-112* UreaN-15 Creat-1.1 Na-141
K-3.7 Cl-103 HCO3-29 AnGap-13
[**2147-9-24**] 05:10AM BLOOD Glucose-131* UreaN-17 Creat-1.0 Na-141
K-3.9 Cl-99 HCO3-34* AnGap-12
[**2147-9-24**] 05:10AM BLOOD Calcium-8.8 Phos-3.8 Mg-2.2
Brief Hospital Course:
As mentioned in the HPI, Mr. [**Known lastname **] was transferred to [**Hospital1 18**]
for surgical management. GU service were consulted secondary to
hematuria (also followed pt during post-op course). He had all
pre-operative work-up done prior to surgery and was brought to
the operating room on [**8-20**] where he underwent a coronary artery
bypass graft x 4 (off-pump). Please see operative report for
surgical details. Following surgery he was transferred to the
CVICU for invasive monitoring in stable condition. Within 24
hours he was weaned from sedation, awoke neurologically intact
and extubated. On post-op day one he was started on beta
blockers and diuretics. He was gently diuresed towards his
pre-op weight. Also on this day his chest tubes were removed and
he was transferred to the SDU for further care. Epicardial
pacing wires were removed on post-op day three. Later on this
day she had episode of atrial fibrillation which was
appropriately treated. She remained in sinus rhythm through
discharge but remained on amiodarone. She continued to slowly
improve while working with physical therapy over the next two
days. On post-op day five he was discharged home with VNA
services and the appropriate follow-up appointments.
Medications on Admission:
At home: Protonix 40mg qd, Aspirin 325mg qd, Colchicine
At TransferL Integrelin gtt, Heparin gtt, Bicarb gtt
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
2. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 7 days.
Disp:*14 Packet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
6. 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. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 6 days: then decrease to 1 tablet daily until
discontinued by Dr. [**Last Name (STitle) 5874**].
Disp:*45 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4
PMH: Gastroesophageal Reflux Disease, Gout, s/p multiple cysts
removed
Discharge Condition:
good
Discharge Instructions:
no driving for 1 month
no lifting > 10# for 10 weeks
may shower, no bathing or swimming for 1 month
no creams, lotions or powders to any incisions
Followup Instructions:
with Dr. [**Last Name (STitle) **] in [**2-4**] weeks
with Dr. [**Last Name (STitle) 5874**] in [**2-4**] weeks
with Dr. [**First Name (STitle) **] in 4 weeks
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2147-9-26**]
ICD9 Codes: 496, 4111, 2749, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3698
} | Medical Text: Admission Date: [**2182-5-11**] Discharge Date: [**2182-5-14**]
Date of Birth: [**2155-12-25**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 24828**] is a gentleman with
end stage renal failure who underwent a cadaveric renal
transplant approximately three months ago. This transplant
was complicated by primary nonfunction. The donor was
hemodynamically unstable at the time of the procurement and
the patient was given the option of taking a chance on
transplantation, given the fact that the premorbid renal
function of the donor was normal. The patient was told of
the risk of delayed function and/or nonfunction and wished to
take the risk to try to get off of dialysis.
HOSPITAL COURSE: The patient underwent transplant and
unfortunately nonfunction did occur. Multiple biopsies
throughout the course revealed no evidence of rejection;
however, there was progressive scarring of the kidney and
worsening acute tubular necrosis. At this point a decision
was made to stop the immunosuppression as the patient was at
risk for infection, and so the immunosuppression was tapered
to off. Unfortunately with the tapering of the
immunosuppression, the patient developed a severe acute
rejection with swollen painful graft.
The patient was admitted and was taken to the Operating Room
for a transplant nephrectomy. This occurred on [**2182-5-12**].
The patient did well postoperatively and had immediate
resolution of symptoms.
DISPOSITION: The patient was stable for discharge on
postoperative day three and will follow-up in my clinic for
relisting for cadaver retransplant.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3598**], MD [**MD Number(1) 3599**]
Dictated By:[**Dictator Info **]
D: [**2182-6-25**] 19:25
T: [**2182-6-25**] 22:01
JOB#: [**Job Number 24829**]
cc:[**Hospital 24830**]
ICD9 Codes: 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3699
} | Medical Text: Admission Date: [**2108-7-28**] Discharge Date: [**2108-8-8**]
Date of Birth: [**2053-1-11**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
Intraparenchymal hemorrhage
Major Surgical or Invasive Procedure:
right craniotomy
right hemicraniectomy
tracheostomy
peg placement
left subclavian line
History of Present Illness:
Patient is a 55M found down after fall from bike; he was taken
to OSH were he was initially conscious. He then complained of
several hours of right sided headache, had a seizure and
developed subsequent left sided weakness. CT scan of the head
was performed and a large IPH was identified. He was intubated
for airway protection and transferred to [**Hospital1 18**] for definitive
neurosurgical care.
Past Medical History:
dyslipidemia
Social History:
non contributory
Family History:
non contributory
Physical Exam:
On admission-PHYSICAL EXAM:
125/73 82 12 100
Intubated; minimally sedated;
Grimaces to stim but not opening his eyes; follows simple
command
on Rt;
PERLA; Face symetric
Moves appropriately Rt side; withdraws Rt LE; almost posturing
Rt
UE
Toes: equivocal on Rt, upgoing on Lt; downgoing bilaterally
On Discharge:Oriented x3, speech dysarthric, left facial, tongue
ML, left hemiparesis (w/d's to noxious on that side), purposeful
on right, follows commands. Improved overall today.
Pertinent Results:
Cardiology Report ECG Study Date of [**2108-7-28**] 8:03:56 PM
Sinus rhythm. Inferior myocardial infarction, age indeterminate.
No previous tracing available for comparison.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
85 168 92 400/443 57 -18 9
Radiology Report CTA HEAD W&W/O C & RECONS Study Date of
[**2108-7-28**] 8:15 PM
CTA HEAD W&W/O C & RECONS IMPRESSION PER Radiology Report: 1.
Interval enlargement of the right parenchymal hematoma with
increased mass effect, including increased sulcal effacement in
the right cerebral hemisphere. 2. New intraventricular extension
of hemorrhage, with slightly increased
compression of portions of the right lateral ventricle. New
dilatation of the left lateral ventricle and of the occipital
[**Doctor Last Name 534**] of the right lateral
ventricle. 3. No evidence of intracranial aneurysm,
arteriovenous malformation, or stenosis.
Radiology Report CT C-SPINE W/O CONTRAST Study Date of [**2108-7-28**]
8:25 PM
CT C-SPINE W/O CONTRAST; OUTSIDE FILMS READ ONLY BY Radiology
Final Report CT OF THE CERVICAL SPINE, [**2108-7-28**]
IMPRESSION: Multilevel degenerative changes with no evidence of
acute cervical spine injury.
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2108-7-29**]
9:17 AM
Final Report By Radiologist
CT HEAD COMPARISON: [**2108-7-28**].
IMPRESSION: 1. Essentially unchanged right basal ganglia
hematoma which also involves the coronal radiata and the
anterior temporal white matter, with unchanged mass effect. 2.
Apparent new small subarachnoid hemorrhage in a left paramedian
frontal sulcus. 3. Unchanged intraventricular hemorrhage.
Unchanged dilatation of the left lateral ventricle and right
occipital [**Doctor Last Name 534**]. Unchanged compression of other components of the
right lateral ventricle.
Radiology Report [**Numeric Identifier 78740**] CAROTID/CEREBRAL BILAT Study Date of
[**2108-7-29**] 2:06 PM CAROT/CEREB [**Hospital1 **] IMPRESSION: [**Known firstname **] [**Known lastname **]
underwent cerebral angiography to look for a source of his
hemorrhage in the right deep basal ganglia area. There was no
evidence of any arteriovenous malformations or fistula.
Cardiology Report ECG Study Date of [**2108-7-31**] 3:12:54 PM
Atrial fibrillation with rapid ventricular response. Poor
precordial
QRS progression. Non-specific inferior T wave changes. Compared
to the previous tracing of [**2108-7-28**] atrial fibrillation is now
present.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
110 0 94 328/415 0 10 12
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2108-7-31**]
5:22 AM
Radiologist final IMPRESSION: 1. The large right basal ganglia
hemorrhage extending to the corona radiata and anterior temporal
white matter is unchanged, but surrounding edema has increased,
resulting in increased leftward shift of midline structures,
partial effacement of the right aspect of the suprasellar
cistern, and mild right uncal herniation. 2.Persistent
intraventricular hemorrhage. Slightly increased dilatation of
the left lateral ventricle. Unchanged compression of the right
lateral ventricle. 3. Possible evolving acute infarction in the
right caudate head.
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2108-8-1**]
11:55 AM
Final Report by Radiologist IMPRESSION: The patient is status
post right frontal temporoparietal craniectomy, no significant
change since the prior examination, persistent midline shift
with approximately 5 mm of deviation towards the left, stable
intracranial and intraventricular hemorrhage. Unchanged edema
surrounding the area of intraparenchymal hemorrhage and similar
mass effect along the left frontal ventricular [**Doctor Last Name 534**].
Radiology Report CHEST (PORTABLE AP) Study Date of [**2108-8-1**] 2:32
PM
REASON FOR EXAM: Fever. Cardiac size is top normal. Bibasilar
opacities have increased compared to [**7-28**], pneumonia cannot
be excluded.
Biapical atelectasis have improved. Cardiac size is normal. ET
tube tip is 5.3 cm above the carina. NG tube is coiled in the
stomach and the tip is in the lower esophagus. Bilateral pleural
effusions are small.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2108-8-4**] 4:17
AM
Final Report SUPINE CHEST X-RAY PERFORMED AT 5:00 A.M.:
Tracheostomy tube is seen in the upper mediastinum 4.4 cm above
the carina. The left subclavian central line catheter is seen
with its tip at cavoatrial junction. PEG catheter is seen at the
paravertebral left upper quadrant abdomen. The patient is
rotated to the left. The cardiomediastinal silhouette is within
normal limits. There is no acute parenchymal abnormality. The
left CP angle is not in the field of the x-ray.
Radiology Report BILAT LOWER EXT VEINS Study Date of [**2108-8-4**]
11:41 AM
BILATERAL LOWER EXTREMITY VENOUS ULTRASOUND: IMPRESSION: No
evidence of DVT in either lower extremity.
[**Known lastname 971**],[**Known firstname **] [**Medical Record Number 83111**] M 55 [**2053-1-11**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2108-8-5**] 6:49
PM
[**Last Name (LF) **],[**First Name3 (LF) 742**] NSURG FA11 [**2108-8-5**] 6:49 PM
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 83112**]
Reason: pna?
[**Hospital 93**] MEDICAL CONDITION:
55 year old man with fever spike to 102
REASON FOR THIS EXAMINATION:
pna?
Wet Read: PXDb SUN [**2108-8-5**] 8:32 PM
Increasing opacity in bilateral lower lobes, R>L, may reflect
ateletectasis,
superimposed on mild volume overload with cephalization and
blurring of
perihilar vasculature. ([**First Name8 (NamePattern2) 30217**] [**Doctor Last Name **] [**Numeric Identifier 83113**])
Final Report
AP CHEST 7:06 P.M. ON [**2108-8-5**]
HISTORY: New fever spike, question pneumonia.
IMPRESSION: AP chest compared to [**8-4**]:
Interval increase in caliber of mediastinal vasculature suggests
that some of
the new interstitial abnormality in the left lower lung is
asymmetric edema,
but there is more consolidation at the left lung base and was
present
previously, concerning for new pneumonia. Heart size is normal.
No pleural
effusion or pneumothorax. Tracheostomy tube and left subclavian
line are in
standard placements.
The study and the report were reviewed by the staff radiologist.
[**Known lastname 971**],[**Known firstname **] [**Medical Record Number 83111**] M 55 [**2053-1-11**]
Radiology Report UNILAT UP EXT VEINS US LEFT Study Date of
[**2108-8-6**] 9:12 AM
[**Last Name (LF) **],[**First Name3 (LF) 742**] NSURG FA11 [**2108-8-6**] 9:12 AM
UNILAT UP EXT VEINS US LEFT Clip # [**Clip Number (Radiology) 83114**]
Reason: 55 year old man with LUE swelling. Eval for DVT. PLEASE
PE
[**Hospital 93**] MEDICAL CONDITION:
55 year old man with LUE swelling. Eval for DVT. PLEASE
PERFORM MORNING OF
[**8-6**]
REASON FOR THIS EXAMINATION:
55 year old man with LUE swelling. Eval for DVT. PLEASE
PERFORM MORNING OF
[**8-6**]
Provisional Findings Impression: JRCi [**Name2 (NI) **] [**2108-8-6**] 10:34 AM
PFI: Near complete occlusive thrombus within the left cephalic
vein.
Final Report
STUDY: Left unilateral upper extremity veins ultrasound.
INDICATION: Left upper extremity swelling.
COMPARISONS: None available at the time of dictation.
FINDINGS: Grayscale, color, and pulsed Doppler son[**Name (NI) 867**] was
performed on
the left internal jugular, subclavian, axillary, brachial,
basilic, and
cephalic veins. Near complete occlusive thrombus is demonstrated
within the left cephalic vein with a small amount of flow
demonstrated. The remaining named veins are patent with normal
compression and waveforms. Note is made of a left subclavian
central venous catheter without clot demonstrated surrounding
the catheter.
IMPRESSION: Near complete occlusive clot within the left
cephalic vein.
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2108-8-8**] 04:58AM 10.5 2.96* 9.1* 27.1* 92 30.8 33.7 12.9
409
Source: Line-L CVL
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
Myelos
[**2108-7-28**] 08:20PM 77* 11* 8* 3 0 0 0 1* 0
RED CELL MORPHOLOGY Hypochr Anisocy Poiklo Macrocy Microcy
Polychr
[**2108-7-28**] 08:20PM NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct
INR(PT)
[**2108-8-8**] 04:58AM 409
Source: Line-L CVL
[**2108-8-8**] 04:58AM 12.3 26.2 1.0
Source: Line-L CVL
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2108-8-8**] 04:58AM 146* 18 0.8 135 3.6 101 26 12
Source: Line-L CVL
Brief Hospital Course:
This is a 55 year old male found down after a fall from a bike
He was taken to outside hospital were was conscious, and
reported several hours of right sided headache prior to biking,
he had a seizure and left sided weakness. His Head CT showed
large IPH right deep basal ganglia. He was intubated and
transferred to [**Hospital1 18**] for further care and received
phosphenytoin. He was admitted to the ICU for close
neurological monitoring. On [**7-29**], his Head CT revealed no
progression of right basal ganglia hematoma with preexisting 6
mm left midline shift and new small subarachnoid hemorrhage in a
left paramedian frontal sulcus.He unserwent an angiogram which
was negative. His cervbical spine was cleared. On [**7-30**], he
followed commands on the right with no movement on the left
side. On [**7-31**], He went to the OR for a Decompressive right
hemi-craniectomy for his intracranial hemorrhage,
post-operatively he was given Mannitol 25 mg q 8 hours, his
post-operative Head CT was consistent with improvement in
leftward midline shift and decreased dilation of the left
lateral ventricle. On [**8-1**], the patients Head Ct was consistent
with no significant change since the prior examination,
persistent midline shift with approximately 5 mm of deviation
towards the left, stable intracranial and intraventricular
hemorrhage and unchanged edema surrounding the area of
intraparenchymal hemorrhage. The patient mannitol dosing was
weaned and his helmut for his craniectomy was ordered. On [**8-2**],
he experienced fevers was started on antibiotics for pneumonia,
the patient was pancultured for other possible sources of
infection. On [**8-3**], the patient ws following simple commands on
the right, his helmut was fitted, and he had a tracheostomy and
PEG placement. He spiked a temperature of 102.3. On [**8-4**] he
was out of bed to the chair with his helmut on and began trach
collar trials off the ventilator. Bilateral Lower Extremity
venous ultrasound was performed with no evidence of DVT in
either lower extremity. On [**8-5**], he was on the trach collar, off
the ventilator for over 24 hours and is awaiting a bed in the
Step-down unit.
On [**8-6**], overnight pt spike a temperature of 102.3 and was
pancultured and a chest x-ray revealed increased opacities in
the lower lobes r>l. A sputum culture was obtained and sent for
culture. They have all been "poor quality to date", No formal
BAL was performed. The patient was started on ciprofloxacin to
emperically to treat a pneumonia on [**2108-8-5**]. He was started on
broad spectrum abx upon discharge to provide more complete
coverage. If the patient re-spikes a fever would consider ID
consult at your facility and obtain appropriate specimens.
Urine cx was negative.
Formal video swallow was not performed as of this time. Passy
Muir valve challenge passed.
Medications on Admission:
ASA, fluoxetine, lipitor
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever/pain.
3. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): insulain sliding scale coverage.
4. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
5. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for fever/pain.
6. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
12. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
14. Labetalol 10 mg IV Q4H:PRN SBP > 120
15. HydrALAzine 10-20 mg IV Q6H:PRN SBP > 140
16. Ondansetron 4 mg IV Q8H:PRN nausea/emesis
17. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
18. 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.
19. Heparin Flush (10 units/ml) 1 mL IV PRN line flush
Temporary Central Access-Floor: Flush with 10 mL Normal
Saline followed by Heparin as above daily and PRN.
20. Vancomycin 1000 mg IV Q 12H Duration: 8 Days
please obtain trough level in between third and fourth doses
pls.
21. CefePIME 2 g IV Q12H Duration: 8 Days
22. Ciprofloxacin 400 mg IV Q12H Duration: 8 Days
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Right Basal ganglia/intraparenchymal hemorrhage
seizure
respiratory failure
Uncal herniation
left hemiparesis
dysphagia
protein / calorie malnutrition
fever
aspiration pneumonia
dysartrhia
left partially thrombosed cephalic vein
Discharge Condition:
Neurologically Stable
Discharge Instructions:
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.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) 26803**], 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:[**2108-8-8**]
ICD9 Codes: 431, 5070, 2724 |
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