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{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3700
} | Medical Text: Admission Date: [**2102-10-23**] Discharge Date: [**2102-11-1**]
Date of Birth: [**2053-8-28**] Sex: F
Service: ACOVE Medicine
HISTORY OF PRESENT ILLNESS: Patient is a 49-year-old female
with past medical history of breast cancer status post
lumpectomy and radiation, asthma, COPD, and current tobacco
use, who was admitted to [**Hospital3 **] on [**10-20**] for an
asthma/COPD exacerbation, and was transferred over to [**Hospital1 1444**] intubated on [**2102-10-23**].
The patient reports having a recent trip to [**Country 2784**] during
which she was treated with prednisone for unknown reason.
Upon return to the United States, she developed shortness of
breath and cough. Presented to [**Hospital3 **] on [**2102-10-20**]. At that time, she was felt to be having an asthma or
COPD exacerbation. Was treated with steroids and inhalers.
On [**2102-10-22**], the patient was found unresponsive and
was an extremely difficult intubation. Several of the
patient's teeth were reportedly chipped on the intubation
attempts, and the patient eventually required a
cricothyroidotomy for immediate airway management.
Her ABG at that time had a pH of 7.01, pCO2 of 195, and a pO2
of 77 with a bicarb of 54. A followup chest x-ray shows
aspiration. She was placed on clindamycin in addition to her
Biaxin for COPD exacerbation. She had a normal
echocardiogram and anterior ST elevations on an EKG at the
outside hospital, but she was ruled out by serial enzymes.
She was transferred over to [**Hospital1 188**] for further management.
PAST MEDICAL HISTORY:
1. Chronic obstructive pulmonary disease.
2. Asthma.
3. Breast cancer.
4. Hypertension.
5. Tobacco use.
ALLERGIES: Penicillin, beta blockers causing wheezing.
MEDICATIONS ON ADMISSION:
1. Protonix 40 mg daily.
2. Tylenol prn.
3. Levofloxacin 500 mg q.d.
4. Clindamycin 600 mg IV q.8.
5. Flovent q.4h.
6. Albuterol q.4h.
7. Methylprednisolone 60 mg IV q.8h.
8. Insulin-sliding scale.
9. Fentanyl and midazolam drips for sedation while intubated.
PHYSICAL EXAMINATION: Temperature 99.2, heart rate 89-118,
blood pressure 153/89, oxygen saturation 92% on 4 liters.
General: Overweight in no acute distress. HEENT: Moist
mucosal membranes. Supple neck. Anicteric sclerae.
Cardiovascular examination: Tachycardic, regular, no murmurs
appreciated. Lungs: Expiratory wheezes heard throughout,
prolonged expiratory phase. Abdomen: Positive bowel sounds,
soft, mild tenderness in the right upper quadrant.
Extremities: No edema, 2+ dorsalis pedis pulses.
Neurological examination: Alert, moves all extremities, and
follows commands.
LABORATORY DATA ON ADMISSION: White blood cell count 12.4,
hematocrit 35.1, platelets 165. BUN 27, creatinine 0.2. AST
and ALT were normal. TSH 0.10 with a normal free T4.
Chest x-ray showed small bilateral pleural effusions and
atelectasis at the right base.
EKG showed sinus rhythm with a question of an old septal
infarct.
HOSPITAL COURSE:
1. Asthma/COPD exacerbation: At the [**Hospital1 190**], the patient quickly improved and extubated in
the OR on [**10-27**], and at that time was noted to be an
easier intubation than previously thought. The patient
tolerated extubation well, but continued to require
albuterol, Atrovent inhalers every four hours as well as high
dose prednisone for several days.
The patient's oxygen requirement decreased. The patient was
transferred out of the Intensive Care Unit to the regular
medical floors on [**10-29**]. At that time, her oxygen
requirement continued to be weaned, and on the day of
discharge, she had oxygen saturations in the mid 90s on room
air. The patient was discharged on prednisone taper and
scheduled Combivent with albuterol prn. The patient was not
treated with antibiotics as she never developed a lobar
pneumonia, bacteremia, or fever. This was felt to be an
asthma exacerbation and antibiotics were not indicated.
2. Tachycardia: The patient was often mildly tachycardic.
This was thought to be secondary to frequent use of albuterol
as well as secondary to deconditioning after a prolonged
hospital stay and intubation. However, in light of the
patient's mild tachycardia and mild hypoxia, an
echocardiogram and chest CTA were performed for pulmonary
emboli.
The chest CTA did not show any evidence of pulmonary emboli.
In addition, there were no lung nodules seen. The only
findings of the chest CTA were thickening of the distal
esophagus, which is not clinically significant at this time
as the patient did not have dysphagia or odynophagia, and
there were also mild emphysematous changes of both lower
lobes of the lungs. The patient's echocardiogram showed only
mild symmetric left ventricular hypertrophy with a
hyperdynamic left ventricle with an ejection fraction of
75-80%. In addition, there was a moderate resting left
ventricular outflow tract obstruction.
3. Breast cancer: The patient reports having a history of
breast cancer with status post lumpectomy and radiation. She
is followed by an outside oncologist. The patient continued
to state that she has new lung nodules that she was very
concerned about. However, a chest CTA did not reveal any
lung nodules at this time. The patient was instructed to
followup with her outside oncologist at [**Hospital3 3583**].
4. Drug seeking behavior: The patient throughout her
hospital stay, continued to demand pain medication as much as
possible. During the hospital stay, the patient was treated
with a 25 mcg/hour Fentanyl patch and Percocet prn for
breakthrough pain. The patient was discharged with her
Fentanyl patch and 10 Percocet for breakthrough pain. The
patient will follow up with her primary care physician within
one week of discharge.
CONDITION ON DISCHARGE: Stable on room air.
DISCHARGE STATUS: To home with followup.
DISCHARGE INSTRUCTIONS: Please follow up with your primary
care physician within one week of discharge. Please follow
up with your outpatient oncologist. An appointment has been
scheduled for your on Friday, [**11-3**] at noon with your
primary care provider, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] for renewal of your pain
medications, and to continue to wean your steroid taper.
DISCHARGE DIAGNOSES:
1. Chronic obstructive pulmonary disease with an acute
exacerbation.
2. Asthma.
3. Tachycardia.
4. Hemoptysis.
5. Breast cancer.
6. Hypertension.
7. Tobacco use.
MEDICATIONS ON DISCHARGE:
1. Fentanyl 25 mcg/hour patch transdermally every 72 hours,
dispensed one patch.
2. Percocet 1-2 tablets p.o. q.4-6h. prn for pain, dispensed
10 tablets.
3. Colace 100 mg p.o. b.i.d.
4. Albuterol/ipratropium inhaler 1-2 puffs every four hours.
5. Albuterol inhaler one puff every 4-6 hours prn for
shortness of breath or wheezing.
6. Prednisone 10 mg tablets, take 60 mg on [**11-2**] and
17th, take 50 mg on [**11-4**] and 19th, take 40 mg on
[**11-6**] to 23rd, take 30 mg on [**11-10**] to 26th,
take 20 mg on [**11-13**] to 29th, take 10 mg on [**11-16**] to [**11-18**], take 5 mg on [**11-19**] to [**11-20**], take 2.5 mg on [**11-21**] to [**11-23**].
[**First Name8 (NamePattern2) **] [**Doctor First Name **], M.D. [**MD Number(1) 19814**]
Dictated By:[**Last Name (NamePattern1) 9609**]
MEDQUIST36
D: [**2102-11-2**] 07:25
T: [**2102-11-3**] 07:17
JOB#: [**Job Number 19815**]
ICD9 Codes: 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3701
} | Medical Text: Admission Date: [**2115-5-22**] Discharge Date: [**2115-5-28**]
Date of Birth: [**2070-5-14**] Sex: F
Service: SURGERY
Allergies:
Adhesive Tape / Ace Inhibitors
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
Hypotension, weakness
Major Surgical or Invasive Procedure:
Intubation
PICC line placement
History of Present Illness:
44-year-old woman with type 1 diabetes, status post living
related renal transplant [**2104**] at [**Hospital1 2025**] and s/p pancreatic
transplant [**2115-5-15**]. presents with hypotension, weakness, and
pale
appearance at home. Per husband, pt was feeling weak yesterday
and UOP was down to 300 cc for the day even though she took
about
3L PO. This AM, he took her BP and it was 80/50 associated with
depressed mental status. This prompted them to present to ED. In
ED, noted to have BP 80/50 and O2 sat 84. After 2-3 L of IVF, BP
did not improve and she was started on peripheral dopa. Pan
cultures were sent and pt transferred to ICU.
Transplant ID was consulted and agreed that Vanc/Zosyn and well
as pan culture and imaging w/u of fever would be appropriate
preliminarily.
Otherwise, she was doing well since her D/C from [**Hospital1 18**]. She
denies recent fevers, chills, sweats. No sick contacts. [**Name (NI) **]
[**Name2 (NI) **],
DOE, sneezing.
Past Medical History:
DM type I since [**16**] y/o
-diabetic retinopathy s/p multiple laser surgeries,
-diabetic neuropathy with foot drop and Charcot foot,
-diabetic nephropathy s/p Ktx in [**2104**],
-neurogenic bladder followed by urologists at [**Hospital1 2025**],
-esophageal dysmotility (EGD and colonoscopy to be done at [**Hospital1 2025**])
HTN, well controlled
History of vulvar intraepithelial neoplasia
Coronary artery disease, s/p CABGx3 [**2107**] at [**Hospital1 2025**]
recent cardiac cath [**8-/2113**] at [**Hospital1 2025**]
Carpal tunnel syndrome
Anemia
.
Past Surgical History:
Multiple laser surgeries
Foot surgeries for Charcot [**2106**]
Triple CABG [**2107**]
Right SLRT from her sister at [**Name (NI) 2025**] - [**2104-6-10**]
Carpal tunnel - [**2112**]
Social History:
She is married. She has no children. She does
not smoke, or take drugs. She drinks alcohol about a few
times a month.
Family History:
Notable for father who has coronary artery disease and
hypertension.
Mother is healthy.
She has five siblings, all are healthy.
Physical Exam:
VS: T 97 85 80/50 18 100 10L NRB
Gen: Awakens to stimuli. At baseline eyes closed. Confused. A+O
x
1, cooperative
C: RRR, S1/S2
R: CTAB
GI: BS + And soft, NT, ND. Inc CDI
Extrem: Warm, well-perfused, palpable distal pulses in UE, non
palp in LE
Pertinent Results:
On Admission: [**2115-5-22**]
WBC-13.4*# RBC-3.41* Hgb-9.2* Hct-27.5* MCV-81* MCH-26.9*
MCHC-33.3 RDW-16.4* Plt Ct-287#
PT-12.6 PTT-28.2 INR(PT)-1.1
Glucose-108* UreaN-18 Creat-1.6* Na-131* K-3.6 Cl-101 HCO3-21*
AnGap-13
ALT-33 AST-21 AlkPhos-99 TotBili-0.7 Lipase-23
Calcium-6.6* Phos-3.1 Mg-1.7
At Discharge [**2115-5-28**]
WBC-9.3 RBC-2.88* Hgb-7.9* Hct-23.2* MCV-81* MCH-27.5 MCHC-34.2
RDW-19.4* Plt Ct-489*
Glucose-107* UreaN-11 Creat-1.1 Na-138 K-3.2* Cl-104 HCO3-25
AnGap-12
ALT-12 AST-9 LD(LDH)-425* AlkPhos-96 Amylase-25 TotBili-0.4
Lipase-49
Calcium-8.3* Phos-3.7 Mg-1.8 Iron-34
calTIBC-181* Ferritn-278* TRF-139*
tacroFK-10.8
Brief Hospital Course:
45 y/o female who received pancreas after kidney on [**2115-5-14**].
She was discharged to home on POD 6 and returns on POD 8 feeling
very weak, had hypotension and after evaluation in the ED was
admitted to the SICU and was immediately intubated.
Her immediate chest xray showed new moderate pulmonary edema and
new small to moderate right pleural effusion with atelectasis.
A head CT was performed due to altered mental status showing no
hemorrhage, edema, or evidence of other acute intracranial
process.
A full torso CT was also performed showing:
-Bilateral small-to-moderate pleural effusions, right greater
than left,
are new since the prior study.
- Multifocal airspace consolidations and peribronchovascular
opacities,
likely represent multifocal pneumonia.
- The patient is status post recent pancreatic transplant, there
is minimal
simple fluid and a single locule of air in the region. This is
unchanged
since the prior study and likely secondary to the recent
surgery. No definite
evidence of an anastomotic leak is detected.
.
She underwent a bronchoscopy with BAL, initial culture was
negative for organisms, and viral, fungal and cmv cultures are
negative to date. Blood CMV viral load is negative.
ID was consulted, she was immediately started on Vanco and
zosyn. On HD 2 she was extubated and on HD 4 she was transferred
out of the SICU.
Her O2 sats were stable on room air, but in the low 90's with
ambulation.
She had some loose stools, c diffs were negative. She received 3
days of flagyl and the cellcept was changed to 500 mg QID, the
stool issue was resolved by day of discharge.
The patient was noted to have a slowly drifting Hct, and
received one unit of blood prior to her discharge. Iron studies
were also sent, but these may be difficult to interpret as she
received blood after the pancreas transplant about 10 days prior
to the testing.
Immunosuppression was monitored daily with prograf levels, and
after her ICU stay she was eventually back to 3 mg [**Hospital1 **]. As
mentioned, the cellcept was changed to QID, she is off steroids.
Her blood sugars were very stable in the low 100's, amylase and
lipase were wnl.
A PICC line was placed and IV Zosyn will be continued through
[**6-4**] at home. Although no cultures ever became positive, the
patient improved dramatically on the Zosyn and ID wanted a full
2 week course. Home teaching for infusion was provided to the
patient.
Medications on Admission:
Sulfamethoxazole-Trimethoprim SS 1 tab PO DAILY
Valganciclovir 900mg PO DAILY
Mycophenolate Mofetil 1000mg PO BID
Tacrolimus 3mg PO Q12H
Nystatin 100,000 unit/mL, 5mL PO QID
Tamsulosin 0.4mg PO qHS
Gabapentin 600mg PO QAM, 1200mg PO qHS
Citalopram 80mg PO daily
Bupropion 150mg PO BID
Bethanechol 25mg PO TID
Aspirin 325mg PO daily
Toprol XL 25mg PO daily
Hydromorphone 2-4mg PO Q3H prn
Omeprazole 20mg PO bid
Colace 100mg PO bid
Discharge Medications:
1. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback Sig:
4.5 grams Intravenous Q8H (every 8 hours) for 23 doses.
Disp:*23 doses* Refills:*0*
2. Sulfamethoxazole-Trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
3. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
4. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation twice a day as needed for shortness of
breath or wheezing.
Disp:*1 inhaler* Refills:*2*
5. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
QID (4 times a day).
6. Bupropion HCl 150 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO twice a day.
7. Citalopram 40 mg Tablet Sig: Two (2) Tablet PO once a day.
8. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO QAM (once a
day (in the morning)).
9. Gabapentin 300 mg Capsule Sig: Four (4) Capsule PO at
bedtime: 1200 mg PM.
10. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
12. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime.
13. Kayexalate Powder Sig: [**5-2**] teaspoons PO As direct by
transplant clinic.
14. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
15. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
16. B Complex Vitamins Capsule Sig: One (1) Capsule PO once
a day.
17. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
18. Bethanechol Chloride 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
19. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
20. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day:
as needed for constipation.
21. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: volume needed
ML Intravenous PRN (as needed) as needed for line flush.
22. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
23. Tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO Q12H
(every 12 hours).
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
Pneumonia (following discharge for pancreas transplant)
s/p pancreas transplant [**5-14**]
Discharge Condition:
Stable
A+O x 3
Ambulatory
Discharge Instructions:
Please call the transplant clinic at [**Telephone/Fax (1) 673**] for fever,
chills, nausea, vomiting, diarrhea, increased difficulty with
your breathing, inability to take or keep down food, fluids or
medications, alteration in mental staus or any other concerning
symptoms.
You will continue the IV antibiotic through [**6-4**] using the
PICC line placed during this hospitalization.
Continue Monday and Thursday lab draws per the transplant clinic
recommendations. They will call you regarding any modifications
to your medications.
Continue to check blood sugars twice daily and call if trends
are increasing or you get readings over 200
Monitor incision for redness, drainage or bleeding
No heavy lifting
[**Month (only) 116**] shower, cover PICC line and do not scrub incision
No driving if taking narcotic pain medication
Followup Instructions:
[**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2115-5-31**] 10:00
[**Last Name (LF) **],[**First Name3 (LF) **] TRANSPLANT SOCIAL WORK Date/Time:[**2115-5-31**] 10:30
[**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2115-6-6**] 9:30
Completed by:[**2115-5-28**]
ICD9 Codes: 0389, 486, 5845, 3572, 4019, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3702
} | Medical Text: Admission Date: [**2198-6-17**] Discharge Date: [**2198-7-6**]
Date of Birth: [**2149-8-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
Sepsis
Major Surgical or Invasive Procedure:
HD cath placement
PICC line placement
History of Present Illness:
48M in USOH until two nights ago, developed "grabbing" lower
abdominal pain lasting minutes which resolved spontaneously.
Next morning with shaking chills and presented to [**Hospital 4683**]. Initially with (?)tick-borne dz, treated with
doxycycline. Subsequent blood cultures - 2 sets, multiple
bottles growing gram-positive rods, gram-negative rods, and gram
positive cocci in pairs. Febrile to 104, rigors on [**2198-6-16**], but
hemodynamically stable and benign abdomen. SBP in 130s, HR 70s.
Labs at OSH notable for WBC 14K (5 bands), HCT 39.6, PLT 175,
Creatinine 1.0, total bili 7.4 (3.4 direct, 4.0 indirect),
transaminases in 200s, alk phos 83. Abdominal U/S with dilated
CBD (7mm)and GB sludge. Abdominal CT with air in biliary tree
and dilated CBD. Concern was for ascending cholangitis and plan
for ERCP. Given polymicrobial bacteremia and air in biliary
tree, pt transfered directly from OSH to [**Hospital Unit Name 153**] for monitoring
given risk of septic shock.
.
On arrival pt complained only of low back pain which he has had
for the past day since lying in bed. Feels drained, but no abd
pain. No recent wgt loss/gain, change in bowel habits, no N/V/D.
Miild HA.
Past Medical History:
GERD, lower back surgery, diverticulitis.
Social History:
married with 2 young children. No smoking, + occ Etoh.
Family History:
No known hx of CA, heart disease.
Physical Exam:
T: (104.3) 99.2 BP: 114/79 HR: 95 RR:12 O2saturation 100% on RA
Gen: Pleasant, well appearing. Jaundiced. Laying in bed.
HEENT: No conjunctival pallor. + icterus. Slightly dry mucous
membranes. Oropharynx clear.
NECK: Supple. No cervical or supraclavicular lymphadenopathy. No
JVD. No thyromegaly.
CV: RRR. Normal S1 and S2. No murmurs, rubs or [**Last Name (un) 549**]
appreciated.
LUNGS: Clear to auscultation bilaterally. Decreased breath
sounds in lower lung fields, bilaterally. No wheezes, crackles,
or rhonci appreciated.
ABD: No surgical scars. Normal active bowel sounds. Soft.
Nontender and nondistended. No guarding or rebound. Liver edge
not palpated. No splenomegaly appreciated.
EXT: Warm and well perfused. No clubbing or cyanosis. No lower
extremity edema, bilaterally.
SKIN: Jaundiced, No rashes.
NEURO: Alert and oriented to person, place, date.
Pertinent Results:
[**2198-7-6**] 09:49AM BLOOD WBC-6.7 RBC-3.18* Hgb-9.9* Hct-28.2*
MCV-89 MCH-31.2 MCHC-35.1* RDW-14.1 Plt Ct-549*
[**2198-7-4**] 05:23AM BLOOD WBC-7.9 RBC-2.50* Hgb-7.7* Hct-23.0*
MCV-92 MCH-30.9 MCHC-33.6 RDW-14.0 Plt Ct-649*
[**2198-6-17**] 08:15PM BLOOD WBC-28.4* RBC-3.70* Hgb-12.9* Hct-32.9*
MCV-89 MCH-34.8* MCHC-39.0* RDW-14.9 Plt Ct-146*
[**2198-6-28**] 05:19AM BLOOD Neuts-80.9* Lymphs-6.6* Monos-10.3
Eos-1.9 Baso-0.2
[**2198-6-19**] 12:43AM BLOOD Fibrino-592*
[**2198-6-18**] 12:28PM BLOOD Parst S-NEGATIVE
[**2198-6-18**] 06:34PM BLOOD QG6PD-9.1
[**2198-6-18**] 06:34PM BLOOD Ret Aut-1.6
[**2198-7-6**] 09:49AM BLOOD Glucose-176* UreaN-43* Creat-10.2*#
Na-138 K-3.8 Cl-98 HCO3-26 AnGap-18
[**2198-6-28**] 05:19AM BLOOD Glucose-97 UreaN-90* Creat-15.0*# Na-125*
K-4.5 Cl-87* HCO3-18* AnGap-25*
[**2198-6-17**] 08:15PM BLOOD Glucose-109* UreaN-38* Creat-1.0 Na-142
K-4.1 Cl-105 HCO3-21* AnGap-20
[**2198-7-6**] 09:49AM BLOOD ALT-8 AST-11 AlkPhos-148* TotBili-1.4
[**2198-6-27**] 05:32AM BLOOD ALT-26 AST-28 LD(LDH)-499* AlkPhos-112
TotBili-2.5*
[**2198-6-19**] 12:43AM BLOOD ALT-181* AST-285* LD(LDH)-1662*
CK(CPK)-292* AlkPhos-86 Amylase-800* TotBili-21.8* DirBili-19.2*
IndBili-2.6
[**2198-6-21**] 05:52AM BLOOD Lipase-184*
[**2198-7-6**] 09:49AM BLOOD Calcium-8.4 Phos-6.4*# Mg-2.0
[**2198-7-4**] 05:23AM BLOOD Calcium-7.9* Phos-9.4* Mg-2.0
[**2198-6-21**] 06:13PM BLOOD calTIBC-204* Ferritn-GREATER TH TRF-157*
[**2198-6-18**] 06:34PM BLOOD Triglyc-387*
[**2198-6-17**] 08:15PM BLOOD TSH-1.9
[**2198-6-17**] 08:15PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE
[**2198-6-28**] 05:19AM BLOOD PEP-NO SPECIFI
[**2198-6-27**] 05:32AM BLOOD C3-105 C4-16
[**2198-6-29**] 05:23AM BLOOD HIV Ab-NEGATIVE
[**2198-6-17**] 08:15PM BLOOD HCV Ab-NEGATIVE
[**2198-6-17**] 08:15PM BLOOD LEPTOSPIRA ANTIBODY-Test
[**2198-7-4**] 04:10PM URINE Color-STRAW Appear-Clear Sp [**Last Name (un) **]-1.005
[**2198-7-4**] 04:10PM URINE Blood-LG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2198-6-18**] 12:27PM URINE Hours-RANDOM UreaN-202 Creat-71 Na-44
K-41 Cl-36 Phos-0.6 HCO3-LESS THAN
[**2198-7-3**] 06:06AM URINE Hours-RANDOM Creat-47 Na-68
[**2198-6-27**] 09:02AM STOOL CLOSTRIDIUM DIFFICILE TOXIN B ASSAY-Test
[**2198-7-4**] URINE URINE CULTURE-FINAL INPATIENT
[**2198-7-3**] CATHETER TIP-IV WOUND CULTURE-FINAL INPATIENT
[**2198-7-1**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC
BOTTLE-PENDING INPATIENT
[**2198-7-1**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC
BOTTLE-PENDING INPATIENT
[**2198-6-27**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL
INPATIENT
[**2198-6-26**] CATHETER TIP-IV WOUND CULTURE-FINAL INPATIENT
[**2198-6-25**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL INPATIENT
[**2198-6-25**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL INPATIENT
[**2198-6-24**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL INPATIENT
[**2198-6-24**] URINE URINE CULTURE-FINAL INPATIENT
[**2198-6-24**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL INPATIENT
[**2198-6-23**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL
INPATIENT
[**2198-6-21**] STOOL OVA + PARASITES-FINAL INPATIENT
[**2198-6-20**] STOOL OVA + PARASITES-FINAL; CLOSTRIDIUM DIFFICILE
TOXIN ASSAY-FINAL INPATIENT
[**2198-6-20**] SEROLOGY/BLOOD RAPID PLASMA REAGIN TEST-FINAL
INPATIENT
[**2198-6-19**] STOOL FECAL CULTURE-FINAL; CAMPYLOBACTER
CULTURE-FINAL; OVA + PARASITES-FINAL; CLOSTRIDIUM DIFFICILE
TOXIN ASSAY-FINAL INPATIENT
[**2198-6-19**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
INPATIENT
[**2198-6-18**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL
INPATIENT
[**2198-6-18**] URINE URINE CULTURE-FINAL INPATIENT
[**2198-6-17**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL INPATIENT
[**2198-6-17**] SEROLOGY/BLOOD LYME SEROLOGY-FINAL INPATIENT
[**2198-6-17**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL INPATIENT
CT OF THE ABDOMEN: The lung bases are clear. Hypoattenuation of
the liver (45 Hounsfield units versus 65 Hounsfield units for
the spleen) is consistent with fatty infiltration. There is
heterogeneous perfusion of the liver with focal areas of
nonenhancement in the posterior aspect of the right lobe - 1.5 x
1.3 cm in the posterior medial aspect (3b:133) and 2.9 x 2.7 cm
more latarally (3b:140) as well as other small hypoattenating
foci. There is no intra- or extra- hepatic biliary dilatation
and no evidence of intrabiliary air. One tiny focus of air
(3a:70) The gallbladder is mildly distended measuring 4.1 cm,
however there is no wall edema or pericholecystic fluid. No
radiopaque gallstones are seen.
There is no pancreatic ductal dilatation and the pancreas is
unremarkable. The adrenal glands are normal. Two tiny
hypoattenuating lesions within the left kidney are likely cysts.
The kidneys enhance and excrete contrast normally. There is no
free air or free fluid in the abdomen. The small bowel appears
normal. Extensive diverticulosis of the sigmoid colon and milder
diverticulosis of the descending colon are noted with no
evidence of diverticulitis. The appendix is normal.
CT OF THE PELVIS: Contrast fills the bladder. The prostate gland
is not enlarged, and has dystrophic calcifications within it.
The sigmoid colon again is notable for diverticulosis. The
rectum is normal. No pelvic free fluid or lymphadenopathy.
No bone findings of malignancy.
IMPRESSION:
1. Focal areas of hypoperfusion within the liver, in a
background of heterogeneous perfusion. Given patient's clinical
situation (leukocytosis, Total bilirubin level of 30), these
findings are concerning for hepatic necrosis. No evidence of
biliary dilatation or intrabiliary gas to suggest cholangitis,
though this can be a subtle radiographic diagnosis. Recommend
ERCP or MRCP for further evaluation.
ADDENDUM: Review of outside hospital CD performed at [**Hospital **]
Hospital at 12:35 PM on [**2198-6-17**] reveals small foci of
intrahepatic biliary air. The patient has no apparent history of
recent ERCP or remote sphincterotomy. This finding is concerning
for emphysematous cholangitis, though the lack of air on the
current study, and the lack of intrahepatic biliary dilatation
or inflammatory changes in the porta hepatis makes this less
likely.
2. Fatty infiltration of the liver.
3. Left renal cyst.
4. Sigmoid diverticulosis without diverticulitis.
5. Normal appendix.
ERCP - IMPRESSION: Opacification of the biliary tree without
abnormality detected. Per endoscopist's report there was direct
visualization of a periampullary diverticulum.
US liver - IMPRESSION:
1. Rounded hypoechoic 2.2 cm lesion within the left lobe of the
liver. This can be further evaluated with MRI.
2. Echogenic liver which can be seen in fatty infiltration.
Other forms of advanced liver disease including hepatic
fibrosis/cirrhosis cannot be excluded.
3. No stones or hydronephrosis.
4. Pneumobilia which is expected status post biliary stent
placement.
5. Sludge-filled gallbladder.
MRI L spine - IMPRESSION:
1. Low T1 signal within the bone marrow could be consistent with
a reactive or infiltrative marrow lesion. No evidence of bone
marrow edema.
2. Large right-sided paracentral and foraminal disc herniation
at L5-S1 likely compressing the right S1 nerve root.
Conclusions:
The left atrium is elongated. Left ventricular wall thickness,
cavity size,
and systolic function are normal (LVEF>55%). Regional left
ventricular wall
motion is normal. Right ventricular chamber size and free wall
motion are
normal. The aortic root is moderately dilated at the sinus
level. The
ascending aorta and arch are moderately dilated. No dissection
flap is
seen/suggested (does not exclude). The aortic valve leaflets (3)
are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen.
The mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The estimated
pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
IMPRESSION: Dilated ascending aorta and arch. No valvular
pathology or
pathologic flow identified.
Renal ultrasound [**2198-6-19**].
FINDINGS: The right kidney measures 12.5 cm. The left kidney
measures 13.7 cm. No hydronephrosis, stone, or mass is
identified. The bladder is decompressed and poorly evaluated.
Doppler evaluation is limited by patient respiratory motion
throughout the exam. High resistive indices in the right mid and
lower pole measure 0.79 and 0.75 respectively. Resistive indices
in the right upper pole is within normal limits at 0.64.
Arterial and venous waveforms of the main right and left renal
artery and vein are unremarkable, though limited due to
respiratory motion. The left kidney demonstrates an elevated
resistive index at the lower pole measuring 0.78. The mid and
upper pole demonstrates resistive indices of 0.62 and 0.64
respectively.
IMPRESSION:
1. No hydronephrosis.
2. Although evaluation is limited by patient respiration,
slightly elevated resistive indices in the right mid and lower
pole and left lower pole are nonspecific findings. These may
represent an underlying medical renal disease and Doppler follow
up is recommended.
CT PELVIS W/O CONTRAST [**2198-6-23**] 5:02 AM
CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST
Reason: ABD DISTENSION/PAIN
Field of view: 42
[**Hospital 93**] MEDICAL CONDITION:
48 year old man with recent hepatic necrosis, bacteremia and new
onset acute renal failure, now with abdominal pain and
distension
REASON FOR THIS EXAMINATION:
r/o appendicitis, diverticulitis, obsturction
CONTRAINDICATIONS for IV CONTRAST: recent renal failure
INDICATION: Hepatic necrosis, bacteremia and renal failure, now
with abdominal pain and distention. Rule out obstruction,
diverticulitis or appendicitis.
COMPARISON: Abdominopelvic CT, [**2198-6-17**].
TECHNIQUE: Multidetector helical scanning of the abdomen and
pelvis was performed without contrast due to renal failure. Oral
contrast was administered.
CT OF THE ABDOMEN: The lung bases demonstrate a new right-sided
pleural effusion that is small, with associated atelectasis. No
consolidations or nodules are identified. There is a tiny
pericardial effusion, likely physiologic and the heart size is
normal.
The liver is again heterogeneous in attenuation with focal
stable hypoattenuating areas in the posterior right lobe,
concerning for hepatic necrosis. Intrahepatic biliary air is
seen, likely related to CBD stent which is seen entering the
duodenum. The gallbladder is nondilated with no pericholecystic
inflammatory changes or fluid. The spleen and adrenal glands are
unremarkable. The kidneys have enlarged since the prior scan and
there is mild residual contrast enhancement (last contrast
injection was 5 days ago) consistent with known acute renal
failure. There is no free air or free fluid. Contrast passes
through nondilated loops of small bowel with no evidence of
obstruction. There is no bowel wall thickening. The colon has
scattered diverticuli with no evidence of diverticulitis. The
appendix is normal.
CT OF THE PELVIS: The bladder is unremarkable. A small amount of
free fluid is seen in the pelvis, measuring simple fluid
density, presumably related to resuscitation. Sigmoid colon and
rectum are unremarkable with diverticulosis but no
diverticulitis.
BONE WINDOWS: Joint space narrowing at L5-S1 is noted with no
suspicious lytic or sclerotic lesions.
IMPRESSION:
1. No new intra-abdominal findings to explain the patient's
sudden abdominal pain. No bowel obstruction or free air.
Diverticulosis without diverticulitis. The appendix is normal.
2. Heterogeneous attenuation of the liver with focal areas of
hypoattenuation in the posterior right lobe, unchanged since the
prior exam and again suggesting hepatic necrosis. Further
evaluation is limited due to lack of IV contrast.
3. CBD stent seen entering the duodenum with associated
intrahepatic biliary air.
4. Small amount of free fluid in the pelvis liked related to
resuscitation
MRI - IMPRESSION: High signal intensity lesions seen within the
liver and spleen, most likely abscesses given the patient's
history of polymicrobial bacteremia. Evaluation is limited
without intravenous contrast. Focal infarctions in the liver sre
less likely. Segment VII amorphous wedge- shaped lesion
peripheral to suspected abscess may be reactive edema or
infectious spread. Limited interrogation of the portal vein is
unremarkable on these non- contrast sequences.
[**Numeric Identifier 4684**] FLUORO GUID PLCT/REPLCT/REMOVE CENTRAL LINE [**2198-7-5**] 8:56
AM
Reason: For dialysis
[**Hospital 93**] MEDICAL CONDITION:
48 year old man with ARF, needs a permanat HD access
REASON FOR THIS EXAMINATION:
For dialysis
INDICATION: This is a 48-year-old man with acute renal failure,
presents for placement of a tunneled hemodialysis catheter for
dialysis.
Details of the procedure and possible complications were
explained to the patient and informed consent was obtained.
Timeout was performed.
RADIOLOGISTS: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], nurse practitioner, performed the
procedure supervised by Dr. [**First Name (STitle) 4685**] [**Name (STitle) 4686**], attending
radiologist.
Using sterile technique, local anesthesia, and conscious
sedation, the right internal jugular vein was punctured via just
ultrasound guidance using a micropuncture set. Hard copy of
ultrasound images were obtained before and immediately after
venous access documenting vessel patency. The tract was dilated
with serial dilators and a peel-away sheath was then placed. A
subcutaneous tunnel was made on the right anterior chest wall
and the catheter was introduced through the tunnel and placed
through the peel-away sheath with its tip positioned in the
right atrium under fluoroscopic guidance. The peel- away sheath
was then removed. Position of the catheter was confirmed by
chest x-ray in one view. The incision on the neck was closed
with Dermabond. The catheter was secured to the skin and a
sterile dressing was applied.
The patient tolerated the procedure well. There were no
immediate complications.
Moderate sedation was provided administering divided doses of
Versed and fentanyl throughout the total intraservice time of 55
minutes, during which the patient's hemodynamic parameters were
continuously monitored. The total dose administered of fentanyl
was 100 mcg and of Versed 3 mg.
IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided
tunneled hemodialysis catheter placement via the right internal
jugular venous approach with the tip in the right atrium. Ready
for use
Brief Hospital Course:
Sepsis from aeromionas, enterococcus fecium, clostridium - the
exact source of infection was not clear, could be from a
diverticular infection that tracked up to the portal system. The
liver abscesses were confirmed on MRI abdomen. Prolonged course
of antibiotics was recommended by the ID consult team -
levofloxacin atleast toll [**2198-7-23**] when ID follow up is arranged.
A repeat MRI was recommended by the liver team for follow up of
the abscesses. Prior to discharge, the patient was afebrile for
several days and cultures were negative at the time of writing
this discharge sumary.
Acute renal failure - Acuite tubular necrosis on dialysis - the
patient developed ATN as a result of sepsis. Was initially
anuric, last started urinating and was non-oliguric. Despite
this his creatinine continued to rise and after a break of 6
days of HD when his creat was upto 15 and started getting
acidotic, he was restarted on HD via a tunnelled cath. HD
arranged for 3/wk (T,T,S) at [**Location (un) **] as below. Given this is
ARF, it is a possibility that the patinet's kidneys may recover.
Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1366**] will follow patient there.
Anemia - likely multifactorial - sepsis, renal failure,
malnutrition. Started on Fe and epo with HD and alsot transfused
2 units prior to discharge with dialysis.
The patient will get a repeat MRI and then an ID follow up. he
is advised to continue to take the levofloxacin and flagyl till
the ID follow up and thereafter at their discretion. HD to
continue per Dr [**Last Name (STitle) 1366**]. Advised to follow up with PCP.
The abnormal MRI L spine (refer above) will need follow up.
Deferred to PCP for follow up.
Medications on Admission:
prilosec
Discharge Medications:
1. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 20 days.
Disp:*60 Tablet(s)* Refills:*0*
2. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H (every
48 hours) for 20 days.
Disp:*10 Tablet(s)* Refills:*0*
3. Sevelamer 800 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3
TIMES A DAY WITH MEALS).
Disp:*60 Tablet(s)* Refills:*0*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*0*
6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*30 Tablet(s)* Refills:*0*
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
9. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection
ASDIR (AS DIRECTED): with dialysis.
Discharge Disposition:
Home
Discharge Diagnosis:
Sepsis from aeromionas, enterococcus fecium, clostridium
Liver lesions/abscess
Acute renal failure - Acuite tubular necrosis on dialysis
Anemia
Discharge Condition:
stable
Discharge Instructions:
Dialysis has been arranged for next week on tuesday. The
dialysis nurse has explained the details to you.
Call your doctor if you have any symptoms of concern to you.
keep your appointments.
make a follow up appointment with Dt [**Last Name (STitle) 4687**] in the next 1 week.
Followup Instructions:
Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2198-7-17**]
4:20
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2198-7-23**] 11:45
Provider: [**Name Initial (NameIs) **] SUITE GI ROOMS Date/Time:[**2198-8-23**] 8:00
Please call Dr [**Last Name (STitle) **],[**First Name3 (LF) **] H. [**Telephone/Fax (1) 4688**] -
ICD9 Codes: 5845 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3703
} | Medical Text: Admission Date: [**2189-12-3**] Discharge Date: [**2189-12-10**]
Date of Birth: [**2140-7-14**] Sex: M
Service: [**Last Name (un) **]
CHIEF COMPLAINT: Transfer for liver failure.
HISTORY OF PRESENT ILLNESS: The patient is 49 year-old man
who was transferred to us from [**Hospital6 **] for
treatment of his liver failure and evaluation for liver
transplantation. Since he cannot give any history the
history is recorded from his records and reported by his
wife. [**Name (NI) **] is a 49 year-old man who by vocation is a car
salesman who is known to have hepatitis for about 15 to 19
years. He has been followed by his primary care physician
for this. Over the last six months to one year he has been
getting increasingly ill and has been complaining of
confusion, fatigue and mild jaundice. In the middle of
[**Month (only) **] approximately a month and a half ago he experienced
worsening confusion and some shortness of breath, which led
him to going to an outside hospital. At this hospital he was
found to be in liver failure acutely sick and was transferred
to [**Hospital6 **] for further care. His initial
evaluation raised the possibility of cholangitis along with
his primary liver failure from hepatitis. Given this
consideration he received an endoscopic retrograde
cholangiopancreatography and removal of stones and sludge
from his biliary tree. Despite endoscopic retrograde
cholangiopancreatography, however, his primary disease was
believed to be liver failure from his hepatitis, which was
the primary reason for his progression into kidney failure
officially given him the diagnosis of hepatorenal syndrome.
Due to his worsening hepatorenal syndrome and worsening
mental status he was transferred to [**Hospital1 190**] for further care and consideration for liver
transplantation.
PAST MEDICAL HISTORY: Hepatitis B and C, history of
intravenous drug abuse six years ago, history of ethanol
abuse in the distant past up to approximately ten years ago.
Gastroesophageal reflux disease. Status post laminectomy.
ALLERGIES: No known drug allergies.
MEDICATIONS AT HOME: Protonix, Lactulose, Lasix,
Clindamycin, Spironolactone.
MEDICATIONS ON TRANSFER: Levofloxacin, Flagyl, Lactulose,
Albuterol, Zantac.
FAMILY HISTORY: No history of cancer or liver failure.
Mother died of myocardial infarction at age 60.
PHYSICAL EXAMINATION: Temperature 97.2. Pulse 95. Blood
pressure 112/40. Respirations 31. O2 sat is 95 percent on
vent support. Intubated, sedated and jaundice frail looking
man with truncal obesity secondary to fluid. Heart
examination shows a regular heart. There is no
lymphadenopathy. There are no carotid bruits. There are no
oral lesions and the pupils are equal and reactive. Lung
examination shows decreased breath sounds in the right chest.
Abdominal examination shows a soft, but distended abdomen
without any incisions or apparent guarding. Rectal
examination shows rectal bag with melena. Extremity
examination shows jaundiced extremities with peripheral
deconditioning and mild edema. Pulse examination shows
palpable bilateral femoral radial and dorsalis pedis pulses.
LABORATORIES ON ADMISSION: White blood cell count 12.3,
hematocrit 27.9, platelet count 75, PT 19.8, PTT 44, INR 2.5,
fibrinogen of 134, potassium 5.9, sodium 153, BUN of 126,
creatinine of 4.4, glucose 126, alkaline phosphatase was 75,
total bilirubin of 34. Chest x-ray shows a right
hydrothorax.
HOSPITAL COURSE: The patient was transferred to the [**Hospital1 1444**] under conditions described
above in the history of present illness. On arrival he was
extremely confused, agitated and short of breath. This
required immediate intubation for control of his airway.
Immediate evaluation was begun for consideration for liver
transplantation. On arrival he received a head CT, which
showed no infarcts or hemorrhage. He received an ultrasound
of his liver, which showed patent vessels. He received a
Swan Ganz catheter for optimal hemodynamic management and a
dialysis access line for continuous dialysis. He also
required a right chest thoracentesis for huge right
hepatohydrothorax and a paracentesis for 6 liters for
increased abdominal girth. His neurological status upon
intubation was unresponsive, not following commands, moving
all four extremities, occasionally and withdrawing to pain
without reliability. After initial studies for consideration
of liver transplantation the patient also received an
esophagogastroduodenoscopy study secondary to melena, which
was noticed on transfer. The esophagogastroduodenoscopy
showed varices in the esophagus and dried blood in the
stomach, but no active bleeding. The [**Hospital 228**] hospital
course was prolonged and complicated and will be summarized
below by systems.
Neurologically, on arrival the patient was extremely agitated
and intermittently unresponsive requiring intubation for
protection of his airway. After intubation the best mental
status was occasional movement of all extremities, which over
the first 24 hours deteriorated to no response and no
withdraw to pain. Despite being off sedation from [**12-3**]
to [**12-10**] he did not regain any neurological signs of
alertness. He received a head CT scan on arrival, which was
negative for any hemorrhage or ischemia. At the end of his
hospital course once he was made comfort measures only he was
placed on intravenous morphine for comfort until his death.
Cardiovascular, the patient was found to be hypodynamic by
his heart rate and cardiac output on arrival. On his arrival
to [**Hospital1 69**] he received a right
internal jugular Swan Ganz line placement. During his
subsequent hospital course he was managed through his Swan
Ganz numbers to optimize his cardiac output and peripheral
resistance. He did not suffer from any instability during
the course, however, his blood pressure continued to remain
on the lower side with the systolics between to 100.
Eventually approximately five days into his hospital course
he required neo-Synephrine support to maintain his blood
pressure. Neo-Synephrine was continued in moderate doses
until it was determined that he will not be a candidate for a
liver transplantation.
Respiratory, the patient arrived with a large right
hepatohydrothorax in his right chest. This hydrothorax was
drained on arrival for 2700 cc of serosanguineous fluid. He
was managed on the ventilator with a goal PCO2 of 35 to
optimize his cerebral function. Over the course of his
hospital stay he reaccumulated the right hydrothorax
requiring higher PEEPS for support. This required right
sided pigtail catheter placement on [**2189-12-8**]. This
catheter was in place until the time of his death and
functioning properly.
Gastrointestinal, the patient presented with acute liver
failure with bilirubins of 34. This bilirubin progressed to
a level of 45 over his hospital course. He was treated with
Lactulose to minimize his hepatic encephalopathy. He was
considered for liver transplantation, however, given his
comorbidities and unstable status including an extremely poor
neurological status he was deemed non transplantable. The
patient also presented to our hospital with a
gastrointestinal bleed, which was presumed very likely to be
an upper gastrointestinal bleed. This was confirmed with
upper endoscope, which showed dried blood in the stomach and
esophageal varices. In the middle of his hospital course on
[**12-6**] he was noticed to have bright blood coming from
his nasogastric tube. This required progressive transfusions
and corrections of his coags. A scope was placed again and
multiple bands were performed again and the multiple bands
were placed for banding esophageal varices. Two days after
the banding procedure on [**12-8**] he developed an upper
gastrointestinal bleed again, which required placement of a
[**State **] tube with a gastric balloon for control of
hemorrhage. This tube was continued for 24 hours before its
discontinuation and subsequently later the patient was made
comfort measures only.
Infectious disease, the patient was treated with empiric
Vancomycin and Zosyn for prevention of infections, which may
lead to sepsis, which he will not tolerate given his tenuous
state. He was cultured routinely for surveillance cultures
and did not develop any sepsis by culture or physiology
during his course. His antibiotic levels were dosed
according to his renal function.
Renal, the patient presented to us in complete renal failure
with a diagnosis of hepatorenal syndrome. He was placed on
continuous hemodialysis through a right femoral hemodialysis
access line. He was maintained on this until [**2189-12-9**] when he was deemed non transplantable.
Hematology, the patient required continued transfusions of
platelets, fresh frozen platelets, and blood to maintain his
platelet level over 80, INR level less then 2 and hematocrits
about 28. Increasing amount of blood products were given
during his upper gastrointestinal bleed. On hospital day
four he was placed on an fresh frozen platelets drip to
support his coagulation status awaiting improvement in his
neurological status. Since this improvement did not come the
transfusions were stopped on [**12-10**] prior to his demise.
Endocrine, the patient maintained adequate blood sugar levels
during his course.
Social support, the patient was seen by our social workers
through the transplant office and the family was provided
with as much support as possible during this difficult time.
Code status, the patient failed to improve neurologically
over nine days of his hospital stay and continued to show no
signs of progress despite aggressive care. Eventually he
also developed significant gastrointestinal bleed, which
required aggressive support to maintain life. Given this he
was deemed to be a very poor candidate for liver
transplantation with almost no survival benefit should a
transplant be attempted. Given this he was deemed non
transplantable and the family was made aware of this. After
extensive discussions he was made comfort measures only on
[**2189-12-10**] and expired at 5:45 p.m. on [**2189-12-10**]. Morphine was started after comfort measures only code
status was implemented.
DISCHARGE DISPOSITION: Death.
DISCHARGE DIAGNOSES: Liver failure.
Renal failure.
Hepatitis B.
Hepatitis C.
Hepatic encephalopathy.
Gastroesophageal reflux disease.
Gastrointestinal bleed.
Hepatorenal syndrome.
Hepatic hydrothorax.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**], M.D. [**MD Number(2) 6727**]
Dictated By:[**Name8 (MD) 22102**]
MEDQUIST36
D: [**2189-12-10**] 18:56:55
T: [**2189-12-11**] 09:41:30
Job#: [**Job Number 60077**]
ICD9 Codes: 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3704
} | Medical Text: Admission Date: [**2135-9-19**] Discharge Date: [**2135-10-3**]
Date of Birth: [**2053-2-19**] Sex: M
Service: MEDICINE
Allergies:
Procainamide / Morphine
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
s/p Fall
Major Surgical or Invasive Procedure:
[**9-19**]: Emergent Left Frani for SDH evacuation
History of Present Illness:
82M on coumadin and asa for St [**Month/Year (2) 923**]'s valve who fell approx 2
am. This am c/o headache, came to ED. Reportedly following all
commands with some R arm weakness. Was intubated due to
respiratory decline.
Past Medical History:
1. Atrial Fibrillation ?????? on coumadin and amiodarone
--s/p pacemaker placement ?????? Dr. [**Last Name (STitle) **] - pacemaker originally
placed [**2118**] d/t AV block
--s/p generator change in [**2128**]
--s/p lead revision [**4-9**]
2. Bicuspid aortic valve disease, s/p [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] replacement - [**2118**]
3. CHF - TTE [**3-12**]: LVEF>55%, dilated LA, dilated LV, Tr AR. Mod
MR. Mod to severe TR. Significant pulmonic regurg. severe PA
HTN.
4. Hypothyroidism ?????? secondary to amiodarone
5. Pancytopenia - anogenic myeloid metaplasia
-- s/p bone marrow bx
6. BPH ?????? Dr. [**Last Name (STitle) 986**]
7. Hiatal hernia w/o GERD
8. s/p cholecystectomy [**2117**]
9. HTN
10. hypercholesterolemia
11. VSD
12. s/p coronary cath [**2126**] - showed clean coronaries
13. Aberrant L subclavian artery, 50% tracheal compression.
14. Traumatic L upper thigh bleed
15. Lumbar scoliosis
16. Sciatica with posterior disc protrusion
17. CRF - baseline Cr 2.3-3.0
18. Gout
19. Vasculitis
20. ex-lap/LOA [**2130**]
Social History:
Retired, was a property manager previously
Family: lives with wife in [**Name (NI) **], married 60years
Travel/Exp/Pets: no recent travel or exposures.
No pets.
Alc/Tob: No EtOH in past 14 years, before that, social EtOH. no
tobacco.
Family History:
Father died at 84 from oral cancer
Brother with skin cancer
Mother died at 25 for ?pneumonia
not significant for DM, HTN, or other CA history
Physical Exam:
On Admission:
Gen: WD/WN,intubated, sedated in ED
HEENT: Pupils: 2 min reactive
Neck:in hard collar
Extrem: Warm and well-perfused.
Neuro:
Mental status: intubated, sedated. no eye opening. when meds
lightened, did move all 4 extrem antigravity to stim.
Pertinent Results:
Labs on Admission:
[**2135-9-19**] 06:39AM BLOOD WBC-6.7 RBC-3.13* Hgb-10.5* Hct-31.3*
MCV-100* MCH-33.4* MCHC-33.4 RDW-15.6* Plt Ct-172
[**2135-9-19**] 06:39AM BLOOD Neuts-73.1* Lymphs-20.5 Monos-4.9 Eos-1.4
Baso-0.1
[**2135-9-19**] 06:39AM BLOOD PT-39.7* PTT-38.1* INR(PT)-4.3*
[**2135-9-19**] 06:39AM BLOOD Glucose-113* UreaN-48* Creat-2.7* Na-142
K-3.4 Cl-104 HCO3-28 AnGap-13
[**2135-9-19**] 06:39AM BLOOD cTropnT-0.02*
[**2135-9-19**] 06:39AM BLOOD Calcium-10.0 Phos-3.3 Mg-2.9*
Labs on Discharge:
XXXXXXXXXX Imaging XXXXXXXXXX
Head CT([**9-19**])-Pre-op:
IMPRESSION: Large left subdural hematoma, likely hyperacute on
acute, with
associated rightward subfalcine herniation and uncal herniation.
CT C-Spine ([**9-19**]):
IMPRESSION:
1. No acute fracture or malalignment identified.
2. Multiple degenerative changes.
Head CT([**9-19**]): Post-op
There is a new approximately 3 x 3 cm left parieto-occipital
intraparenchymal hemorrhage. Expected post-surgical changes from
left
craniotomy with evacuation of subdural hematoma. The degree of
midline
shift and mass effect is markedly reduced. Subfalcine and uncal
herniation
has resolved.
gall bladder us: IMPRESSION: Prominent hepatic venous
vasculature suggestive of passive hepatic congestion.
Brief Hospital Course:
Patient is an 82 y/o M with history of atrial fibrillation and
[**Month/Year (2) 1291**] on coumadin, amiodarone, s/p Pacemaker, diastolic CHF,
admitted s/p fall with SDH. He was originally admitted to the
neurosurgery service and had an evacuation of Subdural
hemorrhage with a left sided craniotomy for bleed with
hernation. His post operative course was complicated by
diastolic CHG exacerbation and strep pneumonia VAP. He remained
unresponsive after the second intubation and was made CMO. he
was extubated [**10-3**] and passed away 2 hours later.
.
Respiratory Failure: intially intunated for neurosurgery
evacuation [**9-19**], extubated [**9-20**]. ReIntubated [**9-24**] after 1 day on
bipap for increased work of breathing and airway protection in
setting of pulmonary edema and pneumonia. Etiology of resp
failure is infections and cardiogenic. Patient was alkalotic, is
overbreathing the [**Last Name (LF) **], [**First Name3 (LF) **] decrease tidal volume. He was
treated with ceftriaxone for the strep pneumonia and despite
better volume status and treatment of PNA, he remained
unresponsive on no sedation. He failed several pressure support
trials secondary to hyperventilation and low tidal volumes, he
likely had neurogenic respiratory failure.
Subdural hemorrhage: s/p Craniotomy and evacuation [**9-19**], done
emergently. had unequal pupils [**2-24**] and had stat Head CT showing
no interval change. Pupils became equal again after several
days. He was started and continued on dilantin prophylaxis. The
dose was decreased given low albumin and corrected level higher
than measured. Despite Improving Dilantin level and correcting
hyponatremia, patient continued to have poor mental status.
Anemia: unclear etiology. Patient was hypercoaguable around the
time of fall. Not bleeding in brain, may have spontaneous RP
bleed. Hct went from 23 -> 20 hospital day 6, and responded to 2
units pRBCs. Patient also has underlying myeloid metaplasia. His
Hct did not drop after that.
[**Month/Year (2) 1291**]/Coagulpathy: patient with [**Month/Year (2) 1291**] with [**Hospital3 **] valve that
needs to be anticoagulated with INR goal [**2-6**]. Warfarin has been
held since admission and Pt recieved 3 units FFP on admission.
on [**9-25**] patient had INR 3.8 and recieved a total of 4 units FFP.
For several days, the INR remained >2 despite any
anticoagulation. When it fell below 2, coumadin 1mg was started.
Cardiology had been consulted by neurosurgery service, and the
decision was made to start coumadin without bolus when IRN <2
given the SDH on admisision. Possible etiologies of persistent
coagulopathy were vitamin K deficiency vs liver damage vs most
likely supratherapeutic phenytoin. When phenytoin values
normalized, INR also normalized.
Altered mental status: Patient unresponsive off sedation.
Etiology is likely multifactorial: subdural, hypernatremia,
uremia, and infection. Hypernatremia, uremia, infection were all
treated and he remained unresponsive.
Diastolic heart failure: EF >60% ([**3-12**]). Patient was on lasix
drip for a day, on intermittent lasix until euvolemic.
Transaminitis: unlikely from propofol as trigylcerides are
normal. Shock liver unlikely, has not been hypotensive. [**Month (only) 116**] be
septic. eventually trended down.
CKD: baseline creatinine is 2.3-2.8. trended down and
normalized.
- renally dose meds
Hypertension: His blood pressure was eventually controlled on
the following regimen.
- Hydralazine titrated up to 37.5mg TID, Isosorbide mononitrate
increased from 10 to 20 PO BID, metoprolol 25mg [**Hospital1 **].
Atrial fibrillation: continue Amiodarone 200 [**Hospital1 **]
Hypothyroidism: home dose of 75mcg PO levothyroxine
HYperlipidemia: continue statin
Hypernatremia: has been trending up, likely contributing to
mental status
- free water boluses from 200q6 to 300q4.
BPH: held tamsulosin and finastride, not crushable via PEG
** Numerous family meeting were held, and given the lack of
improvement in his mental status in the setting of the large
subdural hematomas, the decision was made to transition the
patients care to comform measures. Family was brought in from
out of town, and the patient was extubated [**2135-10-3**]. He passed
away a few hours after extubation.
Medications on Admission:
allopurinol,amiodarone,aspirin,calcium,fish oil, flomax, folic
acid,
hydralizine,imdur,levoxyl,lipitor,MVI, proscar,toprol xl,
toresemide,coumadin
Discharge Medications:
deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
Acute Lt SDH
diastolic heart failure
respiratory failure
Coagulpathy
Hypertension
Discharge Condition:
deceased
Discharge Instructions:
deceased
Followup Instructions:
deceased
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
Completed by:[**2135-10-11**]
ICD9 Codes: 5070, 2760, 4280, 4241, 5859, 2859, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3705
} | Medical Text: Admission Date: [**2102-6-29**] Discharge Date: [**2102-7-13**]
Date of Birth: [**2050-2-22**] Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 11415**]
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
[**2102-6-30**] ORIF Left SI joint and anterior ring pelvis-Krod
[**2102-7-5**] POSTERIOR INSTRUMENTATION FUSION T11-T12, L1, L2, L3
[**2102-7-10**] Revision pelvic fixation with additional sacroiliac
[**Last Name (LF) 112030**], [**First Name3 (LF) **] Additional symphysial plate and reinforcement with
anterior external fixator frame.
History of Present Illness:
52 year old gentleman who is s/p fall off of a ladder today
while working on a tree. He fell 25 feet striking the left side
of his body. he was taken to an OSH for evaluation and imaging
there showed an L1 burst fx with retropulsion of fragments, L5
transverse process fx, as well as an open book pelvic fracture.
He was transferred to [**Hospital1 18**] for further care and evaluated as a
trauma upon arrival. Per report he had no bulbocavernous reflex
and decreased rectal tone. given this Spine was emergently
consulted and we evaluated the patient. He denies sensory
deficit
or perceived weakness.
Other injuries include open book pelvic fx, L1 burst, L5 TP fx.
Past Medical History:
PMH: HTN, HLD
PSH: R hand tendon surgery @ 18yo
Family History:
NC
Physical Exam:
At admission:
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRL EOMs intact without nystagmus
Neck: hard C-Collar in place Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: abrasions along left side of torso. Soft, NT, BS+
Extrem: abrasions to left LLE as well as ecchymosis along left
lateral thigh and anterior foot. Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
D B T WE WF IP Q H AT [**Last Name (un) 938**] G
Sensation: Intact to light touch, proprioception, pinprick and
vibration bilaterally.
Proprioception intact
Toes downgoing bilaterally
Rectal exam slightly decreased
At discharge:
afebrile, VSS
NAD
A&Ox3
Ex-fix pin sites without erythema or drainage
LLE: WWP, +DP pulse
+TA [**Last Name (un) 938**] G/S
SILT saph sural DPN SPN plantar nerves
Pertinent Results:
[**2102-6-29**] 11:54PM GLUCOSE-138* UREA N-17 CREAT-0.9 SODIUM-140
POTASSIUM-3.7 CHLORIDE-106 TOTAL CO2-25 ANION GAP-13
[**2102-6-29**] 11:54PM CALCIUM-7.9* PHOSPHATE-3.9 MAGNESIUM-1.8
[**2102-6-29**] 11:54PM WBC-9.3 RBC-3.65* HGB-11.8* HCT-34.8* MCV-96
MCH-32.3* MCHC-33.8 RDW-14.1
[**2102-6-29**] 11:54PM PLT COUNT-184
[**2102-6-29**] 06:10PM URINE HOURS-RANDOM
[**2102-6-29**] 06:10PM URINE GR HOLD-HOLD
[**2102-6-29**] 06:10PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.030
[**2102-6-29**] 06:10PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2102-6-29**] 06:10PM URINE RBC-98* WBC-4 BACTERIA-NONE YEAST-NONE
EPI-0
[**2102-6-29**] 06:10PM URINE HYALINE-1*
[**2102-6-29**] 06:02PM COMMENTS-GREEN TOP
[**2102-6-29**] 06:02PM GLUCOSE-155* LACTATE-1.7 NA+-140 K+-3.6
CL--101 TCO2-25
[**2102-6-29**] 06:02PM HGB-14.4 calcHCT-43
[**2102-6-29**] 05:55PM UREA N-16 CREAT-1.1
[**2102-6-29**] 05:55PM estGFR-Using this
[**2102-6-29**] 05:55PM LIPASE-55
[**2102-6-29**] 05:55PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2102-6-29**] 05:55PM WBC-18.5* RBC-4.32* HGB-13.8* HCT-42.0 MCV-97
MCH-32.0 MCHC-33.0 RDW-14.2
[**2102-6-29**] 05:55PM PLT COUNT-225
[**2102-6-29**] 05:55PM PT-10.9 PTT-22.7* INR(PT)-1.0
[**2102-6-29**] 05:55PM FIBRINOGE-175*
IMAGING:
[**6-29**] CT C/A/P - L1 Burst fracture. Displaced fracture of superior
portion of left hemisacrum with widening of left sacroiliac
joint. Fracture of L5 transverse process. Diastasis of the pubic
symphisis. 6cm x 4cm left retroperitoneal hematoma.
[**6-29**] LLE Xrays:
IMPRESSION: No evidence of left lower extremity fracture.
[**6-29**] Pelvis Xray:
IMPRESSION: Pubic symphysis and left sacroiliac joint
diastasis. An external fixation device has been placed in the
distal lower extremity. To evaluate for fracture, consider CT.
[**7-6**] CT T and L spine:
IMPRESSION:
1. No evidence of hardware complications. The lumbar fusion
hardware is
better evaluated on the concurrent lumbar spine CT. There is no
evidence of postoperative hematoma or fluid collection.
2. Stable burst fracture of L1 with persistent retropulsion of
the fragment fractures and associated mild-to-moderate spinal
canal narrowing.
3. Bilateral small pleural effusions and dependent atelectasis.
[**7-7**] CXR 2 view:
IMPRESSION: No acute cardiopulmonary process.
Brief Hospital Course:
Mr. [**Known lastname **] was initially admitted to the Trauma SICU on [**6-29**] for
further management of his spinal and pelvic fractures. His
initial toxicology screen was negative. He required 4 units of
pRBCs. On [**6-30**], he was taken to OR with the Orthopaedic Surgery
service for ORIF pelvic fracture. He tolerated the procedure
well and was taken to the PACU and then the floor in stable
condition.
He remained stable during his floor course. On [**2102-7-5**], he was
transferred to the Neurosurgery service and underwent the above
stated procedure. Post-operatively, he was transferred to the
ICU for acute anemia as well as pain management. He was fitted
for a TLSO brace to be worn while out of bed. Hemovac drain was
removed on [**7-7**]. On [**7-8**], he was started on Aspirin and his
TLSO brace was re-fitted due to discomfort. He was seen by the
Orthopaedic Surgery service on [**7-9**] due to complaints of
"clicking" in his hips as well as pelvic pain. An x-ray of the
pelvis was performed that showed loss of reduction wo he went
back to the OR for revision ORIF and ex-fix placement. The
patient tolerated the procedure without complications and was
transferred to the PACU in stable condition. Please see
operative report for details. Post operatively pain was
controlled with a PCA with a transition to PO pain meds once
tolerating POs. The patient tolerated diet advancement without
difficulty and made steady progress with PT.
The patient received peri-operative antibiotics as well as
lovenox for DVT prophylaxis. The incision was clean, dry, and
intact without evidence of erythema or drainage; and the
extremity was NVI distally throughout. The patient was
discharged in stable condition with written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient will be continued on chemical DVT
prophylaxis for 4 weeks post-operatively. All questions were
answered prior to discharge and the patient expressed readiness
for discharge.
Medications on Admission:
asa, lipitor, fish oil
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Atorvastatin 20 mg PO DAILY
3. Fish Oil (Omega 3) 1000 mg PO DAILY
4. Acetaminophen 650 mg PO Q6H
5. Bisacodyl 10 mg PO/PR DAILY
6. Diazepam 2-5 mg PO Q8H:PRN spasm
7. Docusate Sodium 100 mg PO BID
8. Enoxaparin Sodium 40 mg SC DAILY
9. HYDROmorphone (Dilaudid) 2-4 mg PO Q4H:PRN pain
hold for excess sedation or RR < 12. Pls use IV as breakthrough
RX *Dilaudid 2 mg every four (4) hours Disp #*80 Tablet
Refills:*0
10. Milk of Magnesia 30 mL PO Q6H:PRN constipation
11. Senna 1 TAB PO QHS
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
- Left sacroiliac joint dissociation and symphysial disruption
with vertical shear pelvic fracture - s/p ORIF anterior ring
with plating and s/p ORIF left sacroiliac joint with sacroiliac
[**Hospital3 112030**].
- L1 burst fracture s/p Posterior approach for open reduction,
instrumented fusion T10, T11, T12, L1, L2-L3, L4 using bilateral
pedicle [**Hospital3 112030**], posterior rods, cross-links, global system;
autologous autograft using right sided iliac crest; Allograft
(morselized bone); Open reduction.
Back pain
post operative anemia
constipation
scrotal edema
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: as above
Discharge Instructions:
NEUROSURGERY INSTRUCTIONS:
?????? Do not smoke.
?????? Keep your wound(s) clean and dry / No tub baths or pool
swimming for two weeks from your date of surgery.
?????? Dressing may be removed on Day 2 after surgery.
?????? No pulling up, lifting more than 10 lbs., or excessive bending
or twisting.
?????? Wear the TLSO brace any time you are out of bed or
chair.
?????? Take your pain medication as instructed; you may find it best
if taken in the morning when you wake-up for morning stiffness,
and before bed for sleeping discomfort.
?????? Increase your intake of fluids and fiber, as pain medicine
(narcotics) can cause constipation. We recommend taking an over
the counter stool softener, such as Docusate (Colace) while
taking narcotic pain medication.
?????? 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:
?????? Pain that is continually increasing or not relieved by pain
medicine.
?????? Any weakness, numbness, tingling in your extremities.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, and drainage.
?????? Fever greater than or equal to 101?????? F.
?????? Any change in your bowel or bladder habits (such as loss of
bowl or urine control).
ORTHOPEDIC SURGERY INSTRUCTIONS:
******SIGNS OF INFECTION**********
should experience severe pain, increased swelling, decreased
sensation, difficulty with movement; fevers >101.5, chills,
redness or drainage at the incision site; chest pain, shortness
of breath or any other concerns.
-Wound Care: You can get the wound wet/take a shower starting
from 3 days post-op. No baths or swimming for at least 4 weeks.
Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment. No dressing is needed
if wound continued to be non-draining.
******WEIGHT-BEARING*******
Strict non-weight bearing in left lower extremity. Touch down to
full weight bearing in right lower extremity for transfers to
chair or commode only. It is ok to go to cahir or commode, but
no other activity.
******MEDICATIONS***********
- Resume your pre-hospital medications.
- You have been given medication for your pain control. Please
do not operate heavy machinery or drink alcohol when taking this
medication. As your pain improves please decrease the amount of
pain medication. This medication can cause constipation, so you
should drink 8-8oz glasses of water daily and take a stool
softener (colace) to prevent this side effect.
-Medication refills cannot be written after 12 noon on Fridays.
*****ANTICOAGULATION******
- Take Lovenox for DVT prophylaxis for 4 weeks post-operatively.
Physical Therapy:
Strict non-weight bearing in left lower extremity. Touch down to
full weight bearing in right lower extremity for transfers to
chair or commode only. It is ok to go to cahir or commode, but
no other activity.
Treatments Frequency:
physical therapy
wound care
nursing
Followup Instructions:
Follow Up Instructions/Appointments for Neurosurgery:
??????Please return to the office in [**8-1**] days (from date of surgery)
for removal of your staples/sutures and/or a wound check. This
appointment can be made with the Nurse Practitioner. Please
make this appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite
a distance from our office, please make arrangements for the
same, with your PCP.
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **] to be seen in 8 weeks.
??????You will need CT-scan of the lumbar spine prior to your
appointment. This can be scheduled at the same time as your
appointment.
Orthopedic Surgery Follow-up:
******FOLLOW-UP**********
Please have your sutures/staples removed at your rehabilitation
facility at post-operative day 14.
Please follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**11-5**] days
post-operation for evaluation. Call [**Telephone/Fax (1) 1228**] to schedule
appointment upon discharge.
Please follow up with your PCP regarding this admission and any
new medications/refills.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**] MD, [**MD Number(3) 11417**]
ICD9 Codes: 2851, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3706
} | Medical Text: Admission Date: [**2142-3-26**] Discharge Date: [**2142-4-12**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
dyspnea on exertion
Major Surgical or Invasive Procedure:
Left sided Talc Pleurodesis
Intubation [**2142-4-3**]
Upper Endoscopy (EGD - esophagogastroduodenoscopy): [**2142-4-3**] and
[**2142-4-11**].
History of Present Illness:
Ms. [**Known lastname 7864**] is an 87 Russian-speaking woman from the [**Location (un) 3156**]
with history of dCHF, Hypertension, Hypothyroidism,
Hyperlipidemia, with >1yr history of exudative bilateral pleural
effusions, presenting for elective admission for medical
thorascopy with talc pleurodesis of left effusion. Bilateral
pleural effusions initially attributed to CHF, did not respond
completely to diuresis, found to be exudative and lymphocytic
after multiple thoracenteses. Last [**Month (only) **], patient underwent
medical thoracoscopy with talc pleurodesis on right side, which
improved right sided effusion temporarily. Cytology and culture
negative at that time, and effusion still exudative. Patient
admitted now for elective mediastinal thorascopy on left in
setting of recurrent Left sided pleural effusions and persistent
fatigue and dyspnea on exertion. Thoracentesis was attempted
[**12/2141**], but procedure was stopped after 500ml were removed in
setting of discomfort and question of trapped lung.
Patient underwent talc pleurodesis on left on day of admission,
requiring ketamine for sedation. Received nerve block prior to
procedure. Nonspecific inflammation, patchy erythema seen in
pleura with no overt evidence of cancer. Fluid sent for AFB
smear and culture, fungal culture, gram stain and culture,
cytology. Pleural biopsy done for pathology as well. She was
given 800 cc LR in the OR and 250cc bolus in PACU. Pleurex
catheter and chest tube in place to suction. Vitals in PACU
post-op as follows: BP 120/80 HR 60-80s RR SaO2 96% 6L NC. She
took a few hours to recover from sedation and ketamine, but on
arrival to the floor, she felt well overall. She denied any
pain in her chest/lungs. Denied shortness of breath at rest.
Past Medical History:
CHRONIC BILATERAL PLEURAL EFFUSIONS, S/P TALC PLEURODESIS [**9-/2141**]
HYPERTENSION
HYPERLIPIDEMIA
HYPOTHYROIDISM
Gastritis - per EGD [**2134**]
H/O NEPHROLITHIASIS
H/O BASAL CELL CARCINOMA [**2135**]
*S/P SPLENECTOMY [**2133**]
*S/P CHOLECYSTECTOMY
CHRONIC CONSTIPATION
URINARY INCONTINENCE
OSTEOPOROSIS
CHRONIC UTI on methenamine
Social History:
Prior to admission, she was living in her own apartment [**Location 7865**]in [**Location (un) **]. Her daughter lives [**Name2 (NI) 3592**] [**Last Name (NamePattern1) 7866**]. Her grandson is the HCP.
Retired factory worker from the [**Location (un) 3156**]. Widowed with adult
children. She has no history of tobacco, alcohol, or illicit
drug use. Walks with the assist of a cane or walker. Mobile
every day.
Family History:
Mother had hypertension.
Physical Exam:
ADMISSION EXAM:
Vitals: 97.8 128/78 70 16 95% on 3L NC
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, mild conjunctival pallor, MMM,
oropharynx clear
Neck: supple, JVP ~ 9cm
Lungs: Bilateral crackles halfway up posteriorly
CV: Regular rate and rhythm, + systolic murmur and S4 loudest at
apex
Chest: chest tube and pleurex catheter from left lower back
draining serosanginous fluid
Abdomen: soft, very mild LLQ tenderness, non-distended, no
rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 1+ bilateral lower extremity edema
DISCHARGE EXAM:
afebrile 130/55 p59 R18 94%RA
GEN: well appearing, comfortable.
RESP: CTA B. L Pleurex in place. Good AE. Breathing
comfortably.
CV: RRR. JVP wnl.
Pertinent Results:
Microbiology:
[**2142-3-29**] 10:13 am URINE Source: Catheter.
**FINAL REPORT [**2142-3-30**]**
URINE CULTURE (Final [**2142-3-30**]):
YEAST. 10,000-100,000 ORGANISMS/ML..
Pathology:
Pathology Examination
SPECIMEN SUBMITTED: Left Parietal Pleura.
DIAGNOSIS:
Pleura (left parietal), biopsy (A):
Pleura with lymphoid infiltrate consistent with reactive
inflammatory process (see note).
Pathology Examination
SPECIMEN SUBMITTED: Cell block of pleural fluid
DIAGNOSIS:
Pleural fluid, cell block: Negative for carcinoma; [**Year/Month/Day **] and
scattered mesothelial cells.
Note: See cytology (C12-7517V).
Cytology Report PLEURAL FLUID Procedure Date of [**2142-3-26**]
NEGATIVE FOR MALIGNANT CELLS.
Mesothelial cells, macrophages and [**Date Range **].
Radiologic Studies:
Radiology Report CHEST (PORTABLE AP) Study Date of [**2142-3-26**]
IMPRESSION:
1) Tiny left apical pneumothorax. New left thoracostomy tubes.
2) Improved left lung aeration.
3) New right mediastinal contour may reflect a new loculated
effusion.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2142-3-27**]
IMPRESSION:
Moderate right pleural effusion with adjacent compressive
atelectasis is
unchanged from the prior exam.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2142-3-29**]
12:12 AM
IMPRESSION:
1. Interval development of a hazy left upper zone opacity, which
may signify focal atelectasis or pneumonia.
2. No pneumothorax.
3. Worsening left lower lobe collapse.
4. Unchanged moderate right pleural effusion with adjacent
atelectasis.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2142-3-30**]
UPRIGHT AP VIEW OF THE CHEST: A left-sided chest tube terminates
in the left upper lung as before. Severe left basilar
atelectasis is similar to prior.
Moderate left increased and moderate right pleural effusions are
again seen.
right basilar atelectasis is present. Subtle left upper lung
opacity is little changed from the prior study. There is no new
consolidation.
Cardiomediastinal silhouette is unchanged.
Radiology Report CT CHEST W/CONTRAST Study Date of [**2142-3-30**]
IMPRESSION:
1. Dilated esophagus with oral contrast retained proximally,
aerosolized
material filling the remainder, and distal tapering, concerning
for distal
obstruction. Although no mass like lesions is identified,
differential
diagnosis includes malignancy, benign stricture, and achalasia.
Severe
dysmotility is less likely. Oral contrast is also sequestered in
the
oropharynx.
2. Interval placement of left chest tube with new small left
anterior
pneumothorax.
3. New right flank subcutaneous soft tissue edema.
5. Decreased size of right axillary fluid collection.
6. Loculated bilateral pleural effusions, with left pleural
calcifications.
Radiology Report CT NECK W/CONTRAST (EG:PAROTIDS) Study Date of
[**2142-3-30**] IMPRESSION:
1. Dilated esophagus with oral contrast retained proximally,
aerosolized
material filling the remainder, and distal tapering, concerning
for distal
obstruction. Although no mass like lesions is identified,
differential
diagnosis includes malignancy, benign stricture, and achalasia.
Severe
dysmotility is less likely. Oral contrast is also sequestered in
the
oropharynx.
2. Interval placement of left chest tube with new small left
anterior
pneumothorax.
3. New right flank subcutaneous soft tissue edema.
5. Decreased size of right axillary fluid collection.
6. Loculated bilateral pleural effusions, with left pleural
calcifications.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2142-3-31**] 3:17
AM
FINDINGS: Comparison is also made to prior CT scan from [**2142-3-30**].
Heart size is enlarged. There are bilateral pleural effusions,
right side
worse than left. There is a left retrocardiac opacity. There is
faint if any density projecting over the mid upper esophagus.
This could correlate with the retained barium seen in this
location on the prior CT scan; however, it is better assessed on
the CT. There is no pneumothoraces. These findings have been
discussed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7867**] with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
Radiology Report CHEST PORT. LINE PLACEMENT Study Date of
[**2142-3-31**] IMPRESSION:
1. Interval placement of right subclavian PICC line with its tip
near the
junction of the brachiocephalic vein with the superior vena
cava. Dr. [**Last Name (STitle) 7868**] discussed this with [**First Name8 (NamePattern2) 1785**] [**Last Name (NamePattern1) **] by phone
on [**2142-3-31**] at 8:30 p.m. There is a small-to-moderate sized
layering right effusion which may have slightly increased in
size since the previous study. In addition, there is persistent
opacity at the left base with a suggestion of some air
bronchograms which may represent lower lobe collapse, although a
pneumonia in this vicinity should also be considered. Interval
improvement in mild perihilar edema. No pneumothorax. Heart
remains enlarged. Mediastinal contours are within normal limits.
Radiology Report CT ABD & PELVIS WITH CONTRAST [**2142-4-1**]
IMPRESSION:
1. Stranding surrounding the second portion of duodenum is
nonspecific. No
free air.
2. Stable loculated bilateral pleural effusions. Left PleurX
catheter in
stable location.
3. Stable cardiomegaly and small pericardial effusion.
4. Stable dysmorphic appearing liver, perihepatic ascites, and
periportal
edema.
5. Bilateral non-obstructing nephrolithiasis and renal
hypodensities, some of which too small to fully characterize,
but most likely cysts.
6. Improved lower esophageal dilation since two days prior.
7. Unchanged fat and fluid-containing ventral hernia.
8. Splenosis status post splenectomy.
9. Stable left adrenal thickening.
[**2142-4-2**] 9:00:00 AM - EGD report
Impression: An adherent clot was seen in the esophagus at 35cm
from the incisors. This was unable to be washed or suctioned
off. There appeared to be an ulcer in the clot. No active
bleeding was seen.
Normal mucosa in the stomach
Two openings were noted in the proximal duodenum (D1). They were
consistent with either duodenal diverticula or potentially
hepaticoduodenostomy.
Otherwise normal EGD to third part of the duodenum
Recommendations: The clot in the esophagus is the likely
etiology of the coffee ground emesis and odynophagia.
Would keep NPO today and advance to slowly to soft solids.
Continue [**Hospital1 **] PPI
Can stop fluconazole as no evidence of [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] need repeat endoscopy. F/u with inpatient GI team to
determine exact timing.
[**2142-4-11**] - EGD report
Impression: Ulcer in the lower third of the esophagus
Granularity and erythema in the stomach body and antrum
Previous choledochoduodenostomy of the first part of the
duodenum
Otherwise normal EGD to third part of the duodenum
Recommendations: Continue PPI therapy.
Further recommendations as per inpatient GI consult team.
Additional notes: The procedure was performed by the attending
and the GI fellow. The attending was present for the entire
procedure. The patient's home medication list is appended to
this report. FINAL DIAGNOSES are listed in the impression
section above. Estimated [**Year (4 digits) **] loss = zero. No specimens were
taken for pathology.
[**2142-3-26**] 09:40PM [**Year/Month/Day 3143**] WBC-10.3 RBC-2.65* Hgb-9.7* Hct-27.5*
MCV-104* MCH-36.6* MCHC-35.3* RDW-15.5 Plt Ct-206
[**2142-4-12**] 02:05AM [**Month/Day/Year 3143**] WBC-6.6 RBC-2.45* Hgb-8.1* Hct-25.6*
MCV-105* MCH-33.2* MCHC-31.8 RDW-18.0* Plt Ct-285
[**2142-3-26**] 09:40PM [**Year/Month/Day 3143**] Glucose-116* UreaN-24* Creat-0.9 Na-145
K-4.3 Cl-108 HCO3-29 AnGap-12
[**2142-4-2**] 02:27AM [**Year/Month/Day 3143**] Glucose-677* UreaN-31* Creat-0.8 Na-125*
K-3.6 Cl-96 HCO3-25 AnGap-8
[**2142-4-8**] 07:00AM [**Month/Day/Year 3143**] Glucose-87 UreaN-21* Creat-1.6* Na-136
K-4.6 Cl-104 HCO3-25 AnGap-12
[**2142-4-12**] 02:05AM [**Month/Day/Year 3143**] Glucose-67* UreaN-19 Creat-0.9 Na-138
K-3.7 Cl-103 HCO3-27 AnGap-12
[**2142-4-1**] 05:34AM [**Year/Month/Day 3143**] Hapto-<5*
[**2142-4-1**] 05:34AM [**Year/Month/Day 3143**] LD(LDH)-206 TotBili-1.2
MICRO:
____________________________
Time Taken Not Noted Log-In Date/Time: [**2142-3-26**] 12:15 pm
PLEURAL FLUID LEFT PLEURAL FLUID.
GRAM STAIN (Final [**2142-3-26**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white [**Year/Month/Day **] cell count..
FLUID CULTURE (Final [**2142-3-29**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2142-4-1**]): NO GROWTH.
ACID FAST SMEAR (Final [**2142-3-27**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
________________________________
Time Taken Not Noted Log-In Date/Time: [**2142-3-26**] 12:15 pm
TISSUE LEFT PARTIAL PLEURA.
GRAM STAIN (Final [**2142-3-26**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final [**2142-3-29**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2142-4-1**]): NO GROWTH.
ACID FAST SMEAR (Final [**2142-3-27**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
Brief Hospital Course:
Ms. [**Known lastname 7864**] 87F Russian speaking woman from [**Location (un) 3156**] with
history of chronic diastolic congestive heart failure, chronic
bilateral exudative pleural effusions of unclear etiology,
admitted after elective talc pleurodesis of left side, who
developed severe odynophagia during hospitalization and
hematemesis, found to have a clot on esophageal ulcer, without
evidence of active bleeding or candidal esophagitis.
# BILATERAL EXUDATIVE PLEURAL EFFUSIONS: Unclear etiology of
exudative pleural effusions which have been present for the past
year. She is s/p talc pleurodesis of right side in [**9-/2141**] which
worked temporarily. She underwent medical thoroscopy and talc
pleurodesis of left side [**2142-3-26**], and she required repeat talc
placement [**2142-3-28**] because mild fluid overload made the talc less
effective the first time. Procedure was done under conscious
sedation, also given ketamine. She was not intubated for
procedure. Chest tube was removed [**2142-3-30**], and pleurex catheter
remained for drainage. Pleural studies again showed exudative
effusion, negative gram stain and culture. Cytology was
negative. Pleural biopsies also showed negative gram stain,
culture and lymphoid infiltrate consistent with reactive
inflammatory process. The pleurex catheter was managed by IP
team. The volume of her pleural effusions was noted to trend
with the status of her heart failure, with significantly
decreased output after diuresis to euvolemia. She was
discharged with home VNA services with daily Pleurex drainage.
# ODYNOPHAGIA/HEMETEMESIS/ESOPHAGEAL ULCER: Patient developed
severe odynophagia roughly 1-2 days after procedure and was
unable to tolerate po intake. ENT was consulted and did not see
enlargement of tonsils or any source of bleeding from the
cervical portion of esophagus. Flovent was stopped in setting
of potential candidal esophagitis, though patient did rinse
mouth out after every Flovent use and there was no evidence of
thrush. She was also complaining of epigastric tenderness and
was spitting up food and drink tinged with [**Last Name (LF) **], [**First Name3 (LF) **] IV PPI was
started for potential acute gastritis, as she does have a
history of gastritis as seen on EGD in [**2134**]. She was given oral
viscous lidocaine PRN throat pain with some relief. GI was
consulted, and patient was started empirically on sucralfate and
fluconazole for potential candidal esophagitis, though she was
unable to tolerate any PO medications at this point. She began
to spit up gross [**Year (4 digits) **] several times per day. Hematocrit
trended downwards slowly from 29 to 22, and patient was
transfused 1u pRBCs with appropriate bump in Hct. Of note, she
very difficult to crossmatch due to her autoimmune hemolytic
anemia and multiple antibodies. CT neck and chest showed very
dilated esophagus, gastrografin unable to pass through because
of food and [**Year (4 digits) **] stuck in esophagus. She was transferred to
[**Hospital Ward Name 332**] ICU for high risk EGD with intubation and underwent the
procedure on [**2142-4-2**], which showed an adherent clot over a
likely ulcer base, no active bleeding and no evidence of
candidal esophagitis. Fluconazole was stopped and patient was
continued on Protonix. Her diet was restarted on [**2142-4-3**] and
patient underwent repeat EGD which showed a clean based
superficial ulcer. She will continue on [**Hospital1 **] ppi at discharge.
# INTERMITTENT HYPOXIA: Patient was having intermittent
hypoxia, requiring up to 5L O2 by nasal canula while on the
floor. This is likely secondary to significant atelectasis, as
visualized on CXR with RLL collapse and likely atelectasis also
on left above heart. Hypoxia improved when she was seated in
upright position and made to breathe deeply. No clear pneumonia
on CXR and no coughing clinically. She is encouraged to use
incentive spirometry. Her oxygen requirement stabilized
throughout her hospital stay.
# ANEMIA: Hematocrit trended down slowly in setting of
serosanguinous chest tube drainage and spitting up gross [**Hospital1 **].
She remained hemodynamically stable on the floor. She was
transfused 1u pRBCs with good response in Hct. She has known
history of gastritis, as seen on EGD in [**2134**]. Initial EGD
showed showed an adherent clot over a ulcer base, no active
bleeding and no evidence of candidal esophagitis. Of note,
patient was difficult to crossmatch because of multiple
antibodies. There was concern for hemolytic process given
patient's low haptoglobin, but patient had normal LDH and total
bilirubin. Her hematologist, Dr. [**Last Name (STitle) **] was contact[**Name (NI) **] and
clarified that given her cold agglutinin disease, her
haptoglobin would be chronically low, and LDH and bilirubin
should be followed for evidence of hemolysis. Her cold
agglutinin disease also requires that her [**Name (NI) **] be warmed
through a warmer prior to transfusion.
# CHRONIC DIASTOLIC CHF, with acute exacerbation:
# Acute renal failure:
Patient's volume status was difficult to keep even initially.
Initial talc pleurodesis not completely effective in setting of
mild overload. Her home diuretics were initially because she
was unable to take POs and keep herself hydrated, so she became
very dry, requiring gentle IVFs. She subsequently developed
volume overload, with mild acute renal failure. She was
diuresed initially with IV lasix, and was then resumed on her
home Lasix 60 mg po q day. Her acute renal failure resolved
with diuresis. She appeared euvolemic at the time of discharge.
# HYPERNATREMIA: Patient developed hypernatremia in setting of
poor PO intake given odynophagia. She was given gentle
maintenance rate of D5W to correct her free water deficit and
her hypernatremia resolved.
# CHRONIC UTI: Patient has chronic UTIs, normally on
methanamine, which she was unable to take most of
hospitalization, as she was unable to tolerate POs. It was
restarted at the time of discharge.
Medications on Admission:
ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler -
1-2 puffs(s) by mouth every four (4) to six (6) hours as needed
for cough/wheezing
CYANOCOBALAMIN (VITAMIN B-12) - 1,000 mcg/mL Solution - inject
monthly first dose was [**11-25**]
FENOFIBRATE NANOCRYSTALLIZED [TRICOR] - 145 mg Tablet - 1
Tablet(s) by mouth QDay
FLUTICASONE [FLOVENT HFA] - 110 mcg/Actuation Aerosol - 1
inhalation(s) by mouth QDay Rinse mouth after use
FUROSEMIDE - (Prescribed by Other Provider) - 40 mg Tablet - 1.5
Tablet(s) by mouth daily
HYDROCORTISONE - 2.5 % Cream - apply to rash as needed do not
use for more than 2 weeks
LABETALOL - 100 mg Tablet - twice a day
LEVOTHYROXINE - (Dose adjustment - no new Rx) - 75 mcg Tablet by
mouth daily
LOSARTAN - 50 mg Tablet - 1 Tablet(s) by mouth daily
METHENAMINE HIPPURATE - (Prescribed by Other Provider:
[**Name Initial (NameIs) **]) - 1 gram Tablet - 1 Tablet(s) by mouth twice a day
NIFEDIPINE - 90 mg Tablet Extended Rel 24 hr - 1 Tablet(s) by
mouth daily
SIMVASTATIN - 40 mg Tablet - 1 Tablet(s) by mouth once a day
ACETAMINOPHEN - 500 mg Tablet - 2 Tablet(s) by mouth every 6
hours as needed for rib pain
ASPIRIN - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by
mouth QDay
CALCIUM CARBONATE-VIT D3-MIN - (On Hold from [**2141-11-20**] to
unknown for hypercalcemia) - 600 mg-400 unit Tablet - 1
Tablet(s) by mouth QDay
CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D-3] - 1,000 unit Tablet,
Chewable - 1 Capsule(s) by mouth QDay
INCONTINENCE PAD, LINER, DISP [BLADDER CONTROL PAD LONG] - Pad
- Use as needed up to six times per day
SENNOSIDES [SENNA] - 8.6 mg Capsule - 1 Capsule(s) by mouth
twice a day as needed for constipation
SODIUM CHLORIDE - 0.65 % Aerosol, Spray - 1 spray IN twice a day
Discharge Medications:
1. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
2. cyanocobalamin (vitamin B-12) 1,000 mcg/mL Solution Sig: One
(1) mL Injection once a month.
3. fenofibrate nanocrystallized 145 mg Tablet Sig: One (1)
Tablet PO once a day.
4. fluticasone 50 mcg/actuation Spray, Suspension Sig: One (1)
spray each nostril Nasal twice a day.
5. Flovent HFA 110 mcg/actuation Aerosol Sig: One (1) puff
Inhalation once a day.
6. furosemide 40 mg Tablet Sig: 1.5 Tablets PO once a day.
7. labetalol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. methenamine hippurate 1 gram Tablet Sig: One (1) Tablet PO
twice a day: per other provider.
11. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO every
eight (8) hours as needed for pain.
13. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
14. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO once a day.
15. senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed for constipation.
16. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
17. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily) as needed for
constipation: may purchase over the counter as Miralax.
Discharge Disposition:
Home With Service
Facility:
suburban home care
Discharge Diagnosis:
Primary Diagnosis: Bilateral Exudative Pleural Effusions
# Esophageal ulcer/bleeding
# Acute renal failure
# Acute on chronic diastolic heart failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname 7864**],
You were admitted to the hospital because you have fluid
collections in your lungs on both sides, and the Interventional
Pulmonary doctors wanted to help stop one of those collections
(pleural effusions) from coming back by putting talc powder in
the space just outside your lungs. Unfortunately, nobody knows
why you have these pleural effusions. You are going home with a
catheter to drain this fluid, and you will have visiting nurses
to help with this fluid drainage.
While you were here, you started to have severe pain with
swallowing and were not able to eat anymore. You then started
to spit up a lot of [**Known lastname **].
Upper endoscopies (EGD) were performed, which showed an ulcer in
your esophagus. You are being treate with medication to
decrease the amount of acid in your stomach to treat this.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Please be sure to keep all of your follow up appointments as
listed below:
Department: [**Hospital3 249**]
When: THURSDAY [**2142-4-19**] at 4:10 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7869**], MD [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 5180, 5849, 2760, 5990, 2851, 4280, 2449, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3707
} | Medical Text: Admission Date: [**2147-4-20**] Discharge Date: [**2147-4-26**]
Date of Birth: [**2111-12-11**] Sex: M
Service: NEUROLOGY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Left sided weakness
Major Surgical or Invasive Procedure:
Transesophageal echocardiogram
History of Present Illness:
HPI; 35 yo M with history of HTN presenting with acute onset of
left face and arm weakness at 9:50 PM while eating dinner. He
was noted to have water spill out the side of his mouth and have
slurred speech. He was sitting and was unsure if his leg was
involved. The episode lasted five minutes and resolved
spontaneously. Shortly after he had another episode and
continued to have intermittent episodes lasting 5-10 minutes at
a
time with last one lasting up to an hour. He was taken to an
OSH
and upon presentation BP 168/116, CT head was reported to be
unremarkable, INR 1.04, plts 115, and FS was normal. His
symptoms continued to wax and wane. At midnight records
indicate
he had no deficits and then again developed left face and arm
weakness at 00:05. He was noted to have a NIHSS of 12 and given
IV TPA prior to transfer to [**Hospital1 18**] for further care. Of note at
0118 he was noted to "grip equally, moving all extremities"
prior
to transfer. He was noted by EMS to have recurrence of his
symptoms five minutes after his TPA infusion ended and minutes
prior to arrival at [**Hospital1 18**]. He currently denies headache,
nausea,
or vomiting. ROS otherwise negative.
Past Medical History:
HTN
Social History:
Lives with his girlfriend in [**Name (NI) 47**]. Works as a
construction worker. No history of smoking or illicits.
Family History:
Grandmother with a history of stroke.
Physical Exam:
VS; T 178/98 RR 13 P 80 98% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally
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. Language is fluent with intact repetition
and comprehension. Normal prosody. There were no paraphasic
errors. Able to read without difficulty. Speech was not
dysarthric. Able to follow both midline and appendicular
commands. 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. Normal saccades.
V: Decreased sensation to light touch V1-V3 on left
VII: Left facial droop
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L 0 0 0 0 0 0 0 0 0 0 0 0 0 0
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
-Sensory: Decreased to light touch and pinprick on left.
Extinguishes to DSS but inconsistently.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No dysmetria on right. Unable to assess on left
-Gait: deferred
Pertinent Results:
Admission Labs:
140 | 103 | 21
---------------< 106
3.5 | 26 | 1.0
Ca: 8.9 Mg: 2.3 PO4: 4.2
14.9
10.8 >-----< 254
42.6
CK: 87 Trop: <0.01
Multiple hypercoagulatibility and secondary hypertension studies
were performed to assess the underlying etiology:
-Normal complement levels
-[**Doctor First Name **] negative
-ANCA negative
-Tox screen negative
-Lupus anticoagulant - neg
-Aldosterone < 1
Pending results requiring follow up:
-Anticardiolipin antibodies
-Protein C/S
-AT III
-Factor V Leiden
-Metanephrines, plasma
-Prothrombin mutation
-Renin
Imaging:
NON-CONTRAST CT HEAD: There has been no significant interval
evolution over
approximately a 3/2 hour time interval of the ill-defined
hypodensities within
the right centrum semiovale, right lentiform nucleus, and right
subinsular
cortex. The remaining [**Doctor Last Name 352**]-white matter differentiation is
otherwise
preserved. There is mild hypoattenuation of the periventricular
and deep
subcortical white matter. The ventricles and cortical sulci are
normal in
size and configuration without evidence of mass effect or shift
of the
normally midline structures. There is no evidence of intra- or
extra-axial
hemorrhage. There are mucus retention cysts or polyps within
both maxillary
sinuses. There is opacification involving multiple bilateral
ethmoid air
cells, the sphenoid sinuses, and the frontal sinuses. The
mastoid air cells
and middle ear cavities are well aerated.
CTA HEAD: The right vertebral artery is dominant. The right
posterior
communicating artery is hypoplastic. The left posterior
communicating artery
is visualized. There is mild narrowing involving the
mid-to-distal M1 segment
of the right MCA. The remaining intracranial arterial
vasculature is within
normal limits. There is no evidence of aneurysm or arteriovenous
malformation.
CT PERFUSION: The perfusion images are nondiagnostic secondary
to technical
failure.
CTA NECK: The great vessel origins at the level of the aortic
arch are within
normal limits. The vertebral artery origins are patent. The
paired vertebral
arteries are normal in course and caliber without evidence of
occlusion,
flow-limiting stenosis, or dissection.
The common, internal, and external carotid arteries are normal
in course and
caliber without evidence of occlusion, flow-limiting stenosis,
or dissection.
Cross-sectional analysis of the internal carotid arteries is as
follows:
On the right: Proximal DMIN 7.0 mm; distal DMIN 4.2 mm.
On the left: Proximal DMIN 5.8 mm; distal DMIN 4.0 mm.
The lung apices are clear. The airway is patent. The thyroid
gland
demonstrates homogeneous attenuation. There are no osseous lytic
or blastic
lesions identified.
IMPRESSION:
1. Hypodensities of indeterminate age in the right centrum
semiovale, right
subinsular cortex, and right lentiform nucleus with mild
narrowing of the mid
to distal right M1 segment, which may be secondary to intrinsic
disease or
thrombus. Recommend MRI for further evaluation of acute
infarction.
2. Pansinus disease as described above, the activity of which is
to be
determined clinically.
3. No CT evidence of aneurysm, dissection, or arteriovenous
malformation.
MRI:
FINDINGS: Increased FLAIR signal of the posterior limb of the
right internal
capsule extending to involve the posterior caudate nucleus and
putamen with
corresponding diffusion restriction is consistent with acute to
early subacute
infarct. There is no intracranial hemorrhage, edema, or shift of
midline
structures. The ventricles and cerebral sulci are normal in size
and
configuration. Basal cisterns are preserved.
There is a mucous retention cyst of the right anterior maxillary
sinus, and
mucosal thickening of the ethmoid air cells, frontal sinuses and
fluid levels
in the sphenoid sinuses. The mastoid air cells are clear.
IMPRESSION:
1. Acute to early subacute infarct of the posterior limb of the
right
internal capsule, extending into the posterior caudate nucleus
and putamen.
Discussed by Dr. [**Last Name (STitle) 20059**] with Dr. [**Last Name (STitle) 7594**] on [**2147-4-20**] at
3 p.m.
2. Pansinus disease.
Carotid Dopplars:
Findings: Duplex evaluation was performed of bilateral carotid
arteries. On
the right and the left there is no plaque seen.
On the right systolic/end diastolic velocities of the ICA
proximal, mid and
distal respectively are 69/30, 51/23, 51/23 cm/sec. CCA peak
systolic
velocity is 86 cm/sec. ECA peak systolic velocity is 74 cm/sec.
The ICA/CCA
ratio is .8. These findings are consistent with no stenosis.
On the left systolic/end diastolic velocities of the ICA
proximal, mid and
distal respectively are 83/28, 58/27, 57/28 cm/sec. CCA peak
systolic velocity
is 109 cm/sec. ECA peak systolic velocity is 100 cm/sec. The
ICA/CCA ratio is
.76. These findings are consistent with no stenosis.
Right vertebral antegrade artery flow.
Left vertebral antegrade artery flow.
Impression: Right ICA no stenosis.
Left ICA no stenosis.
Multiple hypercoagulatibility and secondary hypertension studies
were performed to assess the underlying etiology:
-Normal complement levels
-[**Doctor First Name **] negative
-ANCA negative
-Tox screen negative
-Lupus anticoagulant - neg
-Aldosterone < 1
Pending results requiring follow up:
-Anticardiolipin antibodies
-Protein C/S
-AT III
-Factor V Leiden
-Metanephrines, plasma
-Prothrombin mutation
-Renin
Carotid series [**4-21**]:
Impression: Right ICA no stenosis.
Left ICA no stenosis.
Renal ultrasound [**4-21**]:
IMPRESSION:
1. No evidence of hydronephrosis, or renal stone.
2. No evidence of renal artery stenosis bilaterally.
TTE [**4-21**]:
Conclusions
The left atrium is normal in size. No atrial septal defect or
patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF 60%). Right ventricular chamber size and free wall motion
are normal. The aortic root is mildly dilated at the sinus
level. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion
TEE [**4-24**]:
The left atrium and right atrium are normal in cavity size. No
spontaneous echo contrast or thrombus is seen in the body of the
left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. No atrial septal defect or patent
foramen ovale is seen by 2D, color Doppler or saline contrast
with maneuvers (though prominent inflow from the inferior vena
cava directed towards the interatrial septum by the Eustachian
valve seems to blunt the amount of superior vena caval inflow
that comes in contact with the interatrial septum). There is
mild symmetric left ventricular hypertrophy with normal cavity
size and global systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The ascending,
transverse and descending thoracic aorta are normal in diameter
and free of atherosclerotic plaque to 40 cm from the incisors.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic stenosis. No masses or
vegetations are seen on the aortic valve. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. No mass or vegetation
is seen on the mitral valve. No vegetation/mass is seen on the
pulmonic valve.
IMPRESSION: No cardiac source of embolism. No evidence of atrial
septal defect or patent foramen ovale with saline contrast and
maneuvers. No significant valvular abnormality. Normal thoracic
aorta to 40 cm from the incisors.
If exclusion of a PFO is a clinical necessity, injection of
saline via a femoral vein might help to completely exclude a
PFO.
Brief Hospital Course:
35 yo M with history of HTN presenting with acute onset of left
face and arm weakness at 9:50 PM while eating dinner. Symptoms
have had a stuttering course and he was given IV TPA for NIHSS
12 prior to transfer. He was called as a CODE
STROKE for recurrence of his deficits shortly after infusion of
tPA and minutes prior to arrival to [**Hospital1 18**]. His examination is
notable for a dense left hemiplegia as well as decreased
sensation on the left.
#Neuro: He received IV tPA prior to transfer, so was initially
admitted to the Neuro ICU. He underwent an MRI which confirmed
the presence of a posterior limb of the right internal capsule
infarct, extending into the posterior caudate nucleus and
putamen. He had a carotid dopplers, as well as a CTA of the
head and neck which showed no signs of vascular occlusion.
TTE and TEE were peformed (see above) which failed to show a
PFO, ASD, right to left shunt or a source of an embolism.
Echocardiograms were notable for mild symmetric left ventricular
hypertrophy with normal cavity size and global systolic function
(LVEF>55%) suggestive of prior hypertension. The ascending,
transverse and descending thoracic aorta were normal in diameter
and free of atherosclerotic plaque.
Fasting lipids showed LDL of 121 and an A1C was 5.1. Patient
was started on Simvastatin.
It was thought that his infarct was secondary to hypertension,
however possibility of an embolic infarction (though no clear
source was identified) which can occur in up to many patients
with this presentation could not be ruled out. Given his risk
of stroke recurrence (3-5% per year) and age, he was started on
coumadin daily (goal INR [**1-25**]) with ASA bridge until therapeutic.
He will require further monitoring of INR, at time of discharge
was 1.1 (coumadin initiated on [**4-24**] at 5mg daily and may need
adjustment). He will require follow up with Dr. [**Last Name (STitle) **] of
neurology at [**Hospital1 18**] which was arranged.
#CV: The patient was hypertensive on admission, and reported
that this was a problem his PCP had been following for several
years, recommended dietary changes at this time. Given his
relatively young age, he underwent an evaluation for secondary
causes of hypertension, including a renal ultrasound which
showed no signs of renal artery stenosis, and plasma renin,
aldosterone and metanephrines which are pending at time of
discharge. Given persistently elevated SBPs (150-170s) mmHg
even 4 days after the CVA, he was started on Lisinopril 10mg
daily. No significant response was noted after 2 days of
therapy, thus dose was increased to 20mg daily on [**4-26**]. No
change in Cr was observed after tx initiation. This will
require follow up. His eventual goal of BP is 130/80 and should
be achieved within 1-2 months after his CVA.
Due to LDL of 127 and CVA, he was started on Simvastatin to
control the RFs.
The following studies will require follow up (pending at [**Hospital1 18**]):
-Anticardiolipin antibodies
-Protein C/S
-AT III
-Factor V Leiden
-Metanephrines, plasma
-Prothrombin mutation
-Renin level
Neurological exam notable for:
Alert, oriented to time, place person. Language intact.
CNs: L facial droop, mild Leftward tongue deviation (due to
facial)
Motor: RUE and RLE full in strength. LUE flaccid. LLE: [**2-24**] IP,
[**1-27**] Hamstring, [**1-27**] quadriceps, Remainder is 0/5.
Tone: Flacid in LUE, LLE mildly increased relative to LUE.
DTRs 3+ at L biceps, triceps, patella.
Toes: extensor bilaterally.
Sensory: intact LT, proprioception.
Extinction on the LEFT with DSS.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for rash in armpit.
7. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
9. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. 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.
11. HydrALAzine 10 mg IV Q6H:PRN SBP>180
Discharge Disposition:
Extended Care
Facility:
[**Hospital 38**] Rehab in [**Location (un) 1110**]
Discharge Diagnosis:
Primary: Right Anterior Choroidal Artery
Secondary: Hypertension, Hyperlipidemia
Discharge Condition:
Neurological exam notable for:
Alert, oriented to time, place person. Language intact.
CNs: L facial droop, mild Leftward tongue deviation (due to
facial)
Motor: RUE and RLE full in strength. LUE flaccid. LLE: [**2-24**] IP,
[**1-27**] Hamstring, [**1-27**] quadriceps, Remainder is 0/5.
Tone: Flacid in LUE, LLE mildly increased relative to LUE.
DTRs 3+ at L biceps, triceps, patella.
Toes: extensor bilaterally.
Discharge Instructions:
You were admitted to the hospital after sudden onset left sided
weakness. You were found to have a significant stroke in the
right side of your brain.
You underwent a thorough evaluation for the source of this
stroke (detailed in discharge summary). After a thorough
evaluation, we were unable to identify a definite source of the
stroke, however, it was felt that it was due to hypertension and
a possible embolic source. Because of this, you were started on
the following medications:
- Coumadin 5mg daily
- ASA 325mg until coumadin is therapeutic range (INR [**1-25**])
- Simvastatin 20mg
- Lisinopril 20mg
- Bowel regimen, pain regimen as per your rehabilitation
physician
Because of the aftermath from your stroke, you will require
extensive rehabilitation. You were discharged to such a
facility
There are still tests pending that will require follow up:
Followup Instructions:
Please follow up with the following providers:
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2147-6-27**] 1:00
Please call the PCP's office to arrange for a follow up
appointment in 1month from your discharge:
Name: [**Last Name (LF) **],[**First Name3 (LF) **]
Address: [**Location (un) **] [**Apartment Address(1) 5524**], [**Location (un) **],[**Numeric Identifier 7331**]
Phone: [**Telephone/Fax (1) 7401**]
Fax: [**Telephone/Fax (1) 7400**]
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
Completed by:[**2147-4-26**]
ICD9 Codes: 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3708
} | Medical Text: Admission Date: [**2122-1-14**] Discharge Date: [**2122-2-6**]
Date of Birth: [**2057-2-17**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Fentanyl / Oxycodone / Meperidine
Attending:[**First Name3 (LF) 11040**]
Chief Complaint:
ARDS seconrday to septic shock
Major Surgical or Invasive Procedure:
Tracheostomy and G-tube placement.
History of Present Illness:
Ms. [**Known lastname 69940**] is a 64 year old woman with HTN, RA, Type 2 DM
admitted to OSH on [**1-10**] with confusion, chills, fevers to 103
and a week of green sputum found to have PNA on CXR,
hypotension, and hypoxic respiratory failure. She was intubated
in ED, started on dopamine, and transfered to the ICU. She ruled
in for NSTEMI. She was switched to Norepinephrine (per cards)
and hydrocort. She also received Xigris. Within 24 hours her HCT
dropped from 35% to 28% and Xigris was stopped. Pt was initially
on Ceftriaxone and Azithro which was changed to Levoquin Vanco
and Clinda which was stopped on [**1-14**]. Due to possible [**Location (un) **]
exposure, Doxycycline was also started. She went into A flutter
with RVR and was cardioverted once unsuccessfully at the OSH.
She was started on Diltiezem drip for rate control. For ? PCP
PNA, she was started on high dose Bactrim as well. Throughout
her OSH course she developed an increasing O2 requirment, and
there was concern for ARDS with increasing difficulty in
ventilation. Her last ABG on transfer was 7.30/45/51 sating 88%
on 100%FiO2; IMVO 14; PEEP 8; Tv 700. She was transfered here
for further management.
.
PCP: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Past Medical History:
RA- Stopped Methotrexate 5 months ago for a "reverse effect"
according to notes. Maintained on 20mg Prednisone daily
HTN
NIDDM
GERD
Social History:
Lives with husband, quit smoking 23 years ago, occasional wine,
no drug use.
Family History:
Non-contributory
Physical Exam:
PE: Admitted intubated, on rotating bed
T:36.9 HR:104 BP:133/51 (off pressors) RR:19 90% O2 Sats
Wt:98.6kg
AC Tv:400 FiO2:100% Peep:15 PP:24
Gen: intubated, sedated
HEENT: ET tube in place
NECK: unable to asses JVP 2/2 habitus
CV: Regular Rate and rhythym, occasional PVCs.
LUNGS: course BS anteriorly/laterally
ABD: Soft, NT, ND. NL BS.
EXT: No edema. 2+ DP pulses BL
SKIN: No lesions
Pertinent Results:
[**2122-1-14**] 11:03PM PT-12.9 PTT-27.2 INR(PT)-1.1
[**2122-1-14**] 11:03PM PLT COUNT-268
[**2122-1-14**] 11:03PM WBC-15.9* RBC-3.81* HGB-11.4* HCT-31.7*
MCV-83 MCH-30.1 MCHC-36.1* RDW-16.8*
[**2122-1-14**] 11:03PM CALCIUM-5.9* PHOSPHATE-1.9* MAGNESIUM-2.1
[**2122-1-14**] 11:03PM estGFR-Using this
[**2122-1-14**] 11:03PM GLUCOSE-275* UREA N-30* CREAT-0.9 SODIUM-138
POTASSIUM-3.8 CHLORIDE-108 TOTAL CO2-22 ANION GAP-12
[**2122-1-14**] 11:09PM freeCa-0.72*
[**2122-1-14**] 11:09PM LACTATE-2.3*
[**2122-1-14**] 11:09PM TYPE-ART PO2-69* PCO2-45 PH-7.38 TOTAL CO2-28
BASE XS-0
.
OSH MICRO DATA:
Mycoplasma IgG - posative
Blood Cx [**1-10**] - Gm posative cocci, speciation/sensis pending
Legionella - negative
Strep Pneumo antigen - negative
RSV - negative
Influenza A/B - negative
.
STUDIES: CXR - has large left pulmonary infiltrate
.
[**1-21**] CT abd/pelvis:
1. Uncomplicated pancreatitis with no evidence of abscess or
fluid collection.
2. Pleural effusions, left greater than right, with
consolidation in the right lower lobe consistent with pneumonia.
3. Old fractures of the pelvis.
Brief Hospital Course:
# Hypoxic Respiratory Failure - Secondary to mycoplasma PNA for
which she completed 14 day course of levofloxacin, evolved to
ARDS from sepsis. Subsequently complicated by likely ventilator
associated pneumonia, culture and bronchial lavage negative,
empirically treated with a course of Vancomycin and Cefepime.
Also, complicated by severe polyneuropathy from likely critical
care neuropathy. NIF was measured and was in the 30s range. Pt
was weaned to PS 5/0 on the 13th day of hospitalization and
extubation was attempted. However the patient became
increasingly tachypneic and agitated about 12 hours after
extubation and was reintubated. Failure was thought to be due to
respiratory muscle fatigue, poor underlying lung function in the
context of pneumonia, possible component of volume overload. A
tracheostomy was placed the next day as well as a PEG tube. She
was successful with trach mask trials several days after trach
placement on high flow O2. She was successful for > 12hours
daily, but on several occasions became tachypneic in the
evening, thought to be influenced largely by anxiety rather than
fatigue, requiring placement back on PS overnight. She was,
however, trialed for 24 hours on trach mask and was fatigued the
following day requiring full 24 hours back on PS. This was
likely [**3-6**] to true respiratory muscle fatigue.
.
# PNA: From mycoplasma, treated with 14 day course of
levofloxacin. Subsequently complicated by likely ventilator
associated pneumonia, culture and bronchial lavage negative,
empirically treated with a course of Vancomycin and Cefepime.
.
# Septic shock: Lactate on admission 2.3, hypotension, elevated
WBC with 2 bands, tachypnea and tachycardia. Initially with
pressor requirement. Initial broad spectrum Abx were
discontinued once source of sepsis was found to be due to
mycoplasma and a course of 14 days of Levofloxacin was
completed. The patient also was treated with stress dose
steroids initially, which were subsequently weaned to baseline
Prednisone dose for chronic RA of 20mg.
.
# Clostridium difficile infection: diagnosed on [**1-22**]. Pt. will
complete a 7 day (post other antibiotics) course of flagyl
(flagyl course to be completed on [**2122-2-6**] after receiving her tid
dosing that day). Diarrhea is much improved.
.
# Pancreatitis: Thought [**3-6**] to propofol originally with
elevated amylase and lipase. Once her propofol was d/c'd, her
amylase normalized. Her lipase decreased, but remained elevated
in the 150s. Other LFTs were normal. Her tube feeds were held
transiently when her lipase failed to completely resolve and she
had mild epigastric discomfort. Given that her epigastric
discomfort was post G tube placement, it resolved and tube feeds
were reinitiated. She did have high residuals so was not
originally at goal. Reglan was started and tube feeds were
advanced. She is now tolerating tube feeds at goal without
reglan.
.
# Critical illness neuropathy: severe distal weakness, slight
improvement towards the end of her hospital stay. EMG and nerve
conduction studies showed mild, proximal myopathy with a
superimposed geneneralized polyneuropathy, predominantly axonal.
The picture is consistent with critical illness polyneuropathy
and myopathy. Her strength has been consistently increasing,
but deficit remains. She will need continued physical therapy
for this.
.
# Rash, eosinophilia: During her course of cefepime and
vancomycin she developed a rash and eosinophilia. Once her 7
day course of cefepime and vanco was complete, her rash resolved
although she remained mildly subjectively itchy requiring
fexofenadine. Her eosinophils remained elevated, but this also
started to resolve. There was no other clear drug source and
suspiscion for infective cause was very low.
.
# Low grade fever: Intermittent low grade fever to Tmax of
100.2. She has BAL, Urine and blood cultures pending from
[**2122-2-5**], but suspiscion for infection is low given normal WBC
count and no left shift on diff. These cultures should be
followed up.
.
# Rheumatoid arthritis: Patient was transiently on stress dose
steroids in the setting of sepsis. Steroids were reduced to her
home dose of 20mg PO prednisone with the resolution of sepsis.
The need for PCP prophylaxis was discussed given chronically on
20mg prednisone daily. The need for this dose in the setting of
her RA and PCP prophylaxis was discussed with her rheumatologist
and her dose of prednisone was decreased to 15mg po prednisone
as she is not currently complaining of joint symptoms. She was
not started on bactrim while inpatient and if her chronic
prednisone dose requirement increases, this should be
readdressed. Additionally, given her age, sex and chronic
prednisone, she was started on vitamin D and calcium.
.
# Anemia with hct drop: HCT has been stable 24-26 from original
drop from 29-31. Anemia w/u included abd CT not revealing for
bleed. LDH is elevated, haptoglobin elevated as well, but this
is in the setting of inflammation and, thus may not reflect
accurately hemolysis. Stools were guaiac negative. Iron
revealed normal iron, elevated ferritin, and low TIBC c/w ACD.
.
# Depression: Patient has a history of depression and was on
elavil previously. She is not sure why this was discontinued
originally. While hospitalized, she was experiencing low mood
and general anxiety. Thus, celexa was started at 20mg daily on
[**2122-1-31**]. This can be titrated as appropriate upon discharge.
.
# Hypertension: after hypotension in the context of sepsis has
resolved, the patient hypertension which was controlled with
Labetalol and Captopril. She did require occasional fluid bolus
in setting of negative fluid status and low UOP and transient
hypotension, to which her BP responded well.
.
# A-Flutter: transient episodes in the context of high
adrenergic state after acute sepsis resolved. Hemodynamically
stable and was in NSR for > 1week prior to discharge, continued
on BB.
.
# Steroid induced hypergylcemia: transiently on glargine, then
changed to Regular SS only as steroids were weaned. Her blood
sugars have been well controlled. She has not been requiring SS
coverage, but this should be initiated if glucose control
worsens.
# FEN: PEG tube in place. Tube feeds restarted after PEG tube
placement on [**2122-1-29**].
.
# PPx: Heparin SQ, PPI
.
# CODE: Full Code
Medications on Admission:
MEDS on Transfer:
Doxycycline 100mg [**Hospital1 **]
Lopressor 2.5mg IV q4' and 5mg IV q6'
ASA 81mg daily
Zithromax 500mg IV Daily (started [**1-14**]- one dose given)
Bactrim 400mg IV q8' (started [**1-14**]- one dose given)
Solumedrol 60mg IV q6' (was 125mg IV q6hour until [**1-13**])
Fludrocortisone 0.1mg NGT Daily
Reglan 5mg IV q8'
Vancomycin 1gm IV q12' (started [**1-14**]- got one dose)
Digoxin 0.125mg Daily NG since [**1-12**]
Lovenox 40mg SC Daily
Nexium 40mg Daily
Lantus 20u SC daily
Lopid 300mg via NG [**Hospital1 **]
RISS
Ativan PRN
Tylenol ORN
Morphine PRN
Levaquin 500mg IV Daily (started [**1-10**])
Discharge Medications:
1. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
2. Nystatin 100,000 unit/mL Suspension [**Last Name (STitle) **]: Five (5) ML PO QID
(4 times a day) as needed.
3. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol [**Last Name (STitle) **]: Six
(6) Puff Inhalation Q4H (every 4 hours) as needed for when on
vent.
4. Albuterol 90 mcg/Actuation Aerosol [**Last Name (STitle) **]: Six (6) Puff
Inhalation Q4H (every 4 hours) as needed for when on vent.
5. Insulin Regular Human 100 unit/mL Solution [**Last Name (STitle) **]: See sliding
scale for appropriate dosing Injection ASDIR (AS DIRECTED).
6. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1)
Injection TID (3 times a day).
7. Trazodone 50 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO HS (at bedtime) as
needed.
8. Captopril 12.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3 times
a day).
9. Labetalol 200 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO TID (3 times a
day).
10. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
11. Acyclovir 5 % Ointment [**Last Name (STitle) **]: One (1) Appl Topical 6X/D (6
times a day).
12. Citalopram 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
13. Albuterol Sulfate 0.083 % Solution [**Last Name (STitle) **]: [**2-3**] Inhalation Q4H
(every 4 hours) as needed for shortness of breath, wheeze.
14. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Month/Day (2) **]: Two (2)
Tablet PO DAILY (Daily).
15. Calcium Carbonate 1,250 mg/5 mL(500 mg) Suspension [**Month/Day (2) **]: Ten
(10) ML PO TID (3 times a day).
16. Metronidazole 500 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO TID (3
times a day) for 2 doses: to complete 3 doses on [**2122-2-6**] and then
to be discontinued.
17. Prednisone 5 mg Tablet [**Date Range **]: Three (3) Tablet PO DAILY
(Daily).
18. Heparin Lock Flush (Porcine) 100 unit/mL Syringe [**Date Range **]: [**2-3**]
MLs Intravenous DAILY (Daily) as needed.
19. Ativan 1 mg Tablet [**Month/Day (2) **]: 0.5-1 Tablet PO every 4-6 hours as
needed for anxiety.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]
Discharge Diagnosis:
Primary:
1. Hypoxic respiratory failure requiring intubation now s/p
tracheostomy and PEG
2. Community acquired pneumonia
3. Ventilator associated pneumonia
4. ARDS
5. Pancreatitis
6. Depression
7. Rheumatoid arthritis
8. Polyneuropathy and myopathy of critical illness
9. Anemia
10. Clostridium difficile colitis
Discharge Condition:
Stable, had been tolerating trach mask, currently on pressure
support and tolerating well.
Discharge Instructions:
Return to the emergency room if you develop fever, chills, if
diarrhea persists or worsens post antibiotic course, worsening
abdominal pain, nausea, inability to advance tube feeds.
.
Please take your medications as prescribed. Please note we have
started you on the antidepressant celexa. Additionally, we have
decreased your prednisone for rheumatoid arthritis to 15mg
daily. If your dose increases chronically from this, you should
discuss with your doctor the need for PCP [**Name Initial (PRE) 1102**].
Followup Instructions:
Please follow up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 69941**]t when appropriate from rehab.
ICD9 Codes: 5119, 486, 4280, 5849, 4019, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3709
} | Medical Text: Admission Date: [**2197-2-12**] Discharge Date: [**2197-3-4**]
Date of Birth: [**2137-12-26**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3531**]
Chief Complaint:
Dyspnea.
Major Surgical or Invasive Procedure:
Inferior vena cava filter placement.
History of Present Illness:
Mrs. [**Known lastname **] (aka "[**Known firstname 17563**]") is a 59 year old lady with a history
of breast cancer (s/p mastectomy) and PEs in [**2189**] who presented
to an OSH ED on [**2197-2-12**] unresponsive after having a productive
cough for five days. In the field, she had an O2 sat of 47%. In
the OSH ED, CXR showed LUL PNA with T of 100.3. Initial labs
were notable for CK 49, CKMB 12, TropI 0.06, ABG 7.31/78/19. She
was started on CTX/Azithro for CAP and put on BiPAP and
transferred to [**Hospital1 18**]. In the [**Hospital1 18**] ED, she was weaned to an NRB
and maintained her mental status. She had hemoptysis but was
guiac negative. CT showed large bilateral PEs. She received ASA
325mg PO x1, heparin IV, 1LNS, and albuterol and ativan for
respiratory distress.
Mrs. [**Known lastname **] was transferred to the MICU with VS 99.5, 94, 121/86,
12, 92%NRB. She was awake and responsive, but lethargic. She
reported feeling fine but was unclear why her husband brought
her to the hospital.
In the ICU, on [**2-12**], her oncologist Dr. [**Last Name (STitle) 19**], was emailed about
the possibility of Mrs. [**Known lastname **]' letrozole being responsible for
her PEs. He wrote back saying OK to hold letrozole for now but
that it was unlikely the etiology. Her IV heparin was changed to
lovenox, and her diet was advanced, given her hemodynamic
stability. She was nervous and sleepless most of the night, and
called her sister repeatedly (who then called the unit). The
patient appeared to be in opiate withdrawal, so oxycodone was
increased but remained below her total home dose.
On [**2-13**], Mrs. [**Known lastname **] still required 6L of NC to maintain O2 sat in
low 90s. She remained very anxious about her narcotic regimen,
so oxycontin 20 mg [**Hospital1 **] was added. Metoprolol was held in the
setting of R heart strain; captopril 6.25mg TID was started
because SBP increased to 160s. Her husband asked for narcotics
for himself, and the house officer refused.
On [**2-14**] she was going to be called out but was still requiring
5-6L O2. She also had a mechanical fall. She was very anxious
about leaving the ICU.
She improved overnight and was called out on [**2197-2-15**]. Vitals on
transfer were: HR: 91, BP: 159/106, O2Sat: 91-97% on 2-3L NC.
Past Medical History:
Breast CA s/p left mastectomy in [**2193**]
Chemotheraphy neuropathy, and resultant narcotics addiction
Nephrolithiasis
Chronic pain
Depression/anxiety
Pulmonary emboli in [**2189**]
Social History:
Drinks ~6 oz Vodka daily
Smokes: [**12-12**] cigarettes daily for many years
Lives with husband in [**Name (NI) 6687**]
Narcotics abuse (prior to admission her PCP was prescribing
[**Name9 (PRE) 16604**] 40mg PO QID)
Family History:
Mother had bilateral breast cancer. No other breast or ovarian
cancers
Father died at age 69. He had a history of arrhythmia
She denies any other history of clotting disorders
Her maternal mother died at age 69 of a brain aneurysm
Her paternal grandmother died at age 45 from stomach cancer
Physical Exam:
(On admission)
VS: 96.9 102/58 94 14 95% NRB; 91% 5L NC
GEN: Tearful, alert and oriented, intermittently pausing during
speech, overall comfortable appearing.
SKIN: Red skin, worse with coughing
HEENT: No JVD, neck supple, No lymphadenopathy appreciated
CHEST: Wheezes in all lung fields, L sided rhonchi.
CARDIAC: S1 & S2 regular without murmur, Left mastectomy
ABDOMEN: Tender with guarding but not tense or rigid. Bowel
sounds present.
EXTREMITIES: Tender L calf, bilateral edema, warm without
cyanosis
NEUROLOGIC: Alert and appropriate, tearful. CN II-XII grossly
intact.
.
(On discharge)
Gen: NAD.
Skin: some bruising on abdomen and upper extremities from
enoxaparin injections.
Chest: CTAB with no adventitious sounds.
CV: RRR without murmurs.
Abdomen: +BS, soft, nontender, nondistended (bruising as above).
Ext: Resolving ecchymoses on left medial thigh/groin and
posterior right leg. No edema, warm, well perfused.
Neuro: A&Ox3, grossly intact.
Psych: Anxious at times, but overall positive affect and goal
directed thinking.
Pertinent Results:
Admission labs:
[**2197-2-12**] WBC-8.3 HGB-14.7 HCT-45.0
[**2197-2-12**] NEUTS-78.5* LYMPHS-13.0* MONOS-7.6 EOS-0.6 BASOS-0.2
[**2197-2-12**] GLUCOSE-141* UREA N-13 CREAT-1.0 SODIUM-139
POTASSIUM-4.1 CHLORIDE-96 TOTAL CO2-31
.
Discharge labs:
[**2197-3-3**] WBC-8.3 Hct-36.2 Plt Ct-412
[**2197-3-3**] PT-19.4* PTT-102.6* INR(PT)-1.8*
[**2197-3-3**] Glucose-134* UreaN-11 Creat-0.7 Na-138 K-3.8 Cl-101
HCO3-26 [**2197-2-22**] ALT-15 AST-29 LD(LDH)-220 AlkPhos-46
TotBili-0.8
.
Relevant studies:
[**2197-2-12**] Echo - Right ventricular cavity enlargement with free
wall hypokinesis c/w pulmonary embolism.
.
[**2197-2-13**] Echo - Compared with the prior study (images reviewed) of
[**2197-2-12**], right ventricular cavity size is smaller and free wall
motion is more vigorous.
.
[**2197-2-12**] ECG - Sinus rhythm. There are non-diagnostic Q waves in
the inferior leads. Non-specific ST-T wave changes. Compared to
the previous tracing these findings are new.
.
[**2197-2-12**] CT Chest -
1. Bilateral, multifocal segmental PE, with significant clot
burden resulting in right heart strain. Emboli are seen in
vessels supplying the right upper, middle and lower lobes, and
the lingula, with extension of embolic material into multiple
peripheral vessels supplying both lungs. There are prominent
subsegmental PE in vessels supplying the posterior left lower
lobe.
2. Enlarged right ventricle and straightened intraventricular
septum
consistent with right heart strain. No pulmonary infarct at this
time.
3. Heterogeneous peribronchovascular nodules in the left upper
lobe, could
reflect hemorrhage or infectious etiology. Unlikely to represent
infarct.
Recommend re-imaging after treatment for PE.
.
[**2197-2-13**] CXR - Portable AP chest radiograph was compared to chest
CT from [**2197-2-12**]. The current study demonstrates known
opacities in the left perihilar area consistent with known
infection. Cardiomegaly is unchanged. Mediastinal position,
contour and width are stable. There is no interval development
of appreciable pleural effusion and there is no pneumothorax.
Brief Hospital Course:
Mrs. [**Known lastname **] is a 59 year old woman found unresponsive found to
have large bilateral PEs and a LUL PNA. She was transferred from
another hospital to [**Hospital1 18**] where she was admitted to the MICU on
[**2197-2-12**]. She was transferred to the general medicine floor for
several days and was discharged on [**2197-2-21**].
.
# Pulmonary Emboli/Left thigh hematoma: The patient had
extensive bilateral PEs with hypoxia intially requiring 5L NC.
She remained hemodynamically stable throughout her admission.
Underlying contributing factors include obesity, smoking,
history of PEs, and malignancy. She may also have a hereditary
coagulopathy. Heparin gtt was started in the ICU. LENIs were
negative for DVT. Echo showed evidence of right heart strain and
RV hypokinesis. When hemodynamics remained stable for several
hours, heparin was switched to lovenox. Oxygen requirement
improved to 3L NC prior to call-out to the medical service.
On the medicine floor, Mrs. [**Known lastname **] remained stable and she no
longer had an oxygen requirement by the week before discharge.
Around [**2-20**] the patient developed a large left groin/thigh
hematoma. On ultrasound on [**2197-2-21**] thigh u/s showed the
hematoma to be 8 x 5 x 8 cm. She had a [**4-14**] point hematocrit
drop, that intially remained stable but on [**2-24**], her hematocrit
droppeed from 29 to 25. Her thigh was re-ultrasounded and at the
time the hematoma measured 14 x 7.6 x 6.4 cm. Because of the
hemaocrit drop and increasing size of hematoma, her lovenox was
stopped. She had an IVC filter placed. Upper extremity
ultrasound showed DVT in the distal left brachial veins. CT
angiogram of the thigh showed no active extravasation of blood.
From [**Date range (3) 69967**] she was off anticoagulation. Her hct was
stable over these 3 days, so on [**2197-2-27**] she was started on a
heparin drip, intially with low goal PTT of 50-70, her hct was
stable, and goal was increased to 80. She was started on
coumadin on [**2197-3-1**] 7.5mg the first day and then [**Date range (1) 26123**], she
recieved 5mg coumadin.
Her INRS:
[**3-3**] 7am: 1.8
[**3-4**] 6am: 2.2
[**3-4**] 12pm: 2.6
She recieved 1 lovenox injection prior to leaving the hospital
in order to completw 24 hour of overlap between therapeutic PT
with heparin/lovenox.
She was discharged with plan for 4mg coumadin until she ses her
PCP on Tuesday [**3-7**]. Given her bleeding earlier in the hospital
course, her goal INR is 2-2.5, and she was instructed to return
to the hospital with any bleeding, lightheadedness, new hematoma
formation.
We have also made f/u appointments for Ms. [**Known lastname **] with pulmonary
in [**Month (only) **] to follow up the PE and with Interventional radiology to
remove the IVC filter (also in [**Month (only) **]).
.
# Pneumonia: The patient had evidence of a LUL PNA on outside
hospital CXR, positive sputum. She was afebrile with no
leukocytosis. Torso CT at [**Hospital1 18**] confirmed LUL PNA. Courses of
ceftriaxone (7 days) and azithromycin (5 days) were completed.
Blood and sputum cultures were negative.
On Monday, [**2197-2-20**], Mrs. [**Last Name (STitle) **] had a fever of 101 degrees. She then
had a nebulizer treatment and incentive spirometry to see if
this reduced her temperature. She also had a repeat chest xray
and blood cultures and urinalysis sent. All cultures were
negative, and the fever was thought to be from the hematoma.
.
# COPD flare: The patient was started on prednisone 60mg daily
burst and this was stopped after five days without consequence.
She received standing ipratropium nebs Q6H and albuterol nebs
PRN. As an outpatient she will likely need PFTs when she
recovers from her acute illness.
.
# Alcohol/Opiate Abuse: The patient has a history of alcohol and
opiate abuse to which she readily admits. Last drink was the day
prior to admission. She was given thiamine/folate. She was on a
CIWA scale with lorazepam and did not demonstrate any signs of
withdrawal. She was intially given oxycodone 10 mg q4h as needed
for pain control given high dose opiate use at home. She later
demonstrated symptoms of withdrawal, and this was uptitrated to
her total home dose of long- and short-acting opiates. On the
medicine floor, she was restated on her home dose of oxycontin
40mg PO QID with good effect. On [**2197-2-22**], the patient was found
to be unresponsive. She responded to narcan IV. On further
questioning, her husband her brought her extra doses of
Oxycontin from home, which she he had taken earlier that
evening. Her head CT was negative. The patients oxycontin was
held intially. On [**2197-2-25**] she showed signs of narcotic
withdrawal-- crampy abdominal pain, tremor, diarrhea, nausea; so
was started on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] scale, given 10mg PO oxycodone for [**Doctor Last Name **]
>10. FOr the first few days, she required 10mgPO about 3 times a
day. After several days on this regimen, she was was switched to
10mg PO Oxycodone twice daily standing. Then, on [**2197-3-3**], this
was decreased to Oxycodone 5mg three times a day standing. The
patient is intersted in detox programs, and is being dicharged
with enough 5mg oxycodone pills to last her until her PCP
[**Name Initial (PRE) 648**].
.
# Breast Ca: history of breast CA, seen by Dr. [**Last Name (STitle) 19**], thought to
be without recurrence. Letrozole was held given rare side
effect of DVT. Dr. [**Last Name (STitle) 19**] was contact[**Name (NI) **] and agreed with stopping
letrozole temporarily.
.
# Depression: Patient demonstrated considerable emotional
lability. Paxil was continued. Social work was consulted.
.
# HTN: Mrs. [**Known lastname **] received her home dose of metoprolol during
her stay. She was also started on lisinopril 5mg PO daily. Her
pressures remained stable throughout admission.
.
# Chemotherapy Neuropathy: Neurontin was continued. Lasix was
held given inital concern for hemodynamics. It was later
restarted at her home dose without problems.
.
Code status was discussed and patient refused to decide code
status. Thus, she remained full code.
.
CONTACT: [**Name (NI) 4906**] [**Name (NI) **] [**Name (NI) 23657**] [**Telephone/Fax (1) 69968**]; Sister [**Name (NI) **]
[**0-0-**]
Medications on Admission:
Medications at home:
Lasix 20mg PO daily
Neurontin 600mg PO QID
Letrozole 2.5mg PO daily
Ativan 2mg PO QID
Metoprolol XL 25mg PO daily
Oxycodone 40mg PO QID
Paroxetine 20mg PO daily
ASA PRN
Thiamine 100mg PO daily
Discharge Disposition:
Home
Discharge Diagnosis:
Bilateral pulmonary emboli.
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
You were admitted to [**Hospital1 18**] from [**2197-2-12**] until [**2197-2-20**] for
evaluation and treatment of your pulmonary embolism. You were
in the medical intensive care unit for several days before being
transferred to the general medicine floor. You were discharged
on Monday, [**2197-2-20**].
The following addition was made to your outpatient medications:
- Enoxaparin 150 mg/mL Syringe Sig: One (1) Subcutaneous Q12H
(every 12 hours).
- Lisinopril 5mg daily
- Oxygen
Followup Instructions:
Please schedule a followup appointment with your oncologist, Dr.
[**Last Name (STitle) 19**], within one to two weeks.
.
Please schedule a followup appointment with your primary care
physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 3403**] [**Last Name (NamePattern1) **] within two weeks. Call
[**Telephone/Fax (1) 52946**].
Completed by:[**2197-3-6**]
ICD9 Codes: 486, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3710
} | Medical Text: Admission Date: [**2149-7-29**] Discharge Date: [**2149-8-3**]
Date of Birth: [**2104-5-6**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5810**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
45 year-old male with chronic pancreatitis (on TPN for last 2.5
months) presents with abdominal pain, nausea, and vomiting that
began at 2:00 AM on the morning of admission. Emesis was
non-bloody. Pt had fever and rigors at home. Denies
constipation, diarrhea, blood per rectum or melena, cough, chest
pain, or shortness of breath, erythema, pain, or discharge from
around PICC line (placed 2.5 months ago for TPN).
Initial VS in ED: T 100.7, HR 110, BP 124/68, RR 18, O2 100% on
room air. He developed severe pain and a drop in SBP to 80's.
PICC pulled for concern of possible line-associated infection.
Vancomycin given, then patient developed Temp 104 with rigors,
so Zosyn added. CT Abdomen and Pelvis was unremarkable. Bedside
echo by ED team was also unremarkable. Patient received 6L NS in
ED.
Patient admitted to the ICU for management of presumed sepsis.
In the ICU, patient continued on Vanco and Zosyn. He developed
RUQ abdominal pain with elevated AST/ALT, but normal Alk Phos
and T. Bili are normal. Patient states on the afternoon of [**7-30**]
in the ICU, the he had a sudden decrease in abdominal pain and
it felt as if he had passed something.
Review of Systems:
(+) Per HPI and chronic back pain, sciatica with
numbness/weakness of right leg, and abdominal pain.
(-) Denies fevers, chills, night sweats, weight change, visual
changes, oral ulcers, bleeding nose or gums, shortness of
breath, palpitations, orthopnea, PND, lower extremity edema,
hemoptysis, nausea, vomiting, dysuria, hematuria, easy bruising,
skin rash, myalgias, joint pain, dizziness, vertigo, headache,
confusion, or depression. All other review of systems negative.
Past Medical History:
- Chronic pancreatitis with pancreatic duct stenosis (1st
episode [**1-9**])
- Question of chronic obstructive pulmonary disease
- Tobacco use
- Chronic back pain
- Herniated lumbar intervertebral disc with radiculopathy
- S/p cholecystectomy on [**2148-5-2**]
- Right shoulder surgery in [**2144**]
- L5 laminectomy in [**2141**]
- Lumbar radiculopathy
Social History:
Married, lives at home with wife and 2 children (8 and 14 years
old). Not currently working, disabled secondary to pain. Reports
smoking less than 1 pack per day, 20-pack year history. Denies
alcohol or illicit drug use.
Family History:
Mother with diverticulitis. Denies any family history of HTN,
hyperlipidemia, diabetes, cancer, or pancreatitis.
Physical Exam:
EXAM IN ICU:
Vitals: T: BP: P: R: 18 O2:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
RUE former PICC site C/D/I, no erythema or pus
EXAM AFTER ARRIVING TO MEDICAL FLOOR:
VS: 98.1 102/68, 74, 20, 98% on room air
PAIN [**7-11**] RUQ abdomen
GEN: NAD
HEENT: EOMI, anicteric sclerae, MMM, no oral lesions
NECK: Supple
CHEST: CTAB
CV: RRR, normal S1 and S2, no murmurs
ABD: Soft, no increase in tenderness with palpation of RUQ,
nondistended, bowel sounds present
SKIN: No rashes or other lesions. No jaundice
EXT: No lower extremity edema
NEURO: Alert, oriented x3, CN 2-12 intact, sensory intact
throughout, strength 5/5 BUE/BLE, fluent speech, normal
coordination
PSYCH: Calm, appropriate
Pertinent Results:
Admission labs:
[**2149-7-29**] 10:00AM BLOOD WBC-6.5# RBC-4.10* Hgb-12.3* Hct-35.6*
MCV-87 MCH-30.0 MCHC-34.4 RDW-13.7 Plt Ct-179
[**2149-7-29**] 10:00AM BLOOD Neuts-89* Bands-2 Lymphs-4* Monos-5 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2149-7-29**] 10:00AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+
[**2149-7-29**] 10:00AM BLOOD Plt Ct-179
[**2149-7-29**] 10:00AM BLOOD Glucose-76 UreaN-18 Creat-0.8 Na-137
K-4.5 Cl-100 HCO3-26 AnGap-16
[**2149-7-29**] 10:00AM BLOOD ALT-68* AST-53* AlkPhos-55 TotBili-0.3
[**2149-7-29**] 10:00AM BLOOD Albumin-4.4 Calcium-9.1 Phos-3.6
[**2149-7-30**] 04:16AM BLOOD calTIBC-202* VitB12-767 Folate-15.9
Ferritn-1361* TRF-155*
[**2149-7-29**] 10:14AM BLOOD Lactate-2.3*
[**2149-7-29**] 01:45PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
Iron 15, TIBC 202, Ferritin 1361, TRF 155
ALT 68->274-->189, AST 53->163-->74, Alk Phos 66, LDH 248
Microbiology:
Blood culture [**7-29**], [**7-30**] no growth to date
Urine culture [**7-29**] NEGATIVE
Catheter tip [**7-29**] NEGATIVE
MRSA Screen [**7-29**] NEGATIVE
Hepatitis B and C serologies NEGATIVE
Galactomannan NEGATIVE
Aspergillous PENDING
Radiology:
CXR [**2149-7-29**]: No acute cardiopulmonary process.
CT Abdomen & Pelvis [**2149-7-29**]:
1. No acute intra-abdominal process to explain the patient's
pain or clinical circumstance.
2. Unchanged to minimally increased periportal edema
3. Unchanged mild, irregular pancreatic ductal dilatation
compatible with provided history of chronic pancreatitis.
RUQ Ultrasound [**2149-7-30**]:
1. Coarse echotexture of the liver without distinct lesions.
2. Stable appearance of slightly prominent CBD, likely
post-surgical in
nature.
3. Normal appearance of the pancreas with prominent duct
measuring up to 4 mm
in maximum diameter, compatible with the patient's reported
history of chronic
pancreatitis.
EKG: Sinus tachycardia 123, no ST changes, similar to prior
except for tachycardia
MRCP [**2149-7-31**]:
1. Mild intrahepatic biliary dilatation with CBD dilatation
measuring 10 mm,
and mild pancreatic duct dilation, both stable when compared
with prior
imaging studies.
2. No peri-biliary enhancement to suggest cholangitis. No
evidence for
choledocholithiasis.
Brief Hospital Course:
45 year-old man presented with fever, RUQ pain, and hypotension
concerning for sepsis. BP normalized and stable after IV fluid
resuscitation, PICC removal, and broad-spectrum antibiotic
administration. Cultures have been no growth to date. AST/ALT
with transient elevation now downtrending. Hepatitis B and C
serologies were negative. Downtrending AST/ALT correlated with
patient's abdominal pain suddenly improving suggesting that
possibly he may have passed a gallstone from his bile duct. RUQ
ultrasound was unrevealing. Antibiotics were changed to cipro
and flagyl for treatment of cholangitis. MRCP ordered to rule
out a retained gallstone.
PROBLEM LIST:
# Suspected cholangitis given fever, acute RUQ pain, transient
elevation in AST/ALT with sudden improvement in labs and
symptoms. Patient fully resuscitated with IV fluids, now stable
vital signs on antibiotics. All cultures no growth to date. RUQ
ultrasound no stones, but MRCP ordered to better rule out
retained gallstones. Started ursodiol. No abnormalities seen on
MRCP. Vanco and Zosyn narrowed to Cipro and Flagyl for
cholangitis coverage. Blood cultures remained no growth to date
(from [**7-29**], [**7-30**]). PICC line removed, tip did not grow.
# Chronic pancreatitis: Has been on TPN for 2.5 months. Tried to
advance diet 2 weeks ago, but developed pain. No PO's for the
past week.
Gi team involved. Patient was started on clear liquids and diet
slowly advanced, which he tolerated without change in his pain.
Continued on home chronic pain meds (MS Contin 130mg q8h), did
receive some toradol and intermittent immediate release pain
med, Morphine IR 15mg po q6, which he reqiured 1-3 times per
day.
# Anemia, normocytic: Initial large HCT drop in ED in the
setting of 6L NS. HCT now back up, so likely dilutional. Iron
studies reveal iron deficiency. There is no frank blood per
rectum. [**Month (only) 116**] in part be due to acute illness.
# Thrombocytopenia: Unclear cause, likely related to acute
illness, improved prior to discharge.
# DVT rophylaxis: Subcutaneous heparin
# Code status: Full code
Medications on Admission:
Gabapentin 800 mg Tab three times a day
Morphine ER 130mg q 8 hrs
Discharge Medications:
1. amitriptyline 25 mg Tablet Sig: One (1) Tablet PO at bedtime:
as per outpt regimen.
2. gabapentin 400 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
3. morphine 15 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for breakthrough pain for 14 days.
Disp:*28 Tablet(s)* Refills:*0*
4. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
5. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
6. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 5 days.
Disp:*15 Tablet(s)* Refills:*0*
7. ursodiol 300 mg Capsule Sig: Two (2) Capsule PO BID (2 times
a day).
Disp:*120 Capsule(s)* Refills:*2*
8. Ultrase MT 12 223 mg (12,000 -39K-39K unit) Capsule, Delayed
Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO
three times a day: unclear of dosing, as per outpt regimen.
9. MS Contin 100 mg Tablet Extended Release Sig: One Hundred
Thirty (130) Tablet Extended Release PO every eight (8) hours.
Discharge Disposition:
Home
Discharge Diagnosis:
Cholangitis/septicemia
Chronic pancreatitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with abdominal pain, nausea, vomiting and
fevers. This was likely due to infection in bile duct called
cholangitis and you may have passed a gall stone. You improved
with antibiotics and IV fluids. Your picc line was also removed
given the fever, though the culture from this was negative. You
also had an MRCP that did not show any abnormalities.
You should continue your antibiotics for another 5 days. Please
continue to advance your diet as tolerated as an outpatient. We
decided not to replace the picc line or restart TPN at this time
as you were starting to be able to take in some food.
Followup Instructions:
Please schedule a follow-up with your primary care in the next
2-3 weeks
Department: DIV. OF GASTROENTEROLOGY
When: THURSDAY [**2149-8-7**] at 1 PM
With: [**First Name4 (NamePattern1) 1386**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Department: DIV. OF GASTROENTEROLOGY
When: MONDAY [**2149-9-1**] at 11:00 AM
With: [**First Name4 (NamePattern1) 1386**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
ICD9 Codes: 0389, 2859, 2875, 496, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3711
} | Medical Text: Admission Date: [**2126-12-14**] Discharge Date: [**2127-1-23**]
Date of Birth: [**2066-2-27**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Biaxin / Vioxx / Erythromycin Base / Wellbutrin /
Trazodone / Advair Diskus / Benadryl
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
Hypoxia, Perforated sigmoid diverticulitis, sepsis, respiratory
distress
Major Surgical or Invasive Procedure:
Percutaneous tracheostomy
Exploratory laparotomy, revision of ileostomy
Percutaneous gastrostomy tube
History of Present Illness:
Patient is a 60 year-old woman with history of diverticulosis,
asthma, significant smoking (>60 pack years) who developed
diarrhea on New Year's Day of this year and then subsequently on
[**12-10**] acute severe rectal and pelvic pain followed by multiple
episodes of vomiting admitted to [**Hospital6 **]
on [**12-10**] for perforated proximal rectum by CT. Patient
subsequently underwent emergent partial resection of perforated
sigmoid colon with diverting colostomy on evening of admission.
Transferred to ICU postoperatively with hypotension Hospital
course since that time has been complicated by sepsis with
bacteroides bacteremia, E. Coli and pseudomonal peritoneal
isolates, S. aureus pneumonia and likely ARDS, respiratory
failure, coagulopathy. Patient transferred to [**Hospital1 18**] on [**12-14**]
night for worsening hypoxia, intubated before transfer.
Past Medical History:
diverticulosis, last colonoscopy in [**4-9**] benign polyps
TIA [**4-/2121**] R face, hand and foot paresthesias/MRI at time showed
b/l lacunar infarcts in basal ganglia by MRI
osetoporosis dx [**9-6**]
T12 compresssion fracture and scoliosis
[**2124**] sacral fracture
hyperlipidemia
asthma
depression
remote alcohol abuse, sober since [**1-8**]
got pneumovax in [**11-9**]
tobacco 1.5 packs per day since [**2085**]
peptic ulcer disease
seizure [**1-8**] valium vs. alcohol
giant cell tumor in forearm
DVT but undocumented (?[**2081**]'s)
cholecystectomy
kyphoplasty
breast biopsy with atypical hyperplasia
Echo [**12-13**]-EF of 70%, trace mr, pleural effusions, normal pulm art
pressure
Pulm function testing [**2126-3-8**]-normal FEV1, FVC
Social History:
1.5 packs per day since [**2085**] (intermittent periods of quitting)
history of alcohol abuse, sober since [**1-8**] as per some reports,
but nursing notes from OSH note 2 vodka tonics per day.
Lives with her daughter and works as a nurse [**First Name (Titles) **] [**Name (NI) 58990**] State
Hospital
Family History:
Mother-alive with hypothyroidism and hyperlipidemia
Father-died at 71 from prostate cancer and ALS
Paternal aunt with breast cancer.
Alcohol abuse among her father, brother and son
Physical Exam:
VS: temp 99.3, BP: 102/53 HR 121 RR 16-no pressors, weight 65 kg
Vent: AC 500 x 14, PEEP 7, Fio2 100%, spo2 100%
general: intubated, sedated, diaphoretic
HEENT:neck is supple, RIJ c/d/i, no JVD, no carotid bruits, no
cervical or supraclavicular lymphadenopathy, op without lesions
lungs: coarse breath sounds
heart: distant, hard to assess over vent/coarse breath sounds
abdomen: hypoactive bowel sounds, distended, staples C/D/I, JP
drain with serosanguinous fluid, colostomy with stool, dressing
C/D/I
extremities:no edema, pneumoboots, 2+DP pulses
skin:warm, damp, no mottling, no petechiae or rashes
neuro:intubated, sedated,
Pertinent Results:
From [**Hospital6 54196**]:
Labs: [**12-13**]
Notable for WBC 16.2, with 21 bands 73 polys, 5 lymphs, 1 mono
Sodium 151, potassium 3.6, chloride 117, bicarb 27, bun 12,
creatinine 0.6, glucose 128, mag 1.7, INR 1.33, PTT 50.9
[**12-14**] wbc: 17.2 with 87 polys, 7 bands, crit 29.4, plt 206
sodium 150, pot 2.8, chl 117, bicarb 33, bun 15, creat 0.6
mag 1.7, ca 8.1 phos 1.5,
PTT 36.7, INR 1.25
aalb 1.5, bnp 298
Micro: [**1-10**] blood cultues from [**12-10**] with bacteroides
Pelvic:[**12-11**] E. coli and pseudomonas
Sputum [**12-12**]: with Staph Aureus
ABG today of 7.458/41.2/58/28/4.3
EKG [**12-11**]:sinus tachycardia, poor R wave progression
trop I of <0.04 on [**12-11**] 6 AM, BNP of 306/245 on [**12-11**] and [**12-12**]
CXR::[**12-11**] new diffuse pulmonary infiltrates
[**12-12**] b/l upper lung field infiltrates, sensities at both bases
which represent combination of effusions and consolidation
[**12-13**] Pulmonary edema increased from the 6th , infiltrate in right
lower zone, b/l pleural effusions
Echo: [**2125-12-12**] Ef 70%, pleural effusions, normal pulmonary artery
pressures, trace MR/TR
CTA chest [**12-11**]: large bilateral pleural effusions with
significant compressive atelectasiss in right and left lower
lobes, bilateral upper lobe pulm infiltrates, no PE
[**12-11**] LENI: negative for DVT
[**12-10**] abdominal upright: no acute process
[**12-10**] CT abdomen: Acute diverticulitis with perforation of
diverticulum resulting in extravasation of rectal contrast into
the pericolic soft tissues.
RESULTS HERE:
Admit labs:
[**2126-12-15**] AM EKG:
sinus tachycardia rate of 120, normal axis, PVC, poor R wave
progression, no significant change from OSH EKG.
[**2126-12-15**] AM Chest x-ray:
Brief Hospital Course:
Assessment and Plan: 60 year-old woman transferred from OSH
after perforated sigmoid diverticuli s/p partial sigmoid
resection, right-sided weakness, colostomy, sepsis, respiratory
failure, pneumonia and ARDS, quite notable on CXR. Due to her
respiratory status, she received a percutaneous tracheostomy
tube on [**12-18**]. She also underwent an exploratory laparotomy with
revision of her ostomy site, at which time by report she
underwent a 5cm bowel resection; the final operative report was
not available at time of this writing. She continued on TPN,
however, as she was felt to be unable to swallow, and in need of
aggressive nutrition. An MRI on [**12-20**] confirmed the clinical
diagnosis of left MCA stroke, eliciting her right-sided
weakness. She continued aggressive antibiotic and antifungal
therapy at the recommendation of the infectious disease service.
As she experienced return of bowel function, she was
transitioned from TPN to tubefeeds, and was at goal tubefeeds by
[**12-24**]. A further cardiology workup revealed a mitral
endocarditis, for which she was treated with aggressive
antibiotic therapy by the cardiology team. Her ARDS was slow to
improve, and was closely followed with chest x-rays and clinical
monitoring. Pt continued a slow but steady improvement.
It was only by [**1-12**] that any significant radiologic improvement
was noted in her ARDS, although she seemed to be tolerating the
tracheosotomy well, with good saturations. A follow up CXR on
[**1-17**], however, still showed large infiltrates bilaterally. In
order to maximize her nutritional status, a percutaneous
gastrostomy tube was placed on [**2127-1-15**]. As her post-operative
fever and wbc cell count remained elevated, a tagged wbc scan
was undertaken, which showed no focal aggregations of white
blood cells. ALthough of unclear origin, her difficulty
swallowing remained. She did not tolerate a Passy-Muir valve;
she had quite thick secretions and was noted to be in some
distress with the valve. She is quite comfortable on the trach
collar. Her white blood cell count stabilized, and she remained
afebrile for over a week. By [**1-22**], the nature of her care
requirements was more suitable for an acute care rehabilitation
facility (she will require extensive rehabiliation, and a
skilled nursing facility would be inappropriate), and was
transferred to [**Hospital **] [**Hospital **] Hospital in good
condition.
Medications on Admission:
TO OSH: ecottrin 81, paxil 10, fosamax 70, singulair 10, flovent
and albuterol (not using last 3), muxinex 600BIDprn, ultram 50
q6 hr prn, xanax 0.25 mg prn flying
calcium 500 with vitamin D, [**Hospital1 **]
Allergies: nectarines=anaphylaxis, penicillin causes rash, GI
upset with biaxin, vioxx, diarrhea with erythromycin, insmnia on
wellbutrin, dizziness on trazadone, headache with advair, hyper
on benadryl. Previous history of hypotension with morphine
From OSH:
vancomycin day 1, flagyl day 4, primaxin day 1, solumedrol 40 IV
q 8, mucinex 600 [**Hospital1 **], protonix 40 iv, fentanyl patch, paxil 10,
demerol and visteril prn.
also received cipro on [**12-11**], levoquin on [**11-22**]
Discharge Medications:
1. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for temp > 101.
3. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Four (4)
Puff Inhalation QID (4 times a day).
4. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
5. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours).
6. Sodium Chloride 0.65 % Aerosol, Spray Sig: Four (4) Spray
Nasal [**Hospital1 **] (2 times a day).
7. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily): Through
G-tube.
8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Atenolol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Acetylcysteine 20 % (200 mg/mL) Solution Sig: Three (3) ML
Miscell. Q4-6H (every 4 to 6 hours) as needed.
11. Lorazepam 2 mg/mL Syringe Sig: 0.5 mL Injection Q4H (every 4
hours) as needed.
12. Haloperidol Lactate 5 mg/mL Solution Sig: Two (2) mg
Injection Q4-6H (every 4 to 6 hours) as needed.
13. Morphine Sulfate 10 mg/mL Syringe Sig: 0.2-0.6 Injection
Q3-4H () as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Acute middle cerebral artery stroke
Perforated diverticulitis
Adult Respiratory Distress Syndrome
Sepsis
Post-operative fever
Post-operative ileus
Respiratory Distress
Diverting ileostomy
Discharge Condition:
Stable.
Discharge Instructions:
Please take all medications as prescribed. If you develop
fevers>101.5, chills, nausea/vomiting, or other concerning
symptoms, please contact our office and the physicians at your
rehabiliation facility. Dr [**Last Name (STitle) 519**] will wish to see you in 4 weeks,
please call his office to schedule that appointment.
Followup Instructions:
Dr [**First Name4 (NamePattern1) 518**] [**Last Name (NamePattern1) 519**] will wish to see you in 4 weeks, please call
his office to schedule that appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
ICD9 Codes: 5185, 5119, 2760, 5789, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3712
} | Medical Text: Admission Date: [**2118-6-2**] Discharge Date: [**2118-6-14**]
Date of Birth: Sex: F
Service: MICU and then to [**Doctor Last Name **] Medicine
HISTORY OF PRESENT ILLNESS: This is an 81-year-old female
with a history of emphysema (not on home O2), who presents
with three days of shortness of breath thought by her primary
care doctor to be a COPD flare. Two days prior to admission,
she was started on a prednisone taper and one day prior to
admission she required oxygen at home in order to maintain
oxygen saturation greater than 90%. She has also been on
levofloxacin and nebulizers, and was not getting better, and
presented to the [**Hospital1 18**] Emergency Room.
In the [**Hospital3 **] Emergency Room, her oxygen saturation was
100% on CPAP. She was not able to be weaned off of this
despite nebulizer treatment and Solu-Medrol 125 mg IV x2.
Review of systems is negative for the following: Fevers,
chills, nausea, vomiting, night sweats, change in weight,
gastrointestinal complaints, neurologic changes, rashes,
palpitations, orthopnea. Is positive for the following:
Chest pressure occasionally with shortness of breath with
exertion, some shortness of breath that is positionally
related, but is improved with nebulizer treatment.
PAST MEDICAL HISTORY:
1. COPD. Last pulmonary function tests in [**2117-11-3**]
demonstrated a FVC of 52% of predicted, a FEV1 of 54% of
predicted, a MMF of 23% of predicted, and a FEV1:FVC ratio of
67% of predicted, that does not improve with bronchodilator
treatment. The FVC, however, does significantly improve with
bronchodilator treatment consistent with her known reversible
air flow obstruction in addition to an underlying restrictive
ventilatory defect. The patient has never been on home
oxygen prior to this recent episode. She has never been on
steroid taper or been intubated in the past.
2. Lacunar CVA. MRI of the head in [**2114-11-4**]
demonstrates "mild degree of multiple small foci of high T2
signal within the white matter of both cerebral hemispheres
as well as the pons, in the latter region predominantly to
the right of midline. The abnormalities, while nonspecific
in etiology, are most likely secondary to chronic
microvascular infarction. There is no mass, lesion, shift of
the normal midline strictures or hydrocephalus. The major
vascular flow patterns are preserved. There is moderate
right maxillary, moderate bilateral ethmoid, mild left
maxillary, minimal right sphenoid, and frontal sinus mucosal
thickening. These abnormalities could represent an allergic
or some other type of inflammatory process. Additionally
noted is a moderately enlarged subtotally empty sella
turcica".
3. Angina: Most recent stress test was in [**2118-1-3**]
going for four minutes with a rate pressure product of
10,000, 64% of maximum predicted heart rate without evidence
of ischemic EKG changes or symptoms. The imaging portion of
the study demonstrated no evidence of myocardial ischemia and
a calculated ejection fraction of 84%. The patient denies
angina at rest and gets angina with walking a few blocks.
Are alleviated by sublingual nitroglycerin.
4. Hypothyroidism on Synthroid.
5. Depression on Lexapro.
6. Motor vehicle accident with head injury approximately 10
years ago.
MEDICATIONS ON ADMISSION:
1. Hydrochlorothiazide 25 q.d.
2. Prednisone 60 mg, 50 mg, 40 mg, 20 mg.
3. Levofloxacin 500 mg q.d.
4. Imdur 60 mg q.d.
5. Synthroid 75 mcg q.d.
6. Pulmicort nebulizer b.i.d.
7. Albuterol nebulizer q.4. prn.
8. Lexapro 10 mg q.d.
9. Protonix 40 mg q.d.
10. Aspirin 81 mg q.d.
ALLERGIES: Norvasc leads to lightheadedness and headache.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: Lives with her husband, Dr. [**Known lastname 1809**] an
eminent Pediatric Neurologist at [**Hospital3 1810**]. The
patient is a prior smoker, but has not smoked in over 10
years. She has no known alcohol use and she is a full code.
PHYSICAL EXAM AT TIME OF ADMISSION: Blood pressure 142/76,
heart rate 100 and regular, respirations at 17-21, and 97%
axillary temperature. She was saturating at 100% on CPAP
with dry mucous membranes. An elderly female in no apparent
distress. Pupils are equal, round, and reactive to light and
accommodation. Extraocular movements are intact. Oropharynx
difficult to assess due to CPAP machine. No evidence of
jugular venous pressure, however, the strap from the CPAP
machine obscures the neck exam. Cranial nerves II through
XII are grossly intact. Neck is supple without
lymphadenopathy. Heart exam: Tachycardic, regular, obscured
by loud bilateral wheezing with increase in the expiratory
phase as well as profuse scattered rhonchi throughout the
lung fields. Positive bowel sounds, soft, nontender,
nondistended, obese, no masses. Mild edema of the lower
extremities without clubbing or cyanosis, no rashes. There
is a right hand hematoma. Strength is assessed as [**5-9**] in the
lower extremities, [**5-9**] in the upper extremities with a normal
mental status and cognition.
LABORATORY STUDIES: White count 19, hematocrit 41, platelets
300. Chem-7: 127, 3.6, 88, 29, 17, 0.6, 143. Troponin was
negative. CKs were negative times three. Initial blood gas
showed a pH of 7.4, pO2 of 66, pCO2 of 54.
Chest x-ray demonstrates a moderate sized hiatal hernia,
segmental atelectasis, left lower lobe infiltrate versus
segmental atelectasis.
EKG shows normal sinus rhythm at 113 beats per minute, normal
axis, no evidence of ST-T wave changes.
BRIEF SUMMARY OF HOSPITAL COURSE:
1. COPD/dyspnea/pneumonia: The patient was initially placed
on an aggressive steroid taper and admitted to the Medical
Intensive Care Unit due to her difficulty with oxygenation
despite CPAP machine. She was also given nebulizer
treatments q.4h. as well as chest PT. The nebulizers were
increased to q.1h. due to the fact that she continued to have
labored breathing.
Due to persistent respiratory failure and labored breathing,
the patient was intubated on [**2118-6-7**] in order to improve
oxygenation, ventilation, and ability to suction. A
bronchoscopy was performed on [**2118-6-7**], which demonstrated
marked narrowing of the airways with expiration consistent
with tracheomalacia.
On [**2118-6-9**], two silicone stents were placed, one in the left
main stem (12 x 25 and one in the trachea 16 x 40) by Dr.
[**First Name (STitle) **] [**Name (STitle) **] under rigid bronchoscopy with general anesthesia.
On [**2118-6-11**], the patient was extubated to a cool mist shovel
mask and her oxygen was titrated down to 2 liters nasal
cannula at which time she was transferred to the medical
floor. On the medical floor, the steroids were weaned to off
on [**2118-6-14**], and the patient was saturating at 97% on 2
liters, 92% on room air.
On [**2118-6-14**], the patient was seen again by the Interventional
Pulmonology service, who agreed that she looked much improved
and recommended that she go to pulmonary rehabilitation with
followup within six weeks' time status post placement of
stents in respiratory failure.
2. Cardiovascular: The patient was ruled out for a MI. She
did have another episode on the medical floor of chest pain,
which showed no evidence of EKG changes and negative
troponin, negative CKs x3. She was continued on aspirin,
Imdur, and diltiazem for rate control per her outpatient
regimen.
3. Hypertension: She was maintained on diltiazem and
hydrochlorothiazide with adequate blood pressure control and
normalization of electrolytes.
4. Hematuria: The patient had intermittent hematuria likely
secondary to Foley placement. The Foley catheter was
discontinued on [**2118-6-14**]. She had serial urinalyses, which
were all negative for signs of infection.
5. Hyperglycemia: Patient was placed on insulin-sliding
scale due to hyperglycemia, which was steroid induced. This
worked quite well and her glucose came back to normal levels
once the steroids were tapered to off.
6. Leukocytosis: Patient did have a profound leukocytosis of
20 to 22 during much of her hospital course. As the steroids
were tapered to off, her white blood cell count on [**2118-6-14**]
was 15,000. It was felt that the leukocytosis was secondary
to both steroids as well as question of a left lower lobe
pneumonia.
7. For the left lower lobe pneumonia, the patient had
initially received a course of levofloxacin 500 p.o. q.d.
from [**2118-6-4**] to [**2118-6-10**]. This was restarted on [**2118-6-12**]
for an additional seven day course given the fact that she
still had the leukocytosis and still had marked rales at the
left lower lobe.
8. Hypothyroidism: The patient was continued on outpatient
medical regimen.
9. Depression: The patient was continued on Lexapro per
outpatient regimen. It is recommended that she follow up
with a therapist as an outpatient due to the fact that she
did have a blunted affect throughout much of the hospital
course, and did appear clinically to be depressed.
10. Prophylaxis: She was maintained on proton-pump inhibitor
with subQ Heparin.
11. Sore throat: The patient did have a sore throat for much
of the hospital course post extubation. This was treated
with Cepacol lozenges as well as KBL liquid (a solution
containing Kaopectate, Bismuth, and lidocaine) at bedtime.
12. Communication/code status: The patient was full code
throughout her hospital course, and communication was
maintained with the patient and her husband.
13. Muscle weakness: The patient did have profound muscle
weakness and was evaluated by Physical Therapy, and was found
to have impaired functional mobility, impaired
musculoskeletal performance, impaired gas exchange, impaired
endurance, impaired ventilation, and needed help with supine
to sit. However, she was able to tolerate sitting in a chair
for approximately one hour.
On motor exam, her flexors and extensors of the lower
extremities were [**4-8**] at the knee, [**4-8**] at the ankle, [**4-8**] at
the elbows, and [**4-8**] hips. It was felt that this weakness was
most likely due to a combination of steroid myopathy as well
as muscle atrophy secondary to deconditioning after a
prolonged hospital course.
14. Speech/swallow: The patient had a Speech and Swallow
evaluation showing no evidence of dysphagia, no evidence of
vocal cord damage status post tracheal stent placement.
DISCHARGE CONDITION: The patient was able to oxygenate on
room air at 93% at the time of discharge. She was profoundly
weak, but was no longer tachycardic and had a normal blood
pressure. Her respirations were much improved albeit with
transmitted upper airway sounds.
DISCHARGE STATUS: The patient will be discharged to [**Hospital1 **]
for both pulmonary and physical rehabilitation.
DISCHARGE MEDICATIONS:
1. Levothyroxine 75 mcg p.o. q.d.
2. Citalopram 10 mg p.o. q.d.
3. Aspirin 81 mg p.o. q.d.
4. Fluticasone 110 mcg two puffs inhaled b.i.d.
5. Salmeterol Diskus one inhalation b.i.d.
6. Acetaminophen 325-650 mg p.o. q.4-6h. prn.
7. Ipratropium bromide MDI two puffs inhaled q.2h. prn.
8. Albuterol 1-2 puffs inhaled q.2h. prn.
9. Zolpidem tartrate 5 mg p.o. q.h.s. prn.
10. Isosorbide dinitrate 10 mg p.o. t.i.d.
11. Diltiazem 60 mg p.o. q.i.d.
12. Pantoprazole 40 mg p.o. q.24h.
13. Trazodone 25 mg p.o. q.h.s. prn.
14. SubQ Heparin 5000 units subcutaneous b.i.d. until such
time that the patient is able to get out of bed twice a day.
15. Cepacol lozenges q.2h. prn.
16. Levofloxacin 500 mg p.o. q.d. for a seven day course to
be completed on [**2118-6-21**].
17. Kaopectate/Benadryl/lidocaine 5 mL p.o. b.i.d. prn, not
to be given around mealtimes for concern of dysphagia induced
by lidocaine.
18. Lorazepam 0.5-2 mg IV q.6h. prn.
FOLLOW-UP PLANS: The patient is recommended to followup with
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1407**], [**Telephone/Fax (1) 1408**] within two weeks of leaving
of the hospital. She is also recommended to followup with
the Interventional Pulmonary service for followup status post
stent placement. She is also recommended to followup with a
neurologist if her muscle weakness does not improve within
one week on physical therapy with concern for steroid-induced
myopathy.
FINAL DIAGNOSES:
1. Tracheomalacia status post tracheal and left main stem
bronchial stent placement.
2. Hypertension.
3. Hypothyroidism.
4. Restrictive lung defect.
5. Depression.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-207
Dictated By:[**Last Name (NamePattern1) 1811**]
MEDQUIST36
D: [**2118-6-14**] 11:30
T: [**2118-6-14**] 11:33
JOB#: [**Job Number 1812**]
ICD9 Codes: 486, 2761, 2449, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3713
} | Medical Text: Admission Date: [**2133-3-21**] Discharge Date: [**2133-4-3**]
Date of Birth: [**2048-11-1**] Sex: F
Service: NEUROLOGY
Allergies:
Diphenhydramine
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
bilateral cerebellar infarcts [**Last Name (NamePattern1) 18095**] during spinal fusion
with iliac bone graft
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 1452**] [**Last Name (Titles) 18095**] a fall down a flight stairs in [**12/2132**]
during which she suffered a fracture of C1 and C2 with fracture
of the dens (C2). She was treated conservatively and transferred
to rehab but continued to complain about pain and thus was
brought to [**Hospital6 2910**] for further management.
She was found to have non [**Hospital1 **] of the dens and was taken for
spinal fusion on [**2133-3-19**]. There she had instrumentation with
iliac crest bone graft. After the surgery, she did not wake up
as expected and she was kept intubated. On [**2133-3-20**] she went for
CT head scan where it was discovered that she had suffered
cerebellar infarcts.
Past Medical History:
A-fib on Coumadin
HLD
OA
Anxiety
Dysphagia
GERD
CHF hx unknown EF
Hx of Right middle lobe PE
Hx of Distal left radial Fx
Social History:
Ms. [**Known lastname 1452**] lives alone and is very independent woman, had been
planning to drive to FL alone as she does every year. Pt has 3
daughters, and a supportive family.
Family History:
Non-contributory
Physical Exam:
PHYSICAL EXAM:
Gen: Intubated but opening eyes spontaneously
HEENT: Pupils: 3mm reactive. Prominent downward gaze. EOMs not
reactive.
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: Afib
Abd: Soft, NT
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam
Orientation: Oriented to person, place
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light. Visual fields
cant be tested due to downward gaze.
III, IV, VI: Extraocular movements cant be tested, pt. has
locked
downward gaze.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation couldnt be tested
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue couldnt be tested
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength 4/5 throughout.
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Toes downgoing bilaterally
Coordination: couldnt be tested, patient is intubated and wasnt
able to follow commands for this.
Pertinent Results:
[**2133-3-21**] 02:38AM BLOOD WBC-19.2* RBC-3.61* Hgb-11.3* Hct-32.9*
MCV-91 MCH-31.3 MCHC-34.4 RDW-14.6 Plt Ct-191
[**2133-4-2**] 06:10AM BLOOD WBC-9.9 RBC-3.49* Hgb-10.7* Hct-31.7*
MCV-91 MCH-30.7 MCHC-33.8 RDW-14.1 Plt Ct-318
[**2133-3-21**] 02:38AM BLOOD PT-14.1* PTT-25.2 INR(PT)-1.2*
[**2133-3-22**] 12:55AM BLOOD Glucose-126* UreaN-12 Creat-0.3* Na-132*
K-3.7 Cl-101 HCO3-25 AnGap-10
[**2133-3-21**] 02:38AM BLOOD Calcium-7.6* Phos-1.5* Mg-2.1
[**2133-3-30**] 06:05AM BLOOD %HbA1c-5.8 eAG-120
[**2133-3-30**] 06:05AM BLOOD Triglyc-70 HDL-50 CHOL/HD-3.3 LDLcalc-101
[**2133-3-29**] 06:28PM URINE RBC-0-2 WBC-[**7-10**]* Bacteri-MANY Yeast-NONE
Epi-<1
[**2133-3-29**] 06:28PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-SM
Brief Hospital Course:
Ms. [**Known lastname 1452**] was admitted to [**Hospital1 18**] on [**2133-3-21**] from OSH s/s C1-2
fusion on [**3-19**] for malunion type 2 dens fracture [**Month/Year (2) 18095**] in
[**2132-12-1**]. She was at NEBH for Fusion and she was
comatose post surgery. A CT scan demonstrated cerebellar
infarcts and she was transferred to [**Hospital1 **] for further care. She was
initially in the ICU as she was comatose, intubated and with
signs concerning for tectal pressure. Per the ICU course she was
extubated on [**3-24**] at [**Hospital1 18**], re-intubated on [**3-24**] secondary to
respiratory distress, and ultimately extubated on [**3-25**]. A chest
x-ray on [**3-26**] indicated increased bibasilar atelectasis and
bilateral pleural effusions.
She was transferred to the stroke Neuromed floor for further
care on [**2133-3-30**]. She was started on ciprofloxacin per sputum
culture and sensitivity (GNR's) and will continue this until
[**2133-4-13**].
On the Neuromed floor she was on diltiazem drip for a-fib rate
control and she was started on PPN. She had a PEG tube placed
and the diltiazem gtt was weaned off and PO dilt was started.
This produced good rate control.
She also developed auto diuresis, renal was consulted and
suggested that it was SIADH and recommended lowering the amount
of free water. Heparin gtt was switched to Lovenox 1mg/kg Q12hrs
for the Coumadin bridge and with the IV drips off her free water
PEG flushes were decreased.
On [**2133-4-3**] Supplemental salt was initiated. She will need her
lytes (sodium) measured at least Q48hrs and if less then 125
will need to come back to [**Hospital1 18**] for further fluid management.
Renal's thoughts are that she may have developed a reset central
osmostat.
Ortho recommended a flexion/ extension XR of the C-Spine before
going to a soft collar but was not obtained prior to discharge.
There is an Ortho appointment set up in the coming weeks.
Fosamax was not restarted at this hospitalization.
Medications on Admission:
Home: ASA 325, captopril 12.5 TID, Diltiazem 120mg TID, Colace
200mg daily, coumadin 3.5mg daily, fosamax,pravastatin 40mg
daily, prilosec 20mg daily
Discharge Medications:
1. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. diltiazem HCl 30 mg Tablet Sig: 1.5 Tablets PO QID (4 times a
day).
3. enoxaparin 40 mg/0.4 mL Syringe Sig: Forty (40) mg
Subcutaneous Q12HRS (): Please stop once INR at goal range of
[**3-5**].
4. warfarin 1 mg Tablet Sig: 3.5 Tablets PO Once Daily at 4 PM.
5. sodium chloride 1 gram Tablet Sig: Two (2) Tablet PO BID (2
times a day).
6. ciprofloxacin 500 mg/5 mL Suspension, Microcapsule Recon Sig:
One (1) Suspension, Microcapsule Recon PO Q12H (every 12 hours)
for 10 days.
7. pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours).
8. Ondansetron 4 mg IV Q8H:PRN nausea
9. HYDROmorphone (Dilaudid) 0.125-0.25 mg IV Q3H:PRN pain
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
New
- Stroke with history of a.fib off anti coagulation.
- SIADH
- pneumonia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
It was a pleasure taking care of you during your stay with us.
You were admitted as a transfer after being found comatose
following a spinal surgery. You had a history of atrial fib. and
were off your coumadin during the surgery. You had a CT scan
that demonstrated strokes involving the cerebellum. You did not
have an MRI scan to look for other strokes but it is likely that
you had strokes in other areas during this episode. You were
evaluated by neurosurgery but no intervention by them was done.
You were restarted on anticoagulation in order to prevent future
strokes. You also had developed a pneumonia and you were started
on an antibiotic for this. You were placed on medication in
order to control your heart rate, and you had a G-tube placed
for nutrition. Other issues that arose were something called
SIADH. This was managed by decreasing the amount of fluids that
you were getting and your sodium level should be checked every 2
days to ensure that it does not go below 125. You will need to
follow up with Dr [**Last Name (STitle) 29336**] in order to get your C-collar off (see
below).
Followup Instructions:
Neurology Appointment: Dr [**Last Name (STitle) **] [**Last Name (NamePattern4) **]. Date/Time: [**6-16**] at
3:30 pm
Please call ([**Telephone/Fax (1) 7394**] one week before to ensure time and
location.
You have a follow up appointment with Dr. [**Last Name (STitle) 29336**] in Orthopedics
at NEBH ([**Telephone/Fax (1) 29337**]) on [**4-28**] at 11:00.
Completed by:[**2133-4-3**]
ICD9 Codes: 486, 5990, 5119 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3714
} | Medical Text: Admission Date: [**2151-2-20**] Discharge Date: [**2151-4-7**]
Date of Birth: [**2096-2-11**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 55-year-old
male with a history of upper GI bleed, acute renal failure,
who was admitted to the medical Intensive Care Unit at [**Hospital1 1444**] in early [**Month (only) 956**] with an
upper GI bleed. At this point he was found to have a
superior mesenteric artery aneurysm as well as gastric
duodenal artery bleed. The gastric duodenal artery was
embolized. The patient presents on [**2-20**] with abdominal pain,
it was intermittent sharp and dull abdominal pain. He went
to the [**Hospital3 3583**] Emergency Room and was transferred to
the Emergency Room at [**Hospital1 69**]
where he was found to have decreased white cells, stable
hematocrit and LFTs were improving from his previous
admission. Abdominal CT in the Emergency Room showed
decreased hematoma compared to prior CT as well as some
pericholecystic fluid. Surgical team was consulted. Patient
was admitted to the hospital.
PAST MEDICAL HISTORY: Significant for spontaneous
pneumothorax, immune complex glomerulonephritis, acute renal
failure, peptic ulcer disease, SMA aneurysm with
retroperitoneal hematoma, [**2151-1-29**] pneumonia, [**2151-1-29**]
increased bilirubin with biliary sludge, status post
percutaneous stent in [**2151-1-29**] by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 19731**].
Fluid overload with echo, EF greater than 55% and history of
narcotic addiction and paranoia.
MEDICATIONS: On admission, Lipitor, Lasix, Protonix,
Nephrocaps, Colace, Senna, Labetalol, OxyContin.
ALLERGIES: Sulfa, Aspirin, Naproxen.
SOCIAL HISTORY: Lives with wife, denies any alcohol, smoking
history up until his [**2151-1-29**] admission.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: Vitals on admission were 97.9, blood
pressure 150/80, pulse 88, 91% on room air, respirations 18.
He was fatigued and mildly uncomfortable, alert and oriented
times three. Pupils are equal, round, and reactive to light
and accommodation. HEENT exam was otherwise unremarkable.
Neck was supple with no lymphadenopathy. Chest showed
slightly decreased breath sounds at bilateral bases,
otherwise clear. Heart was regular without murmurs, rubs or
gallops. GI showed positive epigastric and right upper
quadrant tenderness, no guarding, slight rebound tenderness
in the epigastrium. There are bowel sounds present. Abdomen
was soft, guaiac positive. Extremities showed 2+ edema
bilaterally. Neuro, cranial nerves II through XII intact.
Upper extremities and lower extremities showing [**5-2**]
bilaterally.
LABORATORY DATA: On admission sodium 138, potassium 3.3,
chloride 104, CO2 25, BUN 21, creatinine 1.0, glucose 92,
white count 13 down from 16 upon discharge, hematocrit 26
down from 28.2. Platelet count 622,000, MCV 89, 78%
neutrophils, 12% lymphs. ALT, AST were 27 and 27, alkaline
phosphatase 365, total bilirubin 1.7, lipase 132, albumin
1.8, calcium 7.9, phosphorus 3.4, magnesium 1.4. Urinalysis
showed [**3-2**] white cells, otherwise within normal limits.
Chest x-ray showed improved alveolar pattern, question of
left lower lobe atelectasis vs consolidation as well as small
bilateral pleural effusion. Abdominal CT showed gallbladder
with minimal pericholecystic fluid, pancreas is unremarkable.
Hematoma 8?????? by 5.5 cm slightly decreased from discharge in
mid [**Month (only) 956**], slight thickening adjacent to colon. His stent
in his common bile duct with associated pneumobilia. This
was a contrast negative CT.
HOSPITAL COURSE:
1. GI: Patient was taken to the OR for concern over a
re-bleed of his SMA aneurysm. This was unable to be fixed by
the vascular surgery service. Based on its proximity to the
pancreas, the patient subsequently underwent SMA artery
aneurysm on [**2-22**] with interventional radiology service.
Other GI issues during this admission were the presence of
the two biliary stents by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 19731**]. Dr. [**Last Name (STitle) 19731**]
was aware of his prolonged hospital course and planned to
remove the two some time during the patient's upcoming
rehabilitation stay. Patient had a PEG tube placed on [**3-23**]
and was tolerating tube feeds. At the time of discharge he
was also beginning to tolerate solid po intake with only
intermittent vomiting. Pancreatic enzymes which had been
elevated earlier in the hospital course came down to normal
at the time of discharge.
2. Cardiovascular: The patient was in the SICU with poorly
controlled hypertension from [**2-20**] to [**3-8**] and was started on
Labetalol as well as Captopril and Isordil and Lasix. In mid
[**Month (only) 958**] the patient had an EKG which showed diffuse T wave
inversion. The patient's enzymes were cycled and he ruled
out for MI. Shortly thereafter chest x-ray showed congestive
heart failure and patient was diuresed and his respiratory
status improved but echocardiogram at that point showed a
decrease in his EF from 55% in early [**2151-1-29**] to 20-25% in
mid [**2151-2-26**] with multiple wall motion abnormalities in the
left anterior descending artery territory. On approximately
[**3-24**] to [**3-25**] the patient's blood pressure began to rise again
and was treated with Labetalol, Captopril. A repeat echo on
[**3-25**] showed an ejection fraction which had increased back to
greater than 50%. At that point there were still some
residual wall motion abnormalities in the left anterior
descending artery. The patient was followed by a cardiology
consult service for the remainder of this hospital stay.
They questioned, and it was felt appropriate that the patient
undergo cardiac catheterization for evaluation of anterior
descending artery wall motion abnormalities. The patient
deferred cardiac catheterization until after his rehab stay.
He will follow-up with Dr. [**Last Name (STitle) 96121**] at [**Hospital1 190**] for further evaluation and planning of his
elective catheterization.
Hypertension: The patient remained with significant
hypertension running systolic pressures in the 150's to 180's
and diastolic pressures in the 70's to 90's throughout the
remainder of the hospital course. Antihypertensives were
titrated up such that on the day of discharge his
antihypertensive regimen including Labetalol 600 mg po bid,
Isordil 60 mg po tid, Captopril 100 mg po tid, Losartan 100
mg q d, Lasix IV 120 mg [**Hospital1 **] and a Clonidine patch.
3. Neurology: The patient was stable with normal mental
status at the time of admission, however, on [**3-15**] mental
status declined and at that point CT of his head was negative
for acute CNS bleed. One day prior to this the patient had
been in the vascular Intensive Care Unit where he was noted
to have three generalized tonic clonic seizures that were
witnessed by staff on the floor. MRI and CT showed bilateral
watershed infarct. At this point the patient was started on
Dilantin and his mental status declined. He was in a coma
for approximately two weeks but then his mental status
improved. As of [**3-29**] his mental status was at his baseline
and he remained that way throughout the remainder of his
hospital stay.
4. Pulmonary: The patient had known effusions at the time
of admission and had an oxygen requirement. A chest CT done
on [**3-14**] showed a large right lower lobe pulmonary embolism
and the patient was started on Heparin, however, on [**3-17**] he
had hematocrit drops on Heparin so Heparin was discontinued
and inferior vena cava filter was placed on [**3-18**]. The
patient had bilateral pleural effusions, left greater than
right throughout the remainder of the hospital stay. Left
sided effusion was tapped on [**3-1**] for one liter of
transudative fluid with symptomatic improvement. The patient
still had bilateral pleural effusion at the time of discharge
with an oxygen requirement of approximately three liters by
nasal cannula and the plan was to attempt to minimize the
size of the effusion with diuresis. His oxygen requirement
was stable at the time of discharge.
5. Hematology: The patient required multiple transfusions
during the stay. However, from [**3-29**] to [**4-7**] the patient's
hematocrit was stable in the high 20's requiring only one
unit of packed red cells. The patient was restarted on
Coumadin for anticoagulation on [**4-2**] and should have his INR
followed at rehab.
6. Infectious Disease: The patient had an episode of
pneumonia early in this hospital stay which resolved.
However, the patient did relatively well from an infectious
disease standpoint during this admission. On [**3-29**] he had a
blood culture positive for coag negative staph, however, this
was taken off the PICC line and blood cultures drawn at that
time were otherwise negative. The line was pulled.
Surveillance cultures remained negative and the decision was
made not to treat him. This bacteria was found to be not
coag negative staph but Vancomycin resistant enterococcus.
7. Renal: Patient's creatinine was stable throughout this
admission. He has a history of type 3 membranoproliferative
glomerulonephritis with heavy proteinuria. He was found to
have approximately 21 gm of protein in his urine per day.
The renal consult service followed him and started him on an
angiotensin receptor block and Losartan 100 mg po q d for
treatment of his proteinuria. At the time of discharge he
was stable with regards to his proteinuria. He should
follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 951**] of renal team. Ultimately the
plan is to start him on steroids for his proteinuria.
8. Diet: Patient is currently on tube feeds as well as oral
feeds. His oral feeds should be increased as tolerated.
DISCHARGE DIAGNOSIS:
1. SMA artery aneurysm status post embolization.
2. Pulmonary embolism status post IVC filter placement and
Coumadin anticoagulation.
3. Mild focal wall motion abnormalities in the left anterior
descending artery distribution.
4. Hypertension.
5. Type III membranoproliferative glomerulonephritis.
DISCHARGE MEDICATIONS: Labetalol 600 mg po bid, Captopril
100 mg po tid, Losartan 100 mg po q d, Isordil 60 mg po tid,
Clonidine patch .1 mg q 24 hours, Lipitor 10 mg q d, Lasix IV
200 mg [**Hospital1 **]. This will be changed to po calcium carbonate 500
mg [**Hospital1 **], subcu Heparin 5,000 units subcu [**Hospital1 **], Albuterol
Atrovent nebs q 4 hours prn.
DISCHARGE CONDITION: Good with oxygen requirement of
approximately three liters.
DISCHARGE STATUS: To [**Hospital 38**] Rehab facility.
FOLLOW-UP: With Dr. [**Last Name (STitle) 96121**] of the cardiology service, Dr.
[**Last Name (STitle) **] of nephrology service and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 19731**] of the
GI service. The patient will be given phone numbers for
appointments.
[**First Name11 (Name Pattern1) 2515**] [**Last Name (NamePattern4) 4517**], M.D. [**MD Number(1) 4521**]
Dictated By:[**Last Name (NamePattern1) 2396**]
MEDQUIST36
D: [**2151-4-7**] 11:12
T: [**2151-4-7**] 12:03
JOB#: [**Job Number 96122**]
ICD9 Codes: 5185, 4280, 5119, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3715
} | Medical Text: Admission Date: [**2197-8-16**] Discharge Date: [**2197-8-22**]
Date of Birth: [**2135-5-14**] Sex: F
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname 1124**] is 62 year old female with a history of small cell
lung diagnosed in [**2188**] status post chemo and x ray therapy,
severe chronic obstructive pulmonary disease, recurrent right
pleural effusion, pseudomonal pneumonia and respiratory failure
with tracheostomy in [**4-25**]. The patient was recently discharged
from a rehabilitation facility to home where she was doing well
using ventilation only at night when she experienced the sudden
onset of dyspnea on the day of admission. She was suctioned but
only had a transient improvement. EMS was called and the patient
was transfered to an outside hospital where she was
unresponsive. After receiving two nebulizer treatments and a
dose of unasyn she improved. There, she was changed to assist
control ventilation 400/12/40%/PEEP 5, following which she
became alert and responsive. She was then transfered to [**Hospital1 18**]
for further management. A chest x ray from the outside hospital
showed right pleural effusion and/ or right lower lobe collapse.
Past Medical History:
1. small cell lung cancer diagnosed [**2188**] status post x ray
therapy, chemotherapy, stem cell rescue, and prophylactic total
body irradiation
2. COPD
3. hypothyroidism
4. atypical pneumonias
5. recurrent right pleural effusions status post multiple
thoracentesis with negative cytology
6. cognitive impairment since total body irradiation
7. recurrent right pneumonia secondary to pseudomonas
8. sinus tachycardia
9. metabolic alkalosis
Social History:
Daughter [**Name (NI) **] is Health Care Proxy. She is a former [**Name (NI) 1818**] of
70 pack years. She quit smoking in [**2188**]. She denies alchohol or
drugs.
Family History:
mother- DM, father- HTN.
Physical Exam:
Tmax 98.7, Tcurrent 98.5, BP 107/55, Heart Rate 72,
Vent Settings: Assist Control, tidal volume 400, respiratory
rate of 13, PEEP 8, and FiO2 0.50, O2 sat 99.
Ins 1670 Outs 1495.
Gen: alert and oriented but with difficulty communicating
because of trach in place
HEENT: MMM, false teeth in place
Pulm: course rhonchi on right, rhonchi on left vs transmitted
from right
CV: tachycardic, difficult to assess secondary to breath sounds
Abd: decreased bowel sounds, distended but [**Last Name (LF) 6416**], [**First Name3 (LF) 282**] tube
in place with minimal serosanguinous drainage, using abdominal
muscles to breath
Ext: WWP, no c/c/e, PT, radial pulses 2+ bilaterally
Pertinent Results:
[**2197-8-20**] 04:51AM BLOOD WBC-13.8*# RBC-4.04* Hgb-11.7* Hct-34.9*
MCV-89 MCH-28.9 MCHC-32.4 RDW-14.9 Plt Ct-220
[**2197-8-22**] 04:12PM BLOOD Neuts-82.6* Lymphs-7.3* Monos-7.1 Eos-2.7
Baso-0.3
[**2197-8-22**] 04:12PM BLOOD Plt Ct-214
[**2197-8-22**] 04:12PM BLOOD Glucose-85 UreaN-33* Creat-1.2* Na-141
K-3.7 Cl-93* HCO3-36* AnGap-16
[**2197-8-21**] 04:02AM BLOOD CK(CPK)-19*
[**2197-8-21**] 04:02AM BLOOD CK-MB-2 cTropnT-0.05*
[**2197-8-22**] 05:21AM BLOOD Calcium-8.9 Phos-3.3 Mg-2.2
[**2197-8-17**] 05:46PM BLOOD calTIBC-209* Ferritn-392* TRF-161*
[**2197-8-21**] 04:02AM BLOOD TSH-6.3*
[**2197-8-19**] 12:45PM BLOOD Type-ART pO2-65* pCO2-53* pH-7.44
calHCO3-37* Base XS-9
[**2197-8-17**] 12:52 am SPUTUM
GRAM STAIN (Final [**2197-8-17**]):
THIS IS A CORRECTED REPORT [**2197-8-18**].
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
PREVIOUSLY REPORTED AS [**2197-8-17**].
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Final [**2197-8-20**]):
HEAVY GROWTH OROPHARYNGEAL FLORA.
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH. 2ND ISOLATE.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
| PSEUDOMONAS AERUGINOSA
| |
CEFEPIME-------------- 4 S 8 S
CEFTAZIDIME----------- 8 S 4 S
CIPROFLOXACIN--------- 0.5 S <=0.25 S
GENTAMICIN------------ =>16 R =>16 R
MEROPENEM------------- 1 S <=0.25 S
PIPERACILLIN---------- <=4 S <=4 S
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ 4 S 4 S
Chest X ray: Since the previous study there has been worsening
in the degree of bilateral pulmonary vascular congestion.
Unchanged right pleural effusion and compressive atelectasis of
the right lower lobe and the right middle lobe and possibly
necrotizing pneumonia in the right middle lobe and the right
lower lobe.
Brief Hospital Course:
1) The respiratory failure most likely secondary to mucous
plugging and it was thought that there was potential for
pneumonia or a COPD flare. The patient was started on zosyn for
treatment of pneumonia on [**8-16**] for a total of 14 days treatment.
A bronchoalveolar lavage was performed that showed thick
secretions in the right upper lung, right middle lung, and right
lower lung. Cultures grew out pseudomonas sensitive to
piperacillin/tazobactam. Ms. [**Known lastname 1124**] also underwent aggressive
suctioning, chest physical therapy, and treatment with
albuterol/ipratropium/fluticasone respiratory therapy. She was
also thought to be in mild heart failure, for which she received
small doses of IV lasix during her hospital stay.
2) Cardiomyopathy / hypertension: Mrs. [**Known lastname 1124**] was found to be in
mild acute renal failure so her hydrochlorothiazide was held on
admission; she remained normotensive on diltiazem, isosorbide
dinitrate, and hydralazine. Her creatinine normalized since
admission and she was able to resume her outpatient med regimen
once discharged to home. At one point during her course, she
developed asymptomatic atrial fibrillation that responded to
lopressor. It was decided not to rule her out for a myocardial
infarction since she was not a candidate for a
3) Hypothyroid: Ms. [**Known lastname 1124**] has a history of hypothyroidism for
which her synthroid was continued.
4) Acute Renal Failure: The patient was found to have a
creatinine of 1.5, up from 0.3. Her FeNa was not indicative of
pre-renal cause, and urine eosinophils were only mildly
positive. The patient's creatinine normalized over time and her
hctz was held during hospitalization. She was asked to resume
this at home.
5) Hyponatremia: Ms. [**Known lastname 6417**] hyponatremia was likely secondary
to sydrome of inappropriate antidiuretic hormone from her lung
process. Her serum osmolality was checked and she was fluid
restricted, leading to improvement.
6) Anemia: Ms. [**Known lastname 1124**] presented with a hematocrit of 24.3 and
tolerated a transfusion of 2 units of blood without
complications. It appeared to be secondary to iron deficiency
anemia in combination with anemia of chronic disease.
The decision was made to discharge Ms. [**Known lastname 1124**] home with nursing
care and potential bridge to hospice.
Medications on Admission:
1. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Four
(4) Puff Inhalation [**Hospital1 **] (2 times a day). Disp:*1 1* Refills:*2*
2. Levothyroxine Sodium 150 mcg Tablet Sig: One (1) Tablet PO QD
(once a day).
3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO QD
(once a day). Disp:*30 Tablet(s)* Refills:*2*
4. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-23**]
Puffs Inhalation Q6H (every 6 hours) as needed. Disp:*1 1*
Refills:*0*
5. Piperacillin-Tazobactam 2-0.25 g Recon Soln Sig: One (1)
Recon Soln Intravenous Q6H (every 6 hours) for 8 days. Disp:*32
Recon Soln(s)* Refills:*0*
6. Captopril 25 mg Tablet Sig: One (1) Tablet PO three times a
day. Disp:*90 Tablet(s)* Refills:*2*
7. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO three times
a day. Disp:*90 Tablet(s)* Refills:*2*
8. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day. Disp:*30 Tablet(s)* Refills:*2*
9. Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for sleep. Disp:*30 Tablet(s)* Refills:*2*
Discharge Medications:
1. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Four
(4) Puff Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 1* Refills:*2*
2. Levothyroxine Sodium 150 mcg Tablet Sig: One (1) Tablet PO QD
(once a day).
3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
4. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-23**]
Puffs Inhalation Q6H (every 6 hours) as needed.
Disp:*1 1* Refills:*0*
5. O2 Sat monitor
please provide a monitor
6. O2
Please provide home O2 tanks for ventilator
7. Piperacillin-Tazobactam 2-0.25 g Recon Soln Sig: One (1)
Recon Soln Intravenous Q6H (every 6 hours) for 8 days.
Disp:*32 Recon Soln(s)* Refills:*0*
8. Captopril 25 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*90 Tablet(s)* Refills:*2*
9. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO three times
a day.
Disp:*90 Tablet(s)* Refills:*2*
10. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
Disp:*30 Tablet(s)* Refills:*2*
11. Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for sleep.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 5065**] Healthcare
Discharge Diagnosis:
hypothyroidism
recurrent R pleural effusions status post multiple thoracentesis
(cytology negative)
cognitive impairment since total body irradiation
recurrent R pneumonia secondary to pseudomonas
sinus tachycardia
metabolic alkalosis
small cell lung cancer
ventilation dependent COPD
Discharge Condition:
fair
Discharge Instructions:
continue your ventilator. The current settings are AC with tidal
volume 400, respiratory rate of 13, PEEP of 8 and FiO2 of 0.50.
You need to continue to take antibiotics (Pip tazo) for 8 more
days.
Continue your synthroid, captopril, and diltiazem.
Continue the pureed diet plus tube feeds 5 times per day.
Followup Instructions:
please set up an appointment with your primary doctor in 1 week.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
ICD9 Codes: 5180, 5119, 5849, 4254, 2761 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3716
} | Medical Text: Admission Date: [**2196-1-11**] Discharge Date: [**2196-1-13**]
Date of Birth: [**2133-11-10**] Sex: M
Service: MEDICINE
Allergies:
Lipitor / Food Extracts
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
palpitations
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 62 year old male with history of significant CAD with
CABG in [**2177**] and PTCI in [**2193**] as well as chronic systolic CHF
and episodes of ventricular tachycardia s/p AICD placement in
[**2192**] who presented tonight after an ICD firing. Per the patient
he has been feeling a bit off for about a month now with
occasional episodes of dizziness and palpitations with standing.
Over the fast five days, however, this has been considerably
worse. He reports every time he stands up suddenly or exerts
himself he will feel palpitations and get light-headed though
he can breathe out hard and will feel this go away. he has
never lost consciousness, he just feels weak and generally very
unwell when this happens. He has no chest pain associated with
this. The patient received a defibrillator shock from his ICD
at around 10:00 pm on [**2196-1-10**] and presented to the emergency
room soon afterward.
.
In the ED, he was noted to go into intermittent episodes of VT
with overdrive pacing and vagal maneuvers quickly leading to a
reversion to sinus rhythm. He remained hemodynamically stable.
He was started on an amiodarone IV load and admitted to the
cardiology service. After arrival to the cardiology service the
patient had multiple episodes of VT terminating similar to the
events in the ED. Thus, he is transferred to the CCU for closer
monitoring.
.
Cardiac review of systems is notable for palpitations and
presyncope as noted. It is also notable for the presence of
chronic dyspnea on exertion related to asthma without lower
extremity edema, orthopnea, or PND. He denies chest pain of
syncope.
Past Medical History:
CARDIAC HISTORY:
-Coronary Artery Disease s/p the following interventions
****CABG in [**2177**] with LIMA to LAD, SVG to OM2, SVG to OM1, SVG
to R Marg. Cath results from [**2189**] as below showed LMCA 95%
lesion.
****NSTEMI [**2192-12-31**] cath at OSH(no interventions)
****PTCI [**2194-1-29**] showing: Three vessel coronary artery disease,
occluded SVG to the OM1 and OM2, diffusely diseased SVG to the
RCA acute marginal, Patent LIMA to the LAD)
-Chronic Systolic Heart Failure with EF 30%, last echo in [**2193**]
-NSVT in [**2192**] s/p ICD placed in [**1-/2193**]
-Dyslipidemia
-HTN
<br>
Other Past History:
- OSA on CPAP
- Asthma
- Diverticulitis
- Esophagitis
Social History:
Social history is notable for previous heavy tobacco use with
patient smoking >50 pack years. He has quit for two months
currently. Minimal alcohol use. No illicit drug use. He lives
with his wife and works as a carpenter/tiler.
Family History:
Notable for two identical twin sons with CAD in their 30's.
Dad-heart disease at 78 YO
Physical Exam:
VS: T=97.9, BP=116/60 HR=65, RR=15 O2 sat= 97% on 2L
General Appearance: Well nourished, No acute distress,
Overweight / Obese
Eyes / Conjunctiva: PERRL, No(t) Pupils dilated
Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition
Lymphatic: Cervical WNL, Supraclavicular WNL
Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Diminished), (Left
radial pulse: Present), (Right DP pulse: Present), (Left DP
pulse: Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Wheezes : diffuse wheezes, Diminished: ), diminished air
movement
Abdominal: Soft, Non-tender, Bowel sounds present, Obese
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent, No(t) Cyanosis, No(t) Clubbing
Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand
Skin: Warm, No(t) Rash: , No(t) Jaundice
Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Oriented (to): person, place, time, situation,
Movement: Purposeful, Tone: Normal
Pertinent Results:
ADMISSION LABS:
[**2196-1-11**] 12:00AM BLOOD WBC-9.3 RBC-4.65 Hgb-14.7 Hct-42.4 MCV-91
MCH-31.6 MCHC-34.7 RDW-13.2 Plt Ct-176
[**2196-1-11**] 12:00AM BLOOD Neuts-57.2 Lymphs-33.0 Monos-5.8 Eos-2.6
Baso-1.5
[**2196-1-11**] 12:00AM BLOOD PT-12.0 PTT-25.3 INR(PT)-1.0
[**2196-1-11**] 12:00AM BLOOD Glucose-116* UreaN-21* Creat-1.1 Na-140
K-3.8 Cl-104 HCO3-24 AnGap-16
[**2196-1-11**] 12:00AM BLOOD ALT-34 AST-28 LD(LDH)-211 CK(CPK)-270
AlkPhos-62 TotBili-0.5
[**2196-1-11**] 12:00AM BLOOD CK-MB-5
[**2196-1-11**] 12:00AM BLOOD cTropnT-<0.01
[**2196-1-11**] 12:00AM BLOOD Calcium-9.8 Phos-4.0 Mg-2.0
[**2196-1-12**] 04:17AM BLOOD TSH-1.9
[**2196-1-12**] 04:17AM BLOOD T3-77* Free T4-1.3
[**2196-1-11**] 12:10AM BLOOD Lactate-1.8
--------------------
DISCHARGE LABS:
[**2196-1-13**] 07:25AM BLOOD WBC-7.9 RBC-4.45* Hgb-14.1 Hct-41.0
MCV-92 MCH-31.6 MCHC-34.3 RDW-13.1 Plt Ct-149*
[**2196-1-13**] 07:25AM BLOOD PT-12.9 PTT-28.1 INR(PT)-1.1
[**2196-1-13**] 07:25AM BLOOD Glucose-117* UreaN-20 Creat-1.0 Na-138
K-3.7 Cl-102 HCO3-27 AnGap-13
[**2196-1-13**] 07:25AM BLOOD Calcium-8.9 Phos-3.9 Mg-2.1
[**2196-1-12**] 04:17AM BLOOD TSH-1.9
[**2196-1-12**] 04:17AM BLOOD T3-77* Free T4-1.3
--------------------
STUDIES:
.
EKG ([**2195-1-11**]): NSR at 67. Normal axis. Prolonged QT with left
bundaloid morphology. Likely left atrial abnormality. Compared
to previous EKG of [**2195-12-1**] there is no significant change.
.
TTE ([**2196-1-11**]):
The left atrial volume is severely increased. Left ventricular
wall thicknesses are normal. The left ventricular cavity is
moderately dilated. There is moderate regional left ventricular
systolic dysfunction with near-akinesis of the inferior and
inferolateral segments and mild hypokinesis of the other
segments. 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. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion.
Compared with the prior study (images unavailable for review) of
[**2194-4-7**], there is mild aortic regurgitation on the current
study. The other findings are similar.
.
CXR ([**2196-1-11**]):
Transvenous right ventricular pacer defibrillator lead follows
the expected course, left axillary pacemaker. Heart is mildly
enlarged, exaggerated by large mediastinal paracardiac fat
collection. Lungs are fully expanded and not hyperinflated and
clear. No pleural effusion or pneumothorax.
Brief Hospital Course:
This is a 62 y.o. male with CAD, chronic systolic CHF, and
history of VT s/p AICD placement presenting after AICD firing
with multiple episodes of ventricular tachycardia consistent
with VT storm.
.
# VT Storm: Patient's VT is likely scar mediated VT in the
context of his known CAD and previous episodes of ventricular
tachycardia. Unclear what has precipitated increased frequency
of VT. Perhaps new ischemic event versus progressive remodeling
(though >1 year since last intervention/known event). Device
complication (i.e. lead movement) seems extremely unlikely at
this juncture. Patient was started on amiodarone gtt at
1mg/min, which was brought town to 0.5mg/min after he stopped
having VT episodes. Electrolytes were repleted aggressively to
maintain K>4 and Mg>2. Amiodarone gtt was discontinued on the
afternoon of [**1-12**], and he was started on PO amiodarone 400mg
TID. The original plan was take him to EP lab on [**1-13**] for VT
ablation, but since he was VT-free on amiodarone, the procedure
was held off. PLAN: continue on PO amiodarone and follow up in
device clinic, ablating if medication failure
.
# Coronaries: ECG not suggestive of active ischemia though given
CABG and multiple PTCA patient undoubtedly has disease. [**Month/Year (2) **] and
statin were continued. Patient did not want to continue
metoprolol as he believes it exacerbates his asthma symptoms.
Notably, he does have more wheezing after receiving metoprolol.
As a result, he was not discharged home with BB.
.
# Chronic Systolic CHF: Patient with minimal oxygen requirement
and appears euvolemic on exam. Not on diuretic therapy as
outpatient and no history of decompensations. Valsartan was
continued. BB was held as above. He was discharged off of a
beta blocker for two reasons: Amiodarone has a betablocking
effect and he required more albuterol (tachygenic) while taking
it, given his asthma
.
# Asthma: Patient describes poorly controlled symptoms at
baseline and refused Beta agonist due to relationship to
tachycardia. Clinically looking well. Patient felt that
beta-blocker was making his asthma symptoms worse, and refused
to take metoprolol. As a result, he was not discharged home
with beta-blocker. He was put on Fluticasone inhaled daily, and
Ipratropium nebs PRN in the hospital for asthma control.
.
# OSA: Stable and patient uses CPAP at home. CPAP was
continued.
.
# Esophagitis: Stable. Pantoprazole was continued.
.
# Diet: Patient received cardiac healthy diet. He tolerated POs
well.
.
# Contact: Wife [**Name (NI) 4489**] [**Telephone/Fax (3) 19492**]
------------------
------------------
------------------
TO BE FOLLOWED
1) Patient to have device clinic f/u in 30 days
2) Patient needs pulm f/u with PFTs given amio
3) Patient needs Liver enzyme evaluation in 30 days while on
amio and crestor
------------------
------------------
------------------
Medications on Admission:
albuterol inhaler on a p.r.n. basis
clopidogrel 75 mg daily
fluticasone nasal spray on a p.r.n. basis
Imdur 60 mg daily
metoprolol succinate 50 mg daily
Fluticasone/Salmeterol: 500/50 [**Hospital1 **]
pantoprazole 20 mg daily,
rosuvastatin 20 mg daily
Dyazide one tablet daily
Valsartan 160 mg daily
Aspirin 81 mg daily.
Discharge Medications:
1. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal twice a day.
2. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
3. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Dyazide 37.5-25 mg Capsule Sig: One (1) Capsule PO once a
day.
7. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] ().
8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day.
10. NitroQuick 0.4 mg Tablet, Sublingual Sig: One (1) tab
Sublingual [**Last Name (un) **] 5 minutes for total of 3 doses as needed for
chest pain: If you still have chest pain after 3 nitroglycerin
tablets, call 911.
11. Pantoprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
12. ProAir HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: [**12-26**]
puffs Inhalation every four (4) hours as needed for shortness of
breath or wheezing.
13. Singulair 10 mg Tablet Sig: One (1) Tablet PO once a day.
14. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): Take 2 tablets twice daily until [**2196-1-20**], then decrease
to 400 mg once daily.
Disp:*120 Tablet(s)* Refills:*2*
15. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO three
times a day for 7 days.
Disp:*21 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Ventricular tachycardia
Coronary Artery Disease
Chronic Systolic congestive heart failure: EF 25%
Asthma
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
You had ventricular tachycardia that caused your ICD to fire.
You were started on amiodarone, a medicine to prevent the
ventricular tachycardia from occuring and to keep your heart
rate low. This medicine has been very effective in preventing
ventricular tachycardia while you have been in the hospital.
Amiodarone has a long half life or time of effectiveness. You
are undergoing a loading dose of amiodarone now so you will take
400 mg twice daily for one week, then decrease to 400 mg daily
until you see Dr. [**Last Name (STitle) **] again. Please call Dr. [**Last Name (STitle) **] at
[**Telephone/Fax (1) 62**] if the ICD fires again. You have phlebitis from an
IV line that leaked. YOu should continue to use warm compresses
and keep the arm elevated above your heart when sitting or lying
down as much as possible. You will take an antibiotic for one
week for this. Please call Dr. [**Last Name (STitle) **] if you notice that this
area is getting more red, swollen or painful.
Other medication changes:
1. Stop taking Metoprolol XL (Toprol) The amiodarone should keep
your heart rate low instead.
2. Take Cephalexin three times a day for one week to treat the
phlebitis in your right upper arm.
Weigh yourself every morning, call Dr. [**First Name (STitle) **] if weight goes up
more than 3 lbs in 1 day or 6 pounds in 3 days.
Followup Instructions:
Primary Care:
Provider: [**Name10 (NameIs) 2483**],[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 191**] MEDICAL UNIT (SB)
Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2196-7-25**] 11:20
Electrophysiology:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone: [**Telephone/Fax (1) 62**] Date/Time: [**2-18**] at
9:00. Your device will be checked by [**First Name8 (NamePattern2) 16883**] [**Last Name (NamePattern1) **], the nurse
practitioner who works with Dr. [**Last Name (STitle) **] at the same time.
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2196-5-31**]
9:00
Cardiology:
Provider: [**First Name8 (NamePattern2) 870**] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 62**] Date/Time: [**1-26**] at 11:20am.
Provider: [**First Name8 (NamePattern2) 870**] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2196-5-31**] 9:40
Completed by:[**2196-1-13**]
ICD9 Codes: 4271, 4280, 4019, 2724, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3717
} | Medical Text: Admission Date: [**2169-8-29**] Discharge Date: [**2169-9-4**]
Date of Birth: [**2117-6-19**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Erythromycin Base
Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
EGD on [**2169-8-30**] and [**2169-9-1**] with variceal banding
History of Present Illness:
52 yo F with EtOH cirrhosis complicated by portal hypertension
and recurrent variceal bleeding transferred from [**Hospital 1562**]
hospital for TIPS procedure.
.
The patient states that she began drinking around [**2169-8-22**] after
several months of sobriety. She presented to [**Hospital 1562**] Hospital
ED on [**2169-8-27**] with nausea, vomiting and hematemesis. She had a
total of 3 episodes of vomiting with small amounts of dark
blood in the emesis. She describes this as different than her
past variceal bleeds when the blood "kept coming and coming."
This time she describes "clot-like" emesis. She denies
associated dizziness, lightheadedness or chest pain.
.
On presentation to the OSH ED, hr 120, bp 90/60, Hct 29 (down
from 35 two days prior). Her alcohol level was 434. The patient
was admitted to the ICU. She received a total of 3U PRBC as well
as several liters IV NS. She was also started on an IV protonix
and IV octreotide drip as well as IV vitamin K. The patient was
placed on levofloxacin for prophylaxis due to elevated risk of
sepsis in cirrhotics with GI bleed. The patient's Hct appeared
to stabilize without further transfusion though it did not bump
to the PRBC's. The patient describes no further bleeding since
her day of admission. She notes passing gas but no stool. Her
last bowel movement was on [**2169-8-26**] and was dark, not bloody.
.
The patient was transferred for TIPS procedure as treatment for
recurrent variceal bleeding.
.
ROS: The patient describes several weeks of increasing abdominal
distention. Denies fevers, chills, nightsweats, changes in
weight or appetite, headache, blurry vision, neck stiffness or
pain, chest pain, SOB, abdominal pain, dysuria, rashes, myalgias
or arthralgias.
Past Medical History:
EtOH cirrhosis with portal hypertension, grade 3 esophageal
varices, gastric varices, thrombocytopenia
EtOH abuse. Denies history of seizures or hallucinations.
Upper GI variceal bleeding s/p multiple sclerotherapy and
banding procedures.
Boerrhave's syndrome/[**Doctor First Name **]-[**Doctor Last Name **] tear
Esophagitis and duodenitis
H/o cervical and uterine CA s/p TAH/BSO
Chronic renal insufficiency
Social History:
Left her husband 2 years ago but sees him every day. 3 children,
2 daughters live nearby and 1 son in college. Drinks
approximately 1 pint of vodka per day. No tobacco or illicit
drug use.
Family History:
Mother died at 62 of CHF. ?Liver disease.
Father died at 63 of lymphoma. ?Liver disease.
1 Brother and 2 sisters all healthy.
Physical Exam:
98.9 76 113/75 18 98% RA
Gen: NAD. Somewhat anxious.
HEENT: PERRL. Pink, moist oral mucosa without lesions. No
cervical or clavicular lymphadenopathy.
CV: RRR. Normal S1 and S2. No M/R/G.
Pulm: Decreased breath sounds over the right mid-lower lung
fields.
Abd: Distended. Dullness to percussion over the flank with
minimal shifting dullness. No palpable hepatosplenomegaly.
Ext: Spider angioma over the chest.
Neuro: A&Ox3. Tremulous. No asterixis. CN's II-XII intact.
Strength and sensation to light touch intact in all fields.
Pertinent Results:
OSH: Na 135->135, K 4.4->4.6, Cr 1.1->1.3, AST 106, ALT 32, Alk
Phos 120, Alb 3.4, T. Bili 5.0, D Bili 2.3, [**Doctor First Name **] 53, Lip 34, WBC
11->7.7, Hct 29->28, MCV 90, platelets 77->30, INR 1.3, PT 14.2,
PTT 27.3, EtOH 434.
.
[**2169-8-29**] 09:17PM GLUCOSE-112* UREA N-21* CREAT-1.3* SODIUM-133
POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-23 ANION GAP-10
[**2169-8-29**] 09:17PM ALT(SGPT)-30 AST(SGOT)-100* LD(LDH)-189 ALK
PHOS-104 AMYLASE-99 TOT BILI-6.8*
[**2169-8-29**] 09:17PM LIPASE-149*
[**2169-8-29**] 09:17PM ALBUMIN-3.0* CALCIUM-8.1* PHOSPHATE-1.0*#
MAGNESIUM-2.2
[**2169-8-29**] 09:17PM WBC-5.8# RBC-3.39* HGB-10.6* HCT-30.9* MCV-91
MCH-31.2 MCHC-34.2 RDW-18.3*
[**2169-8-29**] 09:17PM PT-16.1* PTT-29.9 INR(PT)-1.5*
.
EKG ([**2169-8-27**]): Sinus tachycardia. Rate 130. Nomal axis and
intervals. No acute ST or T wave changes. No baseline for
comparison.
.
[**2169-8-30**] CXR:
SINGLE AP PORTABLE VIEW OF THE CHEST: Cardiac size is top
normal. The lungs are clear. There is no pleural effusion.
.
[**2169-8-30**] ABD U/S:
IMPRESSION: Nodular echogenic coarse liver consistent with
cirrhosis without focal lesion identified. There is evidence of
portal hypertension including splenomegaly and ascites. The
portal veins demonstrate slow hepatopetal flow.
.
Brief Hospital Course:
52 yo F with EtOH cirrhosis complicated by portal hypertension
and recurrent variceal bleeding transferred from [**Hospital 1562**]
hospital for considerations of TIPS procedure.
# Hematemesis - The patient was admitted directly to the ICU for
EGD. The GI team was consulted and performed an EGD. She was
found to have a large varix that was likely the source of her
bleeding. She became tachycardic and was unable to be banded at
that time. She was maintained on a protonix and an ocreotide
drip for 72 hours. Her diet was slowly advanced to a soft GI
diet. She was also started on a 5 day course of cipro 500mg
[**Hospital1 **]. She had a repeat EGD on [**2169-9-1**] which showed non bleeding
varices which were banded successfully. She remained HD stable
without any blood transfusions. She was started on carafate,
continued on PPI [**Hospital1 **], put on a soft/dysphagia diet x3 days after
24hours of clear liq diet. She had no further N/V/Hematemesis.
She will need a follow up appointment at Liver Clinic (patient
given the number for the clinic) and a repeat endoscopy in [**1-29**]
weeks (can be arranged at Liver Clinic or with a local GI
physician).
# EtOH abuse - The patient denied any history of DT's. She had
been on a 5 day binge prior to admission. She was started on a
valium CIWA scale. She received a total of 20mg valium on
[**2169-8-30**] but since then has not required any benzos for
withdrawal. She has been receiving thiamine, folic acid, and
MVI supplementation. SW evaluated pt for AA or further addiction
counseling and services.
# EtOH cirrhosis complicated by portal hypertension, esophageal
varices. A Abdominal U/S was consistent with cirrhosis and
portal hypertension. A TIPS was not thought to be necessary at
this time. She will continue medical management with diuretics,
and nadalol for varices. She was restarted on her lactulose
prior to discharge.
# Thrombocytopenia. Likely secondary to liver disease. We
monitored her platelets with a goal for maintaining platelets
>20.
.
#. CODE: FULL
Medications on Admission:
Meds (at home per patient):
Furosemide 40mg twice daily
Spironolactone 50mg twice daily
Prilosec 20-40mg once daily
Centrum
Ca
Vit D
Iron
Mg
.
Meds (on transfer):
Vit K 10mg daily x 3 total days, last on [**2169-8-29**]
MVI
Thiamine
Octreotide 50mcg/hr continuous infusion
Pantoprazole 8mg/hr continuous infusion
Levofloxacin 500mg Daily
Metoprolol 2.5mg q6h IV
Discharge Medications:
1. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
5. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
Disp:*2700 ML(s)* Refills:*2*
9. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Hematemosis
Secondary Diagnosis:
ETOH Cirrhosis
Thrompcytopenia
Discharge Condition:
Stable; tolerating a regular diet; hct stable
Discharge Instructions:
You were admitted to the hospital because of bleeding from your
esophagous. You had two EGD's while you were in the hospital
and they were able to band the large varices that was the source
of the bleeding. It is very important that you stop drinking
because it is causing severe damage to your liver.
Please refrain from all alcohol.
Followup Instructions:
-- Please follow up with your primary care doctor, Dr [**Last Name (STitle) **],
within the next 1-2 weeks. Call [**Last Name (un) **] tomorrow at [**Telephone/Fax (1) 62067**]
to set up an appointment.
-- You will need to follow up in the Liver Clinic in [**11-29**] weeks
with Dr. [**Name (NI) **], please call the liver center at ([**Telephone/Fax (1) 16686**] for an appointment.
-- You will need another upper endoscopy in [**1-29**] weeks. This can
be arranged at the Liver Clinic or by a local physician
suggested by your PCP.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]
Completed by:[**2169-9-4**]
ICD9 Codes: 2761, 5849, 9971, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3718
} | Medical Text: Admission Date: [**2114-8-3**] Discharge Date: [**2114-8-11**]
Date of Birth: [**2037-1-17**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Exploratory laparotomy and lysis of adhesions, decompression of
small bowel [**2114-8-3**]
History of Present Illness:
77 yo female with complaints of abdominal pain for several days
that began to worsen on night before presenting to the Emergency
room. +N/V, bilious emesis, no blood and pain in epigastric
region; constipation x 2 days. Abdominal CT scan revealed small
bowel obstruction.
Past Medical History:
Hypothyroid
Anemia
Hypothyroid
Ostoporosis
"Cancer of stomach"
Family History:
Noncontributory
Pertinent Results:
[**2114-8-3**] 07:49PM GLUCOSE-169* UREA N-13 CREAT-0.7 SODIUM-137
POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-24 ANION GAP-14
[**2114-8-3**] 07:49PM CALCIUM-9.1 PHOSPHATE-3.5 MAGNESIUM-1.8
[**2114-8-3**] 07:49PM WBC-16.5* RBC-3.50* HGB-11.0* HCT-31.8*
MCV-91 MCH-31.5 MCHC-34.7 RDW-14.5
[**2114-8-3**] 07:49PM PLT COUNT-303
[**2114-8-3**] 11:02PM HCT-36.9
CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST
Reason: r/o obstruction, ileus, choledocolithiasis, or other
acute a
Field of view: 42 Contrast: OPTIRAY
IMPRESSION:
1. Long-standing partial small bowel obstruction with transition
point in the deep pelvis and fecalization of small bowel.
2. Multiple hernias including a ventral and loer abdominal
hernia that are both fat and mesentery containing without
evidence of incarceration. A third hernia with a knuckle of
transverse colon ventrally demonstrates both proximal and distal
bowel collapse.
ABDOMEN (SUPINE & ERECT)
Reason: eval for obstruction
IMPRESSION: Nonspecific bowel gas pattern without evidence of
obstruction or free intraperitoneal air.
ECG:
Sinus rhythm. Since the previous tracing of [**2109-3-19**] left axis
deviation
consistent with left anterior fascicular block has appeared.
Voltage criteria
for left ventricular hypertrophy in lead aVL are now met.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
67 188 86 420/435 62 -34 15
Brief Hospital Course:
Patient admitted to the Surgery service under the care of Dr.
[**Last Name (STitle) **]. She was taken to the operating room on [**8-3**] for
exploratory lap with lysis of adhesions and decompression of
small bowel. Postoperatively she has done well. Her NG tube was
removed on POD #4, her diet was advanced and she is tolerating a
regular diet; no bowel movement to date. She is on a bowel
regimen. Her pain was initially controlled with prn Dilaudid,
this was changed to Oxycodone and prn Tylenol. her home meds
were restarted. She will need to follow up with Dr. [**Last Name (STitle) **] in [**12-4**]
weeks for removal of her abdominal staples.
Physical therapy was consulted and have recommended short term
rehab stay.
Medications on Admission:
Fosamax
Levothyroxine
Calcium
Discharge Medications:
1. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 1 months.
Disp:*30 Tablet(s)* Refills:*2*
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) for
1 months.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO ONCE (Once) for 3 days.
Disp:*6 Capsule, Sustained Release(s)* Refills:*0*
4. Colace 100 mg Capsule Sig: One (1) Capsule PO three times a
day for 1 months.
Disp:*90 Capsule(s)* Refills:*2*
5. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day for 1 months.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): [**Month (only) 116**] discontinue when fully
ambulatory.
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for pain.
8. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
9. FOSAMAX 70 mg Tablet Sig: One (1) Tablet PO Q Monday: take
with 8 oz water 30 min before breakfast sitting upright and
remaining upright for 45 min after ingested.
10. CALCIUM 500+D 500-125 mg-unit Tablet Sig: One (1) Tablet PO
twice a day.
Discharge Disposition:
Extended Care
Facility:
Heathwood
Discharge Diagnosis:
Small bowel obstruction secondary to phytobezoar.
Discharge Condition:
Good
Discharge Instructions:
Please continue all medications as written, activity and diet as
tolerated, and keep all appointments as scheduled.
Followup Instructions:
Please call [**Telephone/Fax (1) 600**] to schedule a follow-up appointment
with Dr. [**Last Name (STitle) **] in the Surgery Clinic in [**12-4**] weeks.
Completed by:[**2114-8-8**]
ICD9 Codes: 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3719
} | Medical Text: Admission Date: [**2142-10-12**] Discharge Date: [**2142-10-13**]
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
Bright red blood per ostomy
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: 84 year old gentleman with ulcerative colitis s/p colectomy
and end ileostomy with multiple recent admissions for bright red
blood from ostomy. Tonight he presents again with bright red
blood per rectum. He was in pool when noticed his ostomy bag
filled with blood. Went to lie down but continued to have
bleeding and filled up four bags. Pt began to feel light headed
and went to ED HR 95 SBP 130. Hematocrit found to be 21.1,
baseline in the low 30s. 26.5 two days ago. Had some bleeding
from ostomy in ED but much improved per pt. Evaluated by surgery
who decided against doing ostomy revision this admission. Of
note [**9-19**] antral gastritis, [**10-3**] colonoscopy with no source of
bleeding in colon.
Past Medical History:
- DM2
- Ulcerative colitis - [**2127**]-colectomy wtih end ileostomy
- [**2140**] fistulous tract noted on the stoma ?Crohn's
- Alcoholic cirrhosis
- Liver mass 4.6 X 3.7 seen on MRI ([**1-8**]) concerning for HCC.
Pt elected not to get this evaluated (now larger on repeat U/S
today)
- GERD
- h/o malaria
- [**2128**]-abdominal peroneal resection
- cataract surgeries
.
- Prior endoscopic data:
[**2142-9-19**]: ILEOSCOPY: No bleeding was seen from within the small
intestine. On ostomy manipulation, a moderate amount of bleeding
from the ostomy site began. No specific source of the bleeding
was seen and it stopped quickly with non-specific compression.
.
[**2142-9-19**]: EGD: Antral gastritis
.
[**2140-8-21**]: ILEOSCOPY: Submucosal mass 20 cm above the ileostomy
(biopsy- No tumor). Granular, irregular friable mucosa on the
surface of the ileostomy, near the fistulous tract (biopsy-
ulceration with granulation tissue)), cauterized with silver
nitrate). Otherwise normal colonoscopy to 30 cm into the
terminal ileum.
.
[**2140-6-21**]: ILEOSCOPY: Granulation tissue on lip of stoma. No
evidence of stomal varicies, ileitis, or tumor. No obvious
source of bleeding. Otherwise normal ileoscopy to 60 cm.
.
[**2140-6-21**]: EGD: Abnormal mucosa in the esophagus (biopsy-Active
esophagitis, focal, with extensive recent hemorrhage). Nodules
in the stomach body. Duodenitis.
Social History:
Widowed, lives alone. Distant tobacco. Quit alcohol 4 years ago.
Family History:
Mother and sister with stomach cancer
Father had diabetes
Physical Exam:
Physical Exam:
VS: T 97.7, BP 131/52, HR 95, RR 20, 97% on RA
Gen: WD/WN Caucasian male NAD
Eyes: Anicteric
Mouth: MM slightly dry, edentulous
Chest: CTAB
CVS: RRR, 3/6 systolic murmur
Abd: Minimal bowel sounds, nontender/nondistended. Ostomy bag
with dark red blood, ostomy itself pink with clotted blood
Ext: no edema
Neuro: Fully alert and oriented.
Pertinent Results:
[**2142-10-13**] 05:48AM BLOOD WBC-5.1 RBC-3.06* Hgb-9.6* Hct-26.9*
MCV-88 MCH-31.4 MCHC-35.6* RDW-17.7* Plt Ct-120*
[**2142-10-12**] 10:48PM BLOOD Hct-26.2*
[**2142-10-12**] 03:50PM BLOOD Hct-23.6*
[**2142-10-12**] 10:58AM BLOOD WBC-5.7 RBC-2.74* Hgb-8.7* Hct-24.4*
MCV-89 MCH-31.9 MCHC-35.8* RDW-17.2* Plt Ct-112*
[**2142-10-12**] 12:30AM BLOOD WBC-4.7 RBC-2.30* Hgb-7.2* Hct-21.1*
MCV-92 MCH-31.3 MCHC-34.1 RDW-16.4* Plt Ct-145*
[**2142-10-12**] 12:30AM BLOOD Neuts-68.9 Lymphs-23.3 Monos-4.1 Eos-3.2
Baso-0.5
[**2142-10-12**] 12:30AM BLOOD Anisocy-1+ Poiklo-1+ Macrocy-1+
[**2142-10-13**] 05:48AM BLOOD Plt Ct-120*
[**2142-10-13**] 05:48AM BLOOD PT-13.9* PTT-25.8 INR(PT)-1.2*
[**2142-10-12**] 10:58AM BLOOD Plt Ct-112*
[**2142-10-12**] 12:30AM BLOOD Plt Ct-145*
[**2142-10-12**] 12:30AM BLOOD PT-14.4* PTT-24.0 INR(PT)-1.3*
[**2142-10-13**] 05:48AM BLOOD Glucose-119* UreaN-8 Creat-1.2 Na-141
K-3.9 Cl-107 HCO3-26 AnGap-12
CHEST (PORTABLE AP) [**2142-10-12**] 10:12 AM
CHEST (PORTABLE AP)
Reason: evaluate for effusions/edema
[**Hospital 93**] MEDICAL CONDITION:
84 year old man with UGIB, new crackles bilaterally
REASON FOR THIS EXAMINATION:
evaluate for effusions/edema
AP CHEST, 10:20 A.M., [**10-12**].
HISTORY: Upper GI bleed.
IMPRESSION: PA and lateral chest compared to [**2142-9-18**]:
Right middle lobe has cleared. New hazy opacification of the
left lower lung could be due to overlying soft tissue. Routine
radiographs including obliques recommended for evaluation. Heart
size is top normal. No appreciable pleural effusion or
pneumothorax.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
[**2142-10-12**] 10:58AM BLOOD Glucose-105 UreaN-9 Creat-1.0 Na-141
K-4.0 Cl-109* HCO3-25 AnGap-11
[**2142-10-12**] 12:30AM BLOOD Glucose-249* UreaN-11 Creat-1.2 Na-140
K-4.3 Cl-107 HCO3-25 AnGap-12
[**2142-10-12**] 12:30AM BLOOD ALT-16 AST-26 CK(CPK)-86 AlkPhos-68
Amylase-47 TotBili-0.4
[**2142-10-12**] 12:30AM BLOOD Lipase-30
[**2142-10-12**] 12:30AM BLOOD CK-MB-4 cTropnT-0.01
[**2142-10-13**] 05:48AM BLOOD Calcium-8.2* Phos-2.6* Mg-1.8
[**2142-10-12**] 10:58AM BLOOD Calcium-8.1* Phos-3.0 Mg-1.9 Iron-88
[**2142-10-12**] 10:58AM BLOOD calTIBC-278 VitB12-591 Folate-GREATER TH
Ferritn-53 TRF-214
[**2142-10-12**] 12:32AM BLOOD Glucose-259*
[**2142-10-12**] 12:32AM BLOOD Hgb-7.3* calcHCT-22
Brief Hospital Course:
A/P: This is an 84 year old gentleman with a h/o UC s/p
colectomy and ostomy, DM2, alcoholic cirrhosis, and enlarging
liver mass, who
presented with bright red blood per ostomy associated with
lightheadedness, found to have hematocrit of 21.1 significantly
below baseline. Hemodynamically stable with mentation at
baseline.
.
1. GI bleed. From ostomy, most likely source is ostomy itself
given his history
pt. was given 2U pRBCs with appropriate hct. bump. During his
remaining stay here, his hct was stable and he did not have any
BRB per ostomy.
.
2. DM II, on glyburide. Holding given NPO status, will cover
with RISS. FSBGs were well controlled here in the hospital.
.
3. Anemia, likely [**3-8**] iron deficiency in the past. Continued
iron, B12, folate levels were checked and were normal in the
hospital
.
4. Liver mass/history of alcoholic cirrhosis, no active issues.
No sign of varices on last EGD
Medications on Admission:
1. Silver Nitrate Applicators Misc Sig: One (1) Misc Topical
PRN (as needed) as needed for prn for ostomy bleed.
Disp:*30 Misc(s)* Refills:*2*
2. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. glyburide5mg po qd
Discharge Medications:
1. Silver Nitrate Applicators Misc Sig: One (1) Misc Topical
PRN (as needed) as needed for prn for ostomy bleed.
Disp:*30 Misc(s)* Refills:*2*
2. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. glyburide5mg po qd
Discharge Disposition:
Home
Discharge Diagnosis:
Osteomy bleed
____________________
Diabetes Mellitus
Alcoholic cirrhosis
Gastroesophageal reflux disease
Discharge Condition:
good, hematocrit stable, ambulatory, without dizziness,
shortness of breath, or chest pain
Discharge Instructions:
Please seek medical attention if you begin to bleed around your
ostomy site. Please also seek medical attention if you feel
dizzy, develop chest pain or shortness of breath.
Followup Instructions:
please follow up with your PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) **] within a week for a
check of your hematocrit.
You also have th [**Hospital 19506**] medical appointments which you have
scheduled.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2142-10-29**] 9:20
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2142-11-26**] 8:50
ICD9 Codes: 5789 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3720
} | Medical Text: Admission Date: [**2117-7-21**] Discharge Date: [**2117-7-22**]
Date of Birth: [**2041-6-27**] Sex: F
Service: NEUROSURGERY
Allergies:
Dilantin / Erythromycin Base / Peanut / Soy
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
AV Fistula
Major Surgical or Invasive Procedure:
[**2117-7-20**]: Cerebral Angiogram and embolization of AV Fistula
History of Present Illness:
76 y/o woman with history of VP shunt placement and embolization
of dural AVF in [**2117-4-4**]. On [**2117-6-28**] she underwent a
diagnostic angiogram which showed that the previously seen dural
AV fistula was significantly diminished in size but there may be
a small area that still fills, supplied by the external carotid
artery. It was recommended that she undergo re-embolization of
this to prevent future hemorrhage. She electively presents on
[**2117-7-21**] for this procedure.
Past Medical History:
-2 prior strokes about 15 years ago separated by 1-2 years,
presented as seizures, daughter thinks 1 clot and 1 bleed, left
with mild L hemiparesis, etiology unclear but suspected a/w
hormone-replacement therapy
-seizures a/w strokes as above, on Tegretol since with no
additional events concerning for seizures
- cerebellar AVM diagnosed about 15 years ago incidentally when
imaging done for stroke, followed intermittently
- mild concussion x 2 associated with recent falls
- HTN
- HL
- depression
- osteoporosis
- diverticulosis
- restless leg syndrome
- basal cell CA
Social History:
She lives with husband, [**Name (NI) **] lives a few blocks away,
patient has LifeLine. Retired biologist. No tobacco, ETOH or
illicits.
Family History:
Her father had stroke in his 70s, mother and brother have
[**Name (NI) 11964**] vs [**Name (NI) 69031**] disease. No h/o aneurysm or ICH.
Pertinent Results:
[**2117-7-22**] 02:46AM BLOOD WBC-7.9 RBC-3.52* Hgb-10.6* Hct-31.2*
MCV-89 MCH-30.0 MCHC-33.8 RDW-13.9 Plt Ct-380
[**2117-7-22**] 02:46AM BLOOD PT-11.1 PTT-25.9 INR(PT)-1.0
[**2117-7-22**] 02:46AM BLOOD Glucose-94 UreaN-14 Creat-0.6 Na-138
K-3.9 Cl-106 HCO3-23 AnGap-13
Brief Hospital Course:
Pt electively presented and underwent a cerebral angiogram and
partial re-embolization of her Dural AV Fistula. This was
performed without complication and she was admitted to the ICU
for close neurological monitoring. Postoperatively she did well
and remained neurologically stble. On POD1 she was transferred
to the regular floor, advanced her diet and ambulated with her
nurse.
At the time of discharge she was tolerating a regular diet,
ambulating without difficulty, afebrile with stable vital signs.
Medications on Admission:
amlodipine 10 mg tablet 1 (One) Tablet(s) by mouth once a day
labetalol 200 mg tablet 1 (One) Tablet(s) by mouth twice a day
omeprazole 20 mg capsule,delayed release(DR/EC) 1 (One)
Capsule(s) by mouth once a day
simvastatin 20 mg tablet 1 Tablet(s) by mouth qd in evening
ASA 81mg
Discharge Disposition:
Home With Service
Facility:
VNA of [**Location (un) 3307**]
Discharge Diagnosis:
Dural AV Fistula
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Angiogram with Embolization
Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **]
?????? Continue all 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
Followup Instructions:
* Dr. [**First Name (STitle) **] will call you in [**Month (only) 216**] to plan the next stage of
your treatment.
If you have questions before then please call the office at
[**Telephone/Fax (1) 1669**].
Completed by:[**2117-7-22**]
ICD9 Codes: 4019, 2724, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3721
} | Medical Text: Admission Date: [**2185-6-7**] Discharge Date: [**2185-6-17**]
Date of Birth: [**2128-9-11**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
severe pancreatitis
ARDS requiring intubation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
56 y/o transferred from [**Hospital 1562**] Hosp via Med Flight for
hemorrhagic pancreatitis & respiratory failure. Pt originally
admitted to [**Hospital 1562**] Hosp on [**2185-6-2**] from [**Location (un) 3244**] Detox center
following a three week history of binge drinking with epigastric
pain, N/V for 2 days PTA. Dx'd with severe pancreatitis with
hemmorrhagic component. (On coumadin for Afib) requiring 6 u
PRBCs, 6 FFP and plts. Pt intubated at OLH for airway
protection. On [**6-7**] pt transferred to [**Hospital1 18**] for continued care.
Past Medical History:
depression
EtOh at detox
A fib
HTN
Social History:
Married
Hx ETOH abuse (20 oz/day per pt report)
Denies tobacco, IVDA
Family History:
non-contributory
Physical Exam:
On admission to [**Hospital1 18**] SICU:
Patient Intubated and sedated
Coarse bilateral BS
RRR
Abdomen soft with rebound and guarding
Extremeties, Trace Edema.
Now on [**6-17**]
VSS 98.3, 59 112/64 18 100%RA FSBS 66-231
NAD, RRR, Lungs CTA bilaterally,
Abd soft, NT, ND with + BS
Extremeties, no edema noted
Diet advancing to regular, tolerating well
Pertinent Results:
Initial Amylase/Lipase from [**2185-6-3**] [**Telephone/Fax (1) 67692**]
Labs from [**2185-6-7**] 06:16PM
ART PO2-82* PCO2-49* PH-7.35 TOTAL CO2-28 BASE XS-0
GLUCOSE-121* LACTATE-0.9
freeCa-1.12
GLUCOSE-123* UREA N-28* CREAT-1.9* SODIUM-149* POTASSIUM-3.9
CHLORIDE-114* TOTAL CO2-26 ANION GAP-13
ALT(SGPT)-27 AST(SGOT)-68* LD(LDH)-1848* ALK PHOS-177* TOT
BILI-1.8*
AMYLASE-105* LIPASE-254*
ALBUMIN-2.7* CALCIUM-7.7* PHOSPHATE-2.7 MAGNESIUM-2.2
WBC-6.5 RBC-3.43* HGB-10.7* HCT-31.1* MCV-91 MCH-31.3 MCHC-34.4
RDW-15.8*
NEUTS-69 BANDS-2 LYMPHS-11* MONOS-13* EOS-3 BASOS-0 ATYPS-0
METAS-2*
PLT COUNT-172
PT-18.8* PTT-25.8 INR(PT)-1.8* FIBRINOGEN-1224*
CT: [**2185-6-9**] severe pancreatitis w/lg amt fluid/stranding around
the pancreas extending into L paracolic gutter, L ant/post
perirenal space, free fluid in the pelvis,
Labs from [**2185-6-17**]
Na 141 K 4.2 Cl 108 Co2 20 BUN 26 Creat 1.3 glucose 103
Ca: 9.3 Mg: 1.9 P: 4.2
AST: 34 ALT: 47 AP: 127 Tbili: 0.8 Alb: 3.9
[**Doctor First Name **]: 137 Lip: 430
WBC 7.5 Hgb: 11.7 Hct 35.5 Plt 638
PT: 14.1 PTT: 27.8 INR: 1.3
Brief Hospital Course:
57 y/o male with known ETOH abuse, HTN, hyperlipidemia, AFib on
Coumadin/digoxin transferred from [**Hospital 1562**] Hosp after 5 day
admission for hemorrhagic pancreatitis and ARDS. On arrival to
SICU pt was intubated and sedated and was receiving TPN,
imipenem (7 day course). No pressor support. During the one week
ICU course, pt was slowly weaned from vent support, started on
TF and diuresed. Pt did have some renal failure during the
course, but this has since resolved, with current creat at
probable baseline of 1.3. CT showed evidence of severe
pancreatitis with a large amount of fluid and stranding
surrounding the pancreas, extending into the left paracolic
gutter, left anterior and posterior perirenal space, and right
perirenal space. Free fluid is seen extending down into the
pelvis. Assessment of pancreas enhancement is limited, but
appears relatively uniform. No definite thrombus is identified
within the portal and splenic veins. There were also moderate to
large bilateral pleural effusions with associated atelectasis.
Extubation was on [**6-12**], and patient continued to improve and was
transferred to the regular floor on [**6-15**]. Originally pt had a
1:1 sitter which was d/c'd on [**6-16**]. Pt has worked with PT and
has advanced diet. It was felt that he did not require physical
rehab. He required outpatient counseling/work at detox center.
He was discharged home on insulin. He was instructed in how to
check his blood sugars as well as self administer insulin.
He was advised to follow up with PCP as well as an outpatient
gastroenterologist.
Medications on Admission:
Coumadin 5', Digoxin o.125', Lisinopril 40', Librium prn, Librax
0.5',
Effexor XR 150', Lipid 600'
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*0*
2. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
3. Insulin Glulisine 100 unit/mL Solution Sig: Ten (10) ubits
Subcutaneous once a day.
Disp:*1 * Refills:*2*
4. Humalog 100 unit/mL Solution Sig: follow sliding scale
Subcutaneous four times a day.
Disp:*1 * Refills:*2*
5. syringes
1 box
refill:2
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] home health
Discharge Diagnosis:
pancreatitis: resolving
Discharge Condition:
good
Discharge Instructions:
Call [**Telephone/Fax (1) 67693**] with increasing abdominal or back pain,
fever,chills, nausea, vomiting or diarrhea.
Followup Instructions:
Call Primary Care physician for appointment in 2 weeks for
management of blood pressure medications
Completed by:[**2185-7-1**]
ICD9 Codes: 5849, 5180, 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3722
} | Medical Text: Admission Date: [**2112-8-17**] Discharge Date: [**2112-10-30**]
Date of Birth: [**2085-2-4**] Sex: M
Service: MEDICINE
Allergies:
Shellfish Derived
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Respiratory distress, sepsis
Major Surgical or Invasive Procedure:
RIJ catheter placement ([**8-17**])
Arterial line placement ([**8-17**], [**8-30**])
intubation ([**8-17**], [**8-30**], [**10-19**])
extubation ([**8-19**], [**9-7**])
History of Present Illness:
27-year-old male with a history of CLL status post allogeneic
transplant in early [**2111**] complicated by graft-versus-host
disease, capillary leak syndrome, PE on lovenox who is
presenting in septic shock from OSH. The patient was seen on
[**8-16**] in [**Hospital 3242**] clinic where he was noted to have a fever, WBC of 2.1
with 6% bands, Hct of 24.2, Cr of 1.2 (up from 0.7 on [**8-10**]) and
was complaining of overall "not feeling well." Attempts were
made to send him to the ED, however the patient declined and
went home instead. He was sent with Augmentin. On [**8-17**], he was
found by his VNA to be lethargic, hypotensive, and febrile. He
was taken to [**Hospital3 **] where he was hypotensive to the
70s, febrile to 103.2 and hypoxic to 91% on NRB. He got IVF
boluses and started on levophed. CXR showed bilateral lower
lobe opacities. Labs showed WBC of 0.8, H/H [**5-17**] and 16.2. He
got vanco, cefepime, hydrocort 100mg IV, 2 units PRBC, was
intubated, and Med flighted to [**Hospital1 18**].
On arrival to the ICU, patient is intubated and sedated. Does
move all 4 extremities equally.
Past Medical History:
ONCOLOGIC HISTORY:
* Diagnosed in [**2106**] with CLL/SLL and bulky cervical
lymphadenopathy
*Pentostatin/Cytoxan x 1 with transient response and disease
progression prior to 2nd cycle
*R-CHOP x 2 cycles with decline in ejection fraction and
atypical chest pain, resolved over a period of months
*[**1-/2109**] R-CVP x 4
*[**5-/2109**] [**Hospital1 **] (Adriamycin given as thought to be less
cardiotoxic
when given in an infusional way)
*[**12/2109**] Rituxan x 1
*[**9-/2110**] R-[**Hospital1 **] x 2 for increasing cervical adenopathy, with
modest response
*[**11/2110**] Bendamustine x 1 with poor response
*[**12/2110**] FCR x 2
*[**2111-5-1**] Reduced intensity allogeneic stem cell transplant
with TLI, ATG, clofarabine as conditioning regimen. Brother is
donor.
.
POST TRANSPLANT COMPLICATIONS:
*CMV first noted [**2111-5-20**], viral load rose on oral valcyte but
resolved on IV ganciclovir. Reactivated [**2111-7-20**], again received
IV ganciclovir
*BK viruria, received IVIG on [**2111-6-11**].
*GVHD, GI involvement requiring narcotics, TPN, and bowel rest.
*[**8-/2111**] acute change in mental status, ? air embolus
*PE, noted [**2111-10-29**] currently anticoagulated with Coumadin
*[**Year (4 digits) **] perforation [**10/2111**], ? related to colonoscopy
*[**11/2111**] Right chest wall abscess, MRSA
.
OTHER MEDICAL HISTORY:
Asymptomatic cardiomyopathy
Bigeminy/trigeminy
Positive PPD [**2100**]: 12 months of therapy
S/p tonsillectomy [**2107**]
Pulmonary embolism ([**10-24**]) on warfarin
HTN
Social History:
Former heavy drinker (20 beers/week on average) but has stopped
altogether with current treatment. Lives at home with his
girlfriend. Denies drug use. No smoking. Has worked various
jobs, was most recently employed as a machinist but has been
laid off since 2/[**2110**]. He currently receives unemployment
compensation, and hopefully will be eligible for disability
soon. Of note, his mother was his only parent he had a
relationship with. She passed away when [**Known firstname 1116**] was 20 yo after
sustaining a stroke which was witnessed by family. He feels as
if his girlfriend is supportive.
Family History:
Mother had stroke at age 48. Patient does not know his father
well. [**Name2 (NI) **] has 2 brothers.
Physical Exam:
ICU Admission Physical Exam:
Tm 100.4??????F,Tc 100.3??????F, HR128(119 - 151)
BP:108/45(68)108-147/45-79(68-101) RR: 15(13 - 31) SpO2: 100%
General: Intubated, sedated
HEENT: Sclera anicteric, PERRL, no icterus
Neck: supple
Lungs: coarse breath sounds on anterior exam
CV: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
GU: foley in place
Ext: warm, well perfused, 3+ edema throughout lower extremities,
purple striae noted across abdomen and thighs with some bullae
formation, brawny induration noted of upper thighs - Left thigh
erythematous and warm to touch with 2 large bullae
Pertinent Results:
Admission Labs:
[**2112-8-16**] 03:15PM WBC-2.1* RBC-2.96* HGB-7.8* HCT-24.2* MCV-82
MCH-26.5* MCHC-32.4 RDW-20.4*
[**2112-8-16**] 03:15PM NEUTS-78* BANDS-6* LYMPHS-7* MONOS-4 EOS-0
BASOS-0 ATYPS-0 METAS-5* MYELOS-0 NUC RBCS-8*
[**2112-8-16**] 03:15PM HYPOCHROM-3+ ANISOCYT-2+ POIKILOCY-2+
MACROCYT-1+ MICROCYT-2+ POLYCHROM-OCCASIONAL
SPHEROCYT-OCCASIONAL OVALOCYT-1+ SCHISTOCY-OCCASIONAL
TEARDROP-OCCASIONAL ELLIPTOCY-OCCASIONAL
[**2112-8-16**] 03:15PM CALCIUM-9.2 PHOSPHATE-3.9 MAGNESIUM-1.7
[**2112-8-16**] 03:15PM UREA N-20 CREAT-1.2 SODIUM-139 POTASSIUM-3.8
CHLORIDE-100 TOTAL CO2-24 ANION GAP-19
[**2112-8-17**] 05:19PM LACTATE-2.6*
[**2112-8-16**] 03:15PM ALT(SGPT)-42* AST(SGOT)-24 LD(LDH)-638* ALK
PHOS-94 TOT BILI-0.4
[**2112-8-17**] 05:21PM FIBRINOGE-373#
.
Last labs [**10-28**]:
WBC 0.8 Hgb 8.7 Hct 25.6 Plt 27 ANC 672 BUN 57 Cr 1.6 Na 127 K
3.4Cl 86 HCO3 17
[**10-28**] VBG: 7.16/61/45
[**Hospital3 **]:
Please See OMR.
Microbiology:
See OMR for full listing.
blood cultures up until [**9-13**]: no growth
blood culture ([**9-13**])- VRE
blood cultures ([**Date range (1) 62237**]): no growth
urine culture ([**8-17**], [**8-23**], [**8-30**]): no growth
Legionella Urinary Antigen (Final [**2112-8-31**]):
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
[**2112-9-7**] 1:22 am CATHETER TIP-IV Source: L IJ dialysis.
WOUND CULTURE (Final [**2112-9-9**]): No significant growth.
[**2112-8-19**] 1:45 pm STOOL
FECAL CULTURE (Final [**2112-8-21**]): NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final [**2112-8-21**]): NO CAMPYLOBACTER
FOUND.
FECAL CULTURE - R/O VIBRIO (Final [**2112-8-21**]): NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final [**2112-8-21**]): NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final [**2112-8-21**]):
NO E.COLI 0157:H7 FOUND.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2112-8-20**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
.
Sputum GRAM STAIN (Final [**2112-8-31**]):
[**11-8**] PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2112-9-2**]):
SPARSE GROWTH Commensal Respiratory Flora.
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
.
[**2112-8-18**] 2:24 pm TISSUE Source: Skin biopsy.
STAPH AUREUS COAG +. RARE GROWTH.
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
.
[**2112-10-12**] 1:38 pm BLOOD CULTURE
Source: Line-left PICC subclavian line.
**FINAL REPORT [**2112-10-24**]**
Blood Culture, Routine (Final [**2112-10-24**]):
ENTEROCOCCUS FAECIUM. FINAL SENSITIVITIES.
HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml
of
gentamicin. Screen predicts possible synergy with
selected
penicillins or vancomycin. Consult ID for details.
HIGH LEVEL STREPTOMYCIN SCREEN: Susceptible to
1000mcg/ml of
streptomycin. Screen predicts possible synergy with
selected
penicillins or vancomycin. Consult ID for details..
Daptomycin = 16 MCG/ML = NON-SUSCEPTIBLE.
Daptomycin Sensitivity testing performed by Etest.
Daptomycin SENSITIVITY RESULT BEING CONFIRMED ,
REPORTED TO [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 37752**] 12:00PM [**2112-10-17**] SENT TO [**Hospital3 **] ON [**2112-10-18**].
Daptomycin SENSITIVITY TESTING CONFIRMED BY [**Hospital1 4534**]
LABORATORIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS FAECIUM
|
AMPICILLIN------------ =>32 R
LINEZOLID------------- 2 S
PENICILLIN G---------- =>64 R
VANCOMYCIN------------ =>32 R
Anaerobic Bottle Gram Stain (Final [**2112-10-13**]):
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
Reported to and read back by DR. [**Last Name (STitle) 37752**] [**2112-10-13**] 08:00AM.
Aerobic Bottle Gram Stain (Final [**2112-10-13**]):
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
CMV viral load: 2150 copies/ml ([**8-23**]), undetectable ([**8-30**]), 1370
([**9-1**]), 3180 ([**9-6**]), 1710 ([**9-9**]), <600 ([**9-14**]), 2790 ([**9-19**]), [**Numeric Identifier 58169**]
([**9-29**]), 9030 ([**10-3**]),[**2091**] ([**10-26**])
.
Pathology (Skin path and immunoflouresence), [**2112-8-18**]
1. Skin (A):
Fibrin thrombi in papillary and reticular dermal blood vessels
with associated partial epidermal and adnexal necrosis (see
microscopic description and comment).
Microscopic description. Sections show epidermis, dermis and
some superficial subcutaneous fat. There are fibrin thrombi in
the papillary and reticular dermal vessels, extending into the
superficial subcutaneous fat. There is sparse acute
inflammation, predominantly in the deeper dermis and subcutis.
Acute vasculitis is not appreciated in this sample in multiple
tissue levels examined. No fungal or bacterial organisms are
seen on GMS, PAS and PAS-D, or tissue Gram stains, respectively.
The overlying epidermis shows partial necrosis and there is also
focal necrosis of associated eccrine glands.
Comment. The histologic features are those of an occlusive
thrombotic vasculopathy. This may be seen in a variety of
conditions including disseminated intravascular coagulation and
warfarin necrosis, and clinical correlation is necessary to
differentiate between these conditions. The negative bacterial
and fungal stains argue against an acute septic vasculitis or
angioinvasive fungus. Correlation with culture results is
necessary.
2. Skin; direct immunofluorescence:
No immunopathologic abnormality.
No specific immunofluorescence is seen for IgG, IgA, IgM,
complement C3 and fibrin.
.
Imaging:
CXR ([**8-17**])
FINDINGS: Bilateral lung volumes are low. Bibasal atelectasis,
left more
than right, are persisting and unchanged since [**Month (only) **]-3 [**2112**]. A
concomitant left lung base consolidation cannot be ruled out.
Aerated parts of bilateral lungs are free of consolidation.
Cardiomediastinal contours are unchanged. Distal end of the
orogastric tube is below the level of diaphragm and is within
the stomach, though the tip is beyond the view of radiograph.
.
TTE ([**8-18**]):
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= 25 %), with regional variation. The right
ventricular free wall is hypertrophied. Right ventricular
chamber size is normal. with depressed free wall contractility.
The aortic root is mildly dilated at the sinus level. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The main
pulmonary artery is dilated. There is a very small pericardial
effusion. The effusion appears circumferential. The effusion is
echo dense, consistent with blood, inflammation or other
cellular elements. There are no echocardiographic signs of
tamponade.
.
CT Chest Abd Pelvis ([**8-18**]):
1. Asymmetric fat stranding along the soft tissues of the
lateral left hip
and thigh suggesting edema or inflammation. Deep fascial
infection is not
excluded by this study. The extent of deep compartment
involvement of
infection or inflammation is not well characterized and MR could
be of
potential value in further assessment if needed clinically. No
gas or
drainable collection is visualized.
2. Wall thickening and mucosal enhancement seen along the
sigmoid [**Month/Day (4) 499**]
suspicious for colitis.
3. Large quantity of scrotal fluid; clinical correlation is
recommended and consideration of ultrasound if needed
clinically.
4. Stable deep vein thrombosis.
5. Increased lung opacities; although not specific, these are
suggestive of atelectasis.
6. Similar soft tissue defect at site of removed port.
7. Suggestion of fatty liver.
.
CT chest ([**8-22**]):
1. 3.5-cm area of ground-glass lesion in the right upper lobe
may be
resolving since it first appeared on [**2112-8-22**]. Given the
decrease in density, differential diagnosis includes atypical
infection, hemorrhage or infarction.
2. Interval increase since [**2112-8-18**] in lower lobe opacification,
particularly on the left, probable atelectasis, less likely
pneumonia.
3. Small bilateral pleural effusions.
4. Increased small pericardial effusion.
.
CXR ([**8-30**]):
IMPRESSION: Worsening left pleural effusion and complete left
lower lobe
atelectasis. New right focal opacities consistent with
pneumonia.
.
CT chest ([**9-6**]):
IMPRESSION: As compared to [**2112-8-22**], the pre-existing right
upper lobe
opacity is in the course of organization. More subtle opacities
in the right upper lobe have almost completely resolved.
Improved are areas of atelectasis at the bases of the right
lower lobe. The appearance of the left hemithorax, including a
small left pleural effusion, is unchanged. Overall, the
examination is limited by respiratory motion artifacts. No
mediastinal lesions. No substantial pericardial effusion.
.
U/S LUE ([**9-9**]):
FINDINGS: A focused ultrasound examination was performed at the
site of
clinical concern in the right wrist. In this region, there is
fluid with
internal echoes tracking tracking along the subcutaneous soft
tissue planes, extending approximately 2.6 cm in length, without
a discrete drainable fluid collection or hematoma identified.
There is generalized subcutaneous edema and skin thickening. The
underlying vein in the region of interest demonstrates normal
venous flow. IMPRESSION: Subcutaneous edema and fluid tracking
along the soft tissue planes, but no discrete abscess
identified.
.
U/S LUE ([**9-11**]): PRELIM
10 x 20 x 2 mm subcutaneous fluid collection adjacent to but not
involving the nearby tendon sheath.
.
CXR ([**9-13**]):
Low lung volumes with increased right lower lobe atelectasis.
.
CXR ([**9-13**]):
Increased left perihilar and stable right perihilar
consolidations versus edema.
.
CT Chest w/o contrast ([**9-13**]):
As compared to the previous examination, there are newly
appeared
right lower lobe opacities and a slightly more extensive left
lower lobe
opacity. Both opacities have air bronchograms. The pre-existing
bilateral
upper lobe opacities are stable. The changes could correspond to
atelectasis, aspiration, or pneumonia. No pleural effusions. No
mediastinal lymph node
enlargement.
.
CT neck without contrast ([**9-13**]):
There is no evidence of an exophytic mucosal mass. Compared to
the
study on [**2112-8-5**], there is a new 2.3 cm x 1.8 cm x 2.1 cm
enlarged left level 2, without evidence of necrosis or
surrounding inflammatory change. The thyroid gland is
unremarkable. The sublingual and submandibular salivary glands
are unremarkable.
There is opacification of the right and left mastoid tip air
cells. The
paranasal sinuses are better assessed on the concurrent
dedicated sinus CT.
There are no lytic or sclerotic bone lesions.
There is bilateral pulmonary opacities, described in the
concurrent chest CT report.
.
IMPRESSION:
New enlarged left level 2 lymph node. No evidence of an
exophytic mucosal
mass.
.
CT Sinus without contrast ([**9-13**]):
1. Moderate to severe mucosal thickening in the right sphenoid
sinus. Milder mucosal changes in maxillary and ethmoid sinuses.
No osseous erosion or remodeling.
2. No evidence of a mass on noncontrast evaluation.
.
[**9-15**] Echocardiogram: IMPRESSION: Normal left ventricular cavity
size and wall thickness with mildly depressed left ventricular
systolic function. Moderately dilated aortic root. No clinically
significant valvular regurgitation or stenosis. Borderline
pulmonary artery systolic hypertension. Very small percicardial
effusion.
Compared with the prior study (images reviewed) of [**2112-8-29**],
the overall left ventricular systolic function appears to have
minimally improved, although the previously reported ejection
fraction may have been an underestimate.
The absence of valvular vegetations/abscesses on transthoracic
echocardiogram does not preclude its presence. If clinical
suspicion for endocarditis is high, consider transesophageal
echocardiogram.
.
[**9-15**] CXR: FINDINGS: Lung volumes remain low. Bibasilar
atelectasis/consolidation are
not significantly changed. As compared to the prior examination,
a perihilar
opacities appear improved consistent with a component of edema.
No
pneumothorax is seen. The cardiomediastinal silhouette is
unchanged. A
right-sided central line is unchanged with tip reaching the
right atrium.
.
[**9-15**] Dialysis Line Placement: IMPRESSION: Uncomplicated placement
of a 20-cm, three-lumen temporary
hemodialysis line with a VIP port.
.
[**9-16**] RUQ U/s: IMPRESSION:
1. Limited mobile examination without cholelithiasis.
2. Coarsened echotexture of the liver without fatty deposition.
Underlying
hepatocellular disease cannot be excluded on this exam.
.
[**9-16**] CXR: IMPRESSION: The HD line through left internal jugular
approach is new with tip
terminating approximately at cavoatrial junction. Bilateral lung
volumes are
very low. Bibasilar atelectases, left side more than right side
are unchanged
since [**2112-9-15**]. Pleural effusion, if any, appears
minimal on the
left side. Wide cardiomediastinal silhouette is likely from low
lung volumes.
There are lung opacities concerning for pneumonia.
.
[**9-16**] Dialysis Catheter Exchange: IMPRESSION: Uncomplicated
exchange of a temporary hemodialysis line with a
VIP port over the wire
.
[**9-17**] Line PLacement: IMPRESSION: Uncomplicated placement of a
14.4 French temporary dialysis line
in the right IJ. The line length is 15 cm. The tip is in the
right atrium.
The line is ready to use.
.
[**9-17**] line placement: IMPRESSION: Uncomplicated successful
placement of a midline venous line in
the mid axillary vein.
.
[**9-22**] CT Abdomen and Pelvis w/o contrast: IMPRESSION:
1. No renal or ureteral calculi or hydronephrosis.
2. No acute vertebral compression deformity. Stable multilevel
compression
deformities.
3. New ill-defined fat stranding in the retroperitoneum, just
inferior to the
aortic bifurcation with a probable 5 mm associated lymph node.
Lymphatic
involvement of known CLL is considered.
.
[**9-23**] Venous access procedures: PROCEDURES:
1. Conversion of a temporary double-lumen hemodialysis line
inserted by the
right internal jugular vein approach into a tunneled
double-lumen hemodialysis
line,
2. De [**Last Name (un) 11083**] insertion of a tunneled Power double-lumen central
line by the
left internal jugular vein approach,
3. Superior vena cava venogram via the left brachiocephalic
vein: [**2112-9-23**].
.
[**10-3**] CT Chest: IMPRESSION:
Since [**2112-9-13**], bilateral multifocal pneumonia and ground
glass
opacification as well as bilateral lower lobes opacities
representing either
atelectasis, aspiration, or pneumonia have decreased.
.
[**10-3**] CT head: IMPRESSION: No acute intracranial process
.
[**10-6**] CT Chest, Abdomen, and Pelvis: IMPRESSION:
1. No acute intra-abdominal or intrapelvic process.
Specifically, there is
no evidence of RP bleed.
2. Interval increase in patchy ground-glass opacities throughout
the upper
lung zones since the [**2112-10-3**] CT examination
concerning for
worsening multifocal pneumonia.
[**10-9**] CT Chest:
Multifocal ground-glass opacities and pulmonary consolidation in
the upper
lobes are unchanged. Mild interval progression of the dense
consolidation in
the right lower lobe, likely reflecting a combination of
atelectasis,
infection, and or aspiration. New small right pleural effusion
[**10-13**] TTE:
The left atrium is normal in size. The left ventricular cavity
is mildly dilated. There is mild global left ventricular
hypokinesis (LVEF = 40%). Left ventricular dysnchrony is
present. Right ventricular chamber size is normal. with mild
global free wall hypokinesis. The aortic root is mildly dilated
at the sinus level. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. The estimated pulmonary artery
systolic pressure is normal. There is a very small pericardial
effusion. There is an anterior space which most likely
represents a prominent fat pad.
IMPRESSION: Mild global biventricular systolic dysfunction. Very
small pericardial effusion.
Compared with the prior study (images reviewed) of [**2112-9-15**], the
findings are similar
[**10-14**] CXR
Left porta catheter and dual-lumen right central line catheter
end
in the upper right atrium. Bilateral lung volumes are low.
Bilateral lower
lung atelectasis, left side more than right side, are unchanged.
Cardiomediastinal silhouette and hilar contours are stable.
There are no new lung opacities of concern
[**10-16**] Left foot biopsy
Pan-dermal hemorrhage with focal organizing thrombus formation
[**10-19**] CXR
In comparison with the study of [**10-16**], the tip of the
endotracheal
tube measures approximately 5 cm above the carina. Little change
in the
appearance of the central catheter and hemodialysis catheter.
Again, there
are low lung volumes with stable cardiomediastinal silhouette.
Increasing
pulmonary vascular congestion with progression of opacification
in the
retrocardiac region. This is consistent with volume loss in the
left lower
lobe, though the air bronchogram pattern raises the possibility
of
superimposed pneumonia in this region. There is also a more
focal area of
opacification in the right upper and left mid zone, worrisome
for possible
supervening infection
[**10-20**] EKG
Atrial flutter with a rapid ventricular rate of 160 beats per
minute.
Moderate baseline artifact. Non-specific ST-T wave changes.
Compared to the previous tracing of [**2112-10-19**] no diagnostic
interval change.
[**10-21**] Rt Wrist Biopsy
Abundant intravascular and interstitial fungal hyphae with
thrombosis and secondary ischemic subepidermal bulla (see note).
Note: The findings in the clinical context are consistent with
disseminated fungal infection. The non-pigmented broad
ribbon-like hyphae on H&E sections suggests Mucormycosis,
however Aspergillus spp. can sometimes exhibit this morphology.
Final speciation is deferred to microbiology consultation and
culture.
This diagnosis was called to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1182**] (Dermatology) by
Dr. [**Last Name (STitle) **], [**2112-10-22**], at 12:15 PM.
ADDENDUM:
The fungal hyphae do not stain well with PAS and GMS, more
characteristic of Zygomycetes than Aspergillus species.
The presence of fungi within blood vessels and interstitially
within the dermis and panniculus is concerning for, but not
necessarily diagnostic of systemic infection, as this
distribution may also be found in localized infection. This
revises the first statement in the note above.
[**10-22**] CT Sinus
Interval increase in degree of sinus disease, with mucosal
thickening and secretions present in the ethmoid air cells and
nasal cavity,
along with mucosal thickening increased in the bilateral
maxillary sinuses.
Moderate sphenoid sinus thickening as before. Much of this
increased secretion
could be related to intubation. No bony destruction to suggest
invasive
mucormycosis.
[**10-22**] CXR
Endotracheal tube is 2.4 cm above the carina. Left and right
central
catheters remain in satisfactory position. Cardiomegaly is
unchanged. The
heterogeneous infiltrates in both lower lung zones are not
significantly
changed. The infiltrate in the axillary portion of the right
lung may be
slightly improved. There is no evidence of pneumothorax
[**10-23**] Left groin biopsy
Skin and subcutaneous tissue, left thigh, biopsy:
Necrotic skin and panniculus with abundant Gram positive
bacterial cocci and thrombosed blood vessels (see note).
[**10-24**] MRI Rt wrist
1. Marked muscular edema involving all visualized muscles as
well as
extensive subcutaneous edema without focal fluid collection.
Given the
history of positive biopsy, these findings are consistent with
extensive
cellulitis and myositis.
2. Serpiginous bone marrow signal abnormalities involving the
base of the
first metacarpal, distal radius and portions of the distal ulna,
concerning
for bone infarctions given the history of infectious vascular
invasion
[**10-28**] CXR
There are low lung volumes. Moderate pulmonary edema with
bibasilar
atelectasis larger on the left side and unchanged.
Brief Hospital Course:
Primary Reason for Hospitalization: Patient is a 27-year-old
male with a history of CLL status post allogeneic transplant in
early [**2111**] complicated by chronic extensive moderate
graft-versus-host disease involving the GI tract and capillary
leak syndrome, and recent PE who presents in septic shock.
1. Septic Shock: The patient initially presented hypotensive to
the 70s, febrile to 103.2 and hypoxic to 91% on NRB. He was
transferred to the ICU on [**8-17**] intubated and sedated. He
was initially covered broadly with linezolid, cefepime, cipro,
and micafungin. He was noted on admission to have numerous areas
of skin breakdown with erythema on the left thigh concerning for
infection. On the morning of HD1, this area of erythema became
bullous and the blistering extended up to his mid-abdomen/torso
and down to his left knee and became the most concerning and
obvious source of infection. Blood, stool, and urine cultures
were all sent and negative. He was given hydrocortisione 100mg
IV q8 for adrenal insufficiency given his history of chronic
prednisone use. He was given IVF and pressors, and a left IJ
line and an arterial line were placed. As his infectious
sources were controlled with antibiotics, he was weaned off of
pressors by HD3.
On the floors, patient hemodynamically stable and weaned off
hydrocortisone and restarted home dose prednisone 12.5mg daily
Hospital course was prolonged by repeated episodes of hypoxia
requiring ICU transfers. He was noted to have VRE bacteremia,
resistant to daptomycin, during his final ICU stay. He was
treated with linezolid, but due to extremely poor vascular
access, HD and left PICC lines were not removed, but were
treated with daptomycin locks. Blood cultures cleared VRE by
[**10-17**]. Unfortunately, during this time, a bullous right wrist
lesion was noted to be expanding, and biopsy and MRI were
consistent with invasive mucormycosis. He was deemed a poor
surgical candidate for debridement or amputation due to
extensive comorbidities and attempts to treat medically with
ambisome were continued. The size and extent of the right wrist
Mucor infection expanded, and the right hand demonstrated
progressive cysnosis, pallor by [**10-27**]. Additionally, further
skin biopsies showed VRE growing within left groin lesion. By
[**10-27**] patient was pressor dependent, persistent sepsis,
persistent bone marrow failure, with progressive renal
impairment, evolving progressive lactic acidosis, and
progressive systemic acidemia. Following multiple discussions
with health care proxy and extensive number of family members,
all clearly indicated that patient would not want to be
maintained on life support in the context of severe medical
illness and continued decline in condition. On [**10-30**] the
unannomous decision to proceed with assuring comfort as the
priority. Following discontinuation of dialysis and vasopressor
support, the patient peacefully expired in the presence of
family members.
2. Hypoxemic respiratory failure: The patient had large A-a
gradient on presentation, and was therefore intubated and
sedated with fentanyl and midazolam. Patient was soon
extubated, and by the morning of HD3, he was breathing
comfortably on 2L NC. After being transferred to the floor, he
remained on minimal O2 support. However, on [**8-30**], the patient
was found to be hypoxic to the 80s on RA with increased work of
breathing. He was placed on a NRB without significant
improvement and was intubated for respiratory distress. This
was attributed to PNA seen on chest CT as well as metabolic
acidosis secondary to renal failure. He remained on ventilatory
support until HD 21 ([**9-6**]), at which time he was again
extubated. Within four days following extubation, he was able
to maintain oxygenation and ventilation on room air. Following
callout to the floor, however, he developed an episode of large
volume epistaxis and hemoptysis, of unclear etiology, and
developed respiratory distress, likely secondary to aspiration.
He was transferred back to the ICU and was initally placed on
100% oxygen, and following cessation of hemoptysis was
eventually weaned down to 3L oxygen via nasal cannula prior to
transfer back to the floor. His respiratory status waxed and
waned and again required ICU transfer on [**10-8**]. He was again
noted to have significant oropharyngeal bleeding, and due to
repeated aspiration and hypoxia was intubated on [**10-19**]. CXR's
showed persitently low long volumes with bilateral infilatrates.
Additionally, as he developed anuric renal failure and
hypotension, fluid balance was difficult to achieve and he
became grossly fluid overloaded. By [**10-30**], the decision to cease
supplemental O2 with ventilation was made along with his family
and HCP due to insurmountable disease and medical futility.
3. CMV Viremia: Patient had a history of known CMV and while in
the hospital he was continued on gancyclovir. Surveillance CMV
viral loads demonstrated a marked jump in his CMV viral load to
[**Numeric Identifier 58169**], and patient was changed to foscarnet due to likely
resistance to ganciclovir. CMV viral load on [**10-26**] was [**2091**].
4. MSSA scalded skin reaction: The patient first complained of
pain in L upper thigh and inguinal area on [**8-15**] via telephone to
oncology nurse. On admission, he was noted to have purpura,
bullae, erythema and warmness on the left anterior thigh that
progressed to the abdomen. CT torso to knees did not show
evidence of necrotizing fascitis. Two 4mm punch biopsies showed
occlusive thrombotic vasculopathy, consistent with a scalded
skin reaction, and his infection was initially treated with
Vancomycin, but switched to daptomycin because of
vamcomycin-associated [**Last Name (un) **]. His pain was managed with long and
short acting opioid agents, as well as lidocaine gtt and PCA.
Following intubation on [**10-19**], patient remained on fentanyl gtt.
5. Mucormycosis: On [**9-9**] the patient was discovered to have
a small erythematous lesion on his right medial forearm. This
had a small black scab/eschar in the middle and was surrounded
by peeling skin. There was concern for cellulitis, investigated
with ultrasound on [**9-9**] and again on the 28th. Lesion
remained stable until noted to be more painful and expanding on
[**10-15**]. Biopsy showed invasive mucormycosis. Patient was not a
surgical candidate for debridement and hand became cyanotic and
cool. MRI was suggestive of marrow infarction along with
significant invasive diesease. He was treated with ambisome and
CT of sinus showed no evidence of maxillofacial disease, and BAL
showed no sign of pulmonary disease. Biopsy of left groin lesion
showed VRE but no evidence of mucor. Unfortunately, wound
continued to expand aggressively prior to the cessastion of
pressors.
6. PNA: Shortly after the patient's admission, he was noted to
have signs of PNA on CXR and CT. He was already on empiric
antibiotic coverage, so pneumonia was monitored on subsequent AM
CXRs. On HD13 as his respiratory status deteriorated, he was
found to have increased pulmonary edema, pleural effusion, and
PNA. CXR [**8-30**] showed RUL infiltrate and LLL collapse. He was
treated with linezolid and meropenem for presumed HCAP, later
switched to vancomycin and meropenem as he became neutropenic.
This course was continued for 8 days. Subsequent BAL on [**10-20**] and
[**10-26**] showed no evidence of infection despite persistent
consolidations and hypoxemia.
7. Bleeding: The patient developed large volume hemoptysis and
epistaxis on [**2112-9-13**]. ENT was consulted and perrformed a scan
and biopsy/ culture of sinuses. Neisseria was grown, but in
small volume, and thought to be insignificant. The patient was
considered to be too unstable to withstand bronchoscopy. He was
intitially continued on heparin gtt due to his significant
history of known DVT's. HW, as his oropharyngeal bleeding
continued to compromise his tenuous respiratory status, heparin
gtt was discontinued on [**10-17**]. He received numerous platelet
transfusions to maintain platelet count >30.
8. Nutritional: Due to recurrent mucosal bleeding and clots
formation in his OP, patient developed significant dysphagia and
odynophagis during his final ICU transfer. NG and OG tubes were
not able to be placed, and patient was started on TPN sans
lipids. Of note, due to extremely poor venous access, a
dedicated line was not able to be used for TPN.
9. Acute Renal Failure: During the [**Hospital 228**] hospital stay, he
developed a metabolic acidosis and acute renal failure.
Etiology of renal failure thought to be [**2-17**] Vancomycin
(supratherapeutic to trough 35) as well as hypoperfusion from
insensible volume loss. Additionally, some element of foscarnet
toxicity was thought to play a role as well. Albumin 50-100g/day
was given per renal recommendations, without improvement in
renal fucntion. By HD13 he had a Cr of 3.4 and was found to
have a pH of 7.30. He was started on CRRT on HD15, which was
used both to normalize his acid-base status and to reduce the
significant anasarca developed secondary to his skin infection
and fluid resuscitation for sepsis. He was switched to HD with
good results, moving to a 3x weekly schedule on [**9-11**]. As
his blood pressures became lower, he was again transitioned to
CRRT.
8. DVT's: Patient was found to have extensive clots of his
central veins involving the IVC, the subclavian veins, and an
internal jugular vein on this stay. He was treated with heparin
gtt and lovenox. Heparin-dependent antibodies were negative.
Anticoagulation was discontinued on [**10-17**] due to signficant
bleeding.
9. Hypertension: Once the patient's sepsis resolved on HD3, the
patient began to experience hypertension to the SBP 170s,
particularly associated with pain. He is hypertensive at
baseline, controlled with Lasix and metoprolol. As an inpatient
he was given metoprolol with occasional doses of hydralazine for
SBP>170. His volume status was addressed with CRRT/HD.
10. Portacath infection: Port site swab grew MRSA on HD3, one
possible source of infection. Patient was already on vancomycin
for left leg infection, which was continued for an 8 day course
sufficient to cover this skin infection.
11. Anemia: The patient has a baseline anemia, worsened on
presentation. He received 2 units PRBC at OSH and his hct
remained stable on admission. Initial hemolysis labs were
negative and there was no evidence of DIC. His Hct improved
initially, but declined as hospital stay continued, likely due
to severe disease and recurrent bleeding. He received 26 units
pRBC during this admission.
12. Tachycardia: Patient had sinus tach throughout ICU stay,
thought to initially be secondary to sepsis and inflammatory
response and later due to a component of pain from skin
infection that the team was actively trying to control. He was
given fluid boluses as needed for fluid repletion and monitored
on telemetry. During his final ICU admission, he was repeatedly
found to convert to atrial flutter. Blood pressures remained
stable during these episodes, and were treated with IV nodal
agents as needed.
13. Hyperglycemia. Patient was hyperglycemic throughout
admission, likely secondary to IV hydrocortisone and stress
response of illness. No known hx of diabetes. He was maintained
on an ISS.
14. GVHD: Appears stable at this time. Patient was given stress
dose steroids as above and was then tapered back down according
to BMT recommendations.
15. CLL: Patient appears to have been in remission since
transplant, although his transplant course was complicated by
capillary leak. During his stay he was maintained on GVHD
treatment with steroids, and was given antibiotic prophylaxis
with valgancyclovir (CMV), micafungin (fungal), and atovaquone
(PCP). He was treated with Neupogen for neutropenia for a total
5 day course. Given a positive beta-glucan result he was
switched to voriconazole on [**9-10**].
16. Hyponatremia: As patient became increasingly hypervolumic
due to anuric renal failure, patient developed hypervolemic
hyponatremia. Fluid balance was attempted to be controlled by
HD/UF and CRRT with poor results. Na on [**10-28**] was 127.
Transitional Issues:
Deceased
Medications on Admission:
ATOVAQUONE [MEPRON] - 750 mg/5 mL Suspension - 10 mL(s) by mouth
once a day
BUDESONIDE [ENTOCORT EC] - 3 mg Capsule, Ext Release 24 hr - 1
Capsule(s) by mouth three times a day
CITALOPRAM - 20 mg Tablet - 1 Tablet(s) by mouth once a day
CYCLOSPORINE MODIFIED - 25 mg Capsule - 2 Capsule(s) by mouth
twice a day
ENOXAPARIN [LOVENOX] - (Prescribed by Other Provider) - 80
mg/0.8 mL Syringe - 1 Syringe(s) every twelve (12) hours
FOLIC ACID - 1 mg Tablet - 2 Tablet(s) by mouth once a day
FUROSEMIDE - (Dose adjustment - no new Rx) - 20 mg Tablet - 1
Tablet(s) by mouth once a day
LACTULOSE - 10 gram/15 mL Solution - 15-30 mL by mouth once a
day
as needed for constipation
LISINOPRIL - (Dose adjustment - no new Rx) - 10 mg Tablet - 1
Tablet(s) by mouth DAILY (Daily)
LORAZEPAM - 1 mg Tablet - 1 Tablet(s) by mouth every six (6)
hours as needed for nausea, anxiety
METOPROLOL TARTRATE - (Dose adjustment - no new Rx) - 25 mg
Tablet - 0.5 (One half) Tablet(s) by mouth twice a day
MORPHINE - (Prescribed by Other Provider) - 60 mg Tablet
Extended Release - 1 Tablet(s) by mouth every twelve (12) hours
MYCOPHENOLATE MOFETIL - (Dose adjustment - no new Rx) - 250 mg
Capsule - 3 Capsule(s) by mouth twice a day
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s)
by mouth once a day
ONDANSETRON - 4 mg Tablet, Rapid Dissolve - 1 Tablet(s) by mouth
every eight (8) hours as needed for nausea
OXYCODONE - 5 mg Tablet - 1 Tablet(s) by mouth every four (4)
hours as needed for pain
POSACONAZOLE [NOXAFIL] - 200 mg/5 mL (40 mg/mL) Suspension - 5
mL(s) by mouth three times a day
POTASSIUM CHLORIDE - 20 mEq Tablet, ER Particles/Crystals - 4
Tablet(s) by mouth on [**8-10**] and [**8-11**] then 1 tablet daily
PREDNISONE - (Prescribed by Other Provider) - 5 mg Tablet - 2.5
Tablet(s) by mouth once a day
VALGANCICLOVIR [VALCYTE] - 450 mg Tablet - 2 Tablet(s) by mouth
once a day
Medications - OTC
CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D-3] - (Prescribed by
Other Provider) - 2,000 unit Tablet - 1 Tablet(s) by mouth twice
a day
MULTIVITAMIN - Tablet - 1 Tablet(s) by mouth DAILY (Daily)
SENNOSIDES [SENNA] - 8.6 mg Tablet - 1 (One) Tablet(s) by mouth
twice a day as needed for constipation
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Chronic lymphocytic leukemia
Graft versus host disease
MRSA scalded skin syndrome
Invasive mucormycosis
Vancomycin resitant enterococcus sepsis
Cytomegalovirus bactermia
Acute renal failure
Discharge Condition:
Deceased
Discharge Instructions:
N/A
Followup Instructions:
N/A
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
ICD9 Codes: 486, 5070, 5845, 2930, 4254, 5119, 2761 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3723
} | Medical Text: Admission Date: [**2147-6-17**] Discharge Date: [**2147-6-19**]
Date of Birth: [**2097-4-20**] Sex: F
Service: SURGERY
Allergies:
Acetaminophen / Sertraline / Sulfa (Sulfonamides) / Tegaserod /
Venlafaxine
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
50 y/o female transferred from an outside hospital intubated
with a subdural hematoma.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 12101**] was transferred from the referring institution to
the [**Hospital1 18**] ER on [**2147-6-17**]. On arrival she was intubated. Per
report the patient was found the morning of [**2147-6-17**] unresponsive
in bed. She was brought to the referring institution where she
was intubated and a head CT was obtained which showed a large
subdural hematoma with shift.
Past Medical History:
Unknown
Social History:
History of EtOH abuse
Family History:
Non-contributory
Physical Exam:
Gen: critically ill, intubated.
HEENT: Pupils: fixed 4mm bilaterally, unreactive to light or
threat, no corneal reflexes biilaterally
Lungs: rhoncorus bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft
Extrem: multiple subacute contusions on upper and lower
extremities. Warm, well-perfused.
Mental status: Unresponsive voice or to noxious central
stimulation.
Cranial Nerves: pupils fixed, no corneal response, + soft gag.
Motor: Decorticate extensor posturing with bilateral upper
extremity extension. No spontaneous movements. Flaccid tone in
all 4 extrem.
Sensation: no response to noxious stimulation x4 extrem
Toes briskly upgoing bilaterally
Pertinent Results:
[**2147-6-17**] 08:35AM PT-13.3* PTT-22.7 INR(PT)-1.2*
[**2147-6-17**] 08:35AM WBC-11.7* RBC-3.65* HGB-11.2* HCT-33.2*
MCV-91 MCH-30.6 MCHC-33.7 RDW-18.4*
[**2147-6-17**] 08:35AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2147-6-17**] 08:35AM ASA-7 ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
[**2147-6-17**] 08:35AM GLUCOSE-162* UREA N-22* CREAT-1.2* SODIUM-139
POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-22 ANION GAP-18
CT CHEST W/CONTRAST [**2147-6-17**] 11:50 AM
IMPRESSION:
1. Subcutaneous stranding in the anterior chest wall superior to
the left breast prosthesis, likely post traumatic in nature.
2. Diffuse fatty infiltration of the liver.
3. Upper pole cortical parenchymal deficits within the right
kidney consistent with prior inflammatory change.
CT HEAD W/O CONTRAST [**2147-6-17**] 8:38 AM
IMPRESSION:
1. Large mixed density left subdural collection hematoma. There
is significant mass effect on the subjacent cortex with 1.5 cm
of subfalcine herniation and findings worrisome for
transtentorial herniation.
2. Air-fluid levels within bilateral maxillary sinuses without
definite fracture identified. If clinical situation supports
facial fractures a facial CT series may be obtained.
CT HEAD W/O CONTRAST [**2147-6-19**] 6:10 AM
COMPARISON STUDY: [**2147-6-17**] CT scan reported by Dr. [**Last Name (STitle) **]
revealing "large mixed density left subdural collection. There
is significant mass effect on the cortex with 1.5 cm of
subfalcine herniation and findings worrisome for transtentorial
herniation. Air-fluid levels within bilateral maxillary sinuses
without definite fracture identified."
FINDINGS: The very large left cerebral convexity acute subdural
hemorrhage has not diminished in size. There is continued
evidence for a pronounced rightward subfalcine herniation and
the evolution of bilateral anterior cerebral artery territory
infarcts. There is also low density within the brainstem,
particularly the pons with some involvement of the right-sided
cerebellar hemisphere superiorly, suggesting additional infarcts
likely due to transtentorial herniation. There has been no
interval change in ventricular size. There continues to be
moderate-sized air-fluid levels within the maxillary sinuses,
now also seen in the sphenoid sinus, with opacification of both
ethmoid sinuses by soft tissue density, probably a mixture of
fluid and/or mucosal thickening. At least some of these findings
may relate to the intubated status of the patient.
CONCLUSION: Persistent large left cerebral convexity acute
subdural hemorrhage, with secondary infarcts in multiple locales
as noted above. We discussed these findings today by telephone.
Brief Hospital Course:
The patient was transferred to the emergency room from NH
intubated and in a C-collar. On arrival her pupils were fixed
and dilated and she was not responsive to painful stimuli. A
neurosurgery consult was obtained and they determined that due
to the large subdural hematoma and infarction in the middle
cerebral artery territory there was no indication for
neurosurgical intervention. From the ER she was admitted to the
Trauma Surgical Intensive Care Unit. Her neurological
examination did not improve during her admission. A repeat CT
of the head was obtained on [**2147-6-19**] which showed no improvement
in her subdural hematoma. On [**2147-6-19**] a family meeting was held
with the patient's sister, husband, and husband's sister. The
condition of the patient and the poor prognosis was reviewed
with the family and the decision was made to make patient
comfort measures only the evening of [**2147-6-19**]. On the evening of
[**2147-6-19**] the patient's pain was controlled with narcotics and she
was palliatively extubated. She expired approximately an hour
and half after extubation. A death certificate was completed,
the medical examiner was contact[**Name (NI) **] and the body was transferred
to pathology for autopsy.
Medications on Admission:
Unknown
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Subdural hematoma
Discharge Condition:
Dead
Discharge Instructions:
None
Followup Instructions:
None
ICD9 Codes: 5185, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3724
} | Medical Text: Admission Date: [**2127-10-14**] Discharge Date: [**2127-10-19**]
Date of Birth: [**2056-12-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2127-10-14**] - Coronary bypass grafting x3 with the left internal
mammary artery to left anterior descending artery and reverse
saphenous vein grafts to the distal right coronary artery and
the ramus intermedius artery.
History of Present Illness:
(History and review of systems obtained via Russian interpreter)
70 year old Russian male with type II diabetes and severe PVD
s/p urgent right fem/[**Doctor Last Name **] bypass surgery in [**2127-2-4**] and
known severe PVD on the left leg. In [**2112**], he had an acute MI
while in [**Country 532**]. He was treated medically and has not had a
catheterization. Since the heart attack, he has been
experiencing exertional angina when he first starts walking. His
symptoms resolve with nitroglycerin and he is able to continue
walking. He walks 1-2 hours several days per week. He has
recently taking nitroglycerin about 5 days per week. The patient
has been seen by Dr. [**Last Name (STitle) 171**] recently and had a stress test back
in [**Month (only) 958**] which was suggestive of possible left main or left main
equivalent multi-vessel disease. He was referred for cardiac
catheterization to further evaluate. He was
found to have three vessel disease upon cardiac catheterization
and is now being referred to cardiac surgery for
revascularization.
Past Medical History:
diabetes type II
arthritis
severe PVD
severe LLE PVD
CAD s/p MI in [**2112**] in [**Country 532**]
dyslpidemia
hypertension
remote stomach ulcer; denies bleeding
remote cyst removed from coccyx
Social History:
Lives with:Wife
Occupation:retired electrical engineer
Cigarettes: Smoked no [] yes [x] quit [**12/2126**] 1 ppd x 30 years
Other Tobacco use:denies
ETOH: < 1 drink/week [] [**2-10**] drinks/week [x] >8 drinks/week []
Illicit drug use:denies
Family History:
Noncontributory
Physical Exam:
Pulse: 60 Resp:16 O2 sat:100/RA
B/P Right:130/76 Left:
Height:5'7" Weight:186 lbs
General:NAD, alert and cooperative
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] no Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] well healed incisions
both lower extremities
Edema [] trace
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: +1 Left:+1
DP Right: +1 Left:+2
PT [**Name (NI) 167**]: +1 Left:+1
Radial Right: +2 Left:+2
Carotid Bruit Right:none Left:none
Pertinent Results:
[**2127-10-14**] ECHO
Prebypass
No atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thicknesses are normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. There are simple
atheroma in the descending thoracic aorta. The aortic valve
leaflets (3) are mildly thickened. There is no aortic valve
stenosis. Mild to moderate ([**1-5**]+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild to moderate
([**1-5**]+) mitral regurgitation is seen. There is no pericardial
effusion. Dr. [**Last Name (STitle) **] was notified in person of the results on
[**2127-10-14**] at 915 am.
Post bypass
Patient is AV paced and receiving an infusion of phenylephrine.
Biventricular systolic function is unchanged. Mild mitral
regurgitation persists. Aorta is intact post decannulation.
cxr
PA and lateral upright chest radiographs were reviewed in
comparison to
[**2127-10-16**].
Right internal jugular line tip is at the level of mid SVC.
Heart size and
mediastinum are unremarkable. There is no evidence of pulmonary
edema or
focal consolidations to suggest infectious process. Small amount
of pleural
effusion is noted better on the lateral view as well as left
basal
atelectasis.
Sinus rhythm. Left anterior fascicular block. Right
bundle-branch block. Low voltage. Since the previous tracing of
[**2127-10-6**] the right bundle-branch block is new. Clinical
correlation is suggested.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
84 140 142 414/456 33 -19 -14
[**2127-10-19**] 05:45AM BLOOD WBC-6.9 RBC-3.38* Hgb-10.9* Hct-31.2*
MCV-92 MCH-32.2* MCHC-34.9 RDW-12.9 Plt Ct-223#
[**2127-10-14**] 12:46PM BLOOD WBC-8.6 RBC-2.93*# Hgb-9.6*# Hct-26.7*#
MCV-91 MCH-32.8* MCHC-36.0* RDW-12.3 Plt Ct-137*
[**2127-10-19**] 05:45AM BLOOD Glucose-159* UreaN-18 Creat-1.0 Na-136
K-4.7 Cl-100 HCO3-28 AnGap-13
[**2127-10-14**] 12:46PM BLOOD UreaN-13 Creat-0.9 Na-139 K-3.9 Cl-110*
HCO3-23 AnGap-10
[**2127-10-19**] 05:45AM BLOOD Calcium-8.5 Phos-2.8 Mg-2.3
Brief Hospital Course:
Mr. [**Known lastname 89496**] was admitted to the [**Hospital1 18**] on [**2127-10-14**] for surgical
managment of his coronary artery disease. He was taken to the
operating room where he underwent coronary artery bypass
grafting to three vessels. Please see operative note for
details. Postoperatively he was taken to the intensive care unit
for monitoring. Within 24 hours, he awoke neurologically intact
and was extubated. He remained in the intensive care unit to
wean from his pressors. On postoperative day two, he was
transferred to the step down unit for further recovery. He was
gently diruesed towards his preoperative weight. The physical
therapy service was consulted for assistance with his
postoperative strength and mobility. Beta blockade, aspirin and
a statin were resumed. He continued to make steady progress and
was discharged to his home on postopertaive day five. All
follow-up appointments have been made for him.
Medications on Admission:
FAMOTIDINE 20 mg Tablet [**Hospital1 **]
GLARGINE [LANTUS] 100 unit/mL Solution - 18 units at bedtime
INSULIN LISPRO [HUMALOG] per Sliding scale
ISOSORBIDE MONONITRATE (Not Taking as Prescribed: pt states not
taking b/c concerned about BP dropping
LISINOPRIL 2.5 mg Daily
METFORMIN 1,000 mg [**Hospital1 **]
METOPROLOL TARTRATE 12.5mg [**Hospital1 **]
SIMVASTATIN 20 mg Daily
ASPIRIN 81 mg Daily
Discharge Medications:
1. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*1*
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:*1*
4. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
5. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
Disp:*60 Tablet(s)* Refills:*1*
6. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*1*
7. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours).
Disp:*qs qs* Refills:*0*
8. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*1*
9. Insulin sliding scale
please resume your sliding scale that you were on prior to
surgery
Your lantus dose has been adjusted - please follow up with
[**Last Name (un) **]
10. Lantus 100 unit/mL Solution Sig: Ten (10) units Subcutaneous
at bedtime.
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Coronary artery disease s/p cabg
Diabetes mellitus type II
Peripheral vascular disease
Dyslpidemia
Hypertension
Arthritis
Discharge Condition:
Alert and oriented x3 nonfocal - russian speaking
Ambulating with steady gait
Incisional pain managed with percocet
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right - healing well, no erythema or drainage
Edema none
Discharge Instructions:
1) Please shower daily including washing incisions gently with
mild soap, no baths or swimming until cleared by surgeon. Look
at your incisions daily for redness or drainage.
2) Please NO lotions, cream, powder, or ointments to incisions.
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart provided.
4) No driving for approximately one month and while taking
narcotics. Driving will be discussed at follow up appointment
with surgeon when you will likely be cleared to drive.
5) No lifting more than 10 pounds for 10 weeks
6) Please call with any questions or concerns [**Telephone/Fax (1) 170**]
7) Please continue to monitor blood glucose, and follow up with
[**Last Name (un) **] for adjustments in insulin doses
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] on [**2127-11-20**] at 1:30
Cardiologist: Dr [**Last Name (STitle) 171**] [**Telephone/Fax (1) 62**] on [**2127-11-10**] at 12:40
Wound check - cardiac surgery office [**Telephone/Fax (1) 170**] on [**2127-10-28**]
10:00
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **] in [**4-8**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2127-10-19**]
ICD9 Codes: 4111, 4439, 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3725
} | Medical Text: Admission Date: [**2104-2-6**] Discharge Date:
Date of Birth: [**2041-8-27**] Sex: M
Service: Medicine
CHIEF COMPLAINT: Cough and shortness of breath.
HISTORY OF PRESENT ILLNESS: The patient is a 62 year old man
with a history of Wilson's disease and bipolar disorder,
coronary artery disease and bronchiectasis who presented from
[**Hospital3 **] Hospital with a several day history of
cough and shortness of breath associated with green sputum.
The patient also has experienced nausea and poor p.o. intake.
The patient was started on Levaquin on [**2-3**]. Today,
[**2-6**], the patient had decreased oxygen saturation to 85
to 88% on room air and was tachycardiac. Also by report the
patient vomited today although the patient denies that he
did. He had a lowgrade fever at the nursing home. In the
Emergency Room the patient's temperature was found to be 102.
The patient denied any chest pain, headache, upper
respiratory infection symptoms, abdominal pain, any current
nausea, dysuria, bright red blood per rectum and no change in
bowel movements. The patient has a history of occult blood
positive stool and has follow up with Gastroenterology at
[**Hospital6 1129**]. The patient denies any
melena. He also denies any lower extremity edema,
palpitations or other complaint.
PAST MEDICAL HISTORY:
1. Coronary artery disease
2. Mitral valve replacement
3. Atrial fibrillation
4. Peptic ulcer disease, status post partial gastrectomy for
ulcers
5. Wilson's disease
6. Bipolar disorder secondary to Wilson's disease
7. History of pancreatitis
8. History of cholecystectomy
9. He is hard of hearing.
10. Orthostatic hypotension
11. Partial colectomy in [**2092**] for bowel obstruction
12. Anemia
13. Bronchiectasis
14. Mild chronic renal insufficiency
15. Gastrostomy tube placement for aspiration
16. He is PPD negative in [**2103-12-6**]
SOCIAL HISTORY: The patient is a resident of [**Hospital3 1761**] since [**2103-11-5**]. His legal guardian is
his brother [**Name (NI) **] who lives in [**Name (NI) 4565**]. The patient has
no tobacco history. He is full code.
FAMILY HISTORY: His mother had depression.
ALLERGIES: Penicillin, Ciprofloxacin, Insulin and
Penicillamine.
MEDICATIONS:
1. Megace 400 mg b.i.d.
2. Valproic acid 250 mg t.i.d.
3. Wellbutrin 100 mg b.i.d.
4. Florinef .1 mg q.d.
5. Midodrine 5 mg b.i.d.
6. Zyprexa 20 mg q.h.s.
7. Trazodone 25 mg q.h.s.
8. Prevacid 15 mg q.h.s.
PHYSICAL EXAMINATION: On physical examination in the
Emergency Room vital signs revealed temperature 102, blood
pressure 119/69, heartrate 116, respiratory rate 25, oxygen
saturation 98% on 4 liters nasal cannula. In general, he was
comfortable appearing in no acute distress. Head, eyes,
ears, nose and throat examination, mucous membranes were dry.
Pupils were equal, round, and reactive to light, anicteric.
Neck supple, no lymphadenopathy. Lungs, decreased
breathsounds with rales at the left base, faint rales, right
base. Cardiovascular, tachycardiac, regular rhythm, II/VI
systolic murmur at the left upper sternal border that goes to
the apex. Abdominal examination, soft, nontender,
nondistended, positive bowel sounds. Gastrostomy tube site
is clean, dry and intact. He is guaiac negative on rectal
examination. Extremities, no edema, 2+ dorsalis pedis pulses
bilaterally. Neurological examination, he is alert and
oriented times three. Cranial nerves II through XII intact,
[**6-8**] motor strength bilaterally.
LABORATORY DATA: White count 12.7 with 89 neutrophils, 6
lymphocytes and 6 monocytes. Hematocrit is 32.8, platelets
228. SMA-7, 136, 2.9, 97, 20, 31, 2.2 with a baseline
creatinine of approximately 1.9, 93. Chest x-ray showed a
right middle lobe infiltrate, no congestive heart failure, no
comparison film, although there is a report of bilateral
chronic scarring in the chart on previous chest x-ray.
IMPRESSION: A 62 year old man with a history of Wilson's
disease and bronchiectasis who presents with a two day
history of cough, shortness of breath and fever. He has been
on Levaquin for two days and now presents to the Emergency
Room with mild hypoxia, mild dehydration and mild
hypokalemia.
PLAN: The plan is to send sputum for culture. The most
likely cause of this patient's symptoms are a pneumonia,
although bronchiectasis exacerbation is also possible. A
urinalysis will be sent, blood cultures will be drawn as the
patient spikes a fever. Antibodies will be changed to
intravenous Levaquin and Flagyl will be added for possible
aspiration coverage, given the patient's vomiting today. The
patient will be maintained on oxygen to maintain saturations.
Chest physical therapy will be done and Robitussin as needed
cough. The patient's slight increase in creatinine from
baseline, most likely is secondary to dehydration. He will
be gently rehydrated. His potassium will be repleted. His
Megace will be continued. The patient will be placed on a
Proton pump inhibitor and the patient's Triamterene will be
continued for Wilson's disease. The Zyprexa and Depakote
will be continued. A Depakote level will be checked. The
Midodrine and Florinef will be continued.
HOSPITAL COURSE: The patient was continued on treatment for
an acute pneumonia. Sputum gram stain showed 4+ gram
positive cocci in pairs and clusters. On hospital day #2 the
patient was found to have a narrow complex tachycardia to the
230s. A Medicine Intensive Care Unit consult was obtained
and the patient was transferred to the Medicine Intensive
Care Unit. This tachycardia resolved with oxygen and
Diltiazem. The patient was maintained on Diltiazem drip for
approximately 12 hours. At that time he was changed to
Diltiazem per percutaneous endoscopic gastrostomy and
transferred back to the floor on [**2104-2-8**], the third
hospital day. The patient continued to be maintained on
Levaquin and Vancomycin had been added on hospital day #2
with the results of the gram stain of 4+ gram positive cocci.
The cardiology consult was obtained which recommended an
electrophysiology study. On the p.o. Diltiazem the patient's
heartrate remained in the low 100s. Prior to the
electrophysiology study an echocardiogram was obtained on
[**2-12**] which was the seventh hospital day. That showed an
left ventricular ejection fraction of greater than 55% and
moderate 2+ mitral regurgitation as the only finding. The
patient continued on his other medications including
antibiotics and the tube feeds. At this point the
antibiotics consisted of Levaquin and Flagyl. Vancomycin had
been discontinued after two days and Flagyl had been added
for this likely aspiration pneumonia. These antibiotics were
chosen because the patient had no positive cultures. He did
have a sputum culture that grew out multiple Flora consistent
with oropharyngeal contamination. After the echocardiogram
on [**2-11**] the patient had his electrophysiology study on
[**2-12**]. They did not find an inducible source of
tachycardia and felt it was sinus atrial tachycardia with
rapid atrioventricular conduction and recommended treatment
with a beta blocker. On [**2-12**], Lopressor was added to
the patient's regimen, 25 mg p.o. b.i.d. On [**2-13**], the
patient's heartrate had slowed into the 90s after the second
dose and into the mid to high 70s after the third dose of
Lopressor. This is a good control. This level of beta
blockade can be increased as an outpatient for heartrate
target of 60s to 70s as the primary outpatient team desires.
The patient also had a swallowing evaluation on [**2-12**],
and frankly aspirated both thin and thick liquids, thus he
will remain NPO and his tube feeds were increased to 18 hours
per day of Ultracal from 16 hours a day of Ultracal. On
[**2-13**], the patient was in good health. He continued to
complain of a cough, however, he no longer required oxygen,
saturations of 93 to 94% on room air. His heartrate was
controlled with the Lopressor and he was on tube feeds. He
also continued on the Levaquin and Flagyl. The patient was
in stable condition on [**2-13**] and is likely being
discharged today, back to [**Hospital3 **] Center.
DISCHARGE CONDITION: Stable.
DISCHARGE DIAGNOSIS:
1. Aspiration pneumonia
2. Atrial tachycardia
3. Coronary artery disease
4. Peptic ulcer disease
5. Wilson's disease
6. Bipolar disorder
7. Hard of hearing
8. Orthostatic hypotension
9. Anemia
10. Bronchiectasis
11. Chronic renal insufficiency
DISCHARGE MEDICATIONS: Same as admission except he will be
discharged on Atenolol 25 mg p.o. q.d., Levaquin 500 mg p.o.
q.d., Flagyl 500 mg p.o. t.i.d., these p.o. medicines have
been given per his gastrostomy tube. The patient is also
being discharged on tube feeds 18 hours a day, 105 cc of
Ultracal.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1604**], M.D.
[**MD Number(1) 1605**]
Dictated By:[**Last Name (NamePattern1) 8228**]
MEDQUIST36
D: [**2104-2-13**] 15:17
T: [**2104-2-13**] 15:45
JOB#: [**Job Number 34941**]
cc:[**Hospital3 **]
ICD9 Codes: 5070, 2765, 2768, 4240 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3726
} | Medical Text: Admission Date: [**2136-3-14**] Discharge Date: [**2136-3-15**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
transferred from nursing home for respiratory failure and
hypotension
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
Mr. [**Known lastname 6054**] is a [**Age over 90 **] yo man who was formerly DNR/DNI and "do
not hospitalize" in his USOH at [**Hospital 100**] Rehab until the day of
admission. At rehab, he was found to have a Hct of 21 so was
transfused blood products at 10:00 AM. Starting at noon the
patient was reported to have dyspnea, wheezing, with increased
anxiety. He then spiked a temp to 101.6, then to 104. At the
NH, he was given nebs, tylenol, and Lasix 80 mg IV x 1. The
patient then desatted to 84% on 5L NC. Hematuria was also
noted. Although he was previously DNH, he was sent to the [**Hospital1 18**]
ED. He was still febrile to 104, hypoxic, and hypotensive. His
family was contact[**Name (NI) **] and code status was reversed.
*
In the ED, the patient was intubated. His BP improved. Lactate
was found to be 7, and a code sepsis was called. RIJ was
placed, and 3 liters NS given. He was also started on
vancomycin and unasyn. The patient also received benadryl,
pepcid, solumedrol, and tylenol for the possibility that this
represented a transfusion reaction. His BP then dropped, which
was possibly related to the propofol given, so levophed was
started.
Past Medical History:
Colon cancer (diagnosed [**12-20**], patient refused surgery)
HTN
AFib (not on warfarin)
AAA (5 x 5 cm)
PVD
chronic anemia with intermittent rectal bleeding
dementia
CHF (EF 45% [**2134**])
h/o possible transfusion reaction
BPH
spinal stenosis
PUD
cholelithiasis
Social History:
The patient's wife died two weeks ago. He currently lives at
[**Hospital 100**] Rehab
Family History:
Hypertension
Physical Exam:
Gen: cauc elderly man lying in bed; intubated.
HEENT: PERRL Bilat, anicteric, MMM.
Heart: RRR, S1, S2, no m/r/g
Lungs: CTA bilat, no W/R/R
Abd: obese, soft, NT/ND/no masses
Ext: no edema, + venous stasis ulcers on left leg
Pertinent Results:
[**2136-3-14**] 03:00PM BLOOD WBC-1.8*# RBC-3.29* Hgb-10.1* Hct-32.3*
MCV-98 MCH-30.9 MCHC-31.4 RDW-16.3* Plt Ct-149*
[**2136-3-14**] 03:00PM BLOOD Neuts-67 Bands-15* Lymphs-17* Monos-0
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0 NRBC-4*
[**2136-3-14**] 03:00PM BLOOD Plt Smr-NORMAL Plt Ct-149*
[**2136-3-14**] 03:00PM BLOOD PT-14.7* PTT-30.8 INR(PT)-1.4
[**2136-3-14**] 03:00PM BLOOD Glucose-78 UreaN-41* Creat-1.3* Na-142
K-5.2* Cl-113* HCO3-14* AnGap-20
[**2136-3-14**] 03:00PM BLOOD Calcium-9.6 Phos-3.2 Mg-1.8
[**2136-3-14**] 03:00PM BLOOD ALT-43* AST-123* CK(CPK)-76 AlkPhos-226*
Amylase-75 TotBili-1.6*
[**2136-3-14**] 05:30PM BLOOD Fibrino-194 D-Dimer-9068*
[**2136-3-15**] 02:47AM BLOOD Cortsol-59.9*
[**2136-3-14**] 03:09PM BLOOD Lactate-6.4*
*
CHEST (PORTABLE AP) [**2136-3-14**] 3:01 PM
AP PORTABLE ERECT CHEST X-RAY: When compared with prior PA and
lateral views of the chest dated [**2134-12-21**], there is no
significant interval change. The cardiac silhouette is normal in
size. The aorta is tortuous. The mediastinal and hilar contours
are normal. Pulmonary vasculature is normal. Within the left
lung apex, adjacent to the aortic knob, there is a stable 12-mm
nodule was previously suggested to be a hamartoma. The left lung
base is not imaged secondary to overlying cardiac device. There
are no infiltrates, consolidations, or effusions within the
imaged lungs. Surrounding soft tissues are unremarkable.
IMPRESSION:
No acute cardiopulmonary disease. Twelve-mm left apical lung
mass, which is stable since [**2134-12-21**]. It could represent
a hamartoma, as previously described. However, a slow growing
metastatic lesion cannot be ruled out.
Brief Hospital Course:
Mr. [**Known lastname 6054**] is a [**Age over 90 **] yo man with a history of colon cancer,
chronic anemia due to intermittent rectal bleeding, PUD, HTN,
and AAA who presented from his nursing home with fever, hypoxia,
and hypotension after a blood transfusion. Initially, given the
timeline (2-6 hours after transfusion) and association with
fever after blood transfusion, his presentation was thought to
be secondary to transfusion related lung injury (TRALI).
However, his CXR was unremarkable. This suggested that another
process was responsible for his presenting symptoms of fever,
hypotension, and respiratory distress.
*
Given his hypotension, rising WBC count, and high lactate,
septic shock was more likely responsible for his presenting
symptoms. An infectious source was never determined; however,
pneumonia vs. UTI with urosepsis seems most likley. After
intubation, he was started on empiric therapy with vancomycin
and ceftriaxone. He was also placed on sepsis protocol.
*
Prior to admission, the patient had an advanced directive of
DNR/DNI. His family reversed this code status prior to
admission. He was intubated on admission. After discussion with
the family, it was determined that the patient would be
extubated the day after admission, and not be re-intubated if in
any respiratory distress. The following day, Mr. [**Known lastname 6054**]
was extubated. He was tachypneic, and eventually went into
hypoxemic respiratory failure and passed away later that day.
The family was present during these events.
Medications on Admission:
combivent, bisacodyl, morphine, ambien, lansoprazole, megace,
metoprolol 12.5 twice daily, aldactone 50 twice daily, iron,
bupropion, tylenol, lasix 40 daily, senna, flomax 0.4 daily
Discharge Disposition:
Expired
Discharge Diagnosis:
Hypoxemic Respiratory Failure
Discharge Condition:
deceased
Discharge Instructions:
N/A
Followup Instructions:
N/A
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
ICD9 Codes: 0389, 2762, 2859, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3727
} | Medical Text: Admission Date: [**2107-2-18**] Discharge Date: [**2107-6-8**]
Date of Birth: [**2107-2-18**] Sex: M
Service: NEONATOLOGY
HISTORY: [**Known lastname **] [**Known lastname **] is now a 111-day-old former 24 [**3-6**] week
infant who is being transferred to [**Hospital3 1810**] for a
tracheostomy for possible subglottic stenosis and chronic lung
disease. He was born by cesarean section for breech
presentation to a 39-year-old gravida IV, para III now IV
woman, whose pregnancy was complicated by severe
pre-eclampsia.
Her prenatal screens were: blood type O positive, antibody
negative, rubella immune, RPR nonreactive, hepatitis surface
antigen and group B strep unknown.
His hospital course up until [**3-24**] can be found in the
previous summary.
His birth weight was 688 grams, his birth length 32 cm, and
his birth head circumference 22 cm.
HOSPITAL COURSE BY SYSTEM:
1. Respiratory: On day of life 49, he developed a
pseudomonas pneumonia. See the ID section for further details
of treatment. He has failed multiple attempts at extubation,
both elective and spontaneous, most recently on [**2107-6-7**].
Intubation on [**2107-5-31**] raised a question of subglottic stenosis
as narrowing was noted below the level of the cords. On
[**2107-6-7**], it was only possible to pass a #2.5 endotracheal tube
and the decision was made to move forward urgently with the
tracheostomy. He is currently on ventilator settings of a PIP
of 28, a PEEP of 7, and IMV rate of 25, and 40 to 50% oxygen
at rest. His last capillary blood gas on [**2107-6-5**] was pH 7.35,
PCO2 63, PO2 32, total CO2 36, and base excess 6.
Current pulmonary medications include: Diuril, aldactone, and
Combivent. He is also receiving stress dose of
hydrocortisone and inhaled tobramycin around this planned
surgery.
2. Cardiovascular: He had a patent ductus arteriosus
ligated on [**2107-3-24**]. A cardiac echocardiogram was done on
[**5-20**] to rule out cor pulmonale and showed normal right
ventricular pressure, no patent ductus arteriosus, good
biventricular function, and no coarctation. He has remained
normotensive throughout his Newborn Intensive Care Unit stay.
He has a normal S1, S2 heart sound and no murmur.
3. Fluids, electrolytes and nutrition: His current feeding
regime is preemie Enfamil 32 calories/ounce with added ProMod
at 130 cc/kg/day by gavage. He tolerates his feedings well,
without any complications. His current measurements are
weight 3410 grams, length 51 cm, and head circumference 35.25
cm.
His laboratory values drawn on [**2107-5-30**] were sodium 131,
potassium 4.9, chloride 95, bicarbonate 28, BUN 14,
creatinine 0.2. Calcium 10.4, albumin 3.7, phosphorus 5.0.
He is receiving potassium chloride supplements.
4. Gastrointestinal: He has a right inguinal [**Known lastname 41231**]. The
plan is for surgical repair hopefully under the same
anesthesia for the tracheostomy. There is also a plan for
placement of a gastrostomy tube due to the anticipation of
long-term mechanical ventilation. He is also on Mylicon for
GI gas.
5. Hematology: He has received nine transfusions of packed
red blood cells during his Newborn Intensive Care Unit stay.
His last hematocrit on [**2107-5-29**] was 34.3%, with a reticulocyte
count of 1.1%. He is receiving supplemental iron and vitamin
D.
6. Infectious Disease: On [**2107-4-25**], [**Known lastname **] completed a 14 day
course of gentamicin and tobramycin for pseudomonas
aeruginosa pneumonia. His blood cultures and cerebrospinal
fluid from that time remain negative. 48 hours after his
antibiotics had been discontinued, he had a clinical
decompensation and again was treated for pseudomonas
pneumonia for 21 days, this time with tobramycin and
meropenem. His blood culture and cerebrospinal fluid
cultures did remain negative. His most recent tracheostomy
culture was on [**2107-5-31**], and that showed a colonization of
pseudomonas aeruginosa. It is resistant to imipenem. It is
sensitive to gentamicin, tobramycin and ciprofloxacin.
He was started on tobramycin nebulizer treatment on [**2107-6-7**]
preoperatively as suggested by the Pulmonary consultant
because of the known Pseudomonas colonization.
7. Neurology: He has had four head ultrasounds, all within
normal limits, the last one on [**2107-5-20**].
8. Sensory: An audiology screening has not yet been done,
but is recommended prior to discharge.
Ophthalmology: His last ophthalmology examination on [**2107-6-8**]
revealed one clock hour of Stage III retinopathy of
prematurity anterior zone II in the right eye and [**1-31**] clock
hours of Stage II with no plus disease, in the left eye
improvement was noted with 6 clock hours of Stage I disease
and no plus disease.
9. Psychosocial: The parents are married. The mother
visits several times during the day, and has been very
active, advocating for her son's care during his Newborn
Intensive Care Unit stay.
CONDITION AT DISCHARGE: Guarded.
DISCHARGE STATUS: He is being transferred to [**Hospital3 18242**] for surgery.
PRIMARY PEDIATRIC CARE: Provider has not yet been
identified.
CARE RECOMMENDATIONS:
1. Feedings at the time of transfer: Preemie Enfamil 32
calories/ounce with added ProMod, with 4 calories/ounce from
concentration, 4 calories/ounce from Polycose, and 4
calories/ounce from medium chain triglycerides, and ProMod
one-half teaspoon per 90 cc of formula. His total fluids are
130 cc/kg/day.
2. Medications: Combivent two puffs by metered dose inhaler
every eight hours as needed, Diuril 56 mg by mouth twice a
day, Aldactone 8 mg by mouth/PG once daily, potassium
chloride supplements 2.5 mEq by mouth/PG every 12 hours,
Mylicon 20 mg by mouth/PG every eight hours, tobramycin
nebulizer 150 mg per endotracheal tube for two doses
3. He has received the following immunizations: Hepatitis B
vaccine on [**2107-5-21**], DtaP on [**2107-4-21**], HiB [**2107-4-21**], IPV on
[**2107-4-21**], and Prevnar on [**2107-4-21**].
4. His last state screen was sent on [**4-11**], and was within
normal limits.
5. He has not yet had a car seat position screening test.
One is recommended prior to discharge.
DISCHARGE DIAGNOSIS:
1. Prematurity, 24 4/7 weeks
2. Status post respiratory distress syndrome
3. Bronchopulmonary dysplasia
4. Status post ligation of patent ductus arteriosus
5. Status post pseudomonas pneumonia
6. Status post unconjugated hyperbilirubinemia
7. Status post hypotension
8. Possible subglottic stenosis
9. Retinopathy of prematurity
10. Anemia of prematurity
11. Status post apnea of prematurity
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 37237**], M.D. [**MD Number(1) 37238**]
Dictated By:[**Last Name (NamePattern1) 37333**]
MEDQUIST36
D: [**2107-6-8**] 01:11
T: [**2107-6-8**] 01:31
JOB#: [**Job Number 41233**]
ICD9 Codes: 769, 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3728
} | Medical Text: Admission Date: [**2140-3-21**] Discharge Date: [**2140-3-23**]
Service: [**Doctor Last Name **]-IM
CHIEF COMPLAINT: Respiratory distress.
HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname 4643**] is an 80 year old
nursing home resident who is at baseline not oriented and
unable to do her activities of daily living. She was
diagnosed with a urinary tract infection at her nursing home
on [**2140-3-12**] and was started on Bactrim on [**2140-3-14**]. On
the morning of admission, the patient was hypoxic with a room
air saturation of 78%, which improved to 90% on a
non-rebreather mask. The patient was then taken to [**Hospital6 18075**] where she was transiently put on Bi-PAP of
which she did not tolerate, after which she was intubated for
hypoxic respiratory failure without initial arterial blood
gas.
While at [**Hospital6 2561**], she was found to be
hypernatremic and received a total of six liters of normal
saline which began to improve her hypernatremia. Because the
patient was found to be febrile and had an elevated white
count, she was started on Ceftriaxone and Azithromycin. She
was then transferred to [**Hospital1 69**]
Emergency Department for further evaluation after she
stabilized.
In the Emergency Department, the patient had a chest x-ray
which revealed evidence of a left lower lobe infiltrate
consistent with pneumonia along with a urinalysis that was
positive for infection. She was then transferred to the
Medical Intensive Care Unit Service for treatment of likely
aspiration pneumonia and possible urosepsis.
PAST MEDICAL HISTORY:
1. Alzheimer's dementia; the patient at baseline is
disoriented to place and time, but she would recognize
family. The patient does not perform activities of daily
living. The patient has a history of geriatric psychiatric
admission in [**Hospital1 **] because of severe agitation.
2. History of pneumonia.
3. History of urinary tract infections.
4. History of esophagitis.
5. History of hiatal hernia.
6. History of deep venous thrombosis times two as per
nursing home.
7. Glaucoma.
8. Hypercholesterolemia.
ALLERGIES: Unasyn and penicillin which lead to a rash.
MEDICATIONS:
1. Zyprexa 2.5 mg q. a.m. and q. p.m.; 1.5 mg q. noon.
2. Trazodone 25 mg p.o. q. h.s.
3. Macrobid 100 mg twice a day.
4. Depakote 250 mg twice a day.
5. Vitamin E, 4000 Units q. day.
6. Multivitamin one p.o. q. day.
7. Zantac 150 mg p.o. twice a day.
8. Nystatin Powder p.r.n.
9. Timoptic one drop o.d. q. day.
10. Vitamin C.
11. Ativan p.r.n.
FAMILY HISTORY: Not obtained.
SOCIAL HISTORY: She lives at a nursing home since [**46**]/[**2138**].
Before that she lived with her husband at an [**Hospital3 **]
facility. She cannot perform any activities of daily living.
No history of tobacco use; no history of alcohol use.
PHYSICAL EXAMINATION: Vital signs are temperature 100.8 F.;
pulse of 70; blood pressure 128/58; pulse of 67. On physical
examination, generally, she was intubated and sedated.
HEENT: Her pupils equally round and reactive to light.
Extraocular movements are intact. Her oropharynx was dry.
Cardiovascular was regular rate and rhythm. She had a Grade
II/VI systolic ejection murmur heard best at the left lower
sternal border. Lungs are clear to auscultation anteriorly.
Abdomen was soft, nontender, nondistended, with good bowel
sounds heard. No masses palpated. Extremities: She had two
plus pitting edema bilaterally with two plus dorsalis pedis
and posterior tibial pulses.
LABORATORY: Her white blood cell count was 16.9, hematocrit
48.5, platelets 184. Sodium 152, potassium 4.1, chloride
115, bicarbonate 23, BUN 25, creatinine 1.5, glucose 134.
Her urinalysis was significant for 50 to 100 white blood
cells.
A chest x-ray revealed a left lower lobe infiltrate
consistent with a pneumonia.
HOSPITAL COURSE:
1. Pulmonary: She was started on Vancomycin and Ceftriaxone
upon being admitted and transferred to the Medical Intensive
Care Unit. The etiology of her left lower lobe pneumonia was
thought to be due to aspiration. On hospital day number
three, her nasotracheal tube was switched to an ETT tube, and
then the patient was extubated the next day without any
difficulty. Upon being transferred to the Medicine Floor,
her antibiotics were changed to Levofloxacin p.o. for which
she will finish a 14 day course of antibiotics.
Over the past three days prior to being discharged, the
patient was afebrile and with a normal white count.
2. Fluids, Electrolytes and Nutrition: The patient was
given additional intravenous fluids which completely
corrected her hypernatremia. Upon extubation and transfer to
the Floor, a Swallowing Evaluation was ordered to evaluation
for aspiration. Because there was a lack of staff available
at the hospital, it was decided that the patient would have a
Swallowing Study done as an outpatient. A PEG tube may be
warranted if the patient returns to the hospital again for
pneumonia, likely secondary to aspiration.
3. Neurologic: Because the family noted a decline in mental
status after starting her anti-psychotic medications, it was
decided that these medications would be stopped. She may
need re-institution of these medications if she were to
become agitated or exhibit psychotic behavior.
4. Dermatologic: A vesicular pustular rash was discovered
on the patient's back after being transferred to the Medicine
Floor. A direct antigen test for virus was negative. A
direct antigen test also for herpes simplex virus types 1 and
2 were also negative. Her viral cultures were pending at the
time of discharge. It is likely that this rash is just
folliculitis and may be treated with frequent turning and
Miconazole Powder to prevent the possibility of a fungal
infection.
CONDITION AT DISCHARGE: The patient at the time of
discharge was stable.
DISCHARGE STATUS: Discharged to [**Hospital **] Nursing home.
DISCHARGE MEDICATIONS:
1. Miconazole Powder 2% applied to her back twice a day and
p.r.n.
2. Timolol maleate 0.25%, one drop o.d. twice a day.
3. Multivitamins, one tablet p.o. q. day.
4. Tylenol 325 mg to 650 mg p.o. q. four to six hours p.r.n.
5. Heparin 5000 units subcutaneously twice a day.
6. Levofloxacin 500 mg p.o. q. day, until [**2140-3-30**].
7. Protonix 40 mg p.o. q. day.
8. Zinc Sulfate 220 mg p.o. q. day.
DISCHARGE INSTRUCTIONS:
1. Please return to the Emergency Room if you develop
worsening cough, fever or increasing oxygen requirements.
2. To follow-up with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 41299**]
[**Name (STitle) 41300**], in one week to review the events of this hospital
admission.
DISCHARGE DIAGNOSES:
1. Aspiration pneumonia.
2. Alzheimer's dementia.
3. History of urinary tract infection.
4. History of esophagitis.
5. History of hiatal hernia.
6. History of deep venous thrombosis times two.
7. Glaucoma.
8. Hypercholesterolemia.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3022**], M.D. [**MD Number(1) 3023**]
Dictated By:[**Last Name (NamePattern1) 7690**]
MEDQUIST36
D: [**2140-3-23**] 15:37
T: [**2140-3-23**] 15:59
JOB#: [**Job Number 34614**]
cc:[**Hospital1 41301**]
ICD9 Codes: 5070, 5990, 2761, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3729
} | Medical Text: Admission Date: [**2168-4-19**] Discharge Date: [**2168-5-10**]
Date of Birth: [**2098-7-7**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Congestive heart failure
Major Surgical or Invasive Procedure:
[**2168-4-21**] Redo sternotomy, Tricuspid Valve Replacement utilizing a
29 millimeter pericardial valve
[**2168-4-22**] Laparoscopy
[**2168-5-3**] Left Side Thoracentesis
History of Present Illness:
This is a 70 year old female who underwent a mechanical aortic
valve replacement, replacement of ascending aorta and myomectomy
in [**2156-5-19**]. She recently was hospitalized for congestive heart
failure. Workup was notable for severe tricuspid regurgitation,
mild aortic insufficiency, mild mitral regurgitation, and normal
LVEF. Cardiac catheterization in [**2168-1-20**] showed normal
coronary arteries. Based upon the above results, she was
referred for cardiac surgical intervention. Since her
hospitalization, she has been placed on Lasix with improvement
in symptoms. At the time of this admission, she denied chest
pain, shortness of breath, orthopnea, PND and pedal edema. She
was also recently treated with Amoxicillin for community
acquired pneumonia. A follow up chest x-ray from [**2168-3-19**]
confirmed improving right lower lobe pneumonia. She currently
denies fevers, chills and rigors. She admits to improving cough
of only white sputum.
Past Medical History:
AS, HOCM, Ascending aortic aneurysm - s/p AVR(21 millimeter
[**Company **] [**Doctor Last Name **]), Replacment of Ascending Aorta, and Myomectomy;
Atrial Fibrillation, Hypertension, Diabetes Mellitus Type II,
Pulmonary Hypertension, Peripheral Vascular Disease, Reactive
Airway Disease, Ascites - s/p paracentesis, s/p tubal ligation,
s/p uterine prolapse repair
Social History:
Denies tobacco/EtoH/drugs. Spanish speaking only. Has recieved
most of her medical care in [**Country 13622**] Republic and at [**Hospital 794**]
Hospital in [**Hospital1 789**] RI. She lives alone.
Family History:
Daughter died of aortic aneurysm in her 30's
Physical Exam:
Vitals: BP 130/90, HR 74, RR 16, SAT 96% on room air
General: elderly obese female in no acute distress
HEENT: oropharynx benign, PERRL, EOMI
Neck: supple, mild JVD noted
Heart: irregular rate, normal s1s2, loud holosystolic murmur
Lungs: clear bilaterally
Abdomen: obese, soft, nontender, normoactive bowel sounds
Ext: warm, [**12-21**]+ edema, rubor changes noted bilaterally
Pulses: 2+ distally
Neuro: CN 2-12 intact, MAE, no focal deficits noted
Skin: Sternotomy and right groin incision well healed
Pertinent Results:
[**2168-5-9**] 06:05AM BLOOD WBC-12.6* RBC-3.50* Hgb-10.5* Hct-32.1*
MCV-92 MCH-30.0 MCHC-32.7 RDW-21.0* Plt Ct-317
[**2168-4-19**] 08:30PM BLOOD WBC-12.3* RBC-3.90* Hgb-10.7* Hct-33.7*
MCV-86 MCH-27.3 MCHC-31.6 RDW-16.8* Plt Ct-370
[**2168-5-10**] 06:05AM BLOOD PT-18.3* PTT-65.6* INR(PT)-1.7*
[**2168-4-19**] 08:30PM BLOOD PT-18.3* PTT-23.8 INR(PT)-1.7*
[**2168-5-10**] 06:05AM BLOOD Glucose-96 UreaN-11 Creat-0.9 Na-140
K-4.2 Cl-102 HCO3-27 AnGap-15
[**2168-4-19**] 08:30PM BLOOD Glucose-186* UreaN-6 Creat-0.8 Na-137
K-4.3 Cl-97 HCO3-30 AnGap-14
[**2168-5-3**] 05:25AM BLOOD TotBili-5.3*
[**2168-4-19**] 08:30PM BLOOD Digoxin-1.5
Brief Hospital Course:
Mrs. [**Known lastname 65582**] was admitted several days prior to surgery for
routine preoperative evaluation and heparinization. Workup was
unremarkable and she was cleared for surgery. On [**4-21**], Dr.
[**Last Name (STitle) 914**] performed a redo sternotomy and a tricuspid valve
replacement utilizing a 29mm pericardial valve. The operation
was uneventful and she transferred to the CSRU in stable
condition. On postoperative day one, she was noted to have a
leukocytosis with significant elevation in lactate and bilirubin
levels. Some RUQ abdominal tenderness was concomitantly noted. A
RUQ ultrasound found no focal liver lesions or biliary
dilatation. Subsequent CT scan revealed findings consistent with
colitis involving the right colon and proximal transverse colon.
She was empirically started on broad spectrum antibiotics and
transplant surgery was consulted for exploratory laparoscopy.
Diagnostic laparoscopy was performed on [**4-22**]. The mesentery,
gall bladder, bowel and appendix all appeared normal. The liver
appeared cirrhotic, micronodular. She returned to the CSRU in
stable condition. Over several days, she made clinical
improvements. Her white count, lactate and LFTs improved. She
was eventually extubated and weaned from inotropic support.
Broad spectrum antibiotics were continued. C. Diff cultures were
checked and remained negative. She otherwise maintained stable
hemodynamics and transferred to the SDU on postoperative day
four. She intermittently required Haldol for confusion. By
discharge, her mental status completely returned to baseline.
Warfarin was resumed for her prior mechanical AVR and dosed for
a goal INR between 2.0 - 3.0. Heparin was transiently required
for some time for a sub therapeutic prothrombin time. She
continued to have elevated bilirubin levels for which the
hepatology service was consulted. Lactate and total bilirubin
levels peaked to 687 and 10.6 respectively. She progressively
became jaundiced and started on Ursodiol for cholestasis, the
most likely etiology for elevated bilirubin levels. The
micronodular liver was attributed to right sided congestive
heart failure. Over her hospital stay, her total bilirubin
eventually improved to 5.3. The remainder of her LFTs were
stable and essentially remained normal except for her LDH. The
ID service was also consulted for a persistent leukocytosis. Her
white count remained mostly remained in the 20K range. During
her hospital stay, she remained afebrile. Broad spectrum
antibiotics were empirically continued for a total of 10 day
course. The leukocytosis was attributed to postop pleural
effusions with bilateral upper lobe pneumonia which was
confirmed by chest CT scan. On [**5-3**], left sided
thoracentesis was performed without complication. Approximately
one liter of bloody fluid was drained. Her white count gradually
improved. Serial chest x-rays showed improvement in pleural
effusions. Chest x-rays were also notable for a persistent
finding of a retrosternal opacity corresponding to fluid
collection on recent CT which remained stable in appearance -
most likely mediastinal hematoma. The remainder of her hospital
course was uneventful. She remained mostly in a normal sinus
rhythm with only intermittent atrial arrhythmias and continued
to maintain stable hemodynamics. She was stabilized on medical
therapy and continued to make clinical improvements with
diuresis. She worked daily with physical therapy and continued
to make steady progress. She was eventually cleared for
discharge to home on postoperative day 18.
Medications on Admission:
Lasix 20 qd, Digoxin 0.25 qd, Glipizide 10 qd, Protonix 40 qd,
Aspirin 81 qd, Warfarin 5 qd, Albuterol MDI, Amoxicillin 875 [**Hospital1 **]
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 6-8 hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
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. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Disp:*60 Tablet(s)* Refills:*2*
10. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO once a day.
Disp:*60 Capsule, Sustained Release(s)* Refills:*2*
11. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 MDI* Refills:*2*
12. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day).
Disp:*90 Capsule(s)* Refills:*2*
13. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours).
Disp:*1 MDI* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
VNA of [**Doctor Last Name **]
Discharge Diagnosis:
Tricuspid Regurgitation - s/p TVR; Postop leukocytosis, Postop
cholestasis with elevation of total bilirubin; Postop pleural
effusions with pneumonia, History of Congestive Heart Failure;
AS, HOCM, Ascending aortic aneurysm - s/p AVR(21 millimeter
[**Company **] [**Doctor Last Name **]), Replacment of Ascending Aorta, and Myomectomy
in [**2155**]; Atrial Fibrillation, Hypertension, Diabetes Mellitus
Type II, Pulmonary Hypertension, Peripheral Vascular Disease,
Reactive Airway Disease, Ascites - s/p paracentesis, s/p tubal
ligation, s/p uterine prolapse repair
Discharge Condition:
Good
Discharge Instructions:
Patient may shower, no baths. No creams, lotions or ointments to
incisions. No driving for at least one month. No lifting more
than 10 lbs for at least 10 weeks from the date of surgery.
Monitor wounds for signs of infection. Please call with any
concerns or questions.
Followup Instructions:
Dr. [**Last Name (STitle) 914**] in 4 weeks, call office for appt.
Dr. [**Last Name (STitle) 65583**](PCP) in 2 weeks, call office for appt.
Dr. [**Last Name (STitle) 7594**](cardiologist) in 2 weeks, call office for appt.
Completed by:[**2168-5-11**]
ICD9 Codes: 4280, 486, 5119, 5715, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3730
} | Medical Text: Admission Date: [**2109-7-3**] Discharge Date: [**2109-7-7**]
Date of Birth: [**2050-11-5**] Sex: M
Service: NME
HISTORY OF PRESENT ILLNESS: This is a 58-year-old man with a
history of bipolar disorder and borderline hypertension who
presents from his home with what his wife noticed at 9 PM was
at first agitation. She realized that he was not himself and
then realized that he was speaking but did not make sense.
They brought him to an outside hospital where a CT scan was
done and revealed a 4x3 cm left sided intracranial
hemorrhage. He was not very hypertensive with a systolic
blood pressures 140 to 160. He denies any other headache and
any numbness or weakness. His ability to communicate was
extremely limited and he was very frustrated. He was briefly
placed on a Nipride drip in the emergency room here at [**Hospital3 **] for a systolic blood pressure of 171 but this was
discontinued, his blood pressure has remained in 110 to
120's.
PAST MEDICAL HISTORY: Bipolar disorder.
Borderline hypertension.
Possible hypercholesterolemia.
MEDICATIONS:
1. Aspirin 81 mg
2. Wellbutrin XR 300 mg p.o. q day.
3. Paxil 10 mg p.o. q day.
4. Lithium recently added 200 mg q AM, 300 mg q PM.
5. Pravachol unsure if still taking.
6. Lamictal 200 mg p.o. q day.
7. Flomax 0.4 mg p.o. q h.s.
ALLERGIES: Penicillin.
HABITS: Sneaks occasional cigarette according to his wife,
no alcohol, no drugs.
SOCIAL HISTORY: Married, works at [**Company 55534**]. Functioning very
well at work.
FAMILY HISTORY: Mother had Parkinsonism. Father had
pancreatic cancer.
PHYSICAL EXAMINATION: Temperature afebrile, blood pressure
129/75, heart rate 72, respiratory rate 16, O2 sat 98% on
room air. In general no acute distress. Mucous membranes
moist. Oropharynx is clear. Lungs: Clear to auscultation
bilaterally. Cardiovascular: Regular rate and rhythm. No
murmurs, gallops or rubs. No carotid bruits. Abdomen soft,
nontender. Extremities: No pedal edema, no rashes. Mental
status: The patient attentive to examiner. Has non-fluent
speech largely but is able to get out automatic speech once
in a while. He initially was able to repeat but later on did
not repeat more than one word. He is unable to write or read
a short three word sentence. He is unable to name objects on
a stroke card. He comprehends some simple one step commands
and initially understands questions regarding his medical
history but later he is unable to comply with "touch your
nose." Cranial nerves and visual acuity intact. Visual
fields appear full to threat. Optic discs are normal in
appearance. Eye movements normal and pupils react normally
to light both directly and consensually. Sensation on the
base appears intact to temperature. There is a right facial
droop. Speech is slightly slurred. Hearing is intact to
finger rub. There is no nystagmus. Palate elevates in the
midline. Tongue protrudes in midline and is normal
appearance. The sternocleidomastoid and trapezius muscles
are strong bilaterally. Motor: There is a right pronator
drift. There is some give way weakness of the wrist
extensors and some motor inconsistence but the rest of the
arm is somewhat weak. Tone appears symmetric. There is also
some weakness in the right lower extremity as well. There is
no adventitious movement. The left arm and leg are full
strength. Coordination: Could not be tested due to
inability to follow directions. Reflexes: Deep tendon
reflexes are all present, slightly brisker throughout on the
right. Toe upgoing on the right and down on the left.
Sensory sensation appears intact to light touch and
temperature. Gait deferred.
LABORATORY FINDINGS: White count 8.1, hematocrit 42.1, INR
1.3, urinalysis negative. Chem 10 normal ALT 15, AST 17,
LDL 180, Ruled out for myocardial infarction by enzymes,
alkaline phosphatase 106, total bilirubin 0.7. MRA showed no
evidence of enhancing lesions to indicate neoplasm or
vascular malformation within the area of the left frontal
parietal intraparenchymal hemorrhage. However, images are
significant indurated by patient's motion and suboptimal
study. There is a grossly normal Circle of [**Location (un) 431**].
HOSPITAL COURSE: The patient was admitted for the
intraparenchymal hemorrhage. He did well throughout his
hospital course improving slightly throughout. He did have
brief stay in the intensive care unit but then was brought to
the floor. He had some witnessed seizure activity and was
started on Dilantin. He underwent angiogram to attempt to
evaluate possible causes for his bleed, the results of which
at this moment are pending. He did not have any obvious
etiology on the MRA and most likely cause at this time is
hypertension.
He was seen by physical therapy, occupational therapy and
speech therapy during hospital stay and he is continued on
Dilantin. He was discharged in good condition.
DISCHARGE MEDICATIONS:
1. Wellbutrin XR 300 mg p.o. q day.
2. Paxil 10 mg p.o. q day.
3. Lithium 200 mg q AM, 300 mg q PM.
4. Pravachol.
5. Lamictal 200 mg p.o. q day.
6. Flomax 0.4 mg p.o. q h.s.
7. Dilantin 200 mg p.o. twice a day.
He will have to follow-up with his regular PCP as well as his
psychiatrist and he will also follow-up in the [**Hospital 4038**] Clinic
with Dr. [**Last Name (STitle) **]. He is discharged in good condition. He will
have to obtain a future magnetic resonance imaging after some
of the blood is resorbed in order to further evaluate any
underlying source.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 22585**]
Dictated By:[**Location (un) 55535**]
MEDQUIST36
D: [**2109-7-5**] 17:08:50
T: [**2109-7-5**] 18:04:01
Job#: [**Job Number 55536**]
ICD9 Codes: 431, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3731
} | Medical Text: Admission Date: [**2154-6-11**] Discharge Date: [**2154-6-18**]
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2154-6-13**] - Colonoscopy
[**2154-6-13**] - Esophagogastroduodonoscopy
[**2154-6-14**] - Capsule Study
History of Present Illness:
86 year old male with history of atrial fibrillation and aortic
stenosis ([**Location (un) 109**] 1 on Cardiac catheterization). Over the past 24
hours he presented to outside
hospital with complaint of chest pain, fatique, weakness and
mild upper back pain. EKG with chronic ST segment
changes,inferior infarct, anterior ST changes, troponin 0.4.
His hematocrit was found to be 17 and he was transfused with 2
units PRBC. Additionally INR was elevated 5.7 related to
coumadin for atrial fibrillation and was treated 2 units FFP and
Vitamin K 10mg po. Due to recurrent chest pain he was
transferred for further evaluation due to known coronary artery
disease and aortic stenosis. He was seen by cardiac surgery in
[**Month (only) **] in evaluation for cardiac surgery however declined
surgery.
Past Medical History:
Hard of hearing
Atrial fibrillation- on Coumadin
Aortic valve disorder ([**Location (un) 109**] 1)
Arthritis
Anemia recieves IV Iron
Gastroesophageal reflux disease
Colon cancer s/p colon resection
Prostate cancer s/p radioactive seed implant
Social History:
Last Dental Exam: edentulous
Lives with: widowed, lives with [**First Name9 (NamePattern2) 89616**] [**Doctor First Name 5627**]
Occupation:Retired
Tobacco: none quit [**2113**]
ETOH: [**2-10**]+ beers/day
Family History:
None
Physical Exam:
Pulse:80's irreg, Resp: 14 O2 sat: 2l 98%
B/P Right: 108/52 Left: 109/54
Height: 5'[**52**]" Weight: 80.4kg
General: Hard of hearing, sitting up in chair no acute distress
denies any pain
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [] Irregular [x] Murmur [**2-10**] syst.
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x] well healed mid-line scar s/p partial colectomy
Extremities: Warm [x], well-perfused [x]
Edema- none
Varicosities- minimal
Neuro: alert and oriented x3 nonfocal
Pulses:
Femoral Right: 2+ Left:2+
DP Right: 1+ Left:1+
PT [**Name (NI) 167**]: Doppler Left:doppler
Radial Right: 2+ Left:2+
Carotid Bruit Right: None Left:None
Pertinent Results:
ECHO [**2154-6-13**]
The left atrium is dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. There is moderate global left ventricular hypokinesis
(LVEF = 35 %). Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). The right
ventricular free wall thickness is normal. Right ventricular
chamber size is normal. with borderline normal free wall
function. The ascending aorta is mildly dilated. There are focal
calcifications in the aortic arch. The aortic valve leaflets are
severely thickened/deformed. There is severe aortic valve
stenosis (valve area 0.9 cm2). Mild (1+) aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. Moderate (2+) mitral regurgitation is
seen. [Due to acoustic shadowing, the severity of mitral
regurgitation may be significantly UNDERestimated.] The
tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
Colonoscopy [**2154-6-13**]
Normal terminal ileum
Grade 1 internal hemorrhoids
Diverticulosis of the sigmoid colon
No avms seen
Otherwise normal colonoscopy to cecum and ileum
EGD [**2154-6-13**]
Angioectasia in the second part of the duodenum
Otherwise normal EGD to second part of the duodenum
Capsule study [**2154-6-14**]
Nonbleeding angioectasia
CT scan [**2154-6-17**]
1. Multifocal patchy ground-glass opacities predominantly in the
upper lobes, but also involve the RLL, concerning for multifocal
PNA. DDx also includes NSIP.
2. Moderate bilateral pleural effusions, without evidence of
loculation.
3. Sub-5mm solid nodules in the RML and RLL. Punctate calcified
granuloma in the right base. Calcified perihepatic nodule.
4. Significant 3-vessel coronary artery disease.
5. Small amount of scattered calcified atherosclerotic plaques
in the
ascending aorta, with a 2.8-cm relatively calcification-free
segment starting approximately 1.2 cm superior to the origin of
the right coronary artery.
Carotid ultrasound [**2154-6-18**]
Results pending
Brief Hospital Course:
Mr. [**Known lastname 5239**] was admitted to the [**Hospital1 18**] on [**2154-6-11**] for further
management of his cardiac disease and gastrointestinal bleed. He
was placed in the intensive care unit and a gastroenterology
consult was obtained. Anticoagulation was held and he was
transfused to maintain a hematocrit of 30. A proton pump
inhibitor was started. A cardiology consult was obtained who
recommended a low dose beta blocker and a high dose statin given
his presentation of demand ischemia in the setting of anemia.
His troponin peaked at 1.39. An EGD was performed which showed
angioectasia that were not bleeding in the duodenum with an
otherwise normal study. A colonoscopy was also performed which
showed diverticulum and internal hemorrhoid but was otherwise
normal. He was transferred to the step down unit on [**2154-6-14**] for
further management and surgical planning. As there was no
further evidence of GI bleeding, aspirin was restarted. A
capsule study/virtual colonoscopy was started on [**2154-6-14**] which
showed non bleeding angioectasia. He remained in rate controlled
atrial fibrillation. Coumadin remained on hold and will be
addressed after he has had his surgery. Surgery was scheduled
for [**2154-7-1**]. As he remained stable, he was discharged home on
[**2154-6-18**]. He will have biweekly hematocrits sent to both our
office and Dr.[**Name (NI) 5318**] office drawn by the visiting
nurse.. Surgical consent was obtained with the understanding
that there was a higher risk of further gastrointestinal
bleeding with heparinization with his surgery.
Medications on Admission:
Doxazosin 8 mg daily
Lasix 80 mg daily
Hydroxyurea 1000 mg wednesday and saturday
Prilosec 20 mg daily
Coumadin 5 mg mon-wed-fri-sun, 2.5 mg tues-thrus-sat - last dose
Vitamin C 500mg daily
Leutin 1 tab in am and 1 tab in PM
Tylenol 650 mg twice a day
Ascorbic acid
Aspirin 81 mg daily
Ferrous sulfate 325 mg TID
Multivitamin
Discharge Medications:
1. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
Disp:*30 Tablet, Sublingual(s)* Refills:*0*
2. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
7. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day.
Disp:*30 Tablet, ER Particles/Crystals(s)* Refills:*0*
8. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. PreserVision 226-200-5 mg-unit-mg Capsule Sig: One (1)
Capsule PO BID (2 times a day).
Disp:*60 Capsule(s)* Refills:*0*
10. hydroxyurea 500 mg Capsule Sig: Two (2) Capsule PO 2X/WEEK
(WE,SA).
Disp:*20 Capsule(s)* Refills:*0*
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*0*
12. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Gastrointestinal bleed - source unidentified in setting of
supratherapeutic INR.
Hard of hearing
Atrial fibrillation - Coumadin currently on hold
Aortic valve stenosis
Coronary artery disease
Arthritis
Anemia recieves IV Iron
Gastroesophageal reflux disease
Colon cancer s/p colon resection
Prostate cancer s/p radioactive seed implant
Discharge Condition:
Alert and oriented x3 nonfocal
Discharge Instructions:
1) You will need twice weekly hematocrit blood draws drawn by
visiting nurse.
2) Surgery scheduled for [**2154-7-1**]. You will be contact[**Name (NI) **] by our
office with a surgical time so you know when to arrive at the
hospital on [**2154-7-1**].
3) Visiting nurse to monitor you for signs of heart failure.
4) Call with any blood in stools, dark/tarry stools or abdominal
pain.
5) Call with any questions or concerns.
Followup Instructions:
You are scheduled for surgery on Monday [**2154-7-1**]. You will
be called with the timing by our office prior to your surgery.
Surgeon: Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 1504**]
Cardiologist: Dr. [**Last Name (STitle) 5310**] ([**Telephone/Fax (1) 5319**]
Primary care physician: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 18998**] ([**Telephone/Fax (1) 18999**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2154-6-18**]
ICD9 Codes: 5789, 4241 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3732
} | Medical Text: Admission Date: [**2170-6-26**] Discharge Date: [**2170-7-2**]
Date of Birth: [**2096-8-22**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
abdominal and chest pain
Major Surgical or Invasive Procedure:
[**2170-6-28**]
Repair of ruptured juxtarenal abdominal aortic
aneurysm with a retroperitoneal approach and a 16 mm x 8 mm
bifurcated Dacron graft.
History of Present Illness:
73 previously healthy male presents from an OSH after being
found
to have a large, ~8cm AAA on U/S. The patient first noticed a
pulsatile abdominal mass 1-2 months ago and feels it has
gradually been growing. He denies any associated pain or other
symptoms related to this. Today while working in his home he
experienced 2 bouts of dull chest pain radiating to both armpits
and his jaw. These episodes lasted approximately 20 minutes,
were associated with dizziness and resolved after 10-15 minutes
of rest. His wife called 911 and he was taken to St. [**Hospital 107**]
Medical Center in [**Hospital1 189**], MA. After noticing the large
pulsatile
abdominal mass, an ultrasound was performed and he was
immediately transferred to [**Hospital1 18**] for Managen of this AAA. He
denies back pain/syncopal episodes/shortness of breath. He
denies fevers/chills/nausea/vomiting.
Past Medical History:
PMH: none
PSH: L total hip replacement, R lateral resection of clavicle
Social History:
+tobacco, 1PPD for over 50 years. EtOH socially. Retired
FBI [**Doctor Last Name 360**] (26 years). Lives at home with his wife.
Family History:
NC, denies family history of CAD, vascular disease
Physical Exam:
Afebrile
VSS
Gen: WDWN, NAD, AOx3
Neck: supple, no JVD, trachea midline
CVS: RRR no M/R/G
Pulm: CTA bilat, no W/R/R
Abd: Inicision clean/dry/intact without errythema or drainage;
bs, soft no m/t/o
LE: warm well perfused, no edema bilat
Pulses:
Rad Fem DP PT
[**Name (NI) **] p p p p
LLE p p p p
Pertinent Results:
[**2170-7-2**] 06:25AM BLOOD WBC-7.6 RBC-3.14* Hgb-9.9* Hct-29.1*
MCV-93 MCH-31.6 MCHC-34.1 RDW-15.1 Plt Ct-217
[**2170-7-2**] 06:25AM BLOOD PT-12.7 PTT-25.7 INR(PT)-1.1
[**2170-7-2**] 06:25AM BLOOD Glucose-99 UreaN-16 Creat-1.0 Na-139
K-3.3 Cl-100 HCO3-31 AnGap-11
[**2170-7-2**] 06:25AM BLOOD Calcium-8.0* Phos-2.6* Mg-1.9
[**2170-6-27**] 12:47AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.028
[**2170-6-27**] 12:47AM URINE Blood-NEG Nitrite-NEG Protein-150
Glucose-NEG Ketone-TR Bilirub-SM Urobiln-NEG pH-5.0 Leuks-NEG
[**2170-6-27**] 12:47AM URINE CaOxalX-RARE
[**2170-6-27**] 12:47 am URINE Source: Catheter.
**FINAL REPORT [**2170-6-28**]**
URINE CULTURE (Final [**2170-6-28**]):
STAPHYLOCOCCUS SPECIES. ~1000/ML.
[**2170-6-26**] 9:05 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2170-6-29**]**
MRSA SCREEN (Final [**2170-6-29**]): No MRSA isolated.
Radiology Report CTA CHEST W&W/O C&RECONS, NON-CORONARY Study
Date of [**2170-6-26**] 4:49 PM
[**Last Name (LF) **],[**First Name3 (LF) **] A. EU [**2170-6-26**] 4:49 PM
CTA CHEST W&W/O C&RECONS, NON-; CTA ABD W&W/O C & RECONS; CTA
PELVIS W&W/O C & RECONS Clip # [**Clip Number (Radiology) 21133**]
Reason: Eval AAA. Pt with Cr 1.5 at OSH. Pls proceed with scan.
Plea
Contrast: OPTIRAY Amt: 90
[**Hospital 93**] MEDICAL CONDITION:
73 year old man with AAA on u/s
REASON FOR THIS EXAMINATION:
Eval AAA. Pt with Cr 1.5 at OSH. Pls proceed with scan.
Please evaluate from
top of arch to Mid thigh
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Wet Read: WWM TUE [**2170-6-26**] 5:37 PM
8.2cm OD (4.3 cm ID) infrarenal AAA spanning from renal aa to
bifurcation with
fistula to L renal vein (3:144) [d/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 21134**] at 5:30p]
incidentals: tiny layering gallstones, no cholescystsitis;
emphysema; liver
cysts; adrenal hyperplasia
Final Report
HISTORY: 73-year-old male with AAA.
STUDY: CTA of the torso; MDCT images were generated through the
chest,
abdomen and pelvis after the administration of 90 cc of Optiray
intravenous
contrast. Coronal and sagittal reformatted images were also
generated.
FINDINGS:
CHEST: There is no axillary, hilar or mediastinal
lymphadenopathy. Diffuse
emphysematous changes are noted throughout the lungs. Multiple
pulmonary
nodules are noted throughout the lungs, all of which measure
less than 4 mm.
They do have a spiculated appearance. A metallic density just
inferior to the
left main stem bronchus may represent prior surgical
intervention. The aorta
demonstrates no evidence of intramural hematoma or dissection.
The pulmonary
arteries opacify normally down to the subsegmental level. The
heart appears
unremarkable. There is no pleural or pericardial effusion.
ABDOMEN: In the left lobe of the liver, there are three
well-circumscribed
hypodensities, the largest of which measures 25 x 24 mm (3; 95).
These are
most consistent with cysts. Multiple small hypodensities are
seen in the
right lobe of liver, many of which are too small to characterize
but likely
represent cysts. No intrahepatic biliary dilatation is seen.
Densities
layering within the gallbladder are most consistent with
cholelithiasis,
although no pericholecystic fluid or wall edema is seen. The
spleen is normal
in size and appearance. Pancreas appears unremarkable. The
adrenal glands
are hypertrophic-appearing bilaterally. The kidneys enhance with
and excrete
contrast symmetrically. In the mid pole of the left kidney is a
well-circumscribed hypodensity that measures 25 mm in diameter
and likely
represents a simple cyst. The small and large intestine show no
evidence of
obstruction or wall thickening, enhances normally. No
lymphadenopathy is
seen. No free air or free fluid is noted.
CTA: Just below the takeoff of the renal arteries, there is a
fusiform
abdominal aortic aneurysm that extends down to the iliac
bifurcation, but does
not extend into the iliac vessels. The aneurysm sac maximally
measures 82 mm
in diameter (401; 36). Intimal calcifications line the outer
perimeter of the
sac. The functional lumen of the aorta measures 43 mm in
diameter (401; 36)
and remainder of the sac is filled with nearly complete
circumferential mural
thrombus. The height of the aortic aneurysm is approximately 154
mm from the
renal artery takeoff to the iliac bifurcation. In series 3,
images 143 and
144, there is erosion of the aortic aneurysm into the left renal
vein,
signifying an arteriovenous fistula. Arterial contrast is then
seen refluxing
into the left renal vein and down the IVC in a retrograde manner
to the level
of the iliac veins. Arterial contrast is also seen flowing
antegrade up the
IVC and refluxing into the hepatic veins. This leak of the
abdominal aortic
aneurysm appears to be contained within the venous system and no
retroperitoneal contrast collections are noted.
The [**Female First Name (un) 899**] is occluded. The celiac, SMA, renal, and iliac arteries
opacify
normally, although with the diversion of flow from the high
pressure aortic
system to the low-pressure venous system, decreased flow to the
mesenteric and
lower extremity circulations resulting in underlying ischemia
cannot be ruled
out.
PELVIS: The bladder, prostate and rectum appear unremarkable.
BONES: There is a left total hip arthroplasty that shows no
evidence of
failure or loosening. Degenerative changes are seen in the right
hip in the
form of subchondral sclerosis and subchondral cysts.
Degenerative changes are
seen in the lumbar spine with grade 1 retrolisthesis of L5 on
S1. Vacuum
phenomenon is also noted at the L5-S1 intervertebral discs as
well as at the
L3-L4 and L2-L3 intervertebral discs. No suspicious lytic or
sclerotic
lesions are seen.
IMPRESSION:
1. Fusiform abdominal aortic aneurysm extending from the renal
artery takeoff
to the iliac bifurcation; the aneurysm has eroded into the left
renal vein
creating arteriovenous fistula between the aorta and left renal
vein. No
extravascular contrast leak is seen.
2. Diffuse emphysematous changes with numerous spiculated 4-mm
pulmonary
nodules; while the number of nodules is reassuring, the
possibility of
malignancy cannot be excluded and so a 6- to 12-month followup
chest CT is
recommended.
3. Cholelithiasis without cholecystitis
4. Hepatic and renal cysts.
These findings were discussed by Dr. [**Last Name (STitle) **] with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 21134**]
at 17:30 on
[**2170-6-26**] via phone. Further discussion with vascular surgery
consult resident
was also had.
Brief Hospital Course:
Mr. [**Known lastname 21135**] was admitted from an OSH on [**2170-6-26**] to the VICU. He
was started on an esmolol gtt for BP control as well as mucomyst
and sodium bicarb gtt for renal protection and preoped for
emergent repair. Upon arival a CT scan was done showing
fusiform abdominal aortic aneurysm extending from the renal
artery takeoff to the iliac bifurcation; the aneurysm has eroded
into the left renal vein creating arteriovenous fistula between
the aorta and left renal vein. No extravascular contrast leak is
seen. He was taken to the OR that afternoon where he underwent:
Repair of ruptured juxtarenal abdominal aortic aneurysm with a
retroperitoneal approach and a 16 mm x 8 mm bifurcated Dacron
graft. He tolerated the procedure well, and was transfered to
the CVICU. He received several blood transfusions throughout his
stay, but did very well. His gttw were weaned off and he
remained was hemodynamically stable. Mr. [**Known lastname **] was volume
overloaded post operatively and was diuresed agressively with IV
lasix. He was transfered to the VICU on [**6-28**]. While in the
VICU he was on a free water restriction and continued with lasix
therapy. He was able to void on his own, tolerated a regular
diet and ambulated with physicial therapy who found him to be
safe independently. On [**7-2**] he was deemed stable for discharge
home. He will go on 1 week of diuresis w/ lasix. He should
follow up with his pcp regarding BP control and initiation of a
statin.
Medications on Admission:
none
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): while on narcotics.
2. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 1 weeks.
Disp:*7 Tablet(s)* Refills:*0*
4. Potassium Chloride 10 mEq Tablet Sustained Release Sig: One
(1) Tablet Sustained Release PO ONCE (Once) for 7 days.
Disp:*7 Tablet Sustained Release(s)* Refills:*0*
5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): hold for hr <55.
Disp:*30 Tablet(s)* Refills:*2*
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Ruptured juxtarenal abdominal
aortic aneurysm and aortovenous fistula.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Division of Vascular and Endovascular Surgery Discharge
Instructions
What to expect when you go home:
1. It is normal to feel weak and tired, this will last for [**6-19**]
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 [**2-14**]
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
MEDICATIONS:
You have been started on aspirin and metoprolol (for blood
pressure/ heart rate control. You will be on lasix and potassium
for 1 week to help with fluid retention. You have been given a
prescription for oxycodone, which is a narcotic pain medication.
You should follow up with your primary care provider to have
liver function tests done, and then start on a statin medication
(simvastatin, atorvostatin, etc). The statin medication is
beneficial in people with a history of aortic aneurysm, and
should be started at a low dose, even if your cholesterol is
normal.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 2625**]
Date/Time:[**2170-7-11**] 1:45
call PCP for appt with in 2 weeks
Completed by:[**2170-7-2**]
ICD9 Codes: 2762, 3051, 4019, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3733
} | Medical Text: Admission Date: [**2175-6-19**] Discharge Date: [**2175-7-3**]
Date of Birth: [**2097-3-6**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Shortness of breath and chest discomfort
Major Surgical or Invasive Procedure:
[**2175-6-19**] Cardiac Catherization
[**2175-6-26**] Three Vessel Coronary Artery Bypass Grafting(left
internal mammary to left anterior descending artery with
saphenous vein grafts to diagonal and PDA).
History of Present Illness:
Mr. [**Known lastname 86418**] is a 78 year-old man with a history of inferior MI,
hypertension, hypercholesterolemia and claudication who was
admitted to the CCU following emergent cardiac catheterization
after presenting with acute onset shortness of breath and chest
discomfort. He is a vague historian although does feel that he
has been more fatigued in general over the last 2-3 weeks with
shortness of breath noticed when it was hot and humid. He
noticed he has felt more short of breath since the evening prior
to admission ([**6-18**]) and first noticed this when he was tryng to
go to sleep. He was restless and felt that his breathing was
labored at rest. He also notes epigastric/lower chest discomfort
which was continuous since the evening of [**6-18**] and was a dull
pain which had no particular radiation and was assocated with
some chest heaviness. He denied significant nausea, no vomiting
although he was diaphoretic.
.
His symptoms were considerably worse by the morning of [**6-19**] and
he called EMS and was admitted to the outside hospital ([**Hospital1 **]) ED and ECG at the time showed a LBBB and inferior Q
waves and CXR showed pulmonary edema and cardiac enzymes were
mildly elevated with Trop 0.12, BNP 3490. Baseline labs at
[**Hospital3 **] showed BUN 41 Cr 1.4.
.
In the [**Hospital 97437**] Hospital ED, he was loaded with clopidogrel 600mg
and 4x81mg aspirin and integrilin infusion at 14ml/hour and a
nitroglycerin 50mcg/min infusion. On arrival at [**Hospital3 **] ED
he received furosemide 40mg IV and taken to cardiac
catheterization. Cardiac cath demonstrated diffuse 3-vessel
disease not amenable to PCI.
.
On review of systems, he denied any recent fever, chills, change
in weight, change to bowel or bladder habbits, arthalgia,
myaglia, dizziness, numbness or weakness. Cardiac review of
systems is notable for absence of typical chest pain, although
he was dyspneic at rest, had no paroxysmal nocturnal dyspnea,
orthopnea, ankle edema, palpitations, syncope or presyncope. He
noted bilateral claudication at 200yrds with no rest pain. Of
note he had dark/black stools for three days and settled two
days ago. He has chronic problems with increased urinary
frequency/urgency.
Past Medical History:
- History of Inferior MI [**89**] years ago
- Hypertension
- Hypercholesterolemia.
- Previous gastric/DU 10 years ago and had a GI bleed requiring
hospital admission.
- Mild Osteoarthritis
- GERD
- s/p left knee surgeries
- s/p hemorrhoidectomy
Social History:
Retired [**Doctor Last Name **] at Stop and Shop and limousine driver.
-Tobacco history: 5 cigars/day since teens
-ETOH: 0-2 units per week. Denies prev alcohol excess.
-Illicit drugs: denies
Normally walks unaided and has ET 1 mile on the flat.
Family History:
Mother had MI and pancreatic ca
Father - asthma
Sibs - No cardiac disease. 2 sisters otherwise well
Physical Exam:
Admission Exam
Gen: Well appearing main with some SOB.
HEENT: PERRL, EOMI. MMM. OP clear. Conjunctiva well pigmented.
Neck: Supple, without adenopathy. Some JVD and JVP elevated at
7-8cm above sternal angle.
Chest: Decreased breath sounds bilaterally to midzones and
crackles to midzones bilaterally worse on the left. Dullness at
bases.
Cor: HS SI+ soft SII + ESM with no radiation. RRR. No deviated
apex.
Abdomen: Obese Soft, non-tender.. +BS, no HSM. R groin cath site
no hematoma no bruit.
Extremity: Femorals 2+ b/l Popliteals 2+ on L 1+ on R, DP
present barely on teh left and absent on the right. PT absent
bilaterally. All foot pulses present on doppler with monophasic
waveforms. No peripheral edema. No clinical evidence of DVT.
Neuro: Alert and oriented. CN 2-12 intact. Motor strength intact
in all extremities. Sensation intact grossly.
Pertinent Results:
[**2175-6-19**] WBC-12.4* RBC-4.46* Hgb-12.0* Hct-36.6* Plt Ct-296
[**2175-6-19**] PT-12.7 PTT-23.6 INR(PT)-1.1
[**2175-6-19**] Glucose-140* UreaN-44* Creat-1.7* Na-142 K-4.5 Cl-107
HCO3-20*
[**2175-6-19**] ALT-8 AST-14 LD(LDH)-177 CK(CPK)-25* AlkPhos-126
TotBili-0.6
[**2175-6-19**] CK-MB-2 cTropnT-0.16*
[**2175-6-20**] CK-MB-4 cTropnT-0.17*
[**2175-6-20**] CK-MB-3 cTropnT-0.14*
[**2175-6-21**] CK-MB-2 cTropnT-0.13*
[**2175-6-19**] Albumin-4.0 Calcium-9.5 Phos-5.0* Mg-2.3 Cholest-209*
[**2175-6-19**] %HbA1c-5.9 eAG-123
[**2175-6-19**] Triglyc-167* HDL-30 CHOL/HD-7.0 LDLcalc-146*
[**2175-6-19**] Cardiac Cath:
1. Selective coronary angiography of this right dominant system
revealed two vessel coronary artery disease. The LMCA had mild
diffuse disease.
The LAD had serial 90% stenoses, including near the ostium. The
Lcx had
moderate diffuse disease. The RCA (engaged with AL1) was totally
occluded and filled distally via left to right collaterals.
2. Resting hemodyanmics revealed severely elevated filling
pressures
with RVEDP of 23 and LVEDP of 39 mmHg. There was severe
pulmonary
hypertension with PASP of 50/31 mmHg. There was preserved
cardiac index
of 2.7 L/min/m2. There was a 20mmHg gradient across the aortic
valve,
which was confirmed on LV pullback, consistent with aortic
stenosis.
[**2175-6-19**] Echocardiogram:
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is severely
depressed (LVEF= 25-30 %) with global hypokinesis and regional
inferior, lateral and apical near akinesis. There is no
ventricular septal defect. with borderline normal free wall
function. The aortic root is mildly dilated at the sinus level.
The aortic valve leaflets are moderately thickened. There is
probably moderate to severe aortic valve stenosis (valve area
0.8-1.0cm2) (low output AS). Mild (1+) 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 pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
[**2175-6-20**] Carotid Ultrasound:
Right ICA stenosis 60-69%. Left ICA stenosis <40%.
[**2175-6-26**] Intraop Echocardiogram:
PREBYPASS
No atrial septal defect is seen by 2D or color Doppler. There is
mild symmetric left ventricular hypertrophy. The left
ventricular cavity is severely dilated. There is severe regional
left ventricular systolic dysfunction with thinning and akinesis
of the inferior, inferoseptal walls. There is hypokinesis of the
inferolateral wall.. Right ventricular chamber size and free
wall motion are normal. The aortic root is mildly dilated at the
sinus level. There are complex (mobile) atheroma in the
ascending aorta as demonstrated by an epiaortic scan. There are
complex (mobile) atheroma in the aortic arch. There are multiple
complex (>4mm) atheroma in the descending thoracic aorta. The
aortic valve leaflets are moderately thickened with decreased
mobility of the left and non coronary cusps.. There is severe
aortic valve stenosis (valve area 0.8- 0.9 cm2). Peak/mean
gradient is 25/15 mm Hg. Given the patients low CI of 1.5, this
may represent pseudo-aortic stenosis. Dobuatmine testing of this
hypothesis was not performed. Mild (1+) aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Mild to
moderate ([**12-3**]+) mitral regurgitation is seen. Dr. [**Last Name (STitle) **].
POSTBYPASS
The patient is receiving dobutamine 5 ucg/kg/min
LV systolic function appears slightly improved in the setting of
inotropes. There is slight improvement of the anterior and
lateral walls. The AV gradient peak/mean gradient is now 35/20
and the [**Location (un) 109**] is 1.0-1.1 cm2. The MR is now trace/mild. RV
systolic function remains normal
WBC Hgb Hct Plt Ct
[**2175-7-3**] 12.2* 10.8* 32.9 317
[**2175-7-2**] 12.6* 11.8* 36.0 289
[**2175-7-1**] 11.8* 10.4* 31.7 229
[**2175-6-30**] 13.7* 10.1* 30.6 220
UreaN Creat Na K Cl HCO3
[**2175-7-3**] 34* 1.7* 136 4.2 102
[**2175-7-2**] 35* 1.7* 142 3.7 106 24
[**2175-7-1**] 39* 1.8* 140 3.7 104 25
[**2175-6-30**] 39* 1.8* 141 3.7 104 26
Brief Hospital Course:
While in the CCU, patient had a pre surgical work up which
included echocardiogram and carotid ultrasound. Given that the
patient was stable on medical therapy, surgery was delayed for
Plavix washout. Echocardiogram was notable for moderate aortic
stenosis and severely depressed LV function (EF 25%-30%).
Carotid ultrasound showed moderate disease of the right internal
carotid artery. See result section for further details. Given
potential for valve replacement, patient underwent several teeth
extractions prior to surgery. On admission, creatinine was
elevated at 1.7. Renal function remained stable prior to
surgery.
On [**6-26**], Dr. [**Last Name (STitle) **] performed coronary artery bypass grafting
surgery. Given intraoperative findings, aortic valve replacement
was not performed. See operative note for further details.
Following the operation, he was brought to the CVICU for
invasive monitoring. Within 24 hours, he awoke neurologically
intact and was extubated. He maintained stable hemodynamics and
weaned from inotropic support. On postoperative day two, he
transferred to the SDU. He experienced some confusion which
improved with the discontinuation of narcotics. His chest tubes
and pacing wires were removed without complication. Heart
failure regimen was resumed postoperatively except for the ACE
inhibitor given his chronic renal insuffiency. Single 7 beat run
of NSVT was noted but otherwise he remained in a normal sinus
rhythm with further atrial or ventricular arrhythmias. Over
several days, he continued to make clinical improvements with
diuresis and was eventually cleared for the [**Hospital **] Rehab in
[**Location (un) 686**] on post-operative day seven.
Of note, he had several days of diarrhea prior to discharge
which was D. difficile negative. Despite negative EIA for C.
diff toxin, he will empirically be treated with Flagyl for seven
days. With the negative EIA, antidiarrheals were given.
Medications on Admission:
Propranolol 80mg qd
Gemfibrozil 600mg [**Hospital1 **]
Hydroxyzine 50mg tid
Nitroglycerin patch 0.2mcg/hr applied daily
Multivitamin 1 tab qd
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 7 days: Please stop after one week.
8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day: please
hold if K > 4.5 - dose may need to be titrated accordingly.
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day:
Please titrate accordingly.
10. Outpatient Lab Work
Please monitor weekly CBC, lytes, BUN/Cr while at rehab and fax
results to cardiac surgery office @ [**Telephone/Fax (1) 5793**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 6560**] Care & Rehab Center - [**Location (un) 86**]
Discharge Diagnosis:
Coronary Artery Disease, s/p CABG
Ischemic Cardiomyopathy
Postop Non Sustained Ventricular Tachycardia
Aortic Stenosis
Chronic Systolic Congestive Heart Failure
Non ST Elevation Myocardial Infarction
Hypertension
Dyslipidemia
Chronic Renal Insufficiency
Carotid Disease
Postop Diarrhea(C. difficile negative)
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage. 1+ Edema
bilaterally
PAGE 1 ?????? for VNA and Rehabs
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
Dr. [**Last Name (STitle) **] on [**2175-7-26**] 1PM, call office with any questions
[**Telephone/Fax (1) 170**]
PCP/Cardiologist, Dr. [**Last Name (STitle) **] - call office for appt
Completed by:[**2175-7-3**]
ICD9 Codes: 4271, 2720, 4241, 4280, 2724, 5859, 4168, 4439 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3734
} | Medical Text: Admission Date: [**2145-5-25**] Discharge Date: [**2145-5-28**]
Date of Birth: [**2079-3-13**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 678**]
Chief Complaint:
Cough, fevers, melena
Major Surgical or Invasive Procedure:
Upper Endoscopy x 2
History of Present Illness:
Mr. [**Known lastname **] is a 66 year old male with a history of severe
gastroesophageal reflux disease s/p Nissen fundoplication in
[**2132**] who presented to [**Hospital 191**] clinic on the day of presentation with
cough and fevers for four days. The patient reports that he
felt well the week prior to admission. He developed fevers to
101 degrees associated with a dry cough for the past four days.
He did not have associated nasal congestion, sinus pressure, or
sore throat. He did not have any chest pain or shortness of
breath. He happened to note that for one day prior to admission
he had been having black bowel movements. He has been admitted
for gastrointestinal bleeding in the past but does not remember
ever having black stools. He denies abdominal pain, nausea,
vomiting, hematemasis or bright red blooid per rectum. He
denies lightheadedness, dizziness, or decreased urine output.
He does note that he had taken two ibuprofen the week of
admission for his fevers. In [**Hospital 191**] clinic his blood pressure was
112/70, heart rate of 88 and temperature of 100.7. His stool
was guaiac positive on exam.
In the emergency room his initial vitals were T: 99.0 HR: 79 BP:
137/72 RR: 20 O2: 97% on RA. He underwent NG lavage which was
grossly positive for 500 cc of bright red blood. He had a chest
xray which showed a possible right lower lung opacity. His
initial hematocrit was 40. His blood pressures transiently
dropped to the 80s systolic from the 110s and was responsive to
fluids. He received 2 L of normal saline, 40 mg IV protonix and
was admitted to the medical ICU.
In the medical ICU he underwent emergent upper endoscopy which
revealed old blood in the stomach and a large clot in the fundus
but no active bleeding. He has since been hemodynamically
stable. His hematocrit on transfer to the floor was 31.8. He
has not required any blood transfusions. He did undergo a chest
CT which showed likely aspiration pneumonia with reactive
lymphadenopathy. He was started on levofloxacin and flagyl.
On review of systems the patient currently denies
lightheadedness, dizziness, chest pain, shortness of breath,
nausea, vomiting, abdominal pain, dysuria, hematuria, low urine
output, leg pain or swelling. He notes fevers at home as above
with non-productive cough and melena. All other review of
systems negative in detail.
Past Medical History:
Gastroesophageal Reflux s/p Nissen fundoplication in 10/95
Upper Gastrointestinal Bleeding in [**2131**] and [**2132**]
Sensorimotor axonal neuropathy
Anxiety and Depression
Social History:
Works as a clerk. He lives with his wife and has no children.
He does not drink, smoke or use IV drugs.
Family History:
No history of coronary artery disease or diabetes. His brother
had "esophageal problems" but he cannot specify.
Physical Exam:
VS: T: 99.4 HR: 72 BP: 130/60 RR: 20 O2 sat: 97% on 2L
GENERAL: well appearing male in no acute distress
HEENT: sclera anicteric, slight conjunctival injection in right
eye with mild crusting, pupils equal and round, dry MM
NECK: supple, no LAD
LUNGS: bronchial breath sounds at bases, no wheezes or rales
CARDIAC: RRR, nl S1 S2, no m/r/g
ABDOMEN - distended, soft, non-tender, hypoactive BS
EXT - no cyanosis, clubbing, edema
Neuro: A&Ox3, no focal deficits
Pertinent Results:
Hematology:
[**2145-5-25**] 05:30PM WBC-10.1 RBC-4.42* HGB-13.7* HCT-40.0 MCV-90
MCH-31.0 MCHC-34.3 RDW-13.7
[**2145-5-25**] 05:30PM NEUTS-83.3* LYMPHS-11.0* MONOS-4.1 EOS-1.1
BASOS-0.3
[**2145-5-25**] 05:30PM PLT COUNT-247
[**2145-5-25**] 07:35PM PT-12.2 PTT-24.5 INR(PT)-1.0
[**2145-5-28**] 06:20AM BLOOD WBC-6.8 RBC-3.70* Hgb-11.5* Hct-33.4*
MCV-90 MCH-31.2 MCHC-34.5 RDW-13.5 Plt Ct-316
Chemistries:
[**2145-5-25**] 05:30PM GLUCOSE-105 UREA N-26* CREAT-0.9 SODIUM-141
POTASSIUM-4.4 CHLORIDE-107 TOTAL CO2-26 ANION GAP-12
Urinalysis:
[**2145-5-25**] 09:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.023
[**2145-5-25**] 09:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
Imaging:
CHEST (PA & LAT): Again noted are multiple healed right-sided
rib
fractures. An opacity in the right lower lung most likely
represents middle lobe atelectasis, which is slightly more
pronounced than on the prior study. An infectious process cannot
be entirely excluded. There are no effusions and no
pneumothorax. Cardiomediastinal silhouette is unremarkable.
CT CHEST W/CONTRAST [**2145-5-26**]
This examination is limited due to extensive motion artifact
limiting the sensitivity for small nodules and ground-glass
opacities. There are few prominent though non-pathologically
enlarged lymph nodes along the left lower paratracheal station
measuring 9 and 8 mm in width. There is an enlarged right hilar
lymph node, 16 x 14 mm. There is no pericardial or pleural
effusion. There is a moderate-sized area of consolidation within
the left lower lobe and a smaller area of peribronchiolar
ground-glass opacity within the right lower lobe. These findings
along with history of GERD are in keeping with aspiration
pneumonia. Right middle lobe linear atelectasis is noted. There
is a small amount of airway secretions, within the mid trachea.
There is a peripheral hypodensity within the right lobe of the
liver of approximately 1 cm. There is a 3.5 x 3.0 cm cystic
pancreatic head lesion which (based on prior report -- imaging
unavailable on PACS at this time) has not changed. There are
similar-appearing bilateral simple renal cysts. Suture material
is seen at the gastroesophageal junction consistent with history
of fundoplication.
IMPRESSION:
1. Likely aspiration pneumonia with reactive lymphadenopathy.
2. Recommend two-month followup CT post treatment to evaluate
for resolution of right hilar lymph nodes.
Upper Endoscopy [**2145-5-25**]:
A large adherent blood clot was seen in the stomach fundus,
unable to remove with suction or flushing. Area under the clot
not visualized.
Old blood was seen in the stomach, no fresh blood or bleeding
site was seen. Otherwise normal EGD to second part of the
duodenum.
Upper Endoscopy [**2145-5-27**]:
Esophagus: Mucosa: Slightly irregular z-line of the mucosa was
noted throughout the esophagus.
Stomach:
Lumen: Evidence of a previous Nissen fundoplication was seen.
Mucosa: Patchy erythema of the mucosa without bleeding was noted
in the fundus and stomach body. These findings are compatible
with gastritis.
Excavated Lesions Multiple superficial non-bleeding ulcers
ranging in size from 3mm to 5mm were found circumferentially
around the pylorus. Cold forceps biopsies were performed for
histology and to rule out h. pylori at the stomach antrum. A
single superficial non-bleeding 6mm ulcer was found in the
antrum.
Microbiology:
[**2145-5-26**] 4:49 pm SPUTUM Source: Expectorated.
**FINAL REPORT [**2145-5-29**]**
GRAM STAIN (Final [**2145-5-26**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS, CHAINS, AND
CLUSTERS.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2145-5-29**]):
MODERATE GROWTH OROPHARYNGEAL FLORA.
HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE NEGATIVE.
MODERATE GROWTH.
Beta-lactamse negative: presumptively sensitive to
ampicillin.
Confirmation should be requested in cases of treatment
failure in
life-threatening infections..
[**2145-5-27**] 7:05 am SEROLOGY/BLOOD HELI ADDED TO ACC#[**Serial Number 98851**]R.
**FINAL REPORT [**2145-5-28**]**
HELICOBACTER PYLORI ANTIBODY TEST (Final [**2145-5-28**]):
NEGATIVE BY EIA.
(Reference Range-Negative).
Brief Hospital Course:
Mr. [**Known lastname **] is a 66 year old male with a history of severe
gastroesophageal reflux disease s/p Nissen fundoplication in
[**2132**] who presents with cough, fevers and melena.
Upper Gastrointestinal Bleeding: Patient presented to his
primary care physician noting melena. His hematocrit was 40.0
on admission but this dropped to 33.6 the following morning. NG
lavage in the emergency room was positive for gross blood. He
underwent emergent upper endoscopy which revealed old blood in
the stomach but no active bleeding. He did not require any
blood transfusions. He was treated with bowel rest and high
dose intravenous proton pump inhibitor. He underwent repeat
upper endoscopy two days later which revealed multiple
non-bleeding ulcers in the stomach. H. pylori serologies were
negative. He was advised to discontinue his aspirin and any
NSAIDs. He was discharged on omeprazole 40 mg daily. He will
follow up with his primary care physician.
Aspiration Pneumonia: On admission the patient had a CXR which
was concerning for an infiltrate. He underwent chest CT which
showed evidence of aspiration pneumonia and reactive
lymphadenopathy. Sputum cultures were positive for H. flu. He
was started on levofloxacin and flagyl for a ten day course.
This was switched to moxifloxacin on discharge. He should
undergo repeat imaging of his chest in two months to ensure that
the lymphadenopathy has resolved.
Conjunctivitis: The patient had evidence of mild conjunctival
injection on the right side with crusting on admission.
Although it was felt that this was unlikely to represent a
bacterial infection, given his systemic illness, he was treated
with erythromycin ointment for five days.
Anxiety/Depression: No active inpatient issues. He was
continued on citalopram.
Medications on Admission:
Citalopram 20 mg daily
Multivitamin
Aspirin 81 mg daily
Advil Occassionally
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
3. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 8 days.
Disp:*24 Tablet(s)* Refills:*0*
4. Erythromycin 5 mg/g Ointment Sig: 0.5 strip Ophthalmic QID (4
times a day) for 3 days: To right eye.
Disp:*1 tube* Refills:*0*
5. Omeprazole 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*
6. Multivitamin Capsule Sig: One (1) Capsule PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Upper Gastrointestinal Bleeding
Aspiration Pneumonia
Conjunctivitis
Discharge Condition:
Stable. Ambulating without assistance. Breathing comfortably
on room air.
Discharge Instructions:
You were seen and evaluated for your black stools. You had an
upper endoscopy and were found to have ulcers in your stomach.
You also were found to have pneumonia and were treated with
antibiotics.
Please take all your medications as prescribed. The following
changes were made to your medication regimen.
1. Please take levofloxacin 500 mg once a day for 7 more days
2. Please take flagyl 500 mg three times a day for 8 more days
3. Please take omeprazole 40 mg once a day
4. Please stop taking aspirin and advil until you see Dr. [**9-7**]. Please use erythromycin ointment in your right eye four times
a day for three more days for conjuncivitis
Please keep all your follow up appointments as scheduled.
Please seek immediate medical attention if you experience any
fevers > 101.5 degrees, chest pain, difficulty breathing,
worsening abdominal pain, persistent black stools or bloody
stools or any other concerning symptoms.
Followup Instructions:
Please follow up with your primary care physician [**Last Name (NamePattern4) **]. [**First Name (STitle) 216**] in
one week. Someone from his office will call you to help
schedule an appointment. His office phone number is
[**Telephone/Fax (1) 250**].
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) 684**]
ICD9 Codes: 5070, 4589, 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3735
} | Medical Text: Admission Date: [**2177-3-17**] Discharge Date: [**2177-3-23**]
Date of Birth: [**2105-4-29**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1572**]
Chief Complaint:
Palpitations
Major Surgical or Invasive Procedure:
none
History of Present Illness:
71 M w/Hx of CVA x1 ([**2170**], residual Left sided weakness, hoarse
voice), HTN, dyslipidemia and alcohol abuse presents with
palpitations.
.
Three weeks prior to admission, in [**State 108**], patient had episode
of lightheadness with a fall in a sauna (scraped knee). Since
then he has had occasional recurrences of these symptoms. On
[**3-16**], he felt lighthead in a restaurant, fell and scraped his
chin. No history of seizure, loss of bowel/bladder continence or
tongue biting. He has no recall of this event. In the days prior
to admission, he has had sinus congestion with a 'sinus
infection'. He took Advil Cold & Sinus for several days without
improvement. Then started Nasonex and most recently Moxifloxacin
x several days. Today, [**3-17**], while driving, he felt a racing
heart. Drove to his office, called his staff to arrange an
ambulance.
.
He was taken by EMS to [**Hospital1 **]. He received Amiodarone en route.
At [**Hospital1 **], he had a rate of 250 that fell to 140 with 6 mg of
Adenosine. He then received dilt 10 x 2, metoprolol, dilt drip,
before his primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 311**] arranged transfer
to [**Hospital1 18**].
.
In the [**Hospital1 **] ED, he was afebrile, BP 114/82-125/90, HR 115-125, RR
14, SpO2 1002-3L. He was symptomless and joined by his daughter.
.
REVIEW OF SYSTEMS:
S/he denies any prior history of deep venous thrombosis,
pulmonary embolism, bleeding at the time of surgery, myalgias,
joint pains, cough, hemoptysis, black stools or red stools. S/he
denies recent fevers, chills or rigors. S/he denies exertional
buttock or calf pain. All of the other review of systems were
negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: None
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
#. CVA- history of right inferior MCA stroke in [**2170-8-3**] with
residual mild left hemiparesis
#. Ulcerative Colitis- quiescent, followed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2305**],
M.D.; reportedly had 4+ guaiac stools in the past.
#. Depression
#. HTN
#. History of gastritis
#. Hyperlipidemia
#. Chronic renal insufficiency- Baseline Cr 1.4, followed by
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D.
Social History:
CPA; widower, lost wife 6 months previous (cirrhosis).
-Tobacco history: 1-1.5 PPD
-ETOH: [**2-5**] large cups of Vodka; more than [**1-4**] gallon of vodka
every 10 days
-Illicit drugs: none
Family History:
Mother had CA
Father had MI
Physical Exam:
VS: , BP 114/82-125/90, HR 115-125, RR 14, SpO2 1002-3L
GENERAL: WDWN male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
No oral ulcers. Filled caries
NECK: Supple with non-elevated JVP of 5 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. Tachycardic, normal S1, S2. No m/r/g. No thrills, lifts.
No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, globally
decreased breath sound, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Let sided weakness on neuro exam.
Pulse slows with right sided carotid sinus massage.
Pertinent Results:
ADMISSION LABS
[**2177-3-17**] 03:10PM BLOOD WBC-10.2 RBC-4.30* Hgb-13.8* Hct-41.0
MCV-95 MCH-32.1* MCHC-33.7 RDW-12.8 Plt Ct-261
[**2177-3-17**] 03:10PM BLOOD Neuts-70.3* Lymphs-19.0 Monos-4.4
Eos-5.7* Baso-0.6
[**2177-3-17**] 03:10PM BLOOD Glucose-97 UreaN-23* Creat-1.7* Na-140
K-4.6 Cl-103 HCO3-26 AnGap-16
[**2177-3-17**] 03:10PM BLOOD ALT-16 AST-27 CK(CPK)-77 AlkPhos-72
TotBili-0.7
[**2177-3-17**] 03:10PM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2177-3-17**] 03:10PM BLOOD Albumin-4.7 Calcium-9.6 Phos-3.0 Mg-1.5*
[**2177-3-17**] 03:10PM BLOOD TSH-0.46
CT Chest [**3-18**]
There are no large lung nodules that correspond to the chest
x-ray abnormality. There is bronchial wall thickening in the
lower lobes
bilaterally that might explain the abnormality and is due to
inflammatory
process.
Emphysema.
1-3 mm lung nodules. Followup in one year is recommended.
TTE 3.16
The left atrium is mildly dilated (5.4cm). Left ventricular wall
thicknesses and cavity size are normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is low normal (LVEF 50-55%). 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 estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Low normal left ventricular systolic function.
Compared with the report of the prior study (images unavailable
for review) of [**2170-8-10**], left ventricular function may be less
vigorous. The atrial sizes are larger. Estimated pulmonary
artery pressures are now lower.
Brief Hospital Course:
SUMMARY
71 M with Hx of CVA, HTN, DL presents with 3 weeks of
lightheadedness, falls and 1 day of palpitations. He was found
with a rate of 250 that did not break with adenosine. He has
been kept at 120's with diltiazem. He is admitted for workup and
management of his narrow-complex tachyarrythmia. There was
question as to whether he had atrial tachycardia or atrial
flutter. There was evidence (flutterform waves during carotid
sinus pressure) that his rhythm was flutter. On [**3-20**], he
converted to atrial fibrillation. We attempted to manage him
with nodal agents, but these only lowered his blood pressure (to
the 90's) while his heart rate was steady in the 120's. On [**3-20**],
with low BP and afib, he was transferred to the CCU for
TEE/cardioversion complicated by hypotension requiring transient
pressors. He was started on coumadin (with heparin bridge) and
amiodarone.
BY PROBLEM
1) SVT - Atrial Flutter and Atrial Fibrillation with RVR
Hypotension
The differential for his tachycardia was fairly narrow. It was
either atrial tachycardia or atrial flutter. Right carotid sinus
massage (very light pressure was sufficient) effected a decrease
in the ventricular response with a period of just flutter waves
that also showed atrial repolarization or an "a" wave. His lack
of response to adenosine rules out PSVT. The tracings from the
OSH show a tachycardia to 260 with the same interval as the
space between p waves when he later ran at 130. A long strip
from the outside hospital additionally showed flutter waves. He
had flutter waves with carotid pressure and the interval between
QRSs is variable. He was in atrial flutter with variable
conduction. His risk factors are presumed COPD, alcoholism and
age. CHADS2 score is 3. We attempted to manage him medically
without conversion for the dual concern of stroke and bleeding
on anticoagulation (hx of UC and gastritis). After [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 102218**]
trial of betablockade from 25->75 mg [**Hospital1 **] metoprolol, his rate
did not change and he became hypotensive. The dose was halved to
37.5 and his hypotension persisted, concommittant with his
conversion to atrial fibrillation. He was transferred to the CCU
for TEE/Cardioversion. After cardioversion, he went into a sinus
rhythm with a large amount of atrial ectopy. However, his
hypotension persisted after his cardioversion with blood
pressures in the 60's to 70's systolic and after several boluses
of phenylephrine with only 10 to 20 mm Hg rise in systolic blood
pressure including well after he had been given fentanyl and
propofol for the TEE and cardioversion he remained hypotensive
requiring an arterial line and continuous phenylephrine
intravenous infusion for hypotension which persisted after large
volume of saline infusion (over 2 liters). This was continued
overnight and he remained bradycardic with rates in the 50's
with atrial ectopy and paroxysmal atrial flutter. He was given
amiodarone po the next day because of the concern of his
compromised blood pressure even in sinus rhythm. Overnight his
blood pressure improved to over 100 systolic and the pressor was
weaned and he was returned to the floor from the CCU.
FOLLOW UP: INR checks through Dr. [**Last Name (STitle) **]
FOLLOW UP: Patient placed on Amiodarone and will
need liver, pulm testing at intervals to be determined by
outpatient physicians.
2) Arterial Vasculopathy, confirmed at least by coronary
calcification in all coronary vessels on chest CT and atheroma
in the ascending aorta seen on TEE
Hx of CVA; his stroke is now considered thromboembolic
given recent events.
Peripheral Artery Disease
Hypertension, Dyslipidemia
Patient has risk factors for heart disease but no prior
documentation. He had a fairly large CVA. His TEE showed "simple
atheroma" in the aortic arch and the CT of the chest for
evaluation of a question of a nodule showed calcium in all the
coronaries. Patient has elevated troponin, in the setting of
chronic renal failure. In the hospital, ABI's were performed
where he had bilateral systolics of 60 at the DP with brachial
systolic of 90, indicating PAD. The patient was admitted on
aggrenox and aspirin, was discharged on coumadin w/o
antiplatelet agents to lessen bleeding risk given the history of
gastritis and 4+ guaiac stools in the past thought to be colonic
or related to colitis in origin. Followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1940**].
3) Alcoholism
Patient had his last drink the night prior to admission.
He was placed on a CIWA that was never triggerred. He received
supplementation with multivitamin, thiamine, folate. Social work
saw him as well. He was counselled to stop drinking.
4) COPD/Emphysema
CXR showed hyperinflated lung fields and a LLL opacity. CT
chest non-contrast showed multiple 1-3 mm nodules. Radiology
reccommended 1 year follow up. Patient was counselled to quit
smoking
5). Chronic renal insufficiency: Baseline 1.4, as high as 1.8.
Discharged at 1.3 likely after NSAID abstinence and hydration;
he had been taking NSAIDS chronically for headache to the day
prior to this admission. He was counseled re: abstaining from
all NSAIDS and aspirin and aspirin containing OTC drugs.
.
#. Hyperlipidemia
- lipitor
.
#. H/o CVA - discharged on coumadin for presumptive embolic
source
.
#. Ulcerative colitis - stable
.
# PUMP: There is no clinical suspicion of heart failure. He does
not have electrocardiographic or echocardiographic evidence of
LVH
Medications on Admission:
ATORVASTATIN 40mg daily
DIPHENHYDRAMINE HCL 25mg daily
DIPYRIDAMOLE-ASPIRIN [AGGRENOX] 25 mg-200 mg [**Hospital1 **]
FOLIC ACID 1mg daily
LISINOPRIL 10mg daily
ASPIRIN 325 mg daily
THIAMINE HCL
Discharge Medications:
1. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) as needed for allergy.
6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Disp:*90 Tablet(s)* Refills:*2*
8. Warfarin 5 mg Tablet Sig: 0.5-1 Tablet PO once a day: Take 1
tab tonight, Take [**1-4**] tab tomorrow night and alternate the doses
thereafter.
.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Atrial Flutter
Emphysema
Alcohol Abuse
History of CVA
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 2301**], M.D. Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2177-5-22**] 10:45
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2088**], MD Phone:[**Telephone/Fax (1) 721**]
Date/Time:[**2177-12-2**] 10:30
Arrange followup with Dr. [**Last Name (STitle) **]; INR on [**2177-3-24**]; results
to Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) 311**].
Completed by:[**2177-3-23**]
ICD9 Codes: 5859, 2724, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3736
} | Medical Text: Admission Date: [**2148-5-24**] Discharge Date: [**2148-5-28**]
Date of Birth: [**2073-2-1**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Shortness of breath and chest discomfort
Major Surgical or Invasive Procedure:
[**2148-5-24**]
1. Coronary artery bypass graft x4: Left internal mammary
artery to left anterior descending artery, and saphenous
vein grafts to posterior descending artery and diagonal
and obtuse marginal arteries.
2. Endoscopic harvesting of the long saphenous vein.
History of Present Illness:
75 year old male with hyperlipidemia, GERD, diastolic
dysfunction, who underwent cardiac catheterization in [**2137**] for
angina symptoms. He was found to have mild to moderate CAD with
a 70% ostial D2 and a 90% mid vessel. His OM1 had a 70% lesion.
His RCA was diffusely diseased with a 50% mid an 80% distal. He
opted for medical management and has done quite well. He has
been exercising regularly walking up to 3 miles daily.
Approximately 2 weeks ago he noted some mild shortness of breath
while climbing stairs. This would resolve with rest. He also
noted some mild chest discomfort with exertion that also would
resolve with rest. This also occured during his daily 3 mile
walk. He stopped exercising and contact[**Name (NI) **] his doctor. [**First Name (Titles) **] [**Last Name (Titles) 8783**]t a nuclear stress test which was positive for lateral
wall ischemia and LV dilation at peak exercise. His
Toprol and Lisinopril where increased. He also reports a
constant "odd feeling" in the left side of his neck that does
not change with exertion or position. He has discussed this
concern with Dr. [**Last Name (STitle) 4469**]. He was referred for cardiac
catheterization and was found to have three vessel cornoary
artery disease and was referred to cardiac surgery for
revascularization.
Date:[**2148-5-16**] Place:[**Hospital1 18**]
Right dominant with ectopic circumflex from right cusp and mild
diffuse disease
LMCA: distal 60%
LAD: 99% small second diagonal
LCX: 80% mid with ectopic circumflex
RCA: 80% mid, 99% PDA, 100% posterolateral filling from
collaterals
Past Medical History:
CAD- treated medically since [**2137**]
Diastolic Dysfunction
Mild trivalvular insufficiency
Hyperlipidemia
GERD
Hypertension
Basal Cell CA
Gout
Past Surgical History:
s/p Bilateral hernia repair
Social History:
Race:Caucasian
Last Dental Exam:1 month ago
Lives with:Wife
Occupation:works full time in research for an aviation company.
Tobacco:denies
ETOH: 1 glass of wine with dinner
Family History:
Father with CAD and MI, he died in his 70's. Mother died last
[**Name (NI) 2974**] of esophageal CA at the age [**Age over 90 **]. 2 brothers with MI in
their late 50's early 60's, one with stents and one had CABG
Physical Exam:
Pulse:59 Resp:12 O2 sat:99/RA
B/P Right:156/76 Left:161/88
Height:5'9" Weight:180 lbs
General:NAD, alert and cooperative
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] II/VI Systolic Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: +2 Left:+2
DP Right: +2 Left:+2
PT [**Name (NI) 167**]: +2 Left:+2
Radial Right: +2 Left:+2
Carotid Bruit Right:none Left:none
Pertinent Results:
[**2148-5-27**] 05:30AM BLOOD WBC-10.2 RBC-3.28* Hgb-10.5* Hct-29.6*
MCV-90 MCH-32.0 MCHC-35.4* RDW-14.1 Plt Ct-166
[**2148-5-27**] 05:30AM BLOOD UreaN-24* Creat-1.1 Na-136 K-4.5 Cl-101
[**2148-5-26**] 04:52AM BLOOD Glucose-124* UreaN-32* Creat-1.5* Na-139
K-4.4 Cl-104 HCO3-26 AnGap-13
[**2148-5-24**] TEE
PRE-BYPASS: The left atrium is mildly dilated. No spontaneous
echo contrast or thrombus is seen in the body of the left atrium
or left atrial appendage. A patent foramen ovale is present. A
left-to-right shunt across the interatrial septum is seen at
rest. Overall left ventricular systolic function is normal
(LVEF>55%). The right ventricular cavity is mildly dilated with
normal free wall contractility. There are simple atheroma in the
aortic root. There are simple atheroma in the descending
thoracic aorta. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis. 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. Trivial
mitral regurgitation is seen. There is no pericardial effusion.
POST CPB:
1. Preserved bo-ventricular systolic function
2. No change in valve structure or function
3. Intact aorta
Brief Hospital Course:
The patient was admitted to the hospital and brought to the
operating room on [**2148-5-24**] where the patient underwent coronary
artery bypass graft x4: Left internal mammary
artery to left anterior descending artery, and saphenous vein
grafts to posterior descending artery and diagonal and obtuse
marginal arteries. Overall the patient tolerated the procedure
well and post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. POD 1 found the
patient extubated, alert and oriented and breathing comfortably.
The patient was neurologically intact and hemodynamically stable
on no inotropic or vasopressor support. Beta blocker was
initiated and the patient was gently diuresed toward the
preoperative weight. He did have an increase in creatinine from
1.0-->1.5 and Lasix was changed to oral. Creatinine was back to
baseline at the time of discharge. The patient was transferred
to the telemetry floor for further recovery. Chest tubes and
pacing wires were discontinued without complication. The
patient was evaluated by the physical therapy service for
assistance with strength and mobility. By the time of discharge
on POD 4 the patient was ambulating freely, the wound was
healing and pain was controlled with oral analgesics. The
patient was discharged home with visiting nurse services in good
condition with appropriate follow up instructions.
Medications on Admission:
ALLOPURINOL-(Prescribed by Other Provider) - 300 mg Tablet - 1
(One) Tablet(s) by mouth once a day
LISINOPRIL -(Prescribed by Other Provider) - 10 mg Tablet - 1
(One) Tablet(s) by mouth once a day
METOPROLOL SUCCINATE-(Prescribed by Other Provider) - 50 mg
Tablet Extended Release 24 hr - 1.5 (One and a half) Tablet(s)
by
mouth once a day
NITROGLYCERIN [NITROSTAT]-(Prescribed by Other Provider) - 0.4
mg
Tablet, Sublingual - [**12-25**] Tablet(s) sublingually as needed for
angina
ROSUVASTATIN [CRESTOR]-(Prescribed by Other Provider) - 10 mg
Tablet - 1 (One) Tablet(s) by mouth once a day
Medications - OTC
ASPIRIN-(OTC)- 81 mg Tablet - 1 (One) Tablet(s) by mouth once a
day
CALCIUM CARBONATE -(OTC) - 500 mg calcium (1,250 mg) Tablet - 1
(One) Tablet(s) by mouth once a day
FISH OIL-DHA-EPA - (Prescribed by Other Provider) - 1,200
mg-144
mg Capsule - 1 (One) Capsule(s) by mouth three times a day
MULTIVITAMIN-(OTC) - Tablet - 1 (One) Tablet(s) by mouth once
a
day
RANITIDINE HCL-(OTC) - 150 mg Tablet - 1 (One) Tablet(s) by
mouth
once day
eye drops daily
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
3. allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
4. rosuvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
5. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO DAILY (Daily).
7. omega-3 fatty acids Capsule Sig: One (1) Capsule PO TID
(3 times a day).
8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
1 weeks.
Disp:*7 Tablet(s)* Refills:*0*
10. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO once a day for 1 weeks.
Disp:*14 Tablet Extended Release(s)* Refills:*0*
11. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] VNA
Discharge Diagnosis:
Coronary artery disease
Diastolic Dysfunction
Mild trivalvular insufficiency
Hyperlipidemia
GERD
Hypertension
Basal Cell CA
Gout
Past Surgical History:
s/p Bilateral hernia repair
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Percocet
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Trace Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Wound Check at Cardiac Surgery Office [**Doctor First Name **], Ste 2A,
[**Telephone/Fax (1) 170**] Date/Time:[**2148-6-4**] 10:30
Surgeon: Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 170**] Date/Time:[**2148-7-1**] 1:15
Cardiologist: Dr. [**Last Name (STitle) 4469**], [**7-9**] at 1:45pm
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2148-5-28**]
ICD9 Codes: 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3737
} | Medical Text: Admission Date: [**2126-7-10**] Discharge Date: [**2126-7-14**]
Date of Birth: [**2071-6-27**] Sex: M
Service: MEDICINE
Allergies:
Tapazole
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
coma, glucose 22, seizure activity
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
The pt is a 55-yo man, Type 1 Diabetic with frequent
hypoglycemic episodes, ERSD, and HTN, who was found unresponsive
in the waiting room at Josline Diabetes Center. He had a FSBS of
20 on the scene, and was given Glucagon and 1 amp of D50 without
effect on his mental status. He was brought to the [**Hospital1 18**] ED,
where his FSBS was 150s-170s, but he remained unresponsive (GCS
3). He proceeded to develop seizure-like activity including
tonic movements of his abdominal muscles and limbs. Head CT at
the time was normal, and he was intubated for airway protection.
Labs revealed renal failure with Cr 5.5, hyperkalemia (K 6.2),
and negative serum and urine tox screens. Studies were otherwise
normal, including ECG, CXR, and UA. VS in the ED - afeb
(normothermic), BP 107/66, HR 55, O2-sat 100% on CMV -
500x14/5/100% FiO2. He is admitted to the ICU for further care.
In the ICU: Pt was found to be hypothermic to 93 F, with
continued seizure-like activity of the extremities. He was
placed on a bear-hugger, but he remained unresponsive to any
stimulation. Given his fluctuating neurological exam, the pt was
sent for a repeat Head CT, which was unchanged.
Past Medical History:
1 DM1 X 37 yrs- frequent hypoglycemic episodes; high level of
anti-insulin Ab
- followed by Dr.[**Doctor Last Name 4849**] of [**Last Name (un) **]
- complicated by nephropathy, retinopathy (s/p right eye laser
surgery, repeated [**8-3**])
2 ESRD [**12-29**] DM1
3 Hypertension
4 Anemia, likely [**12-29**] CRI
5 Hyperuricemia
6 Graves' disease
7 Hyperlipidemia
8 Diastolic congestive heart failure with LVH
Social History:
Lives with parents. Works in construction. No alcohol, drugs, or
tobacco.
Family History:
Occupation: Lives with parents. Works in construction.
Drugs: None
Tobacco: None
Alcohol: None
Physical Exam:
Tmax: 37.1 ??????C (98.7 ??????F)
Tcurrent: 37 ??????C (98.6 ??????F)
HR: 73 (54 - 73) bpm
BP: 147/83(98) {103/55(69) - 147/83(98)} mmHg
RR: 9 (9 - 15) insp/min
SpO2: 100%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 75 kg (admission): 75 kg
Height: 68 Inch
General Appearance: intubated, sedated, unresponsive off
sedation
Eyes / Conjunctiva: pupils constricted, minimally responsive to
light, no nystagmus noted
Head, Ears, Nose, Throat: nec supple, no LAD
Cardiovascular: RRR, nl S1-S2, no MRG
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present), cool, no c/c/e
Respiratory / Chest: CTA bilat, no r/rh/wh
Abdominal: NABS, soft/NT/ND, no masses or HSM
Extremities: Right: Absent, Left: Absent
Skin: Not assessed
Neurologic: Responds to: Unresponsive, Movement: No spontaneous
movement, Sedated, Tone: Not assessed, hyper-reflexia
throughout, up-going toes bilaterally
Pertinent Results:
[**2126-7-13**] 05:30AM BLOOD WBC-5.7 RBC-3.08* Hgb-8.5* Hct-24.9*
MCV-81* MCH-27.4 MCHC-34.0 RDW-14.1 Plt Ct-191
[**2126-7-11**] 05:28AM BLOOD Neuts-78.9* Lymphs-14.6* Monos-4.7
Eos-1.3 Baso-0.4
[**2126-7-11**] 05:28AM BLOOD PT-12.7 PTT-28.0 INR(PT)-1.1
[**2126-7-10**] 07:25PM BLOOD Fibrino-501*
[**2126-7-13**] 05:30AM BLOOD Glucose-170* UreaN-72* Creat-5.3* Na-139
K-4.3 Cl-104 HCO3-25 AnGap-14
[**2126-7-11**] 05:28AM BLOOD ALT-34 AST-26 LD(LDH)-292* CK(CPK)-278*
AlkPhos-79 Amylase-105* TotBili-0.3
[**2126-7-13**] 05:30AM BLOOD Albumin-3.4 Calcium-8.6 Phos-4.5 Mg-2.2
[**2126-7-11**] 03:16PM BLOOD VitB12-1027*
[**2126-7-11**] 05:28AM BLOOD TSH-1.5
[**2126-7-11**] 05:28AM BLOOD TSH-1.5
[**2126-7-11**] 05:28AM BLOOD Cortsol-14.7
[**2126-7-12**] 06:24AM BLOOD Phenyto-9.3*
STUDIES:
Renal U/S: Mildly increased cortical echogenicity with no
hydronephrosis and no stones or solid masses
Noncon CTH: No evidence of swelling or infarction. If there is
concern for anoxic brain injury, MR is far more sensitive than
CT
EEG: Markedly abnormal portable EEG due to the very low voltage
background throughout the recording. This suggests a widespread
encephalopathy. Anoxia and medications are two of the most
common
explanations. There were no epileptiform features. The
persistent beta frequency activity suggests some influence of
medication.
CXR: ET tube positioned at/immediately above the carina.
Retraction by at least 3 cm is advised. NG tube in appropriate
position. No acute intrathoracic process.
Brief Hospital Course:
Mr. [**Known lastname **] is a 55 year old gentleman with a PMH significant for
type 1 diabetes, autoimmune antibodies to the insulin receptor,
ESRD, HTN, and CHF admitted for seizure secondary to
hypoglycemia with hospital course significant for MICU admission
with intubation for airway protection.
1. Diabetes Type 1 Uncontrolled with complications: Patient has
type 1 diabetes as well as insulin autoantibody that causes
frequent hypoglycemic episodes with multiple admissions for
similar presenting symptoms. The patient had stable blood
glucose levels on his home regimen of lantus 3 units [**Hospital1 **] and
HISS ([**First Name8 (NamePattern2) **] [**Last Name (un) **]). During the patient's hospitalization,
endocrinology and rheumatology were consulted regarding the
patient's condition. [**First Name8 (NamePattern2) **] [**Last Name (un) **] consultation recommendations,
insulin antibodies, as well as a SPEP and UPEP were sent off
during this admission and will be followed by the patient's
diabetologist. On discharge, the patient was instructed to
continue his home regimen and a prescription for an emergency
glucagon kit was provided. He was instructed to follow-up with
his endocrinologist at the [**Hospital **] Clinic as well as rheumatology
with Dr. [**Last Name (STitle) 20861**].
2. Seizures/Altered mental status: The inciting event most
likely hypoglycemia, as the patient has multiple admissions with
similar presentations. His altered mental status during his
initial presentation was likely multifactorial including post
ictal state, hypothermia, hypoglycemia, and uremia. The patient
did have a CT head that was unchanged and an EEG that
demonstrated encephalopathy. Neurology was consulted during the
patient's admission. On transfer to the general medicine floor,
the patient was mentating well without significant neurologic
abnormalities. On discharge, he continued to mentate well
without signs of altered mental status.
3. Renal failure: The patient has baseline ESRD. He has been
followed by Dr.[**Name (NI) 4849**] at the [**Hospital **] Clinic, and also evaluated
by renal transplant. During the patient's hospitalization, he
was started on nephrocaps, and renal was consulted with regard
to continuity on an outpatient basis. On discharge, the patient
was instructed to follow-up with Dr.[**Name (NI) 4849**] as well as renal
transplant clinic (Dr. [**Last Name (STitle) 816**]
4. SPEP: On the day after discharge, the patient had a IgM
monoclonal spike on SPEP to 368. The patient will require
referral to heme/onc for further evaluation and monitoring.
5. Prophylaxis: Patient was treated with heparin SQ during his
hospital admission for DVT prophylaxis.
6. Follow-up: The day after discharge, the patient was scheduled
with numerous follow-ups as stated below:
[**7-17**] at 11:30 AM: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at the [**Hospital **] Clinic
(Endocrinology).
[**7-18**] at 8:30 AM: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at the [**Hospital **] Medical
Building, [**Location (un) 436**] (Renal [**Hospital 1326**] Clinic).
[**7-24**] at 1:30 PM: Dr.[**Name (NI) 4849**] at the [**Hospital **] Clinic
(Nephrology).
[**8-2**] at 11:20 AM: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], NP at [**Hospital6 2399**], [**Hospital Ward Name 23**] Clinical Center [**Location (un) **], South suite
(Primary Care).
[**8-8**] at 9:00 AM: Dr. [**First Name (STitle) 20862**] [**Name (STitle) 20863**] at the [**Hospital **]
Medical Building, [**Location (un) **] (4B) (Rheumatology).
Medications on Admission:
1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
2. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QFRI (every Friday).
4. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO BID (2 times a day).
5. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
6. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
8. Minoxidil 2.5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. Lantus 100 unit/mL Cartridge Sig: Three (3) units
Subcutaneous twice a day: SQ once in AM and once in PM, spaced
12 hours apart.
12. Humalog 100 unit/mL Cartridge Sig: One (1) Subcutaneous
four times a day: Please use sliding scale as provided by
Diabetes doctors [**First Name8 (NamePattern2) **] [**Last Name (Titles) **].
13. Glucagon (Human Recombinant) 1 mg Kit Sig: One (1)
Injection as needed: Please use as needed for hypoglycemia.
Disp:*5 5* Refills:*0*
14. Crestor 20 mg Tablet Sig: One (1) Tablet PO once a day.
15. Calcium Carbonate 500 mg Capsule Sig: One (1) Capsule PO
three times a day: with meals.
Disp:*90 Capsule(s)* Refills:*2*
Discharge Medications:
1. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a
day.
2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QFRI (every Friday).
3. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: Three (3)
Tablet Sustained Release 24 hr PO once a day.
4. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO Every other
day.
5. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO twice a day.
6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
8. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Minoxidil 2.5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
10. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
11. Insulin Glargine 100 unit/mL Cartridge Sig: Three (3) units
Subcutaneous twice a day.
12. Insulin Lispro 100 unit/mL Cartridge Sig: One (1)
Subcutaneous four times a day: Please use sliding scale as
provided by
Diabetes doctors [**First Name8 (NamePattern2) **] [**Last Name (Titles) **]. .
13. Glucagon Emergency 1 mg Kit Sig: One (1) Injection kit: Use
as needed for hypoglycemia.
14. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
16. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
17. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
18. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
1. Seizure
2. Diabetes, type I
Secondary
ESRD [**12-29**] DM1
Hypertension.
Hyperuricemia.
Graves' disease.
Diastolic congestive heart failure with LVH
Discharge Condition:
Patient discharged in stable condition.
Discharge Instructions:
1. You were admitted for a seizure, which was due to
hypoglycemia or low blood sugar. While admitted, you were
evaluated by the endocrinologists, who you will have to
follow-up as indicated below.
2. You should continue to take you medications as taken prior to
hospitalization unless otherwise indicated. It is very
important that you take your medications as prescribed.
3. It is very important that you make all of your doctors
[**Name5 (PTitle) 4314**].
4. If you develop a fever, chest pain, shortness of breath,
seizures, or other concerning symptoms, please call your PCP or
go to your local Emergency Department immediately.
Followup Instructions:
Please follow-up with your endocrinologist, Dr. [**Last Name (STitle) 10088**] at the
[**Hospital **] Clinic in 1 week. You can schedule an appointment by
calling ([**Telephone/Fax (1) 17240**].
Please follow-up with your nephrologist, Dr.[**Doctor Last Name 4849**] at the
[**Hospital **] Clinic in 1 week. You can schedule an appointment by
calling ([**Telephone/Fax (1) 817**]
Please schedule an appointment with the renal transplant clinic.
You can schedule an appointment by calling ([**Telephone/Fax (1) 3618**].
Please follow-up with your PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2450**] in [**11-28**] weeks.
You can schedule an appointment by calling ([**Telephone/Fax (1) 1300**].
Completed by:[**2126-7-15**]
ICD9 Codes: 5849, 5856, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3738
} | Medical Text: Admission Date: [**2175-2-22**] Discharge Date: [**2175-2-28**]
Date of Birth: [**2114-7-24**] Sex: M
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: The patient is a 60-year-old
[**Country **] Rican gentleman who felt weakness in his left arm
starting at 9 p.m. on the night prior to admission.
He reports that he reached for his cane and could not grasp
it. When he bent over to pick it up he got a throbbing
headache in the center of his forehead. He was still able to
walk normally with his cane but felt slight weakness in his
left leg as well with heaviness.
He woke up at 4 a.m. on the day of admission with worsening
symptoms with weakness in the left side (both arm and leg).
There is a report of falling on the ice and hitting the back
of his head two weeks prior to admission.
PAST MEDICAL HISTORY: (The patient has a past medical
history of)
1. Hypercholesterolemia.
2. Angina.
3. Gout.
4. Hernia repair.
5. Right below-knee amputation 40 years ago after a motor
vehicle accident; he walks with a cane.
ALLERGIES: Allergy to PENICILLIN.
PHYSICAL EXAMINATION ON PRESENTATION: On physical
examination blood pressure was 180/99, heart rate was 80,
respiratory rate was 15, oxygen saturation was 99% on room
air. He was awake, alert, and oriented; answered questions
appropriately. His chest was clear to auscultation
bilaterally. Cardiovascular examination revealed a regular
rate and rhythm. Normal first heart sound and second heart
sound. No murmurs, rubs, or gallops. No carotid bruits.
Neurologically, cranial nerves were intact. Slight increased
tone in the left lower extremity and increased in the left
upper extremity. Normal tone on the right side. Strength
was [**5-29**] throughout in the right upper extremity. The left
upper extremity showed weakness in the deltoids ([**4-29**]), wrist
and finger extension were [**4-29**]. The left leg showed good
strength of [**5-29**] on hip flexion and quadriceps. Slight
weakness at 4/5 on the dorsiflexion. Reflexes were 2+ on the
right and 3+ in the left upper and left lower extremities.
Sensation was intact to pinprick and light touch throughout.
Coordination testing showed a slight decrease in finger
tapping on the left and slight ataxia of the finger-to-nose
on the left. Normal on the right. Gait was not tested.
HOSPITAL COURSE: The patient was admitted to the Intensive
Care Unit for close neurologic monitoring. A computed
tomography of the head showed a right-sided loculated
subdural hematoma with a midline shift.
The patient was taken to the operating room on [**2175-2-23**] and had an evacuation of the subdural hematoma.
Postoperatively, he was monitored in the Surgical Intensive
Care Unit and had a subdural drain in place. He was awake,
alert and oriented times three. He was moving the left side
with improved strength status post drainage of the subdural
hematoma.
On [**2175-2-24**], he had a repeat head computed tomography
which showed good evacuation of the subdural hematoma. The
drain was removed, and the patient was transferred to the
regular floor.
He was seen by Physical Therapy and Occupational Therapy and
found to be safe for discharge to home. He was awake, alert
and oriented times three. He was moving all extremities with
good strength.
DISCHARGE STATUS: The patient was discharged to home.
CONDITION AT DISCHARGE: Condition on discharge was stable on
[**2175-2-28**].
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was to follow up for staple removal on
[**3-2**] to [**Hospital Ward Name 121**] Five.
2. The patient was to follow up with Dr. [**First Name (STitle) **] in one month for
a repeat head computed tomography.
[**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2175-2-28**] 10:44
T: [**2175-2-28**] 10:50
JOB#: [**Job Number 99539**]
ICD9 Codes: 2720, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3739
} | Medical Text: Admission Date: [**2137-7-10**] Discharge Date: [**2137-7-17**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is an 86 year-old
male transferred from [**Hospital3 1280**] Emergency Department for
management of subdural hematoma. The patient was previously
well until [**6-26**] when he sustained a fall at home resulting
in a subdural hematoma for which he was treated
well for two weeks until the morning of admission when he
noted difficulty getting out of bed. At baseline he has a
right upper limb paresis secondary to a distal infarct from
[**2133**] and he uses his left arm to aid in his mobilization. He
was unable to do so on the morning of admission. The
patient's daughter also reports that he was falling to his
left. The patient denies headache, diplopia, dysarthria or
well.
PAST MEDICAL HISTORY: 1. Cerebrovascular accident in [**2133**]
resulting in right upper extremity weakness. 2. Zenker's
diverticulum. 3. Glaucoma. 4. Hypertension. 5. Benign
prostatic hypertrophy.
MEDICATIONS ON ADMISSION: Cozaar 50 mg po q day,
Hydrochlorothiazide 75 mg po q day, potassium chloride 20
milliequivalents po q day, baby aspirin, Pilocarpine eye
drops, Cosopt eye drops.
ALLERGIES: Bactrim and sulfa drugs.
SOCIAL HISTORY: Occasional alcohol. No smoking.
PHYSICAL EXAMINATION ON ADMISSION: Temperature 97.3.
Breathing at 72. Blood pressure 175/96. O2 sat 97% on room
air. In general he is a thin elderly male lying in bed in no
acute distress. HEENT no evidence of trauma. Oropharynx is
clear. Pulmonary clear to auscultation bilaterally.
Cardiovascular regular. Abdomen is benign. Extremities 2+
pulses. Neurologically he is alert and oriented times three.
Knows the months of the year backward and forward.
Calculation is intact. Naming is intact. Language is
fluent. Good repetition, slight slurring, which is reportedly
old per daughter. Registration, coding and recall are all
intact. Right optic disc is blurred. No venous pulsations.
Left optic disc could not be assessed. Visual acuity is
good. No field cuts. Extraocular movements intact. Right
pupil 4 to 3, left pupil 2 to 1.5. No nystagmus. Facial
sensation is intact. He has a right facial droop of a motor
neuron type. Palpebral elevation is symmetrical. Right
trapezius is weak on the left. Sternocleidomastoids are
equal. Motor examination there is decreased bulk throughout,
increased tone in right arm. Strength in the right upper
extremity, deltoid 2, bicep 2, tricep 3, wrist flexors 2,
wrist extensor 2, finger flexors 2+, finger extension 3.
Left upper extremity deltoid 4+, biceps 5, triceps 5, wrist
flexors 5, wrist extensors 5, finger flexors 4+, finger
extensors 4+. Lower extremity on the right hip flexors 4,
knee flexors 4, knee extensor 4+, dorsiflexion 5, plantar
flexion 5, [**Last Name (un) 938**] is 4+. Lower extremity on the left hip flexor
5, knee flexor 5, knee extensor 5, dorsiflexion 5, plantar
flexion 5, [**Last Name (un) 938**] 5. The right toe is equivocal. The left toe
is down going. Right biceps and triceps have 3+ deep tendon
reflexes. All other deep tendon reflexes are 2. Sensation
is intact to vibration and pin prick throughout. Finger to
nose the patient could not do on the right, some pass
pointing on the left as the patient nears target.
LABORATORIES ON ADMISSION: White blood cell count 7,
hematocrit 36.5, platelets 266, PT 12.2, INR 1, PTT 26.5,
sodium 146, potassium 4.3, chloride 106, bicarb 31, BUN 18,
creatinine 1.1, glucose 94. Head CT showed right sided
subdural hematoma increased from last CT of [**6-26**]. There
is positive subfossi herniation.
HOSPITAL COURSE: The patient was admitted to the
Neurosurgery Service. A subdural drain was placed in the
Intensive Care Unit. Repeat head CT demonstrated resolution
of the subdural hematoma and the returned of normal midline
structures to the midline. The patient was continued on
Cozaar. He also received Hydralazine for blood pressure
control acutely. Aspirin was discontinued. No heparin or
other anticoagulants were given. The patient's Pilocarpine
was discontinued as it may have impaired observation of his
pupils. This did not become an issue. The patient had neuro
checks q two hours. The patient continued to do well. The
patient was noted to have
difficulty swallowing on [**7-13**]. He received a swallow
evaluation to further study this. This demonstrated that the
patient had problems related to his [**Name (NI) 42755**] diverticulum,
which are known. After discussion with the patient and his
daughter extensively the patient has decided not to proceed
with a PEG tube or with surgical intervention on the
Zenker's diverticulum. They have been informed of the risk
of aspiration, but have decided to chose this path. The
patient is taking po at this point.
On the evening of [**7-16**] the patient had an aspiration event.
He became acutely short of breath and he sated to 84%.
Suctioning was successful. The patient's O2 sats returned to
[**Location 213**]. He also spiked a fever to 101.9. He was therefore
started on Levaquin 500 mg po q.d. for presumed aspiration
pneumonia, although aspiration pneumonitis is also likely.
DISCHARGE DIAGNOSES:
1. Subdural hematoma.
2. Hypertension.
3. Past cerebrovascular accident.
MEDICATIONS ON DISCHARGE: Percocet one to two tabs po q 4 to
6 hours prn. Losartan 50 mg po q day. Colace 100 mg po
b.i.d., Zantac 150 mg po b.i.d., Cosopt one drop to each eye
b.i.d., Pilocarpine one drop to the left eye t.i.d.,
Levaquin 500 mg po q day until [**7-23**]. The patient should
be on aspiration precautions. He will require extensive
rehabilitation. The patient will follow up with his primary
care physician [**Last Name (NamePattern4) **]. [**First Name (STitle) 7325**] [**Name (STitle) 42756**].
[**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**]
Dictated By:[**Last Name (NamePattern1) 5476**]
MEDQUIST36
D: [**2137-7-17**] 09:08
T: [**2137-7-17**] 09:20
JOB#: [**Job Number 17875**]
ICD9 Codes: 5070, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3740
} | Medical Text: Admission Date: [**2130-1-7**] Discharge Date: [**2130-2-7**]
Date of Birth: [**2130-1-7**] Sex: F
Service: Neonatology
HISTORY OF PRESENT ILLNESS: [**Known lastname **] [**Known lastname 53121**], girl number two,
was born at 32 and 3/7 weeks gestation. Her mother is a 36
year old, Gravida I, Para 0, now II woman. Pregnancy was
complicated with insulin dependent diabetes mellitus for 12
years, with the mother currently on an insulin pump.
Glycosylated hemoglobin during pregnancy was 5.8% and also
complicated with Reynauld's disease.
PRENATAL SCREENS: Blood type 0 positive, antibody negative;
Rubella immune; RPR nonreactive; hepatitis surface antigen
negative and group B strep unknown.
This pregnancy was an in-[**Last Name (un) 5153**] fertilization pregnancy of
diamniotic/dichorionic twins, with concordant growth and
normal fetal surveys. The pregnancy was complicated by
preterm labor since [**54**] weeks gestation, not requiring
medication. On the evening prior to delivery, there was
rupture of membranes, (21 hours prior to delivery), yielding
meconium stained amniotic fluid of twin #1 but clear with
twin #2. The mother was started on antibiotics. A course of
betamethasone was completed on the day of delivery.
A cesarean section was done due to decelerations in the fetal
heart rate of twin #2. The infant emerged apneic, required
brief bag and mask ventilation. Apgars were seven at one
minute and eight at five minutes. The birth weight was 1,875
grams (75th percentile). The birth length was 44 cm (50 to
75th percentile). The head circumference was 29.5 cm (25 to
50 percentile).
PHYSICAL EXAMINATION: Admission physical examination reveals
a preterm infant; anterior fontanel soft and flat;
nondysmorphic, intact palate. Minimal retractions. Breath
sounds equal. Heart with regular rate and rhythm, no murmur.
Femoral pulses were normal. Abdomen soft, nondistended. No
organomegaly. Patent anus. Three vessel umbilical cord.
Normal genitourinary female genitalia. Active and symmetric
tone and reflexes; normal spine, limbs, hips and clavicles.
HOSPITAL COURSE: Respiratory status: The infant has always
been in room air. She has had no apnea or bradycardia of
prematurity. On examination, her respirations are
comfortable. Lung sounds are clear and equal.
Cardiovascular: [**Known lastname **] has remained normotensive throughout
her Neonatal Intensive Care Unit stay. She has had an
intermittent grade 1 over 6 systolic ejection murmur at the
left upper sternal border. This is consistent with peripheral
pulmonic stenosis and is being followed clinically.
Fluids, electrolytes and nutrition: Enteral feeds were begun
on day of life #1 and advanced without difficulty to full
volume feeding. At the time of discharge, she is eating 24
calories per ounce breast milk or formula on an ad lib
schedule. At the time of discharge, her weight is 2,730
grams; length is 46 cm and head circumference is 33.5 cm.
Gastrointestinal: She was treated with phototherapy from day
of life #2 until day of life #3. Her peak bilirubin on day
of life #1 was total of 4.6, direct of 0.3.
Hematology: She has never received any blood product
transfusions during her Neonatal Intensive Care Unit stay.
Her hematocrit at the time of admission is 53.1.
Infectious disease: [**Known lastname **] was begun on Ampicillin and
Gentamycin at the time of admission for sepsis risk factors.
The antibiotics were discontinued after 48 hours when the
infant was clinically well and her blood cultures were
negative.
Sensory: Audiology -- Hearing screening was performed with
automated auditory brain stem responses and the infant passed
in both ears.
Psychosocial: Parents have been very involved in the
infant's care throughout her Neonatal Intensive Care Unit
stay. Both twins are being discharged on the same day.
[**Known lastname **] was discharged in good condition, home with her
parents. Primary pediatric care will be provided by Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 53119**] of [**Location (un) 53122**] [**Doctor Last Name **] Community Pediatrics, [**State 53123**]., [**Location (un) 3307**], [**Numeric Identifier 53124**]. Telephone
#[**Telephone/Fax (1) 43573**].
RECOMMENDATIONS AFTER DISCHARGE:
Feedings of 24 calories per ounce as needed to maintain
weight gain.
Medications:
Iron sulfate 25 mg/ml 0.2 cc p.o. every day.
The infant has passed a car seat position screening test.
The last state screen was sent on [**2130-1-21**] and was within
normal limits.
She received her first hepatitis B vaccine on [**2130-1-18**].
RECOMMENDED IMMUNIZATIONS:
Synagis-RSV prophylaxis should be considered from [**Month (only) 359**]
through [**Month (only) 547**] for infants who meet any of the following three
criteria:
1.) Born at less than 32 weeks.
2.) Born between 32 and 35 weeks with two of three of the
following: Day care during the RSV season, a smoker in the
household, neuromuscular disease, airway abnormalities,
school age siblings.
3.) With chronic lung disease.
Influenza 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 influenza to protect the infant.
FOLLOW-UP APPOINTMENTS:
[**Hospital6 407**].
DISCHARGE DIAGNOSES:
1. Status post prematurity at 32 and 2/7 weeks gestation.
2. Twin #2.
3. Status post mild transitional respiratory distress.
4. Sepsis, ruled out.
5. Status post hyperbilirubinemia.
Reviewed By: [**Doctor Last Name **] [**Last Name (NamePattern5) 36094**], M.D. [**MD Number(1) 36250**]
Dictated By:[**Last Name (NamePattern1) 46595**]
MEDQUIST36
D: [**2130-2-6**] 02:50
T: [**2130-2-7**] 04:44
JOB#: [**Job Number 53125**]
ICD9 Codes: 7742, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3741
} | Medical Text: Admission Date: [**2113-2-3**] Discharge Date: [**2113-2-13**]
Date of Birth: [**2047-8-17**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 64-year-old
woman with recently-diagnosed metastatic colon cancer,
admitted to the Medical Intensive Care Unit on [**2113-2-10**]. The
patient was initially admitted to the hospital on [**2113-2-3**]
after being found down on the floor in her stool-ridden
apartment status post fall. The patient described vague
prodromal symptoms of "flu-like symptoms" for two to three
weeks, which included weakness, lethargy, occasional watery
diarrhea, no melena. She was found down, and EMS was called.
X-rays of her knee on arrival to the Emergency Department
were negative. In the Emergency Department, she was noted to
have an elevated white blood count of 48, with a right upper
quadrant ultrasound suggesting liver metastases. She was
guaiac positive. Abdominal CT scan confirmed liver
metastases with a right colonic mass. At that time, she had
elevated transaminases and elevated alkaline phosphatase and
elevated bilirubin. Her urinalysis was consistent with a
urinary tract infection, and she was started on a course of
Levaquin. Her stool was subsequently found to be positive
for C. difficile, and she was started on a course of Flagyl.
With failure of her diarrheal symptoms to resolve and a
persistently elevated white blood count, the patient was also
treated with oral vancomycin per the Infectious Disease
Department's recommendations.
On [**2113-2-6**], the patient underwent a colonoscopy which
revealed a mass in the distal ascending colon and
diverticulosis of the descending colon/proximal sigmoid
colon. Cytology was positive for poorly-differentiated
adenocarcinoma. The patient's white blood count continued to
rise over the course of the next several days, from 48 on
admission to 65. Her peripheral blood smear was thought to
be consistent with a reactive leukocytosis.
On [**2113-2-6**], the patient developed bloody stool. On [**2113-2-8**],
the patient had persistent bright red blood per rectum with
decreased blood pressure to the 90s systolic. On [**2113-2-8**], she
was transfused one unit of packed red blood cells. The
Hematology/Oncology service was consulted, and in accordance
with the patient's decision to pursue aggressive treatment,
they recommended local excision and a treatment of
chemotherapy with 5-FU and leucovorin.
The Gastroenterology service was reconsulted regarding the
gastrointestinal bleed, and they felt that the bright red
blood per rectum was likely secondary to a bleeding colonic
mass vs. bleeding diverticula. The patient got 5 mg of
intravenous vancomycin x 2 for an elevated INR. The patient
had ongoing diarrhea, which was not well quanitified. From
[**2-9**] to [**2-11**], the patient's creatinine was noted to rise from
1.1 to 1.9. Her white blood count continued to rise, as did
her serum lactate level. Her bicarbonate declined. Surgery
was consulted regarding question of acute abdomen and
possible infarcted bowel. They felt that, given the
patient's absence of abdominal pain and nontender abdomen,
that no surgery was indicated.
From [**2-10**] to [**2-11**], the patient began to complain of increased
shortness of breath. Her lungs remained clear, and her
respiratory rate was noted to be increased secondary to
compensation for her worsening lactic metabolic acidosis.
Her urine lytes suggested a pre-renal picture. Antibiotics
were expanded on [**2-11**] to include ampicillin. A PICC line was
placed that day, complicated by two seven-beat runs of
ventricular tachycardia secondary to instrumentation of the
atrium or ventricle. The patient also had a question left
bundle branch block pattern of 30 seconds duration while
undergoing PICC line placement.
For low blood pressure, the patient was bolused with normal
saline 500 cc x 2 that afternoon. Later that evening, the
patient complained of increased shortness of breath when
lying flat. She was sent for an abdominal CT. While in the
CT scanner, she complained of increased respiratory distress
and was ultimately intubated and transferred to the Medical
Intensive Care Unit.
PAST MEDICAL HISTORY:
1. Osteoarthritis
2. History of tonsillectomy
3. Morbid obesity
MEDICATIONS ON TRANSFER:
1. Levaquin 500 mg by mouth once daily
2. Colace
3. Senna
Both Colace and Senna were being held.
4. Vancomycin 125 mg by mouth four times a day
5. Flagyl 1 gram intravenously every six hours
6. Ampicillin 2 grams intravenously every four hours
7. Tylenol as needed
HOME MEDICATIONS: The patient was on pain medications for
her osteoarthritis.
SOCIAL HISTORY: The patient lived on her own, walked with
two canes. She lived in deplorable home conditions.
FAMILY HISTORY: Father died of lung cancer.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: On admission to the Medical Intensive
Care Unit, vital signs: Temperature 97.6, pulse 108, blood
pressure 70/30, respiratory rate 18, pulse oxygenation 100%
on the ventilator. General appearance: The patient is
intubated, sedated, responding to tactile and painful
stimuli. Head, eyes, ears, nose and throat: Pupils equal,
round and reactive to light, sclerae slightly icteric,
conjunctiva noninjected. Cardiovascular: Regular rate and
rhythm, distant heart sounds, normal S1, S2, no appreciable
murmurs. Neck: Flat neck veins. Lungs: Clear bilaterally.
Abdomen: Obese, distended, with difficult to assess
tenderness secondary to sedation, with hypoactive bowel
sounds. Extremities: 1+ edema. Neurologic examination:
The patient withdraws to pain, moves all four extremities.
Ventilator settings: SIMV with pressure support of 5, tidal
volume 600, respiratory rate 20, PEEP of 5, FIO2 of 1.
LABORATORY DATA: Initial blood gas on admission to the
floor: 7.38/28/383. White blood count 68, hematocrit 34,
platelets 273. Sodium 134, potassium 4.0, chloride 93,
bicarbonate 18, BUN 40, creatinine 1.6, glucose 92.
Urinalysis showed large blood, negative nitrite, 30 protein,
negative glucose, trace ketones, small bilirubin, 4
urobilinogen, small leukocytes. INR 2.5. ALT 62, AST 76,
alkaline phosphatase 765, total bilirubin 4.7. Urine sodium
less than 10, urine creatinine 135, urine osmolality 406.
CEA 15, lactate 6.2, CA-19-9 pending. Chest x-ray showed no
acute process. CT scan of the abdomen revealed evidence of
an umbilical hernia, but no evidence of free air,
obstruction, or abdominal perforation, no evidence of biliary
dilatation or cholangitis. Blood cultures from earlier in
the admission were pending or negative. Urine cultures were
pending. Stool cultures were positive for C. difficile on
[**2113-2-6**]. Pathology from [**2113-2-7**] revealed invasive
adenocarcinoma, poorly differentiated.
HOSPITAL COURSE BY SYSTEM:
1. Cardiovascular: The patient presented hypotensive, in
hypovolemic vs. septic shock. She was aggressively volume
repleted. Her blood pressure initially responded to volume
and low-dose dopamine. Over the course of her
hospitalization, the patient became increasingly
pressor-dependent. She was bolused aggressively with
intravenous fluids, and was 14 liters positive by the end of
her hospital stay. She remained hypotensive, requiring more
aggressive pressor support, despite a jugular venous pressure
of 10 to 12. She was initially transitioned from dopamine to
Levophed. Dobutamine was later added for inotropic support,
and vasopressin for additional blood pressure support. The
patient became increasingly hypotensive, with no evidence of
intra-abdominal bleed. Although CT scan had initially been
negative for abdominal perforation or free air, the patient's
belly became increasingly distended, and it was thought that
she most likely developed sepsis and acidosis from
intra-abdominal perforation. The patient was unable to
maintain mean arterial pressures greater than 30 to 40 on the
final day or two of her hospitalization. She ultimately
coded, developing a rhythm consistent with complete heart
block, and was flat lined. At that point, the patient was Do
Not Resuscitate/Do Not Intubate, and was not deemed
appropriate for cardiopulmonary resuscitation.
2. Pulmonary: The patient presented with respiratory
failure, initially thought secondary to inability to
compensate for her worsening metabolic acidosis from lactate
accumulation. The patient was placed on a ventilator and
maintained good oxygenation and ventilation. The patient's
pH remained low secondary to her metabolic process.
3. Renal: The patient presented in acute renal failure and
eventually became anuric in the setting of her sepsis. She
had a worsening lactic acidosis, which was thought secondary
to ischemic bowel vs. liver failure vs. generalized
hypoperfusion and a low-flow state with acute liver and renal
failure.
4. Infectious Disease: The patient presented with
overwhelming sepsis as described above. She had been treated
earlier in the admission for a urinary tract infection with a
six day course of Levaquin. This was not continued in the
Intensive Care Unit. Urine cultures just prior to her death
were positive for enterococcus.
5. Gastrointestinal: The patient was found to have a large
colonic mass with metastases to the liver. Although she had
wanted aggressive treatment, including local resection and
chemotherapy, she had a likely life expectancy of
approximately one year. The patient also had developed a
gastrointestinal bleed while on the Medical floor following
colonoscopy, thought secondary to bleeding colonic mass. She
had been transfused one unit of packed red blood cells. Her
hematocrit remained stable, without any recurrent
gastrointestinal bleeding while in the Medical Intensive Care
Unit. She was also treated while on the floor for C.
difficile colitis with Flagyl and later with oral vancomycin.
C. difficile antigen was not resent. The patient had
gradually worsening liver function tests, consistent with a
cholestatic picture. Right upper quadrant ultrasound and CT
scan showed no evidence of ductal obstruction or abscess.
While in the Intensive Care Unit, she was on broad-spectrum
antibiotics to cover possible abdominal vs. biliary process
with ampicillin, gentamicin and Flagyl. Blood cultures
remained negative.
6. Hematology: The patient was noted to be having
microcytic anemia, likely secondary to iron deficiency
secondary to chronic gastrointestinal bleed from her colonic
mass. Her persistently elevated white blood count was
attributed to her C. difficile colitis vs. leukemoid reaction
vs. sepsis. She had an elevated INR, reflecting liver
failure-induced coagulopathy. She did respond somewhat to
doses of vitamin K prior to her arrival in the Medical
Intensive Care Unit.
7. Fluids, electrolytes and nutrition: The patient was
hypovolemic by examination. She initially responded to fluid
resuscitation, but ultimately became septic. Peripheral
vasodilation unable to support, and we were unable to support
her blood pressure with fluids or pressors.
DISPOSITION: The patient ultimately died on [**2113-2-13**]. There
had been active communication between the Medical Intensive
Care Unit team and the patient's brother, who became her
spokesperson. He understood that there was little more that
we could offer her, and she was ultimately made Do Not
Resuscitate/Do Not Intubate. We tried to keep her alive with
pressors until the rest of her family could arrive, but the
patient coded from cardiac arrest and was not resuscitated.
The autopsy was requested, and permission was granted by the
patient's family.
DR.[**Last Name (STitle) **],[**First Name3 (LF) 1569**] 12-684
Dictated By:[**Last Name (NamePattern4) 4689**]
MEDQUIST36
D: [**2113-2-13**] 22:09
T: [**2113-2-14**] 00:00
JOB#: [**Job Number 40050**]
ICD9 Codes: 2851, 2762, 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3742
} | Medical Text: Admission Date: [**2163-12-8**] Discharge Date: [**2163-12-16**]
Date of Birth: [**2102-12-3**] Sex: F
Service: MEDICINE
Allergies:
Nickel / Aspirin / Plavix
Attending:[**First Name3 (LF) 1162**]
Chief Complaint:
abdominal pain and weakness
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
Pt is a 61-yo woman with PMHx of PUD, diverticulitis, s/p CCY,
CAD s/p CABG, DM2, PVD, intestinal vascular insufficiency,
chronic kidney disease, presenting with weakness and abdominal
pain. She had been having left-sided abdominal pain since Friday
and had not been able to eat or drink anything. Pain was similar
to the diverticulitis and ulcer pain that she has had in the
past, which she described as crampy and waxing / [**Doctor Last Name 688**]. The
pain then developed into constant peri-umbilical and epigastric
pain. She had also been feeling very weak, lightheaded, and
confused, with multiple falls at home. She noted some nausea and
loose stools, and a dark bowel movement at home, but denied any
subjective fevers. She is currently being treated with Bactrim
for a left middle toe infection.
.
In the ED at OSH: VS - Temp 95F, SBP 60s. Labs significant for
WBC >40, K 7.5, Cr 5.0 (baseline 1.3), and elevated LFTs (ALT
114, AST 163, Alk Phos 158, T.Bili 0.1), amylase (382), lipase
(1665), and lactic acid (6.7). CVL was placed, she was
resuscitated with 4L crystalloid and started on Levophed.
Hyperkalemia was treated with Calcium gluconate, Kayexelate,
Dextrose, and Insulin. CT Abd/Plv showed early pericolonic
inflammatory changes [**1-14**] diverticular disease without abscess
formation in the rectosigmoid, and associated small bowel ileus.
RUQ US was done to eval for cholangitis, which showed dilated
extrahepatic bile ducts (12mm). The patient was started on
Levofloxacin, Flagyl, and Zosyn, and admitted to the SICU
(again, still at the OSH). In the SICU, she improved and was
able to be weaned off pressors. She was evaluated by GI, who
felt that ERCP would be necessary given the suspicion of
gallstone pancreatitis and ascending cholangitis. She was
further stabilized and was transferred to [**Hospital1 18**] for ERCP.
.
On arrival to the floor, the pt was hypotensive and lethargic.
She had been given Dilaudid just prior to transfer, so her
pressures initially responded to fluids, but she then developed
atrial fibrillation with rapid ventricular response and she
became hypotensive again. She was given fluids and started on
Neosynephrine and Diltiazem drips for stabilization after she
did not respond to metoprolol or digoxin. She was then
transitioned to Amiodarone for her atrial fibrillation, and
transiently required both Neosynephrine and Levophed pressors
for hypotension. After discussion with the ERCP team, the
Surgical consult team, and referring SICU team at [**Hospital3 **], it was determined that the patient was at risk for
ischemic colitis and would be treated as such.
Past Medical History:
Hypothyroidism
Hypertension
Diabetes Mellitus Type II, c/b neuropathy
Hyperlipidemia
Hypertensive cardiomyopathy
Coronary artery disease s/p CABG [**2154**]
h/o V-fib arrest s/p pacemaker/AICD placement [**2154**]
h/o Atrial fibrillation
Peripheral vascular disease
Mitral valve disorder
Gastritis
Duodenal ulcer [**2-17**] despite being on high-dose PPI
Gastroparesis
Diverticulitis
Intestinal vascular insufficiency
Chronic kidney disease (baseline 1.3)
Hydronephrosis
Iron-deficiency anemia
s/p AAA repair / aorto-bifemoral bypass grafting
s/p Right Fem-[**Doctor Last Name **] Bypass
s/p Left Fem-[**Doctor Last Name **] Bypass
s/p Cholecystectomy
s/p Hysterectomy
Arthropathy
Social History:
Lives at home with husband, non-[**Name2 (NI) 1818**], denies EtOH.
Family History:
Non-contributory
Physical Exam:
On arrival to MICU:
VS - Temp 97.2F, BP 103/44, HR 102, R 28, O2-sat 91% 4L NC, Ht
5'2", Wt 250lbs
GENERAL - ill-appearing woman, appears uncomfortable
HEENT - NC/AT, PERRL, sclerae anicteric, dry MM
NECK - supple, unable to assess JVD
LUNGS - CTA bilat, no r/rh/wh
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - decreased BS, soft/obese, +TTP over left abdomen and
epigastrium, +guarding, no rebound, unable to assess for
organomegaly
EXTREMITIES - WWP, no c/c/e, faint Dopplerable peripheral pulses
(radials, DPs)
NEURO - lethargic, somewhat responsive, MAE although weak
Pertinent Results:
[**2163-12-8**] 11:55AM ALT(SGPT)-125* AST(SGOT)-176* LD(LDH)-310*
CK(CPK)-1305* ALK PHOS-127* AMYLASE-63 TOT BILI-0.2
[**2163-12-8**] 11:55AM LIPASE-26
.
[**2163-12-8**] 09:01PM ALT(SGPT)-137* AST(SGOT)-235* LD(LDH)-356*
CK(CPK)-3298* ALK PHOS-124* AMYLASE-37 TOT BILI-0.2
.
[**2163-12-8**] 11:55AM WBC-31.7* RBC-3.23* HGB-8.7* HCT-27.7* MCV-86
MCH-27.0 MCHC-31.5 RDW-15.7*
[**2163-12-8**] 11:55AM NEUTS-73* BANDS-22* LYMPHS-1* MONOS-2 EOS-0
BASOS-0 ATYPS-0 METAS-2* MYELOS-0
[**2163-12-8**] 11:55AM PT-17.9* PTT-33.3 INR(PT)-1.6*
[**2163-12-8**] 11:55AM FIBRINOGE-746* D-DIMER-4921*
[**2163-12-8**] 11:55AM CK-MB-23* MB INDX-1.8 cTropnT-<0.01
[**2163-12-8**] 11:55AM GLUCOSE-183* UREA N-53* CREAT-2.3*
SODIUM-148* POTASSIUM-3.7 CHLORIDE-120* TOTAL CO2-16* ANION
GAP-16
.
[**2163-12-8**] 05:57PM LACTATE-2.5*
[**2163-12-8**] 09:01PM WBC-39.0* RBC-3.40* HGB-9.2* HCT-28.8* MCV-85
MCH-27.1 MCHC-32.1 RDW-15.9*
[**2163-12-8**] 09:01PM NEUTS-93* BANDS-4 LYMPHS-1* MONOS-2 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
.
[**2163-12-8**] 09:01PM CORTISOL-51.8*
[**2163-12-8**] 10:00PM CORTISOL-53.1*
[**2163-12-8**] 10:38PM CORTISOL-52.9*
.
[**2163-12-8**] 03:20PM TYPE-ART PO2-102 PCO2-35 PH-7.28* TOTAL
CO2-17* BASE XS--9
[**2163-12-8**] 09:20PM TYPE-ART TEMP-37.2 RATES-[**11-24**] TIDAL VOL-550
PEEP-5 O2-50 PO2-110* PCO2-33* PH-7.29* TOTAL CO2-17* BASE XS--9
-ASSIST/CON INTUBATED-INTUBATED
[**2163-12-14**] 7:34 am SWAB Source: L 3rd toe.
GRAM STAIN (Final [**2163-12-14**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Preliminary):
STAPH AUREUS COAG +. SPARSE GROWTH.
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
Brief Hospital Course:
#. Sepsis -
When pt arrived, appeared to have septic picture but resolved
during stay and by the time of her ERCP she was afebrile, stable
hemodynamics, and without elevated white count. She had been on
Zosyn, PO Vanc and Flagyl, with the latter two being for concern
for C. diff, and the former being coverage for bowel organisms
because of a high suspicion for diverticulitis as the source.
She was C. diff negative x3 now, and had relatively small amount
of stool output, and her white count is stable. She did have a
positive UA at the OSH as well as chronic hydronephrosis. We
discontinued Vancomycin and Flagyl, which had been covering C.
diff. We continued Zosyn for coverage of GI/GU organisms given
earlier septic presentation; although we do not have clear
evidence for what we are treating it is reasonable to think we
have treated something given her clinical course.
.
#. Altered mental status -
Pt presented from OSH lethargic and hypotensive, in the setting
of initial concern for infection / sepsis as described above. By
the time of ERCP she was able to express her dissatisfaction
with her circumstances but in a focused and oriented manner, and
was certainly interactive. This issue appeared to be resolving
or resolved.
.
#. Atrial fibrillation with rapid ventricular response -
After amiodarone loading she eventually remained in sinus. She
should go down to maintenance dose starting [**2162-12-16**]. She remains
stable but given rapid RVR, she may be best served by tele on
the floor for wherever she is transferred.
.
#. Acute on chronic renal failure - Pt with known h/o chronic
kidney disease, baseline Cr 1.3 per OSH records. On arrival to
OSH, the Cr wa 5.0 but recovered to baseline (~1.2). Original
insult was likely pre-renal given sepsis / hypotension. Pt has
known history of hydronephrosis, presumed to be contributing to
her chronic kidney disease, and likely due to fibrotic
post-surgical changes in her abdomen from her numerous vascular
surgeries. We hydrated and avoided nephrotoxins, apparently to
good effect.
.
#. Pancreatitis - The patient was noted to have elevated amylase
and lipase at OSH as evidence of pancreatitis, but on admission
did not have any evidence on CT-scan. Pancreatic enzymes were
trending down and were normal by arrival at [**Hospital1 18**]. However, they
were then increasing theraafter, while [**Hospital1 **] resolved
while pancreatic enzymes were continuing to increase. This was
consistent with an evolving blockage and ERCP was performed and
included stone removal. A summary description of the procedure
was as follows: "Biliary dilation was noted. Given h/o gallstone
pancreatitis and acute cholangitis, a biliary sphincterotomy was
performed. Moderate dilation of pancreatic duct in the head of
the pancreas was noted. (Sphincterotomy, stone extraction.)"
.
#. [**Name (NI) 5779**] - Pt noted to have a [**Name (NI) **] at OSH,
which has since resolved here. Original elevation in AST > ALT,
suggestive of alcohol as a possible cause of [**Name (NI) **] and
pancreatitis; however this would not entirely explain resolution
of [**Name (NI) **] with increase in pancreatitis. More likely this
has been an evolving blockage, perhaps from a migrating stone or
transient contractions/strictures. This should continue to be
followed.
.
#. GI bleeding - By the time of transfer there was no current
evidence for GI bleed; C diff and ischemic colitis were in
differential as well for guiaic-positive diarrhea, but C diff
was negative and clinical course was not consistent with
worsening ischemic colitis. A rectal tube continued to drain
liquid stool.
.
#. Coagulopathy - Pt was noted to have elevated INR to 3.0 at
the OSH, INR down to 1.7 on arrival, and was continuing to
decline. This may be secondary to temporary liver function
decline, now resolving; or from sepsis earlier in her course.
Should be continued to be followed.
.
#. Toe infection. Arrived with 3rd toe infection of L foot.
Podiatry saw, noted that they further debrided the HPK, tract
probed to bone, applied W-D dressing to toe. They recommended
that she will need ulcer excision and removal of distal phalanx
when stable. Her wound culture is pending as of this dictation
but it appears to be growing coag + staph aurues. She will be
discharged to [**Hospital3 2568**] on zosyn and vancomycin. A vancomycin
level should be checked in 3 days given her previous ARF. She
will need podiatry follow-up after transfer; we deferred this
given her other issues and imminent transfer.
#. Diabetes mellitus type II - We kept her on ISS and QACHS
fingersticks. Her glucose control was evolving given times on
and off NPO and likely her scales will need to be adjusted
further.
.
#. Hypothyroidism - Pt maintained on PO levothyroxine as
outpatient. We continued IV levothyroxine maintenance.
.
#. FEN - NPO, IVF, replete lytes PRN
.
#. Access - LIJ, A-line [**12-8**]. We had kept A-line because of
some difficulty getting blood pressures earlier; this seems to
have resolved and if she continues to have uneventful post-ERCP
course this should be able to be pulled.
.
#. PPx - venodynes, no heparin because of GI bleeding though if
course continues well, could revisit this; no bowel regimen
given diarrhea but if stool output continues to reduce in
quantity could consider gentle restart.
.
#. Code - FULL CODE
.
#. Dispo - to [**Hospital3 2568**] (pt requesting transfer).
.
#. IMPORTANT FOLLOW-UP NOTES
-- if continued on amiodarone will need PFTs
-- continue Zosyn for total of [**9-25**] days
-- -- needs podiatry follow-up
Medications on Admission:
HOME MEDICATIONS:
Cymbalta 60mg daily
Lyrica 100mg TID
Avapro 300mg [**Hospital1 **]
Aldactone 25mg [**Hospital1 **]
Zetia 10mg daily
Crestor 40mg daily
Levothyroxine 200mcg daily
Folate 1mg daily
Lasix 40mg daily
Omeprazole 40mg ACB
Prilosec 20mg AD
Bactrim DS [**Hospital1 **]
.
Tx Meds
Levothyroxine Sodium 200 mcg PO DAILY
Acetaminophen (Liquid) 650 mg PO Q6H:PRN
Lidocaine Viscous 2% 20 ml PO TID:PRN perianal pain
Amiodarone 200 mg PO BID Duration: 7 Days Start: In am
Metoprolol 12.5 mg PO TID
Desitin 1 Appl TP PRN
Miconazole Powder 2% 1 Appl TP TID:PRN
Haloperidol 0.5 mg IV Q4H:PRN agitation
OxycoDONE Liquid 5 mg PO Q4H PRN
Oxycodone-Acetaminophen 1 TAB PO Q6H:PRN pain
Pantoprazole 40 mg PO Q24H
Insulin SC (per Insulin Flowsheet)
Piperacillin-Tazobactam Na 2.25 gm IV Q6H
Discharge Disposition:
Extended Care
Facility:
Mt. [**Hospital 28202**] Hospital
Discharge Diagnosis:
Pancreatitis/[**Hospital **]
Discharge Condition:
Stable
ICD9 Codes: 0389, 2760, 5859, 2724, 3572, 2449, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3743
} | Medical Text: Admission Date: [**2143-8-5**] Discharge Date: [**2143-8-24**]
Date of Birth: [**2092-8-15**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 9240**]
Chief Complaint:
hypotension, jaundice
Major Surgical or Invasive Procedure:
US guided placement of cholecystostomy tube
CT guided placement of biloma drain
History of Present Illness:
51 y/o m with h/o PVD p/w 2 weeks of decreased appetite and 3
day hx RUQ pain and increasing jaundice at OSH on admission last
week. He also p/w 20-30 pound weight loss.
.
Of note, on the day of admission, the pt was initially sent to
the ERCP suite for procedure from [**Hospital 8**] Hospital with plan
of returning him post-procedure. However, on arrival, he was
reportedly obtunded, hypoglycemic and hypotensive to 70/40. He
was given D5W and sent back to [**Hospital 8**] Hospital. He was
reportedly fluid responsive there but was sent back to [**Hospital1 **] for
further management.
.
ROS: Unable to fully obtain, pt denied SOB/CP, had severe abd
pain and little appetite.
Past Medical History:
Etoh abuse (confirmed by father)
[**Name (NI) 7792**]
Rheumatoid Arthritis
PVD c/b amputations
Social History:
No sig other or children, father lives in [**Name (NI) **]. Did
not answer questions re: EtoH or smoking
Family History:
Brother with adv esophageal ca
Physical Exam:
Vitals: T 99.4// BP 71/47// HR 94// rr 32// O2 sat 100%2L
Gen: cachetic, jaundiced agitated man, appears older than stated
age
HEENT: Adentulous, mm dry, scleral icterus
Neck: Supple, no LAD, scars midline
Heart: RR no m/g/r
Lungs: Diffusely rhonchorous a/l
ABd: Distended, tender esp in RUQ with guarding no rebound,
hypoactive but present BS
Ext: Warm well-perfused, b/l TMAs, 2+ DPs
Psych: A&O to self, year, [**Location (un) **]Hospital
Pertinent Results:
[**2143-8-5**] 08:05PM GLUCOSE-86 UREA N-4* CREAT-0.3* SODIUM-134
POTASSIUM-3.1* CHLORIDE-106 TOTAL CO2-22 ANION GAP-9
[**2143-8-5**] 08:05PM ALT(SGPT)-162* AST(SGOT)-443* LD(LDH)-223 ALK
PHOS-1501* AMYLASE-26 TOT BILI-13.3*
[**2143-8-5**] 08:05PM LIPASE-32
[**2143-8-5**] 08:05PM ALBUMIN-1.6* CALCIUM-6.3* PHOSPHATE-2.3*
MAGNESIUM-1.5*
[**2143-8-5**] 08:05PM HBsAg-NEGATIVE HBs Ab-NEGATIVE HBc
Ab-NEGATIVE HAV Ab-NEGATIVE
[**2143-8-5**] 08:05PM HCV Ab-NEGATIVE
[**2143-8-5**] 08:05PM WBC-9.1 RBC-2.87* HGB-8.8* HCT-26.8* MCV-94
MCH-30.6 MCHC-32.7 RDW-23.2*
[**2143-8-5**] 08:05PM NEUTS-92* BANDS-0 LYMPHS-1* MONOS-3 EOS-0
BASOS-2 ATYPS-1* METAS-0 MYELOS-1*
[**2143-8-5**] 08:05PM HYPOCHROM-3+ ANISOCYT-2+ POIKILOCY-OCCASIONAL
MACROCYT-OCCASIONAL MICROCYT-OCCASIONAL POLYCHROM-NORMAL
TARGET-OCCASIONAL TEARDROP-OCCASIONAL HOW-JOL-OCCASIONAL
BITE-OCCASIONAL FRAGMENT-OCCASIONAL
[**2143-8-5**] 08:05PM PLT SMR-VERY LOW PLT COUNT-55*
[**2143-8-5**] 08:05PM PT-14.9* PTT-60.8* INR(PT)-1.3*
[**2143-8-5**] 08:05PM FDP-0-10
[**2143-8-5**] 08:05PM FIBRINOGE-380 D-DIMER-1115*
[**2143-8-5**] 07:33PM URINE HOURS-RANDOM CREAT-108 SODIUM-90
[**2143-8-5**] 07:33PM URINE COLOR-Brown APPEAR-Cloudy SP [**Last Name (un) 155**]-1.010
[**2143-8-5**] 07:33PM URINE BLOOD-LGE NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-50 BILIRUBIN-LG UROBILNGN-4* PH-7.0 LEUK-SM
[**2143-8-5**] 07:33PM URINE RBC-880* WBC-15* BACTERIA-MOD YEAST-NONE
EPI-2
[**2143-8-5**] 07:33PM URINE MUCOUS-RARE COMMENT-DUE TO ABNORMAL
URINE COLOR INTERPRET DIPSTICK WITH CAUTION
[**2143-8-5**] GB US:
1. Distended gallbladder with edematous wall which, in the
correct setting, may represent acute acalculous cholecystitis.
Correlation with patient's clinical status and lab values
recommended. Alternatively, HIDA scan could be obtained.
2. Diffusely echogenic liver, compatible with patient's known
history of hepatitis C. No ascites or evidence of portal venous
hypertension. More serious forms of liver disease cannot be
excluded on the basis of this study.
[**2143-8-6**] CT Abd:
Successful readjustment of percutaneous cholecystotomy tube with
the pigtail well formed within the gallbladder.
[**2143-8-6**] Abd US:
A limited ultrasound examination was performed of the right
upper quadrant. The cholecystostomy tube was seen entering the
gallbladder, although its course within the gallbladder and
extension through the posterior wall was not well visualized on
ultrasound despite multiple attempts. Heterogeneously echoic
material was identified within the gallbladder consistent with
hemorrhage/clot.
It was decided that due to the lack of visualization of the
catheter that readjustment of the catheter would be better
performed using CT guidance. Therefore, ultrasound-guided
adjustment of the catheter was aborted.
[**2143-8-6**] CT Abd:
1. Errant course of cholecystostomy tube as described.
Repositioning is suggested. Small collection of blood both
within the gallbladder and moderate- sized around the liver.
2. Heterogeneous pelvic presacral retroperitoneal masses with
adjacent lymphadenopathy. Areas of low attenuation consistent
with fat narrows the differential to include liposarcoma or
teratoma. Extramedullary hematopoiesis would also be a
possibility in the appropriate clinical setting
3. Heavily calcified internal and external iliac vessels
consistent with underlying atherosclerotic disease.
4. Degenerative changes of lower thoracic and lumbar spine.
5. Bilateral pleural effusions and associated atelectasis.
6. Free fluid within both the pelvis and abdomen.
[**2143-8-6**] GB Drainage US:
ULTRASOUND-GUIDED CHOLECYSTOSTOMY TUBE PLACEMENT: Written
informed consent was obtained by the ICU/surgical house staff.
The procedure was performed emergently at bedside in the
Intensive Care Unit. Ultrasound was used to select an
appropriate spot for percutaneous cholecystostomy tube
placement. The area was prepped and draped in sterile fashion.
The skin and subcutaneous tissues were anesthetized using 7 cc
of 1% lidocaine. Using continuous son[**Name (NI) 493**] guidance, a 8
French [**Last Name (un) 2823**] catheter was advanced into the gallbladder.
Aspiration yielded clear dark brown fluid. The needle and
stiffener were then removed. The pigtail was deployed.
Approximately 100 cc of additional bilious fluid was then
aspirated and removed to bag drainage. Post-procedure imaging
showed the catheter within a nearly collapsed gallbladder.
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1968**], the attending radiologist, performed the
procedure.
The patient tolerated the procedure well without immediate
complication.
ICU nursing provided sedation throughout the procedure, during
which the patient was under continuous hemodynamic monitoring. A
total of 75 mcg of fentanyl and 1 mg of Versed were
administered.
IMPRESSION: Bedside placement of percutaneous cholecystostomy
tube.
pCXR:
Cardiac silhouette is enlarged. There is a left retrocardiac
opacity with obscuration of the left medial hemidiaphragm. There
is also some atelectasis seen in the right mid lung field. No
focal consolidation is seen. The patient has a right IJ central
line with distal tip at the mid SVC. There is fixation plate in
the lower cervical spine. A left humeral prosthesis is seen.
[**2143-8-9**]
MRCP
Within the lesser sac, there is a 7.3 x 10.5 X 10.8 cm,
loculated fluid collection with thin septations and a thickened
enhancing wall, which is slightly increased in size compared to
the prior CT study of [**2143-8-6**]. A separate component
extends through the esophageal hiatus into the left chest,
unchanged from the [**2143-8-6**] CECT. A portion of the collection
surrounds the caudate lobe of the liver. The stomach is draped
over this collection superiorly and anteriorly, and its inferior
aspect is bounded by the transverse colon. As such, an
accessible window for drainage by cross sectional imaging is
limited. A CT study after decompression of the stomach with an
NG tube to evaluate for a possible accessible percutaneous
drainage window could be attempted. Alternatively, an endoscopic
approach could be performed.
Previously placed cholecystostomy catheter is seen through the
liver to the gallbladder wall, it's tip is not well identified,
though some images suggest it is within the gallbladder.
There is a tiny 2-cm collection within segment V of the liver
and the gallbladder, unchanged (series 200, image 20).
Small-to-moderate amount of ascites has slightly increased in
the interval.
No focal liver lesions are seen. The spleen, adrenal glands, and
kidneys are normal in appearance.
Findings were discussed with Dr. [**Last Name (STitle) **]. [**Doctor Last Name **] on [**2143-8-13**] at
3:30 p.m.
IMPRESSION:
Mildly complex organized fluid collection in the lesser sac,
likely representing a biloma, which has slightly increased in
size from the CT study of one week prior. No definite
percutaneous accessible drainage window is readily identified.
[**2143-8-14**]
CT Hepatic Drainage:
1. Successful placement of abdominal fluid collection drainage
catheter.
2. Multiple presacral heterogeneous masses suggestive of
liposarcoma, teratoma, nerve sheath tumors or possibly
extramedullary hematopoiesis as previously indicated. Given
profound osteopenia, extraosseous myeloma is considered. MR
would be helpful in further evaluation.Biopsy could be performed
when the patients acute condition allows
3. Dense atherosclerotic calcification and marked degenerative
osseous changes as described above.
4. Bilateral pleural effusions and associated atelectasis.
[**2143-8-20**]
CT OF THE ABDOMEN WITH IV CONTRAST: The lung bases reveal
bilateral improvement in pleural effusions with small fluid
collections within the pleurae persisting bilaterally. No
nodules, opacities, or infiltrates are noted at the lung bases
bilaterally. The visualized heart and pericardium are
unremarkable. No focal lesions are identified within the liver.
The cholecystostomy tube is again identified and is coiled
within the gallbladder. The pancreas, spleen, adrenal glands,
and kidneys are unremarkable. Fluid collection within the lesser
sac is again identified and measures approximately 8 x 5.5 cm.
This is smaller than on the previous study where it measured 11
x 7 cm. A draining catheter is noted in the anterior aspect of
the collection. Visualized loops of small and large bowel are
unremarkable. No free air is identified. Another small fluid
collection is seen in series 2, image 44 in the right side of
the abdomen measuring approximately 22 x 26 mm. Of note, fluid
is seen tracking into the esophageal hiatus and is stable when
compared to previous study. Also noted multiple soft tissue
densities likely representing lymph nodes were identified near
the left crux of the diaphragm retroperitoneally. These are best
seen in series 2, images 5 through 12. Again note is made of
dense atherosclerotic calcification of the aorta and its
branches.
CT OF THE PELVIS WITH CONTRAST: Again the pelvis is poorly
visualized secondary to artifact from bilateral femoral
prostheses. Again identified are two heterogeneous
retroperitoneal masses located presacrally with a third smaller
similar-appearing heterogeneous mass noted superiorly lateral to
the iliac vessels. These are unchanged in appearance compared to
previous exam. Surgical clips are again identified in the right
pelvis. Small amount of pelvic fluid is again identified.
BONE WINDOWS: Osseous structures are significant for bilateral
hip prostheses and diffuse osteopenia. Multiple compression
deformities of the thoracic and lumbar spine are noted on
sagittal images. Multiple previous healed pelvic fractures are
also again noted.
IMPRESSION:
1. Interval successful partial drainage of abdominal fluid
collection. Catheter is located in more anterior aspect of
remaining fluid, which seems to be located more posteriorly.
Since the anterior and posterior aspects of this fluid
collection seem to communicate adjusting patient position may
assist in further drainageI(ie prone position) . If this is
unsuccessful, advancement of the catheter is an option. This was
discussed with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at the time of this dictation.
2. Previously defined multiple presacral heterogeneous masses
with the differential including liposarcoma, teratoma,
extramedullary hematopoiesis, and nerve sheath tumors. Recommend
biopsy as patient's condition allows. Soft tissue masses likely
representing lymphadenopathy also noted in the retroperitoneum
near the left diaphragmatic crux. .
3. Improvement in bilateral pleural effusions.
4. Marked osteopenia and degenerative changes of lumbar and
thoracic spine including compression deformities.
Brief Hospital Course:
1. Hypotension: Presented as high CO state and low SVR,
consistent with sepsis. Given transaminitis, found to have
acalculous cholecystitis. An US guided cholecystostomy tube was
placed. He continued to have severe abdominal pain and a CT was
checked which showed the cholecytostomy tube went all the way
through the gallbladder. The tube was then pulled back under
guidance, and follow up CT showed correct placement. Gallbladder
aspirate grew pansensitive Klebsiella. Pt. was treated with
levofloxacin and flagyl and will continue this for a total of 2
weeks. On the floor pt. improved initially but then developed
persistent abdominal pain/nausea, f/u CT showed interval
development of extracholecystic biloma. A drainage tube was
inserted under CT guidance. The patient then improved greatly
with improved abdominal pain and began tolerating a regular
diet. Pt. then accidentally pulled out the cholecystostomy tube,
but his abdominal pain remained improved. A follow up CT showed
interval decrease in size of his biloma. Pt. will need to have a
follow up CT in 2 weeks ([**9-6**]) after discharge to evaluate his
biloma, if this is improved and the drain is putting out less
than 10cc/d his drain will be pulled by CT radiology.
.
2. Bilateral heterogenous retroperitoneal masses: Discovered
incidentally on CT abdomen. Appearance c/w either teratomas or
lipomyosarcomas. Oncology consulted and HCG and AFP levels
checked and found to be normal, rec f/u as outpatient for CT
guided biopsy when acute illness resolved.
.
3. Adrenal Insufficiency: Found to be persisitently hypotensive
to 70-80/40-50, but asymptomatic. [**Last Name (un) **] stim test showed
inappropriate response, with baseline low cortisol. Seen by
endocrine service and started on prednisone 10 mg daily. They
felt it may be difficult to ever take him off this given his
long h/o steroid use. His aldosterone levels were appropriate
and he was felt not to need florinef.
.
4. EtOH dependence: Initially put on CIWA scale in ICU but never
required much benzodiazepine. No clear signs of EtOH withdrawl.
.
5. [**Last Name (un) 7792**]: Rec'd heparin gtt, BB, ASA at OSH for CE elevation.
CE's positive there. Trop I elevated here and trending up,
despite normal CK. Likely [**1-17**] to hypovolemia and sepsis picture.
Not C/W ACS. CE trended down eventually.
.
6. Bowel movements: Loose stool. ? infection vs. obstruction
C diff negative but given empiric course of flagyl.
.
7. Thrombocytopenia: DDx incl hypersplenism (though no portal
htn on u/s), marrow suppression [**1-17**] EtOH. HIT neg. Platelets
improved on discharge.
.
8. Anemia: Likely in part dilutional, may be related to BM
suppression. Phlebotomy, as well as chronic oozing. Not c/w
acute DIC. Iron studies c/w anemia of chronic disease.
B12/folate wnl. Given 1 unit PRBCs on [**8-7**], subsequently hct
remained stable.
.
10) PPX: Pneumoboots, PPI
.
12) Code: Full
.
13) Comm: Pt and father [**Name (NI) **] [**Known lastname 69375**] [**Telephone/Fax (1) 69376**] cell
Medications on Admission:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Disp:*30 Tablet(s)* Refills:*2*
3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed. Disp:*qs 1 month* Refills:*2*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q3H (every 3
hours) as needed. Disp:*30 Tablet(s)* Refills:*0*
8. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours). Disp:*qs 1 month* Refills:*2*
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
Disp:*qs 1 month* Refills:*2*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
6. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 10 days.
Disp:*30 Tablet(s)* Refills:*0*
7. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q3H (every 3
hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
8. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours).
Disp:*qs 1 month* Refills:*2*
9. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Acalculous Cholecystitis
Intrabdominal Biloma
Bilateral Retroperiteal Masses
Discharge Condition:
stable
Discharge Instructions:
Please continue your regular medications. Please follow up with
your PCP in the next week. Please follow up for your CT scan of
your abdomen on the 22nd. The radiologists will tell you at that
time if your tube can come out. Please change your drain
dressing daily and empty your bag daily.
Followup Instructions:
1. Please have your follow up CT scan of your abdomen on [**2143-9-6**]
at 9am in the [**Hospital Unit Name 1825**], [**Location (un) 470**]. You can call
[**Telephone/Fax (1) 327**] if you have questions. Make sure you have nothing
to eat/drink 3 hours prior to exam. They will use this scan to
determine if your biloma drain can be removed.
2. Please follow up with your PCP in the next week. You will
need to have your bilateral retroperitoneal masses followed up
with either CT guided biopsy or serial imaging.
ICD9 Codes: 2875, 4241, 4439 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3744
} | Medical Text: Admission Date: [**2177-4-25**] Discharge Date: [**2177-5-12**]
Date of Birth: [**2103-9-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Fatigue
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
73 year old male with hypertension who presented on [**4-25**] with
increased abdominal girth, cough. He had developed a cough
productive of copious sputum about 1 week prior to presentation.
His PCP had given him antibiotics, however it did not clear up.
ROS is positive for about 60 pound weight loss over the last 4
months which he had attributed to being on the South Beach Diet.
His wife remarks that his weight loss was interesting, however
in that his pant size actually increased. He had also been
complaining of some "indigestion."
.
He was admitted on [**4-25**] and treated for LLL pneumonia, however
his course has been complicated by development of renal failure,
bilateral deep venous thromboses in his legs, and hypercarbic
respiratory failure requiring intubation. He additionally had
increasing ascites, and a CT of the abdomen demonstrated a large
exophytic right liver mass as well as diffuse peritoneal
thickening/omental caking suggestive of neoplastic involvement.
He subsequently had a paracentesis on [**4-28**], the pathology of
which returned with malignant cells consistent with poorly
differentiated non-small cell carcinoma. The tumor cells are
positive for keratin AE1/AE3, CAM 5.2, CEA, Leu M1 and B72.3 and
negative for calretinin.
Past Medical History:
HTN
H/o polio (involving half his body)
BPH
Physical Exam:
97.9, 131/79, 95, 18, 99% on AC
Gen: Intubated caucasian male appearing ill.
Abd: Tensely distended abdomen, appears to be tender to
palpation.
Extr: 2+ pitting edema of LE b/l.
Pertinent Results:
[**2177-5-12**] 04:46AM BLOOD WBC-9.7 RBC-3.13* Hgb-9.3* Hct-27.9*
MCV-89 MCH-29.8 MCHC-33.4 RDW-15.4 Plt Ct-368
[**2177-5-2**] 04:07AM BLOOD Neuts-76.9* Lymphs-13.0* Monos-5.6
Eos-4.1* Baso-0.4
[**2177-5-12**] 04:46AM BLOOD Plt Ct-368
[**2177-5-12**] 04:46AM BLOOD Glucose-86 UreaN-56* Creat-5.0* Na-135
K-4.8 Cl-102 HCO3-18* AnGap-20
[**2177-5-7**] 05:38AM BLOOD ALT-17 AST-26 LD(LDH)-205 AlkPhos-125*
TotBili-0.2
[**2177-5-12**] 04:46AM BLOOD Calcium-9.2 Phos-6.4* Mg-2.0
[**2177-5-7**] 11:44AM BLOOD CA125-202*
[**2177-4-28**] 06:20AM BLOOD CEA-41* PSA-0.3 AFP-<1.0
Brief Hospital Course:
Patiet was in resp failure. After extensive family discussion,
it was decided to extubate him and he was made CMO. Patient
eventually died.
Discharge Disposition:
Expired
Discharge Diagnosis:
EXPIRED
Discharge Condition:
EXPIRED
Discharge Instructions:
EXPIRED
Followup Instructions:
EXPIRED
Completed by:[**2177-7-28**]
ICD9 Codes: 5845, 0389, 4019, 5070 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3745
} | Medical Text: Admission Date: [**2180-10-3**] Death Date: [**2180-10-4**]
Service: MICU
HISTORY OF PRESENT ILLNESS: Called to evaluate patient in
ED. The patient presented from nursing home and brought to
the ED at the request of his brother who had gone to visit
him. Per brother, the patient had been unable for two days,
also was not feeling well per nursing home staff. The
patient was less responsive than normal and presented to the
ED with temperature of 97, pulse 100, blood pressure 70/palp,
and required 100% O2 to maintain his O2 sat. Urine was noted
to be grossly purulent. Chest x-ray showed a left lower lung
infiltrate. The decision was made to intubate secondary to
hypoxic respiratory failure. This was delayed somewhat while
the brother called the sister to discuss. At the time of
intubation, the patient was on dopamine 10 mcg with the blood
pressures remaining in the 60s/palp. A right femoral triple
lumen was placed. A left femoral A-line was placed. The
patient was started on neo 200, dopamine 20, vasopressin 0.4
and received 78 liters of fluid. This was what was required
to maintain a MAP of 59-60. The patient was easily
oxygenated. Multiple changes were made to the vent. The
last setting prior to leaving the ED was pressure control
ventilation for tidal volumes of 500, FIO2 100%, PEEP 10.
The patient was sedated with ativan. A right IJ central line
was placed with CV noted to be 14. The patient was given
Levofloxacin, Flagyl and vancomycin.
PAST MEDICAL HISTORY: Chronic left lower extremity ulcer,
hypothyroidism, osteopenia, BPH, anemia.
MEDS: Colace 100, aspirin, calcitriol, Synthroid, nystatin,
heparin subcu, Dulcolax.
ADMISSION LABS: White count 4.7 with 53% polys, 38% bands, 4
lymphs, 1 monos, 3 metas, 1 myelo. Crit 30.7 and platelets
of 191. PT 22.4, PTT 69.1, INR 3.3, sodium 147, potassium
5.0, chloride 117, bicarb 16, BUN 105, creatinine 3.8,
glucose 136, CK 299. Initial ABGs - 7.20, 53, 70. Chest
x-ray - left lower lobe consolidation. EKG - afib at 85
beats per minute.
PHYSICAL EXAM: HEENT - pupils minimally reactive, 4 mm,
anicteric. Neck supple without lymphadenopathy. Right IJ in
place. Lungs - bronchial breath sounds in left lower lung
field with bibasilar rales. Cardiovascular - regular rate
and rhythm, normal S1, S2, no murmurs, gallops or rubs.
Abdomen - soft, nontender, nondistended, normoactive bowel
sounds. Extremities - no clubbing, cyanosis or edema.
Bilateral inguinal hernia. Right triple lumen and a left
femoral A-line placed.
SUMMARY OF HOSPITAL COURSE: The patient was aggressively
resuscitated in the ED and continued to receive four pressors
while in the MICU. The patient's oxygenation became more
difficult. A discussion was had with the patient's brother
who felt that withdrawal of care and comfort measures only
was appropriate, after it was demonstrated that the patient
continued to develop multisystem organ failure. The patient
was made comfort measures and the pressors were weaned off.
Mr. [**Known lastname 36666**] died on [**2180-10-4**] at 5:00 pm.
DISCHARGE STATUS: To funeral home.
DISCHARGE CONDITION: Dead.
DISCHARGE DIAGNOSIS: Urosepsis multisystem organ failure.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 7512**]
Dictated By:[**Last Name (NamePattern1) 16516**]
MEDQUIST36
D: [**2180-11-2**] 12:05
T: [**2180-11-6**] 11:18
JOB#: [**Job Number 36667**]
ICD9 Codes: 5070, 0389, 2767, 2765, 5990, 5845, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3746
} | Medical Text: Admission Date: [**2155-10-24**] Discharge Date: [**2155-11-12**]
Service: VASCULAR
CHIEF COMPLAINT: Bilateral lower extremity swelling and
right lower extremity painful ulcerations with back and thigh
pain.
HISTORY OF PRESENT ILLNESS: This is an 83-year-old female
status post right femoral-popliteal bypass in [**2131**] which then
failed six months later, history of congestive heart failure,
coronary artery disease, peripheral vascular disease, history
of myocardial infarction in [**2123**], who presented with a
two-week history of swelling of the lower extremities and
painful ulcerations of the toes in the right lower extremity.
She also complained of posterior thigh and calf pain; this
was unclear whether this pain was at rest or with ambulation.
She did have some rest pain and some discomfort at 10-15 feet
walking. She denied chest pain and shortness of breath. She
is a resident of [**Hospital3 **] Center.
PAST MEDICAL HISTORY: Femoral-popliteal bypass, right, in
[**2131**], occluded. Pacemaker two years ago. Congestive heart
failure. Ejection fraction reported at 25%. Coronary artery
disease. History of myocardial infarction in [**2123**]. History
of hypertension. History of hypercholesterolemia. History
of [**Doctor Last Name 35251**] disease status post lumbar sympathectomy.
History of chronic renal insufficiency with a baseline
creatinine of 1.5 to 2.0. History of chronic obstructive
pulmonary disease. History of peptic ulcer disease with
melena. History of MRSA. History of neuropathic pain.
PAST SURGICAL HISTORY: Tonsillectomy. Hysterectomy.
Appendectomy. Right finger amputation secondary to trauma.
Right femoral-popliteal bypass graft, failed.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
MEDICATIONS ON ADMISSION: Enteric Coated Aspirin 81 mg q.d.,
Wellbutrin 75/37.5 mg, 75 in the morning, and 37.5 in the
afternoon, Os-Cal 500 mg b.i.d., Colace 100 mg b.i.d., Lasix
20 mg Monday and Wednesday, Isordil 5 mg b.i.d., Prevacid 30
mg q.d., Zestril 10 mg b.i.d., Multivitamin, Vitamin C q.d.,
Zocor 40 mg q.d., Mylanta p.r.n., Compazine p.r.n., Milk of
Magnesia p.r.n., Tylenol p.r.n., Darvocet [**2-5**] p.r.n.
PHYSICAL EXAMINATION: Vital signs: Temperature 95??????, blood
pressure 180/70, heart rate 78. General: The patient was an
alert, oriented female in no acute distress. Left arm was
with bruises and well-healing lower extremity ulcerations.
Heart: Distant sounds. Regular, rate and rhythm. Chest:
With a left pacemaker implantation in the anterior chest.
Lungs clear to auscultation. Abdomen: Unremarkable.
Extremities: Left index finger missing. Left arm with
bruising and left lower extremities with excoriations. The
left foot was with ulcerations on all five toes. There was
pitting edema bilaterally, left greater than right. There
was tenderness of the toes on palpation. Pulse exam showed
carotids palpable with no bruits. Radials palpable. Femoral
Dopplerable. Popliteals Dopplerable. Dorsalis pedis pulses
monophasic and posterior tibial biphasic signals only.
LABORATORY DATA: On admission white count was 5.6,
hematocrit 44.1, platelet count 130; PT and INR were normal;
BUN 38, creatinine 1.7, potassium 5.1, glucose 153.
HOSPITAL COURSE: The patient was continued on her current
preadmission medications. Cardiology was requested to see
the patient in anticipation for potential revascularization.
They felt that she was intermediate risk and will require
Persantine Thallium prior to surgery to rule out any
significant coronary artery disease. Pain MIBI demonstrated
a moderate fixed inferior and inferolateral wall Persantine
defect. The ejection fraction was 15%.
Chest x-ray on admission showed left lower lobe opacification
concerning for pneumonia. There may be a small associated
pleural effusion. She had a dual-chamber pacemaker and leads
adequately positioned. She had cardiomegaly with no evidence
of failure.
The patient underwent arterial study on [**10-27**] which
demonstrate severe ostial stenosis of the renal arteries
bilaterally. The was significant ostial stenosis of the
origin of the celiac and superior mesenteric arteries,
occlusion of the right iliac and femoral arteries, and
occlusion of the left hypogastric artery. The patient had
diffuse calcified left common and external iliac arteries and
significant stenosis of bilateral subclavian arteries. The
patient had episodes preprocedure of left brachial artery
spasm which with incomplete response of intra-arterial
vasodilators.
A CT of the head was obtained at the same time requested for
mental status changes, and this was negative for any acute
intracranial hemorrhage or infarct.
Postinterventional procedure, the patient was noted to have
changes in her left arm pulses with absence of the pulse,
associated with the mental status changes, and she had
dysarthria. This was the reason for the head CT. The
patient was begun on intravenous Heparin with a [**2153**] U bolus
and a 600 U/hr with serial PTTs to maintain her PTT at 50-60.
The patient underwent on [**10-28**] an urgent left brachial
artery exploration with [**Doctor Last Name **] thrombectomy and a right
axillo-bifemoral bypass with 6 mm PTFE. The patient required
6 U of packed cells intraoperatively, 2 [**Location 16678**], and 1 U
platelets. The intraoperative findings was a thrombus at the
proximal left brachial artery. The right axial artery inflow
was good. The bilateral SFAs were occluded. The bilateral
profundas were patent, and the right profunda was
endarterectomized. The patient had bilateral Dopplerable
dorsalis pedis pulses at the end of this procedure. Her
postoperative hematocrit was 38.1. Her BUN and creatinine
remained stable. Her total CK was 808. Chest x-ray was
without pneumothorax. Electrocardiogram was with no acute
ischemic changes. She was transferred to the SICU for
continued monitoring and care.
On postoperative day #1, there were no overnight events. She
remained in the SICU intubated and sedated but responding
appropriately to pain. T-max was 99.3??????, heart rate was
60-70, blood pressure 110/58, respirations 22, oxygen
saturation 98%, CVP 5, PAP 54/25, wedge 10, index 1.3, SVR
26.11. She was on Dobutamine 5 mcg/kg/min for inotropic
support. Her postoperative hematocrit was 40.6, PTT 49.3,
INR 1.8, BUN 36, creatinine 1.7; CKs rose to 1700, MBs were
34, troponin was 1.4.
On postoperative day #2, she remained hemodynamically stable
but intubated. She was weaned off her Dobutamine. Diuresis
was continued. On postoperative day #3, there were no
overnight events. She was extubated. Her gases were 7.44,
32, 65, 22, base excess 0. Hematocrit remained stable at
38.2, BUN 51, creatinine 2.4, potassium 3.7, which was
supplemented; INR 1.8, PTT 55. Her pulse exam remained
unchanged. Her urine had E. coli urinary tract infection
which was treated with Levaquin. She was begun on p.o.
intake. Protonix was converted to p.o. She was transferred
to the VICU for continued monitoring and care.
Nutritional Services evaluated the patient and felt that she
was not meeting her caloric needs, and if she remains with
poor intake, recommendations were to start tube feeds until
p.o. intake was adequate.
The patient continued with clinical improvement in her mental
status. On postoperative day #4, her exam remained
unchanged. Her mental status continued to improve. Her
pulse exam was unchanged. Tube feeds were begun, and they
were at goal. She was continued on her Levofloxacin.
On postoperative day #6, the patient removed her NG tube, and
this was replaced. BUN was 63, creatinine improved to 2.0.
Lopressor was converted from IV to p.o.. She was continued
on hydration. Levofloxacin was continued. Case Management
was involved for anticipation of discharge planning.
Respiratory Therapy recommended treatment with Albuterol and
Atrovent nebulizers and pulmonary toileting. The patient
remained afebrile, and hematocrit remained stable.
On postoperative day #7, she was delined and transferred to
the regular nursing floor. Speech and swallow was requested
to see the patient on [**2155-11-4**], because of questions
whether the patient was aspirating. The bedside exam showed
frank aspirations, and recommendations were to make the
patient NPO and continue feeding by tube. TPN was begun at
this time on [**2155-11-6**]. Over the next 24-48 hours, the
patient's respiratory status improve with being NPO. Her
triple line was changed on [**2155-11-6**]. GI was consulted
on [**2155-11-7**], for placement of PEG. They felt that the
patient was a candidate for PEG placement and discussed the
options with the daughter-in-law.
Medicine was consulted on [**11-8**] because of hyponatremia,
and recommendations were for free water and adjustment in her
TPN osmolarity. Her maximum sodium was 151. With adjustment
in her TPN and free water replacement, her hyponatremia
resolved over the next 48 hours. Neurology was requested to
see the patient on [**2155-11-10**], because of mental status
changes. They felt most of this was related to her
hyponatremia, pneumonia, and the current treatment plan was
adequate but to consider decreasing sedation medications.
The patient underwent PEG placement in Interventional
Radiology on [**2155-11-11**]. Her constipation was relieved
with enemas and digital disimpaction. The patient continued
to have episodes of hypoxia. The etiology was probably
pulmonary versus cardiac.
TPN will be continued for several days until tube feeds were
met at goal rate before discontinuing. Consideration to
transfer the patient to the Medical Service was discussed.
Further addendum to the discharge summary will be made at the
time of the patient's discharge.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1477**], M.D. [**MD Number(1) 1478**]
Dictated By:[**Last Name (NamePattern1) 1479**]
MEDQUIST36
D: [**2155-11-11**] 17:55
T: [**2155-11-11**] 18:59
JOB#: [**Job Number 6288**]
ICD9 Codes: 5070, 4280, 496, 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3747
} | Medical Text: Admission Date: [**2171-5-3**] Discharge Date: [**2171-5-10**]
Date of Birth: [**2111-11-11**] Sex: M
Service: Urology
HISTORY OF PRESENT ILLNESS: This is a 59 year old lawyer at
[**Hospital6 1129**] who presents for a chief
complaint of microhematuria. Mr.[**Known lastname **] had a cadaveric renal
transplant three years prior and has been followed by Dr.
[**Last Name (STitle) **] and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. The patient had had
persistent hematuria. The patient has a history of smoking
that dates back to [**2145**] and then quit smoking that year. He
has had a total of 45 year pack history. In addition the
patient came in having noted a lower urinary tract infection
with intermittent urinary urgency, frequency and nocturia two
to four times per night. The patient's urinary symptoms come
on approximately every two to three weeks.
The patient underwent cystoscopy which showed some inflamed
irregularly shaped low signs on the floor of the bladder.
The patient's urine cytology showed atypical cells.
Computerized tomography scan of the abdomen and pelvis showed
no significant upper urinary tract pathology.
PAST MEDICAL HISTORY: Hypertension; membrano proliferative
glomerulonephritis.
PAST SURGICAL HISTORY: Status post appendectomy, status post
cadaveric renal transplant.
MEDICATIONS: Lisinopril, Verapamil, Prednisone, Rapamycin,
Allopurinol, Folic acid, Cellcept, Bactrim.
SOCIAL HISTORY: Lawyer at [**Hospital6 1129**],
quit smoking in [**2145**], two coffees per day, two alcoholic
beverages per day.
PHYSICAL EXAMINATION: On examination the patient was
well-appearing and had regular rate and rhythm. Lungs were
clear to auscultation bilaterally. Examination of the
abdomen revealed obese, nontender, transplanted kidney in the
right lower quadrant and no frank tenderness. Genitourinary
examination showed normal phallus, testes scored on the
urethral meatus.
LABORATORY DATA: BUN and creatinine was 32, 1.8
respectively, and PSA was 0.8.
HOSPITAL COURSE: The patient was admitted to the Urology
Service and underwent cystectomy with ileal conduit. The
patient tolerated the procedure well, however, the patient
was kept intubated when the patient was transferred to the
Post Anesthesia Care Unit. The patient was on Levophed on
admission to the Post Anesthesia Care Unit with epidural and
Propofol for analgesia and sedation. The patient's urine
output was carefully monitored. The plan was to extubate the
patient next morning to manage her metabolic acidosis. On
postoperative day #1, the patient was extubated without any
difficulty. The patient received 2 units of blood for a
hematocrit of 25.7, the patient's creatinine was 2.3. The
patient was extubated without any difficulty and was
continued on pain medications, and epidural without
difficulty.
On postoperative day #2, the patient was followed by renal
attending who recommended holding the Rapamycin until three
to five days after surgery. On postoperative day #2, the
patient started to have some clear fluid from the wound, so
as the patient was afebrile with stable vital signs, the
patient was encouraged out of bed to ambulate. The patient
was continued on nasogastric tube in place. On postoperative
day #3, the patient had no flatus, no complaints, afebrile
with stable vital signs. The patient's wound and dressing
was taken down and showed some erythema along the wound. The
patient's nasogastric tube was removed and he was kept NPO
and the patient was continued on Cellcept and Prednisone for
immunosuppressant and started on Ancef for antibiotics. On
postoperative day #4, the patient had no flatus, no nausea or
vomiting but states he has been burping, was afebrile with
stable vital signs, was making good urine and abdomen was
somewhat distended. He had mild drainage from his abdominal
wound that decreased in severity by post op day 3. The patient
was continued on Cellcept and
Prednisone. On postoperative day #5, the patient states that
he has had flatus, was afebrile with stable vital signs and
the wound was much improved. The patient was advanced to
sips. On postoperative day #6, the patient had a bowel
movement and remained afebrile with stable vital signs and
the wound had 3% erythema. The patient's intravenous fluids
were changed to maintenance of 75 and he was advanced to
clear liquid diet which the patient tolerated without any
difficulties. On postoperative day #7, the patient was
continued on Keflex and Bactrim. The patient had no
complaints, nausea or vomiting. The patient was taken off of
p.o. pain medications. Plan per recommendation by Transplant
Renal Service, was to start the Rapamycin on Saturday and
discharge home with [**Hospital6 407**] and to follow
up with Dr. [**Last Name (STitle) **] and [**Doctor Last Name **] and Dr. [**Last Name (STitle) 4229**] in the future.
The [**Initials (NamePattern4) 228**] [**Last Name (NamePattern4) 1661**]-[**Location (un) 1662**] was removed that day as well
with a creatinine of 1.4.
FOLLOW UP PLANS: Please follow up with Dr. [**Last Name (STitle) 4229**] next
Thursday, please follow up with Dr. [**Last Name (STitle) **] in four to six
weeks. Please follow up with Dr. [**Last Name (STitle) **] in four weeks.
DISCHARGE MEDICATIONS:
1. Prednisone 5 mg p.o. q. day.
2. Bactrim one tablet three times a week, Monday, Thursday
and Saturday.
3. Lisinopril 20 mg p.o. q. day.
4. Verapamil 40 mg sustained release p.o. q. 24 hours.
5. Cellcept [**Pager number **] mg p.o. b.i.d.
6. Percocet 1 to 2 tablets q. 4 to 6 hours prn pain.
7. Keflex 500 mg p.o. q. 6 hours for a few more days.
8. Rapamycin 2 mg p.o. q. day, starting tomorrow.
DISCHARGE STATUS: Home with [**Hospital6 407**].
CONDITION ON DISCHARGE: Good.
[**Doctor First Name **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 8916**]
Dictated By:[**Last Name (NamePattern1) 3118**]
MEDQUIST36
D: [**2171-5-10**] 16:48
T: [**2171-5-10**] 16:56
JOB#: [**Job Number 8917**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3748
} | Medical Text: Admission Date: [**2114-7-17**] Discharge Date: [**2114-7-25**]
Date of Birth: [**2061-7-26**] Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: The patient is a 52-year-old
male with a past medical history significant for hypertension
who had recently lost a large amount of weight, approximately
70 pounds, over the past six to eight months. As per the
wife, the patient had been jogging on the day of admission
about four miles. He came home and started doing push-ups
and started complaining of left arm pain. A little while
later the wife heard a thump. She walked into the room to
find the patient lying on the floor unconscious. She
activated EMS. Upon EMS arrival within ten minutes they
began CPR. The patient subsequently was found to be in
ventricular tachycardia and was shocked for that. The
patient was intubated in the field and taken to an outside
hospital. At the outside hospital he was noted to be
unresponsive, to be in a decerebrate posture. He was found
to have ST elevations on EKG in leads 2, 3 and aVF. He was
given aspirin, heparin, Lopressor, Aggrastat, intravenous
amiodarone and was transferred here to the [**Hospital1 346**] Catheterization Laboratory. In the
Catheterization Laboratory the patient's left main, left
anterior descending and left circumflex arteries were all
found to be normal. His right coronary artery had a very
distal 90% narrowing. No intervention or stenting was
performed. On right heart pressures he had a CVP of 10. His
pulmonary artery pressure was 28/13, wedge pressure was 13.
Cardiac output was 7.56 and his cardiac index was 3.98.
Aggrastat was stopped and he was sent to the Coronary Care
Unit for admission. On the floor in the Coronary Care Unit
the patient was intubated and unresponsive.
PHYSICAL EXAMINATION: Vital signs: He was afebrile with a
temperature of 98.6. His heart rate ranged from 52 to 103.
His blood pressure ranged from 115 to 212 systolic and 91 to
151 diastolic. His respirations ranged from 14 to 22. He
was satting 97% on the vent. Vent settings were FiO2 of 40%,
tidal volume of 600, rate of 14 with a PEEP of 5. On
physical examination, the patient was lying in bed
unresponsive. Patient did not have any jugular venous
distention. His lungs were clear. His heart had a regular
rhythm. No murmurs, rubs or gallops were appreciated. His
abdomen was benign. The extremities were warm. He had good
pulses. On neuro examination, he withdrew to painful
stimuli. He had some extensor posturing and his toes were
downgoing.
LABORATORY VALUES: His white count was 18. Another
significant value was a potassium value of 3.1.
ELECTROCARDIOGRAM: Showed a normal sinus rhythm at 70 beats
per minute.
RADIOLOGY: His chest x-ray did not demonstrate any pulmonary
edema. No infiltrates. He had a CT of his head that showed
no evidence of a bleed and no mass effect. He had a CT of
the neck that showed no fracture.
HOSPITAL COURSE: The patient was started on labetalol for
blood pressure control. Neurology was consulted because of
continued decerebrate posturing. A CT scan of the head was
unremarkable. His loss of arousability was thought to be due
to anoxic brain injury from his cardiac arrest. He was
started on Dilantin for a few days in case his posturing was
due to seizures. An EEG revealed generalized slowing but no
epileptiform activity. He slowly improved per subsequent
Neurology notes and he was extubated on [**7-20**]. An MRI was
ordered because of a right-sided facial droop and weakness
that revealed an increased signal in the left thalamus
internal capsule which may be artifact according to the
official read. Some other medical issues: He was started on
levofloxacin and Flagyl for presumed aspiration pneumonia
given some fever and cough. Because the etiology for his
ventricular tachycardia arrest was not entirely clear, an ICD
was placed on [**2114-7-23**]. He also had coffee ground emesis
on admission which resolved with proton pump inhibitor
therapy.
CONDITION AT DISCHARGE: Stable.
DISCHARGE DIAGNOSES: Acute myocardial infarction.
DISCHARGE MEDICATIONS:
1. Atorvastatin 10 mg p.o. q. day.
2. Heparin 5000 units subcu q. 8h.
3. Aspirin 325 mg p.o. q. day.
4. Protonix 40 mg p.o. q. 24h.
5. Metoprolol 37.5 mg p.o. b.i.d.
6. Captopril 50 mg p.o. t.i.d.
FOLLOW-UP PLANS: The patient is to be transferred to an
acute rehab facility. Patient should follow up with a
cardiologist within one week. The name of the rehab facility
is [**Hospital3 245**]. This chart is dictated up until [**2114-7-24**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**]
Dictated By:[**Last Name (NamePattern1) 51940**]
MEDQUIST36
D: [**2114-7-24**] 16:57
T: [**2114-7-24**] 17:24
JOB#: [**Job Number 51941**]
ICD9 Codes: 5070, 4275, 4271, 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3749
} | Medical Text: Admission Date: [**2182-6-5**] Discharge Date: [**2182-7-11**]
Date of Birth: [**2143-12-21**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Levaquin / Biaxin
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Tracheal Obstruction
Major Surgical or Invasive Procedure:
bronchoscopy
History of Present Illness:
38 y/o male with PMHx significant for type 1 diabetes, history
of jail time, who initially presented at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] with 10
days of chest tightness, mylagias, couging, fever, and wheezing,
as well as shortness of breath. At OSH patient was being treated
for CAP and started on azithromycin and ceftriaxone. Patient had
CXR done at OSH which showed diffuse reticular nodular opacities
involving bilateral lungs. CT chest at OSH was reported to show
diffuse ground glass opacification and diffuse adenopathy. There
was also adenopathy that was compressing the trachea, given this
concern for airway obstruction patient was intubated and
transferred to [**Hospital1 18**] for further management. He was ruled out
for MI with negative CEx3 and negative EKG
Past Medical History:
Type 1 diabetes
Asthma
Diabetic nephropathy
fractures fibula [**3-/2181**]
H/O MRSA PNA
Social History:
Smokes 1ppd for many years, no drug or etoh history, history of
jail time
Family History:
NC
Physical Exam:
PE: T 97.8 BP 110/48 HR 102 RR 16 O2SAt 97% AC 450x14 PEEP 5
FiO2 60 7.21/70/80
Gen: Patient intubated, sitting up in bed, gagging on tube
Heent: PERRL, EOMI, ETT tube in place
Neck: no LAD appreciated
Lungs: diffuse ronchi throughout
Cardiac: tachy, RR S1/S3
Abdomen: soft NT +BS
Ext: no edema
Neuro: awake
Pertinent Results:
[**2182-6-5**] 03:55PM NEUTS-55 BANDS-14* LYMPHS-19 MONOS-8 EOS-4
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2182-6-5**] 04:15PM TYPE-ART RATES-14/ TIDAL VOL-450 PEEP-5 O2-60
PO2-80* PCO2-70* PH-7.21* TOTAL CO2-30 BASE XS--1
INTUBATED-INTUBATED VENT-CONTROLLED
.
CT chest [**6-6**]:
FINDINGS: Endotracheal tube is in place, with tip terminating
just above the level of the aortic arch. The trachea is abnormal
in size and contour. The trachea is enlarged with coronal
diameter of 2.8 cm. Additionally, it has a lunate configuration
with elevated coronal to sagittal ratio. During expiration,
there is excessive collapsibility of the tracheal lumen,
resulting in reduction of cross-sectional area from 149 mm2 to
53 mm2. This likely underestimates the degree of collapsibility
because it was not performed as a dynamic expiratory scan.
Dense consolidation is present throughout both lower lobes with
homogeneous increased density with prominent air bronchograms.
More heterogeneous lung opacities are present within the
anterior, nondependent portions of the lungs, including the
upper lobes, middle lobe and lingula. These areas demonstrate
peribronchiolar ground-glass opacities, areas of consolidation,
and centrilobular/tree-in-[**Male First Name (un) 239**] opacities.
Enlarged lymph nodes are present within the mediastinum,
measuring up to 13 mm within the right paratracheal and
precarinal regions. Additionally, there is diffuse stranding
throughout the mediastinal fat, likely due to edema. The heart
size is normal. There is no pericardial effusion. Small
bilateral pleural effusions are present.
Within the imaged portion of the upper abdomen, there is a trace
amount of ascites. The remaining imaged portion of the upper
abdomen is unremarkable on this unenhanced CT which was not
specifically tailored to evaluate the abdominal organs. Diffuse
anasarca is present throughout the chest and abdominal wall soft
tissues.
IMPRESSION:
1. Enlarged, lunate trachea configuration with associated
tracheomalacia. Severity of tracheomalacia is likely
underestimated on this end-expiratory scanning sequence.
2. Diffuse bilateral lung parenchymal abnormalities, including
peribronchiolar opacities in the upper and mid lungs and
extensive confluent consolidation in the lower lobes. The
findings are most consistent with diffuse infection complicated
by ARDS. A component of hydrostatic edema is also possible,
particularly given the presence of diffuse anasarca and
bilateral pleural effusions.
.
echo [**6-6**]:
Conclusions:
The left atrium is normal in size. Left ventricular wall
thicknesses are
normal. The left ventricular cavity size is normal. Due to
suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Overall left ventricular systolic function is
low normal (LVEF 50%). The right ventricular cavity is dilated.
Right ventricular systolic function is borderline normal; there
are echolucent areas in the basal and midventricular segments of
the right ventricular free wall; the apical segment of the right
ventricular free wall appears thin. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic regurgitation. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. There is moderate pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion.
Impression: status post cardiac arrest; dilated hypocontractile
right
ventricle; consider arrhythmogenic right ventricular
cardiomyopathy
.
CTA [**6-15**]:
IMPRESSION:
1. No evidence of pulmonary embolus.
2. Redemonstration of multifocal parenchymal opacities. Some of
the right lung opacities appear to have progressed, while others
in the left upper lobe, appear slightly better than on [**2182-6-6**].
3. Bilateral lower lobe consolidation, unchanged. Unchanged
bilateral pleural effusions.
4. Severe tracheobronchomalacia. Suggestion of bronchiectasis in
multiple areas, difficult to assess given the presence of
intubation/positive-pressure ventilation.
.
TTE [**6-18**]:
No evidence for intracardiac (right-to-left) shunt identified.
.
PORTABLE ABDOMEN [**2182-7-1**] 11:11 AM
Bowel gas pattern is unremarkable and there is no evidence of
free air on this portable film. Possible nlargement of the liver
silhouette may represent hepatomegaly or a prominent Riedel's
lobe. Surrounding osseous structures are unremarkable.
IMPRESSION: No evidence of ileus or obstruction.
.
CHEST (PORTABLE AP) [**2182-7-2**] 12:45 AM
IMPRESSION: AP chest compared to [**6-26**] through 9.
Small bilateral pleural effusion has increased, with new
fissural components. Atelectasis or consolidation at the left
base has improved since [**6-29**] and atelectasis at the right lung
base, which has been difficult to assess all along appears to
have improved, restricted to the posterior basal segment. Heart
size is normal. No pneumothorax. Tracheostomy tube and right
subclavian line in standard placements. No pneumothorax.
.
CT CHEST W/O CONTRAST [**2182-7-6**] 2:35 PM
There is dense collapse and consolidation of the dependent
aspects of both lung bases, right greater than left. There is
minimal improvement in the aeration of the left lower lobe.
Patchy nodular airspace opacification is again noted involving
the right upper lobe, left upper lobe and the aerated portions
of the left lower lobe. This has not significantly changed from
the prior examination. Small bilateral pleural effusions are
again noted which have slightly improved from the prior
examination. As previously described there is evidence of
tracheomalacia. A tracheostomy tube appears in the mid trachea.
No pericardial effusion is present.
Limited unenhanced images through the upper abdomen are
unchanged.
IMPRESSION: Dense collapse and consolidation of lung bases eith
minimal improvement in the aeration of the left lower lobe.
Patchy nodular airspace disease throughouth the lungs relatively
unchanged consistentwith multilobar pneumonia and ARDS.
.
[**2182-7-10**] 9:47 AM
CHEST, UPRIGHT AP PORTABLE: Comparison is made to five days
earlier and to a more recent CT from [**2182-7-6**]. Patient is
status post tracheostomy. A PICC line terminates at the
cavoatrial junction. Cardiac and mediastinal contours are
unremarkable. There are no effusions or pneumothorax. Patchy
bilateral alveolar opacities are somewhat more extensive than
before.
IMPRESSION: Worsening patchy bilateral, predominantly basilar,
parenchymal opacities.
Brief Hospital Course:
38 y/o M with DM type 1, history of jail time who presented to
OSH with what was thought to be CAP, found to have ground glass
opacification and diffuse adenopathy on chest CT s/p intubation
for airway obstruction, development of ARDS.
.
## Respiratory Failure/ARDS - The patient was admitted with
respiratory failure due to ARDS from PNA. Of note, pt HIV and TB
negative. He could not be consented in house given intubation
and current sedation. The patient was treated per ARDS NET
protocol. He was started on broad spectrum antibiotics, which
initially included vancomycin and ceftazidime. Pt was proned to
aid in ventilation. He required paralytics as he was quite
agitated and needed them to tolerate proning. He underwent BAL
which grew MRSA. (Pt initially treated w/ vanco, and later
linezolid as pt had positive screen for VRE). Patient seemed to
improve over a week or so, no longer needing ARDS
protocol/proning. He then subsequently decompensated and became
more hypoxic, possibly from volume overload. This persisted
despite attempts at aggressive diuresis. Thus, he underwent CTA
which was negative for PE but showed some progression of prior
opacities (along w/ stable b/l effusions). Based on his vent
settings it appeared as if his ARDS might be worsening.
Because of this, he was restarted on paralytics, placed on ARDS
protocol again with proning. Pt was aggresively diuresed (as he
was over 20lb up since admission).
With diuresis & abx, pt slowly improved. Proning was
discontinued during the second week of [**Month (only) **]. He was gradually
weaned off the vent. Pt went for tracheostomy w/ surgery.
Eventually transitioned to trach mask alone. (Of note, on
admission and on CT scan there was question of possible
tracheomalacia/obstruction. This was not seen on pt's
bronchoscopy.) ABG's demonstrate no marked hypercarbia.
Tolerating trach mask well on 0/35 FiO2. Off abx for pneumonia,
stable on trach mask. Treated with abx.
.
## PNA: Pt had been treated with CTX & azithro at OSH. His
coverage was broadened to ceftazidime & vanco following
admission to [**Hospital1 18**]. Pt's BAL grew MRSA (?colonization vs
pathogen). ID was consulted. They felt that pt did not have
typical MRSA PNA picture as cx had low MRSA colony count and
imaging showed lymphadenopathy and ARDS/multifocal pneumonia.
ID recommended extensive workup for other causes, including
legionella, erhlichia, tuleremia, chlamydia, mycoplasma, and
babesia, all of which were negative. Pt received 16 days of
ceftazidime and 14 days of linezolid and doxycycline, the latter
of which was added for empiric tularemia tx. Pt defervesced and
white count decreased with above treatment. Off antibiotics for
pneumonia at the time of discharge to rehab. With slight
worsening appearance of opacities on chest x-ray, still concern
for tularemia or other pathology not covered/
-Follow up on Tularemia abx, blood cx
-Follow up appointment with ID
.
## Pulm Edema: likely ARDS plus component of fluid overload
following aggressive fluid resuscitation. Pt was aggressively
diuresed w/ lasix lasix gtt--this was stopped on [**6-25**]. Pt was
given lasix bolus PRN. CXR shows resolving effusions/edema.
Lasix was given PRN, and as [**7-10**] CXR demonstrated possible fluid
overload 40 IV lasix given. Patient net + 5 liters at time of
discharge. Lasix to be given as needed if signs of overload,
clinical and imaging studies demonstrate need.
.
## Sedation: Pt required enormous doses of sedatives to keep him
calm and prevent him from removing lines/self-extubating. He
required paralytics on top of sedatives for this and to tolerate
the proning. Weaning sedation proved very difficult. Methadone
was started to help wean off IV fentanyl and other sedatives.
Then, fentanyl patch initiated, in attempt attempt to wean
methadone and prevent opiate withdrawal. Fentanyl patch
decreased, use methadone PRN and then DC'd; used haldol PRN
agitation. Final regimen at time of discharge included Fentanyl
patch at 150 mcg to be decreased as tolerated: Clonipine 3 mg
TID, to be weaned as tolerated slowly, Morphine 1-2 mg q 2 for
agitation pain, ativan as needed, and standing Haldol to be
decreased to PRN as needed.
.
## PEA arrest: On the night of admission the patient had pea
arrest, with cpr for 2-5 minutes. The patient responded to epi
and atropine. The cause was likely respiratory as prior to the
event the patient had oxygen sats in the 70's. The patient
required fluids and pressors and eventually was weaned off
pressors.
.
## Hypotension: Thought to be primarily from sepsis, although
high PEEP and large doses of propofol likely also contributed.
His [**Last Name (un) 104**] stim was negative. As his infection was treated and
propofol weaned, he was able to be weaned off Levophed. Once of
sedatives, and ventilator, BP increased and pt was hypertensive
during weaning off narcotics and sedation.
.
## Anemia: The patient had a slow drop in his hematocrit.
Required occasional transfusions. Thought to be due to
infection, renal failure and dilutional effect. Guaiac negative.
EPO was started per renal recommendation. Discontinued several
days prior to DC as felt anemia related to renal failure which
was resolving in addition to acute illness. Stable at time of
discharge, guiac negative.
.
## ARF: ATN from hypotension/contrast nephropathy. Muddy brown
casts on UA. FEUrea 65%. This slowly resolved. However, renal
function again worsened in setting of aggressive diuresis. Renal
followed patient while in house. Once diuresis slowed and
pressors discontinued, pt's renal function improved. Not
worsened with diuresis and close to baseline at the time of
discharge.
.
## HSV: Facial vesicular rash, swab-no virus isolated.
Day 13/14 on day of discharge.
.
## Hyponatremia/Hypernatremia: likely hypervolemic hyper-Na+,
diurese & volume restrict. Resolved. Hypernatremia ensued later
in the course, treated with free water flushes, which resolved
after several days as well.
.
## Hypothermia- axillary, possibly related to propofol,
infection, narcotics.
Resolved at the time of discharge.
.
## Diffuse adenopathy - Noted on admission. this could be
reactive secondary to infection as mentioned above. Given
history of jail time patient with risk factor for TB. PPD
placed at OSH which was negative. Other differential could be
HIV, though this was also negative at OSH. Other concern would
be malignant such as lymphoma. [**Month (only) 116**] still require LN biopsy if
this does not resolve w/ tx of PNA. At time of discharge no
inguinal lymphadenopathy palpated, likely reactive secondary to
infection.
.
## DM type 1 - The patient's sugars were closely followed and
was treated intermittently with insulin drip and when off the
drip glargine and SSI according to his finger sticks. Stable on
glargine and sliding scale at the time of discharge.
.
## PPx: Heparin SC, PPI, bowel regimen
## Code: full
## FEN: on TPN then transitioned tubefeed TF. PEG placed by
surgery. Patient receiving tube feeds at goal via the PEG tube
with minimal residual. Diuresed as needed, but not grossly fluid
overloaded at the time of discharge to the rehab facility.
## Access: PICC line
##Comm: Mother [**Name2 (NI) 41890**] [**Telephone/Fax (1) 41891**]
Medications on Admission:
Lantus 20U qhs
Humalog sliding scale
Combivent
Advair 250/50 [**Hospital1 **]
.
Meds on transfer:
Lantus 12 units
Duonebs q4 via neb
Mucinex 2 tabs [**Hospital1 **]
Azithromycin 500mg q24
Ceftriaxone 1g q24
Advair 250/50 [**Hospital1 **]
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol [**Hospital1 **]: Four (4) Puff
Inhalation Q6H (every 6 hours).
2. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Hospital1 **]: Six (6)
Puff Inhalation QID (4 times a day).
3. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1)
Injection TID (3 times a day).
4. Acetaminophen 160 mg/5 mL Solution [**Hospital1 **]: One (1) PO Q4-6H
(every 4 to 6 hours) as needed.
5. Polyvinyl Alcohol 1.4 % Drops [**Hospital1 **]: 1-2 Drops Ophthalmic PRN
(as needed).
6. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
7. Docusate Sodium 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID (2
times a day).
8. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO twice a day as
needed for constipation.
9. Bisacodyl 10 mg Suppository [**Last Name (STitle) **]: One (1) Suppository Rectal
DAILY (Daily) as needed.
10. Clonazepam 1 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO TID (3 times
a day).
11. Lactulose 10 g/15 mL Syrup [**Last Name (STitle) **]: Thirty (30) ML PO Q8H (every
8 hours) as needed.
12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
13. Fentanyl 100 mcg/hr Patch 72 hr [**Last Name (STitle) **]: One (1) Transdermal
Q72H (every 72 hours): 125 MCG patch.
14. Acyclovir 400 mg IV Q8H
d# 1 [**6-29**]
15. Lorazepam 0.5-1 mg IV Q4H:PRN agitation
16. Haloperidol 5 mg IV TID
17. Morphine Sulfate 1-2 mg IV Q2H:PRN
hold for sedation and rr<10
18. Insulin Glargine 100 unit/mL Cartridge [**Month/Day (4) **]: Twelve (12)
units Subcutaneous at bedtime: in addition to ISS, see attached
table.
Discharge Disposition:
Extended Care
Facility:
Radius
Discharge Diagnosis:
Primary:
ARDS
pneumonia
Acute renal failure
Narcotic withdrawal/agitation
DM I
Anemia
HSV
Hypotension
Hypernatremia
Hyponatremia
.
Secondary:
Asthma
diabetic nephropathy
h/o MRSA pneumonia
Fibula fracture
Discharge Condition:
stable
Discharge Instructions:
You were admitted with ARDS, and had a long hospital stay
-Continue all medications, neb treatments.
-Wean narcotics as tolerated
-Acyclovir x 2 days, to complete 14 day course
-Follow up with infectious disease
-Follow up on pending tularemia antibody and blood culture data
-CXR, abx and diuresis as needed
-Trach and PEG tube placement
Followup Instructions:
Please follow up with PCP from rehab facility
.
Please follow up with infectious disease, discussion of
Tularemia and review of cx and Antibiotic data.
ICD9 Codes: 0389, 4275, 5845, 3051, 2930 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3750
} | Medical Text: Admission Date: [**2187-2-4**] Discharge Date: [**2187-3-8**]
Date of Birth: [**2136-5-25**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
fever, myalgias, bruises
Major Surgical or Invasive Procedure:
placement of central lines
lumbar punctures and intrathecal chemotherapy
History of Present Illness:
50-year-old woman with history of hypertension and
hyperlipidemia was transferred from [**Hospital6 **] after
presenting there with one week of muscle aches, neck tenderness,
several bruises, and fever, found to have WBC 233,000,
concerning for acute leukemia.
Patient was in her usual state of health when about a week ago
she started feeling tired, with myalgias, then tender cervical
adenopathy. She also developed fevers. Her chronic back pain was
also worse. Pt also was reporting heavy menstrual cycles that
lasted 1 week one week prior to admission. Upon admission to
[**Hospital3 **], she was noted to have an elevated WBC of >200,000,
plt: 10 and was transfused and transferred to [**Hospital1 18**] on [**2-4**] for
further management. She had a bone marrow biopsy performed the
same day that was notable for acute myeloid leukemia with
monocytic differentiation. She immediately underwent
plasmapheresis and subsequently went into DIC with onset of ARF.
Past Medical History:
HTN
hyperlipidemia
depression
Social History:
Remote history of smoking. No EtOH. Lives with husband.
Currently unemployed.
Family History:
Mother: breast cancer. Maternal grandmother: gastric or colon
cancer.
Physical Exam:
T 101.7, BP 162/102, HR 92, RR 18, 93%RA
Gen: middle-aged woman looking anxious but in no acute distress
HEENT: EOMI, PERRL, OM moist without lesion
Neck: diffuse tender bilateral anterior cervical adenopathy
Lungs: CTA bilaterally
CV: regular rate, normal rhythm, normal S1/S2 without any m/r/g
Abd: soft, nontender, no HSM, BS present
Ext: no c/c/e
Skin: no ecchymosis
Neuro: oriented x 3, mood appropriate
Pertinent Results:
LABS ON ADMISSION:
[**2187-2-4**] 06:30PM WBC 250,000 RBC-2.96* HGB-9.2* HCT-25.9*
MCV-88 MCH-31.1 MCHC-35.5* RDW-16.5*
[**2187-2-4**] 06:30PM PLT COUNT-77*
[**2187-2-4**] 06:30PM PT-15.5* PTT-31.2 INR(PT)-1.4*
[**2187-2-4**] 06:30PM FIBRINOGE-179
[**2187-2-4**] 06:30PM GLUCOSE-154* UREA N-9 CREAT-1.0 SODIUM-144
POTASSIUM-3.2* CHLORIDE-105 TOTAL CO2-26 ANION GAP-16
[**2187-2-4**] 06:30PM ALT(SGPT)-55* AST(SGOT)-49* LD(LDH)-1490* ALK
PHOS-140* AMYLASE-54 TOT BILI-0.7
[**2187-2-4**] 06:30PM ALBUMIN-3.9 CALCIUM-8.5 PHOSPHATE-1.3*
MAGNESIUM-1.9 URIC ACID-6.0* IRON-128
LABS ON DISCHARGE:
[**2187-3-8**] 12:00AM BLOOD WBC-1.8* RBC-3.30* Hgb-9.5* Hct-27.0*
MCV-82 MCH-28.6 MCHC-35.0 RDW-13.7 Plt Ct-197
[**2187-3-8**] 12:00AM BLOOD Neuts-70 Bands-0 Lymphs-18 Monos-11 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-1*
[**2187-3-8**] 12:00AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-2+ Polychr-OCCASIONAL Spheroc-1+ Ovalocy-1+
Schisto-OCCASIONAL
[**2187-3-8**] 12:00AM BLOOD Plt Smr-NORMAL Plt Ct-197
[**2187-3-5**] 12:00AM BLOOD Fibrino-448*
[**2187-3-8**] 12:00AM BLOOD Gran Ct-1278*
[**2187-3-8**] 12:00AM BLOOD Glucose-107* UreaN-15 Creat-0.9 Na-137
K-3.3 Cl-105 HCO3-24 AnGap-11
[**2187-3-8**] 12:00AM BLOOD ALT-58* AST-44* LD(LDH)-258* AlkPhos-128*
TotBili-1.0
[**2187-2-17**] 05:07PM BLOOD Lipase-74*
[**2187-2-21**] 03:46AM BLOOD CK-MB-3 cTropnT-0.03*
[**2187-3-8**] 12:00AM BLOOD Calcium-8.3* Phos-3.0 Mg-2.0 UricAcd-2.0*
BLOOD COUNTS:
[**2187-2-4**] 06:30PM BLOOD WBC-250.0* RBC-2.96* Hgb-9.2* Hct-25.9*
MCV-88 MCH-31.1 MCHC-35.5* RDW-16.5* Plt Ct-77*
[**2187-2-4**] 11:30PM BLOOD WBC-245.4* RBC-2.89* Hgb-8.8* Hct-25.5*
MCV-88 MCH-30.2 MCHC-34.4 RDW-16.4* Plt Ct-72*
[**2187-2-5**] 12:56AM BLOOD WBC-124.0* RBC-2.61* Hgb-8.1* Hct-22.9*
MCV-88 MCH-31.1 MCHC-35.4* RDW-17.1* Plt Ct-121*#
[**2187-2-5**] 01:25AM BLOOD WBC-101.9* RBC-2.47* Hgb-7.3* Hct-21.8*
MCV-88 MCH-29.5 MCHC-33.5 RDW-16.9* Plt Ct-96*
[**2187-2-5**] 02:22AM BLOOD WBC-59.4* RBC-2.46* Hgb-7.6* Hct-21.5*
MCV-87 MCH-30.8 MCHC-35.2* RDW-16.7* Plt Ct-54*
[**2187-2-5**] 03:28AM BLOOD WBC-89.2*# RBC-2.66* Hgb-8.2* Hct-22.9*
MCV-86 MCH-30.9 MCHC-36.0* RDW-16.9* Plt Ct-33*
[**2187-2-5**] 07:53AM BLOOD WBC-121.7* RBC-2.20* Hgb-6.8* Hct-18.5*
MCV-84 MCH-31.1 MCHC-36.9* RDW-17.0* Plt Ct-19*
[**2187-2-5**] 02:22PM BLOOD WBC-125.2* RBC-2.73* Hgb-8.5* Hct-22.7*
MCV-83 MCH-31.1 MCHC-37.3* RDW-16.8* Plt Ct-58*#
[**2187-2-5**] 07:15PM BLOOD WBC-107.1* RBC-2.57* Hgb-7.9* Hct-21.1*
MCV-82 MCH-30.9 MCHC-37.5* RDW-17.0* Plt Ct-43*
[**2187-2-5**] 07:15PM BLOOD WBC-107.1* RBC-2.57* Hgb-7.9* Hct-21.1*
MCV-82 MCH-30.9 MCHC-37.5* RDW-17.0* Plt Ct-43*
[**2187-2-6**] 01:56AM BLOOD WBC-107.0* RBC-2.56* Hgb-7.9* Hct-21.3*
MCV-83 MCH-30.7 MCHC-36.9* RDW-17.3* Plt Ct-25*
[**2187-2-6**] 07:52AM BLOOD WBC-76.3* RBC-2.53* Hgb-7.8* Hct-21.2*
MCV-84 MCH-30.7 MCHC-36.8* RDW-17.2* Plt Ct-20*
[**2187-2-6**] 02:20PM BLOOD WBC-49.2* RBC-2.86* Hgb-8.5* Hct-23.9*
MCV-83 MCH-29.6 MCHC-35.5* RDW-16.5* Plt Ct-16*
[**2187-2-7**] 01:53AM BLOOD WBC-25.7* RBC-2.85* Hgb-8.4* Hct-24.0*
MCV-84 MCH-29.4 MCHC-34.9 RDW-16.3* Plt Ct-27*#
[**2187-2-7**] 08:04AM BLOOD WBC-11.0# RBC-2.63* Hgb-8.0* Hct-22.8*
MCV-87 MCH-30.5 MCHC-35.3* RDW-16.2* Plt Ct-19*
[**2187-2-7**] 10:51PM BLOOD WBC-1.7*# RBC-2.24* Hgb-6.9* Hct-19.5*
MCV-87 MCH-31.1 MCHC-35.7* RDW-15.8* Plt Ct-7*#
[**2187-2-8**] 08:04AM BLOOD WBC-1.0* RBC-2.88*# Hgb-9.0*# Hct-25.2*#
MCV-87 MCH-31.1 MCHC-35.6* RDW-15.0 Plt Ct-17*
[**2187-2-9**] 12:00AM BLOOD WBC-0.3*# RBC-2.77* Hgb-8.5* Hct-23.7*
MCV-85 MCH-30.6 MCHC-35.9* RDW-15.1 Plt Ct-27*
[**2187-2-9**] 11:24AM BLOOD WBC-0.1*# RBC-2.96* Hgb-9.0* Hct-24.8*
MCV-84 MCH-30.3 MCHC-36.2* RDW-14.8 Plt Ct-21*
[**2187-2-10**] 12:30AM BLOOD WBC-0.1* RBC-2.75* Hgb-8.4* Hct-22.9*
MCV-84 MCH-30.5 MCHC-36.5* RDW-14.9 Plt Ct-6*#
[**2187-2-10**] 12:46PM BLOOD WBC-0.1* RBC-2.50* Hgb-7.6* Hct-21.1*
MCV-85 MCH-30.3 MCHC-35.8* RDW-14.7 Plt Ct-27*
[**2187-2-11**] 12:00AM BLOOD WBC-0.1* RBC-2.95* Hgb-8.8* Hct-25.1*
MCV-85 MCH-30.0 MCHC-35.3* RDW-14.6 Plt Ct-20*
[**2187-2-11**] 12:08PM BLOOD WBC-0.1* RBC-2.59* Hgb-7.8* Hct-22.0*
MCV-85 MCH-30.1 MCHC-35.5* RDW-14.6 Plt Ct-19*
[**2187-2-12**] 12:00AM BLOOD WBC-0.1* RBC-2.35* Hgb-7.3* Hct-20.0*
MCV-85 MCH-30.8 MCHC-36.2* RDW-14.7 Plt Ct-8*#
[**2187-2-13**] 12:35AM BLOOD WBC-<0.1* RBC-3.07*# Hgb-9.1* Hct-25.4*#
MCV-83 MCH-29.7 MCHC-35.9* RDW-14.7 Plt Ct-12*#
[**2187-2-13**] 05:13PM BLOOD WBC-0.1* RBC-2.61* Hgb-7.6* Hct-21.9*
MCV-84 MCH-29.0 MCHC-34.5 RDW-14.9 Plt Ct-18*
[**2187-2-14**] 04:30AM BLOOD WBC-.1* RBC-2.86* Hgb-8.8* Hct-24.2*
MCV-85 MCH-30.7 MCHC-36.3* RDW-14.8 Plt Ct-14*
[**2187-2-15**] 12:00AM BLOOD WBC-0.1* RBC-3.09* Hgb-9.3* Hct-25.9*
MCV-84 MCH-30.3 MCHC-36.0* RDW-14.7 Plt Ct-26*
[**2187-2-19**] 12:10AM BLOOD WBC-0.1* RBC-2.74* Hgb-8.3* Hct-23.2*
MCV-85 MCH-30.2 MCHC-35.6* RDW-14.8 Plt Ct-64*
[**2187-2-20**] 12:00AM BLOOD WBC-0.1* RBC-3.03* Hgb-9.2* Hct-25.4*
MCV-84 MCH-30.3 MCHC-36.2* RDW-14.5 Plt Ct-27*#
[**2187-2-20**] 02:03PM BLOOD WBC-0.2*# RBC-2.98* Hgb-9.0* Hct-24.7*
MCV-83 MCH-30.2 MCHC-36.5* RDW-14.5 Plt Ct-56*
[**2187-2-21**] 03:46AM BLOOD WBC-0.2* RBC-3.36* Hgb-9.8* Hct-28.3*
MCV-84 MCH-29.3 MCHC-34.8 RDW-14.5 Plt Ct-43*
[**2187-2-22**] 12:00AM BLOOD WBC-0.1* RBC-3.00* Hgb-8.9* Hct-24.9*
MCV-83 MCH-29.5 MCHC-35.5* RDW-14.6 Plt Ct-31*
[**2187-2-22**] 11:47AM BLOOD WBC-0.2*# RBC-2.66* Hgb-8.0* Hct-22.3*
MCV-84 MCH-30.1 MCHC-35.9* RDW-14.0 Plt Ct-17*
[**2187-2-23**] 12:00AM BLOOD WBC-0.2* RBC-2.74* Hgb-7.8* Hct-23.2*
MCV-85 MCH-28.4 MCHC-33.6 RDW-14.4 Plt Ct-11*
[**2187-2-23**] 12:22PM BLOOD WBC-0.1* RBC-2.47* Hgb-7.5* Hct-20.7*
MCV-84 MCH-30.5 MCHC-36.4* RDW-14.4 Plt Ct-86*
[**2187-2-24**] 12:10AM BLOOD WBC-0.2*# RBC-3.40*# Hgb-9.8*# Hct-28.9*#
MCV-85 MCH-28.7 MCHC-33.8 RDW-14.3 Plt Ct-75*
[**2187-2-25**] 12:00AM BLOOD WBC-0.1* RBC-2.91* Hgb-8.7* Hct-24.2*
MCV-83 MCH-29.8 MCHC-35.8* RDW-14.2 Plt Ct-45*
[**2187-2-26**] 12:30AM BLOOD WBC-0.1* RBC-2.79* Hgb-8.2* Hct-23.4*
MCV-84 MCH-29.4 MCHC-35.0 RDW-14.1 Plt Ct-22*#
[**2187-2-27**] 06:20AM BLOOD WBC-0.2*# RBC-3.30* Hgb-9.8* Hct-27.1*
MCV-82 MCH-29.8 MCHC-36.3* RDW-14.0 Plt Ct-7*#
[**2187-2-28**] 12:00AM BLOOD WBC-0.3* RBC-3.21* Hgb-9.5* Hct-26.1*
MCV-81* MCH-29.5 MCHC-36.3* RDW-13.8 Plt Ct-37*
[**2187-2-28**] 10:40AM BLOOD WBC-0.4* RBC-3.22* Hgb-9.5* Hct-26.7*
MCV-83 MCH-29.6 MCHC-35.7* RDW-13.7 Plt Ct-40*
[**2187-3-1**] 12:00AM BLOOD WBC-0.4* RBC-2.96* Hgb-8.8* Hct-24.5*
MCV-83 MCH-29.6 MCHC-35.8* RDW-13.6 Plt Ct-28*
[**2187-3-2**] 12:00AM BLOOD WBC-0.5* RBC-2.83* Hgb-8.4* Hct-22.9*
MCV-81* MCH-29.6 MCHC-36.7* RDW-13.5 Plt Ct-89*#
[**2187-3-3**] 12:15AM BLOOD WBC-0.8*# RBC-3.12* Hgb-9.1* Hct-25.6*
MCV-82 MCH-29.2 MCHC-35.6* RDW-13.5 Plt Ct-81*
[**2187-3-4**] 12:00AM BLOOD WBC-0.9* RBC-2.93* Hgb-8.7* Hct-24.1*
MCV-82 MCH-29.5 MCHC-35.8* RDW-13.7 Plt Ct-79*
[**2187-3-5**] 12:00AM BLOOD WBC-1.3* RBC-3.38* Hgb-9.9* Hct-27.6*
MCV-82 MCH-29.3 MCHC-35.9* RDW-14.0 Plt Ct-112*
[**2187-3-5**] 12:00AM BLOOD WBC-1.5*# RBC-3.38* Hgb-9.7* Hct-27.5*
MCV-81* MCH-28.7 MCHC-35.3* RDW-13.9 Plt Ct-149*#
[**2187-3-7**] 12:00AM BLOOD WBC-1.4* RBC-3.12* Hgb-9.1* Hct-25.9*
MCV-83 MCH-29.1 MCHC-35.1* RDW-13.8 Plt Ct-168
GRANULOCYTE COUNTS (ANC):
[**2187-2-9**] 12:00AM BLOOD Gran Ct-24*
[**2187-2-10**] 12:30AM BLOOD Gran Ct-0*
[**2187-2-11**] 12:00AM BLOOD Gran Ct-0*
[**2187-2-12**] 12:00AM BLOOD Gran Ct-0*
[**2187-2-19**] 12:10AM BLOOD Gran Ct-0*
[**2187-2-22**] 12:00AM BLOOD Gran Ct-0*
[**2187-2-22**] 11:47AM BLOOD Gran Ct-30*
[**2187-2-24**] 12:10AM BLOOD Gran Ct-0*
[**2187-2-25**] 12:00AM BLOOD Gran Ct-15*
[**2187-2-26**] 12:30AM BLOOD Gran Ct-0*
[**2187-2-27**] 06:20AM BLOOD Gran Ct-82*
[**2187-2-28**] 12:00AM BLOOD Gran Ct-176*
[**2187-3-1**] 12:00AM BLOOD Gran Ct-264*
[**2187-3-2**] 12:00AM BLOOD Gran Ct-420*
[**2187-3-3**] 12:15AM BLOOD Gran Ct-517*
[**2187-3-4**] 12:00AM BLOOD Gran Ct-612*
[**2187-3-5**] 12:00AM BLOOD Gran Ct-858*
[**2187-3-5**] 12:00AM BLOOD Gran Ct-1186*
[**2187-3-7**] 12:00AM BLOOD Gran Ct-1000*
[**2187-3-8**] 12:00AM BLOOD Gran Ct-1278*
[**2187-2-9**] 12:00AM BLOOD proBNP-3746*
[**2187-2-17**] 12:13PM BLOOD proBNP-1457*
[**2187-2-20**] 02:03PM BLOOD CK-MB-3 cTropnT-0.03*
[**2187-2-21**] 03:46AM BLOOD CK-MB-3 cTropnT-0.03*
Pancreatic:
[**2187-2-13**] 12:35AM BLOOD Lipase-135*
[**2187-2-14**] 04:30AM BLOOD Lipase-198*
[**2187-2-17**] 05:07PM BLOOD Lipase-74*
LFTs:
[**2187-2-4**] 06:30PM BLOOD ALT-55* AST-49* LD(LDH)-1490*
AlkPhos-140* Amylase-54 TotBili-0.7
[**2187-2-5**] 02:22PM BLOOD ALT-83* AST-135* AlkPhos-126*
TotBili-4.0* DirBili-2.0* IndBili-2.0
[**2187-2-5**] 07:15PM BLOOD LD(LDH)-3234* TotBili-4.0*
[**2187-2-6**] 01:56AM BLOOD LD(LDH)-2721* TotBili-2.4*
[**2187-2-6**] 07:52AM BLOOD ALT-65* AST-69* LD(LDH)-2570* AlkPhos-103
TotBili-1.7*
[**2187-2-6**] 02:20PM BLOOD LD(LDH)-2209* TotBili-1.5
[**2187-2-6**] 08:07PM BLOOD LD(LDH)-1847* TotBili-1.3
[**2187-2-7**] 10:51PM BLOOD ALT-36 AST-29 LD(LDH)-1059* AlkPhos-63
TotBili-1.1
[**2187-2-8**] 08:04AM BLOOD ALT-33 AST-28 LD(LDH)-958* AlkPhos-65
TotBili-1.1
[**2187-2-9**] 12:00AM BLOOD ALT-29 AST-30 LD(LDH)-866* AlkPhos-69
TotBili-1.1
[**2187-2-11**] 12:00AM BLOOD ALT-27 AST-35 LD(LDH)-714* AlkPhos-83
TotBili-1.3
[**2187-2-13**] 12:35AM BLOOD ALT-43* AST-56* LD(LDH)-625* AlkPhos-91
Amylase-148* TotBili-2.6*
[**2187-2-14**] 04:30AM BLOOD ALT-32 AST-28 LD(LDH)-526* AlkPhos-67
Amylase-182* TotBili-1.4 DirBili-0.7* IndBili-0.7
[**2187-2-15**] 12:00AM BLOOD ALT-27 AST-23 LD(LDH)-518* AlkPhos-71
TotBili-1.3
[**2187-2-17**] 12:00AM BLOOD ALT-21 AST-20 LD(LDH)-423* AlkPhos-59
TotBili-1.5
[**2187-2-19**] 12:10AM BLOOD ALT-17 AST-18 LD(LDH)-366* AlkPhos-56
TotBili-1.7* DirBili-0.9* IndBili-0.8
[**2187-2-21**] 03:46AM BLOOD ALT-23 AST-22 LD(LDH)-393* CK(CPK)-48
AlkPhos-74 TotBili-2.7*
[**2187-2-26**] 12:30AM BLOOD ALT-29 AST-24 LD(LDH)-279* AlkPhos-111*
TotBili-2.2*
[**2187-3-3**] 12:15AM BLOOD ALT-34 AST-33 LD(LDH)-232 AlkPhos-120*
TotBili-1.4
[**2187-3-4**] 12:00AM BLOOD ALT-39 AST-36 LD(LDH)-245 AlkPhos-115*
TotBili-1.0
[**2187-3-5**] 12:00AM BLOOD ALT-36 AST-29 LD(LDH)-243 AlkPhos-118*
TotBili-1.1
[**2187-3-5**] 12:00AM BLOOD ALT-40 AST-34 LD(LDH)-247 AlkPhos-127*
TotBili-1.2
[**2187-3-7**] 12:00AM BLOOD ALT-57* AST-58* LD(LDH)-250 AlkPhos-119*
TotBili-1.0
[**2187-3-8**] 12:00AM BLOOD ALT-58* AST-44* LD(LDH)-258* AlkPhos-128*
TotBili-1.0
NHIBITORS & ANTICOAGULANTS
Anticardiolipin Antibody IgG 5.4 GPL 0 - 15
0-15 GPL: NEGATIVE;15-20 GPL: INDETERMINATE; >20 GPL: POSITIVE
Anticardiolipin Antibody IgM 5.4 MPL 0 - 12.5
MICROBIOLOGY:
Initial Cultures [**2187-2-4**] - [**2187-2-18**] were all negative.
afebrile for a while
spiked -->
positive culture:
[**2187-2-25**] BLOOD CULTURE Blood Culture, Routine-FINAL
{ENTEROCOCCUS FAECIUM}; Anaerobic Bottle Gram Stain-FINAL;
Aerobic Bottle Gram Stain-FINAL INPATIENT
surveilance cultures:
[**2187-3-4**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2187-3-4**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2187-3-3**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2187-3-3**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2187-3-2**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2187-2-28**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2187-2-27**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2187-2-26**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2187-2-26**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2187-2-25**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
IMAGING:
ECHOCARDIOGRAMS:
[**2187-2-5**]: The left atrium is mildly dilated. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%). There is no ventricular septal
defect. Right ventricular chamber size and free wall motion are
normal. The ascending aorta is mildly dilated. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. The left ventricular inflow
pattern suggests impaired relaxation. The tricuspid valve
leaflets are mildly thickened. There is moderate pulmonary
artery systolic hypertension. There is a trivial/physiologic
pericardial effusion.
[**2187-2-19**]: [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 3841**] dilated. A patent foramen ovale is present.
LVEF >55%. No masses/thrombi/vegetations. There is no VSD.
CHEST X-RAYS:
[**2-4**]: UPRIGHT PORTABLE CHEST RADIOGRAPH: No priors are
available. Other than some left basal linear atelectasis the
lungs appear clear and without evidence of pneumothorax, edema,
effusions, or lymphadenopathy. Cardiomediastinal silhouette are
within normal limits. No osseous abnormalities are noted.
[**2-17**]: Heart size, mediastinal width and pulmonary vascularity
remain
normal. Worsening patchy and linear opacities at both lung
bases, favoring
atelectasis over infectious pneumonia and accompanied by small
pleural
effusions.
[**3-2**]: One view. Comparison with [**2187-2-28**]. There is minimal
streaky density
bilaterally consistent with subsegmental atelectasis as before.
There is new blunting of the left costophrenic sulcus with hazy
increased density in the lower left chest. The heart and
mediastinal structures are unremarkable and unchanged. A central
venous catheter remains in place. IMPRESSION: Evidence for
development of small left effusion.
CT AND MRIs:
MRI Head ([**2-16**]):
1. No evidence of acute infarct, mass effect, hydrocephalus, or
abnormal enhancement.
2. Low signal within the bony structures due to marrow
infiltrative process or hypoplasia.
CT ABDOMEN W/CONTRAST Study Date of [**2187-2-16**] 5:28 PM
1. Colonic wall thickening/edema more marked along right colon
than the left, similar to 3 days ago, but with increased
thickening/edema of terminal ileum. Findings are non-specific,
more likely infectious or inflammatory, but given new AML, if
the patient is undergoing treatment, typhlitis is possible.
Otherwise inflammatory bowel disease such as Crohn's could also
be considered. Prominent right lower quadrant mesenteric lymph
nodes.
2. Increased ascites and third-spacing compared to three days
prior.
3. Splenic infarct as first imaged on [**2187-2-13**].
4. Small bilateral pleural effusions and adjacent atelectasis.
Unchanged liver hypodensities, left adrenal nodule, presacral
perirectal
multilobulated endometriomas.
CT ABDOMEN W/CONTRAST Study Date of [**2187-2-22**] 4:46 PM
IMPRESSION:
1. Persistent cecal and terminal ileum wall thickening is again
seen although
slightly improved compared to prior CT.along the most prominent
in the right
colon, involving the cecum and proximal ascending colon with
involvement of
the terminal ileum.
2. Persistent but slightly decreased ascites, simple in
attenuation.
3. Increased now moderated size pleural effusions with
associated lower lobe
atelectasis.
5. Persistent wedge-shaped hypodensity in the spleen consistent
with an
infarct.
6. Stable left adrenal nodule.
7. Stable presacral and perirectal partially cystic lesion
previously
characterized as endometriomas.
BONE MARROW BIOPSIES:
Procedure date Tissue received Report Date Diagnosed
by
[**2187-2-4**] [**2187-2-5**] [**2187-2-7**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 21496**]/ttl
Previous biopsies: [**Numeric Identifier 60209**] ATYPICAL MOLE RLQ (ABD), RE-EXC
DYSPLASTIC MOLE LLQ
[**Numeric Identifier 60210**] ATYPICAL MOLE LLQ (MID) AND RE-EXCISION DYSPLASTIC
MOLE
[**Numeric Identifier 60211**] GROWTH (LESION) RIGHT FOREARM AND ATYPICAL NEVUS
LLQ X 1
[**Numeric Identifier 60212**] FALLOPIAN TUBE/OVARY FS.
SPECIMEN: BONE MARROW ASPIRATE AND CORE BIOPSY:
DIAGNOSIS:
INVOLVEMENT BY ACUTE MYELOID LEUKEMIA WITH MONOCYTIC
DIFFERENTIATION, SEE NOTE.
Note: Please correlate with cytogenetic findings.
Morphologically and immunophenotypically, this is in keeping
with acute monoblastic leukemia (FAB subtype M5a).
MICROSCOPIC DESCRIPTION
Peripheral Blood Smear:
The smear is adequate for evaluation. Erythrocytes appear
decreased in number and are normochromic with
anisopoikilocytosis, including dacryocytes and ovalocytes. The
white blood cell count appears markedly increased, and consists
predominantly of large cells with moderate amounts of pale blue
cytoplasm, including some with granules, round to indented
nuclei, [**Doctor Last Name **] open chromatin, and prominent nucleoli. Platelet
count appears decreased. Differential count shows 2%
neutrophils, 3% lymphocytes, 1% eosinophils, 94% blasts (43%
monoblasts, 51% promonocytes). Some contain few granules and
some have indented nuclei, morphologically resembling monoblasts
and promonocytes.
Aspirate Smear:
The aspirate material is adequate for evaluation, and consists
of several hypercellular spicules consisting primarily of
monoblasts and promonocytes with morphology similar to that seen
in the peripheral smear. The residual hematopoietic marrow
elements are scant. Megakaryocytes are present in decreased
numbers; abnormal forms are not seen.
Differential shows: 90% Blasts (57% monoblasts, 33%
promonocytes), less than 1% Promyelocytes, less than 1%
Myelocytes, less than 1% Metamyelocytes, less than 1%
Bands/Neutrophils, 2% Plasma cells, 3% Lymphocytes, less than 1%
Erythroid. Blasts include monoblasts and promonocytes.
Occasional scattered eosinophilic precursors are seen.
Clot Section and Biopsy Slides:
The biopsy material is adequate for evaluation, and consists of
a 1.5 cm core biopsy of trabecular bone. Overall cellularity is
estimated to be greater than 90%, and largely consists of large
atypical cells morphologically consistent with blasts. Residual
hematopoietic elements are scant. Touch prep adds no additional
information.
Special Stains:
Iron stain is adequate for evaluation. Storage iron is normal.
No sideroblasts or ringed sideroblasts are seen however these
are difficult to assess due to the scant numbers of erythroid
precursors present.
Flow cytometry studies: show blasts expressing CD4 (dim),
HLA-DR, CD33, CD15, CD11c, CD64, CD56, CD71, CD14 (subset).
Cytogenetics Report BONE MARROW - CYTOGENETICS Procedure Date of
[**2187-2-5**]
Specimen Type: BONE MARROW - CYTOGENETICS
Lab #: [**Numeric Identifier 60213**]
Date and Time Taken: [**2187-2-4**] 8:15 PM Date Processed: [**2187-2-5**]
Requesting Physician: [**Name (NI) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. Location: INPATIENT
Cell culture was established to provide metaphase
cells for chromosome analysis. However, no metaphases were
available from this specimen, therefore the cytogenetic
analysis could not be performed.
Please see results of FISH analysis below.
-------------------INTERPHASE FISH ANALYSIS, 100-300
CELLS-------------------
nuc ish(D8Z2x2),(MLLx2)[100]
FISH evaluation for a MLL rearrangement was performed on
nuclei with the LSI MLL Dual Color, Break Apart Probe
(Vysis) at 11q23 and is interpreted as NORMAL. No
rearrangement was observed in 100/100 nuclei, which is
within the range of a normal hybridization pattern
(up to 1%) established for this probe in our laboratory. A
normal MLL FISH finding can result from absence of a MLL
rearrangement, from a variant MLL rearrangement, or from an
insufficient number of neoplastic cells in the specimen.
FISH evaluation for a chromosome 8 aneuploidy was performed
with the Vysis CEP 8 DNA Probe (chromosome 8 alpha
satellite DNA) at 8p11.1-q11.1 and is interpreted as
NORMAL. Two hybridization signals were detected in 95/100
nuclei examined, which is within the normal range (up to
6%) for this probe in our laboratory. A normal chromosome
8 FISH finding can result from absence of trisomy
for chromosome 8 or from an insufficient number of
neoplastic cells in the specimen.
This test was developed and its performance determined by
the [**Hospital1 18**] Cytogenetics Laboratory as required by the CLIA
'[**65**] regulations. It has not been cleared or approved by the
U.S. Food and Drug Administration. This test is used for
clinical purposes.
D8Z2 at 8p11.1-q11.1
MLL 5' probe at 11q24
MLL 3' probe at 11q24
Cytogenetics Report BONE MARROW - CYTOGENETICS Procedure Date of
[**2187-2-20**]
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 60214**],[**Known firstname **] A [**2136-5-25**] 50 Female
[**Numeric Identifier 60215**] [**Numeric Identifier 60216**]
Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 21496**], La,[**Doctor Last Name **]/mtd
SPECIMEN SUBMITTED: BONE MARROW (1 JAR)
Procedure date Tissue received Report Date Diagnosed
by
[**2187-2-20**] [**2187-2-20**] [**2187-2-22**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 21496**]/dsj??????
Previous biopsies: [**Numeric Identifier 60217**] Immunophenotyping, CSF
[**Numeric Identifier 60218**] immunophenotyping - BM
[**Numeric Identifier 60219**] BONE MARROW BIOPSY (1 JAR).
[**Numeric Identifier 60209**] ATYPICAL MOLE RLQ (ABD), RE-EXC DYSPLASTIC MOLE LLQ
(and more)
SPECIMEN: BONE MARROW ASPIRATE AND CORE BIOPSY:
DIAGNOSIS: Markedly hypocellular marrow (less than 5%
cellular), status post chemotherapeutic ablation.
MICROSCOPIC DESCRIPTION
Peripheral Blood Smear:
The smear is adequate. Erythrocytes appear decreased in
number, are mildly hypochromic with anisopoikilocytosis
including bite cells, echinocytes, acanthocytes, dacrocytes, and
microcytes. The white blood cell count appears markedly
decreased. Platelet count appears decreased; large forms are not
seen. Differential count shows 100% lymphocytes.
Aspirate Smear:
The aspirate material is adequate and consists of several
hypocellular spicules composed of stromal cells, histiocytes,
plasma cells, and lymphocytes. Hemosiderin laden macrophages
are present.
Clot Section and Biopsy Slides:
The biopsy material is adequate and consists of a 1.1 cm core of
trabecular bone. Overall cellularity is less than 5%, and
consists largely of plasma cells and lymphocytes. The remainder
is composed of stromal cells, macrophages, and background
eosinophilic material consistent with ablative chemotherapy.
Marrow clot section is similar to the biopsy.
Specimen Type: BONE MARROW - CYTOGENETICS
Lab #: [**Numeric Identifier 60220**]
Date and Time Taken: [**2187-2-20**] 1:30 PM Date Processed: [**2187-2-20**]
Requesting Physician: [**Name (NI) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. Location: INPATIENT
Cell culture was established to provide metaphase
cells for chromosome analysis. Please see results
of karyotype below.
-------FOCUSED ANALYSIS--------
KARYOTYPE: 46,XX[6]
INTERPRETATION:
No cytogenetic aberrations were identified in 6
metaphases analyzed from this unstimulated specimen.
This normal result does not exclude a neoplastic
proliferation.
Mosaicism and small chromosome anomalies may not be
detectable using the standard methods employed.
This study does not represent a full cytogenetic analysis
of 20 cells due to poor growth of the specimen in culture.
-------INTERPHASE FISH ANALYSIS, 100-300 CELLS---------
nuc ish(ETO,AML1)x2[100]
FISH evaluation for an AML1-ETO rearrangement was
performed on nuclei with the LSI AML1/ETO Dual Color,
Dual Fusion Translocation Probe ([**Doctor Last Name 7594**] Molecular) for ETO
at 8q22 and AML1 at 21q22 and is interpreted as NORMAL.
No rearrangement was observed in 98/100 nuclei, which is
within the normal range (up to 1% dual rearrangement and
3% technical artifact) for this probe in our laboratory. A
normal finding can result from absence of an AML1-ETO
rearrangement, from a variant AML1-ETO rearrangement, or
from an insufficient number of neoplastic cells in the
specimen.
This test was developed and its performance
determined by the [**Hospital1 18**] Cytogenetics Laboratory
as required by the CLIA '[**65**] regulations. It has not
been cleared or approved by the U.S. Food and Drug
Administration. This test is used for clinical
purposes.
Pathology Examination
Procedure date Tissue received Report Date Diagnosed
by
[**2187-3-6**] [**2187-3-8**] [**2187-3-8**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/aas??????
Previous biopsies: [**Numeric Identifier 60221**] BONE MARROW (1 JAR)
[**Numeric Identifier 60215**] BONE MARROW (1 JAR)
[**Numeric Identifier 60217**] Immunophenotyping, CSF
[**Numeric Identifier 60218**] immunophenotyping - BM
(and more)
FLOW CYTOMETRY REPORT
FLOW CYTOMETRY IMMUNOPHENOTYPING
The following tests (antibodies) were performed: CD4, CD14,
CD15, CD19, CD33, CD56, CD45, CD117.
RESULTS:
Three color gating is performed (light scatter vs. CD45) to
optimize blast yield. A limited panel is performed to look for
residual disease.
Approximately 6% of total analyzed events co-express CD4, CD56,
CD33, CD14 and CD15.
INTERPRETATION
The findings are suspicious for increased blasts. However, this
small population of blasts cannot be further distinguished, due
to lack of unique markers. The differential diagnosis includes
residual/blasts relapse of leukemia vs regenerating myeloblasts.
CSF:
Cytology Report SPINAL FLUID Procedure Date of [**2187-2-23**]:
NEGATIVE FOR MALIGNANT CELLS.
Cytology Report SPINAL FLUID Procedure Date of [**2187-3-1**]:
NEGATIVE FOR MALIGNANT CELLS. Rare mature lymphocytes.
Brief Hospital Course:
50-year-old woman with HTN and hyperlipidemia here with
hyperleukocytosis with WBC 250,000 with smear suggesting of
acute myeloid leukemia.
# Acute Monoblastic Leukemia: presented with one week of muscle
aches, neck tenderness, several bruises, and fever, found to
have WBC 233,000, and bone marow biopsy showing acute
monoblastic leukemia (FAB subtype M5a) with monocytic
differentiation. Treated with 7+3 regimen (cytarabine and
idarubicin) with significant complications of prolonged
neutropenic fever, typhlitis, mucositis, all discussed
separately. D14 BM Biopsy showed 5% cellularity without blasts.
D28 BM biopsy, however, was concerning for increased blasts, but
could not be further analyzed due to lack of markers.
# CNS Involvement: Concern for CNS involvement of disease partly
due to perceived mental status changes although in context of
significant pain and medication. LP showed no specific malignant
cells but a high monocyte count felt to be concerning for
leptomeningeal spread of disease. Started on 10 dose (2/week x 5
week) course of IT MTX and cytarabine. Intrathecal Chemo Doses:
[**2-18**] IT Ara C, [**2-23**] IT Cytarabine, [**3-1**] IT Cytarabine, [**3-5**]
IT MTX, [**3-8**] IT Cytarabine.
# Febrile Neutropenia/VRE Bacteremia: Admitted ([**2-4**]) with fever
to 101.7 which rose to 103.2 on day #2 and peaked at 104.9 on
[**2-10**]. No source of infection was initially found, and she was
empirically treated initially with vancomycin, cefepime and
fluconazole but continued to spike. She developed significant
typhlitis (discussed below) which was felt to be a possible
source of infection, and then blood cultures on [**2-25**] grew out
VRE in [**2-15**] bottles. She was treated with a 14 day course of
daptomycin which was continued via PICC line at the time of
discharge to run through [**2187-3-12**]. Fevers gradually resolved. She
was afebrile for 3 days prior to discharge.
# Typhlitis (pseudomembranous enterocolitis): Developed severe
abdominal pain after becoming neutropenic. CT abdomen/pelvis
significant for colonic wall thickening/edema suggestive of
typhilitis in the setting of treatment for AML. Developed
peritoneal signs on exam including significant rebound
tenderness. Surgery consulted however no surgical intervention
appropriate. Treated with bowel rest, IVF, TPN, and continued
antibiotics, as well as glutamine and antiemetics. Resolved
gradually with rising ANC and patient's diet was slowly
advanced. She was tolerating regular food without difficulty
across the final two days of her hospitalization.
# Mucocitis: Patient developed severe Grade III mucositis as she
became neutropenic. Treated with Caphosol, Gelclair, acyclovir
and morphine PCA. Improved as ANC rose.
# Hypertension: Patient with a history of hypertension on
atenolol and lisinopril at home. Lisinopril was initially held
due to the risk of renal failure during the initial treatement
course and atenolol was switched to [**Hospital1 **] metoprolol due to ease
of dosing control. She remaind hypertensive across much of her
admission with difficulty controlling BPs on a range of
medications. She was transferred back to the ICU briefly for
hypertensive urgency in the context of severe pain from
typhlitis. No evidence of end organ damage by history or exam.
BPs improved with increased pain control but she remained
hypertensive across most of the remainder of her
hospitalization. Her pressures normalized during the final three
days of her hospitalization with amlodipine on top of an
increased doses of her home beta blocker and her regular home
lisinopril. The resolution of her pain, however, was felt to
have played the greatest role.
# Hyperleukocytosis: Patient presented with one week of muscle
aches, neck tenderness, several bruises, and fever, found to
have WBC 233,000 concerning for acute leukemia. On admission she
underwent leukopheresis and was started on hydroxyurea and
allopurinol. Her WBC decreased acutely after leukopheresis but
then began to rapidly increase, and then came down with further
hydroxyurea.
# ARF: Developed ARF on second day of hospitalization with
creatinine rising to 2.0 from 1.0 on admission. Gradually
resolved with IVF. Remained stable at 0.7-0.9 across last three
weeks of hospitalization.
# DIC: Developed DIC on second day of hospitalization in
settting of AML with leukocytosis. DIC resolved shortly without
further complications.
# Hypoxic Respiratory Distress: Developed hypoxic respiratory
distress [**2-13**] fluid overload in context of significant IVF given
for ARF and DIC previous mentioned. No intubation. Resolved with
lasix. Small pleural effusion noted on imaging close to
discharge.
# Hyperbilirubinemia: Brief rise in conjugated bilirubin in the
setting of fevers concerning for obstructive process although
with normal LFTs. RUQ U/S showed sludge but no evidence of
cholelithiasis/cholangitis. Resolved shortly thereafter.
# Splenic Infarct: Incidentally found on CT scan, unclear age
and etiology. Small PFO on bubble study. Partial coagulopathy
workup negative, appropriate for outpatient follow up.
# Radiographic Abnormalities for Outpatient Follow-Up: In
addition to the splenic infarct CTs and MRIs showed persistent
liver hypodensities (previously seen on imaging), a left adrenal
nodule, and presacral perirectal multilobulated endometriomas
previously seen on MR in [**2185-3-17**].
Medications on Admission:
atenolol 25 mg qday
lisinopril 10 mg qday
bupropion (not compliant)
simvastatin
Discharge Medications:
1. Daptomycin 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours): infuse 400mg daily through
[**2187-3-12**].
[**Month/Day/Year **]:*qs Recon Soln(s)* Refills:*0*
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
[**Month/Day/Year **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* NOTE:
this was changed to Omeprazole 20mg after discharge due to lack
of insurance coverage for pantoprazole.
3. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
[**Month/Day/Year **]:*60 Tablet(s)* Refills:*2*
4. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
[**Month/Day/Year **]:*30 Tablet(s)* Refills:*0*
5. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for anxiety, nausea, insomnia.
[**Month/Day/Year **]:*40 Tablet(s)* Refills:*1*
6. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-13**] Sprays Nasal
TID (3 times a day) as needed for dry nose.
[**Month/Day (2) **]:*qs * Refills:*0*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
[**Month/Day (2) **]:*60 Capsule(s)* Refills:*2*
8. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Month/Day (2) **]:*30 Tablet(s)* Refills:*2*
9. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Month/Day (2) **]:*30 Tablet(s)* Refills:*2*
10. Zofran 4 mg Tablet Sig: 1-2 Tablets PO every eight (8)
hours.
[**Month/Day (2) **]:*40 Tablet(s)* Refills:*2*
11. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Five
(5) Tablet Sustained Release PO once a day: Take 5 tablets daily
through [**2187-3-12**], and then as directed by your physician.
[**Name Initial (NameIs) **]:*50 Tablet Sustained Release(s)* Refills:*0*
12. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain: please take only as needed for
significant pain.
[**Name Initial (NameIs) **]:*25 Tablet(s)* Refills:*0*
13. Trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
[**Name Initial (NameIs) **]:*30 Tablet(s)* Refills:*2*
14. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Name Initial (NameIs) **]:*30 Tablet(s)* Refills:*2*
15. Hair Prosthetic
ICD: 205.00
Dispense #2
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
Acute Myeloid Leukemia
Hypertension
Typhlitis
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
It was a pleasure taking care of you during your admission at
[**Hospital1 69**]. You were admitted for
acute myeloid leukemia. You were treated with chemotherapy as
well as antibiotics. You developed a few complications during
your treatment which included ongoing fevers, typhlitis (an
inflammation of the bowel during chemotherapy), mucositis, and
high blood pressure. The fevers, typhlitis and mucositis have
all now resolved. Your high blood pressures have come down with
some new medications.
We have changed several of your medications during this
admission. Please take your medications exactly as prescribed.
Please follow up with your oncologist as directed below.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7779**], MD Phone:[**Telephone/Fax (1) 3241**]
Date/Time:[**2187-3-12**] 12:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9574**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 3241**]
Date/Time:[**2187-3-12**] 12:30
ICD9 Codes: 5849, 7907, 5119, 4019, 2724, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3751
} | Medical Text: Admission Date: [**2111-11-7**] Discharge Date: [**2111-11-12**]
Date of Birth: [**2062-10-27**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3006**]
Chief Complaint:
s/p traumatic amputation of R index finger
Major Surgical or Invasive Procedure:
Replantation of R index finger Zone 1 injury with subsequent
revision amputation
History of Present Illness:
This is a 49 yo R hand dominant healthy man who sustained a
complete amputation of his R index finger with a hydraulic wood
splitter 3 hours prior to evaluation at [**Hospital1 18**]. He was initially
seen at an outside facility and transferred to [**Hospital1 18**] for
consideration or replantation.
Past Medical History:
None
Social History:
Lives with wife. Non [**Name2 (NI) 1818**]. Occasional etOH.
Family History:
CAD
Physical Exam:
Afebrile, 87 139/78 20 97% RA
NAD
R index finger: amputation at proximal [**2-17**] of middle phalynx.
PIP flexion intact. Amputated tip is clean with respect to soft
tissue and appropriately preserved with 4 hours cold ischemia
time.
Pertinent Results:
Admission Labs:
[**2111-11-7**] 06:07PM BLOOD WBC-10.2 RBC-4.46* Hgb-13.8* Hct-38.4*
MCV-86 MCH-31.0 MCHC-36.0* RDW-13.4 Plt Ct-245
[**2111-11-7**] 06:07PM BLOOD Neuts-77.8* Lymphs-15.3* Monos-4.7
Eos-1.9 Baso-0.4
[**2111-11-7**] 06:07PM BLOOD PT-13.0 PTT-24.3 INR(PT)-1.1
[**2111-11-7**] 06:07PM BLOOD Glucose-87 UreaN-15 Creat-1.1 Na-139
K-3.9 Cl-103 HCO3-26 AnGap-14
.
Discharge labs:
[**2111-11-11**] 01:10AM BLOOD WBC-7.5 RBC-3.37* Hgb-10.6* Hct-28.8*
MCV-86 MCH-31.4 MCHC-36.7* RDW-13.2 Plt Ct-225
.
HAND (AP, LAT & OBLIQUE) RIGHT [**2111-11-7**] 6:12 PM
Complete amputation at the mid distal second middle phalanx. The
amputated distal tip has been imaged. There is a relative simple
transverse fracture at the amputation site.
Brief Hospital Course:
A long discussion was held with Mr [**Known lastname 68543**] and his wife about
treatment options, incluidn gcompleting the amputation versus
attempting a replantation. We reviewed
unpredictable success rate of replantation, postoperative
stiffness, cold sensitivity if the replant lives, as well as
time out from work. Patient opted to attempt replantation.
.
Replanation was performed on the night of admission.
Post-operatively, the replanted tip was congested. He was
monitored in the ICU and was treated with heparin gtt, ASA,
leeches, and direct warmth to the digit. Despite these
measures, on POD the arterial doppler signal dissipated and the
leeches no longer attached to his distal tip. The tip
subsequently became cool and cyanotic. He underwent revision
amputation on [**2111-11-11**] (POD 4).
Medications on Admission:
Occasional aspirin
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain: do not drive or
operate heavy machinery while taking this medication.
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Replantation of amputated Index finger R with subsequent
revision amputation
Discharge Condition:
Good, afebrile, tolerating POs
Discharge Instructions:
You had a traumatic amputation of your right index finger. It
was surgically replanted, however the replantation was not
successful and you subsequently underwent surgical amputation of
your replanted finger.
You finger is to remain wrapped in the dressing until your
follow-up appointment in hand clinic.
.
Follow up as indicated below.
.
Take all medications as prescribed.
.
Please notify your physician immediately with the following
signs and symptoms:
- Fever >101.1
- Bluish discoloration of your finger or if your finger becomes
cold
- significant increase in pain
- redness, discharge, swelling of your finger or red streaks
extending from your finger
- chest pain
- shortness of breath
- other symptoms that concern you.
Followup Instructions:
You should follow-up in the Hand Clinic this upcoming Tuesday.
Please call ([**Telephone/Fax (1) 7138**] to make an appointment.
.
You should call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] office at ([**Telephone/Fax (1) 2007**]
to make a follow-up appointment in approximately 10 days.
Completed by:[**2111-11-12**]
ICD9 Codes: 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3752
} | Medical Text: Admission Date: [**2178-1-10**] Discharge Date: [**2178-1-24**]
Date of Birth: [**2178-1-10**] Sex: M
Service: Neonatology
HISTORY: Baby [**Name (NI) **] [**First Name4 (NamePattern1) 66296**] [**Known lastname **] delivered at 35-weeks
gestation with a birth weight of 3490 grams and was admitted
to the newborn intensive care nursery for management of
prematurity and respiratory distress.
On the history, mother is a 31-year-old gravida 3, para 2,
now 3 woman with pregnancy complicated by gestational
diabetes mellitus, diet controlled. The prenatal screens
included blood type O-positive, antibody negative, hepatitis
B surface antigen negative, rubella immune, RPR nonreactive,
and group B strep unknown. The mother presented with
abdominal pain and elevated liver function tests with a
question of pyelonephritis. She received antibiotics for a
question of pyelonephritis and was delivered by cesarean
section due to the abdominal pain. Her membranes are rupture
at delivery for clear fluid. She did not have a fever.
This infant was vigorous at delivery. He was bulb suctioned,
dried, and received tactile stimulation, and some free-flow
oxygen. He developed mild grunting and intercostal
retractions in the delivery room. Apgar scores were 8 at 1
minute and 9 at 5 minutes.
Subsequent to the delivery, the mother developed [**Name (NI) 1349**]
syndrome, and she was diagnosed on [**2178-1-18**] and is
being treated for that with replacement hormone.
PHYSICAL EXAM ON ADMISSION: Weight 3490 grams (greater than
the 90th percentile), length 50 cm (90th percentile), head
circumference 34.5 cm (greater than the 90th percentile).
Macrosomic near term infant on warmer with nasal CPAP in
place. Anterior fontanel is soft, flat, nondysmorphic. Palate
intact. Neck normal. Mouth normal. No nasal flaring. Chest
with mild intercostal retractions, good breath sounds
bilaterally, no adventitious sounds. Cardiovascular: Well
perfused, regular rate and rhythm, femoral pulses normal, no
murmur. Abdomen is soft, nondistended, no organomegaly, no
masses, bowel sounds active. Anus patent. Three-vessel
umbilical cord. GU: Normal penis. Testes descended
bilaterally. Neurology: Active, alert, responds to
stimulation, normal tone. Positive suck, root, and gag.
Musculoskeletal system: Normal spine, limbs, hips, and
clavicles.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: Respiratory: Was
placed on nasal prong CPAP room air for some mild grunting
and retracting. Was weaned off the CPAP by 24 hours of age to
room air. Has remained in room air since with comfortable
work of breathing, respiratory rates in the 30s-50s.
Has had mild apnea and bradycardia of prematurity not
requiring any methylxanthine. The last apnea and bradycardia
spell was on [**2178-1-19**].
Cardiovascular: No murmur. Heart rates range in the 130s-
150s. Recent blood pressure 79/39 with a mean of 54.
Fluid, electrolytes, and nutrition: Was initially NPO.
Maintained on intravenous fluid. Started feedings on day of
life 1. Has always orally fed, taking feeds ad-lib with
[**Year (4 digits) 56280**] 20, initially with breast milk. But now because of
mother's [**Doctor Last Name 1349**] disease, her milk supply is diminished and
is expected to lose it. So, the baby is now ad-lib feeding
[**Name (NI) 56280**] 20 taking in excellent amounts. Discharge weight is
3520g.
GI: Was treated for indirect hyperbilirubinemia with
phototherapy for a couple of days. Peak bilirubin was on day
of life 8, total of 14.3, direct 0.4. Repeat bilirubin on
[**1-20**] was total 11.9, direct 0.3 and follow-up on [**1-24**] was
8.6/0.3
Hematology: Patient's hematocrit at birth was 59%. Blood type
was not done.
Infectious disease: He received 48 hours of ampicillin and
gentamicin for rule out sepsis due to respiratory distress.
CBC was benign. Blood culture was negative.
Neurology: Exam is age appropriate.
Sensory: Hearing screening was performed with automated
auditory brainstem responses and passed both ears.
Psychosocial: The parents are from [**Location (un) **] and were here on a
Visa visiting and have to return to [**Location (un) **] on [**2-3**]. They
have a meeting to get a passport for the infant next week.
The mother is [**Name (NI) 8003**] speaking. The father speaks both
[**Name (NI) 8003**] and English.
CONDITION AT DISCHARGE: Stable.
DISCHARGE DISPOSITION: Discharged home with parents.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) 42801**] in [**Hospital **]
Medical Care in [**Location (un) **], MA; telephone number ([**Telephone/Fax (1) 71256**].
CARE AND RECOMMENDATIONS:
1. Feeds: Ad-lib feedings [**Telephone/Fax (1) 56280**] 20 with iron.
2. Medications: None.
3. Car seat position screening test done, passed.
4. State newborn screen was drawn on day of life 3 and again
on day of life 14 and results are pending.
5. Immunizations received: Received hepatitis B immunization
on [**2178-1-21**]. Received Synagis on [**2178-1-14**]
due to 1 of the infants in the NICU had RSV, and all the
infants were immunized with Synagis. Otherwise, this baby
does not qualify for follow-up doses of Synagis.
FOLLOW-UP APPOINTMENTS: Follow-up appointment with
pediatrician within 2 days after discharge.
DISCHARGE DIAGNOSES LIST:
1. Preterm infant at 35-weeks gestation.
2. Large for gestational age.
3. Transient respiratory distress resolved.
4. Sepsis ruled out.
5. Indirect hyperbilirubinemia resolving.
6. Apnea of prematurity resolved.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 56662**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2178-1-23**] 18:57:17
T: [**2178-1-23**] 19:37:09
Job#: [**Job Number 71257**]
ICD9 Codes: 7742, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3753
} | Medical Text: Admission Date: [**2176-10-22**] Discharge Date: [**2176-11-11**]
Date of Birth: Sex:
Service: NEUROLOGY
ADDENDUM: Several days after starting the heparin and
Coumadin for his positive hypocoagulable work-up, the patient
was found on the floor with bradycardia. A CT of the head
was done, showing hemorrhage into the left MCA ischemic
infarction. The anticoagulation was immediately
discontinued. The patient was given SFP and Factor 7 to
reverse his INR down to less than 1.3. The patient was then
transferred to the Intensive Care Unit where he remained
stable and transferred back to the floor.
On the floor, his physical examination showed improvement in
terms of his language, where is now able to comprehend
midline commands. He still has quite severe decreased verbal
output at this point. The patient had another temperature
spike so a urinalysis was obtained, given that he had a Foley
in. The Foley was discontinued and he was put back on
Zonesteride given his big prostate which may be hindering his
micturition. Also during the hospitalization, the patient
did become tachycardiac in the 140's. Cardiology was
consulted and they felt that medical management with
avoidance of nodal blockers were appropriate at this time.
However, they wanted to be reconsulted if they had any
hypotension or clinical deterioration. The rest of the
hospitalization will be dictated by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16188**].
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 13-279
Dictated By:[**Last Name (NamePattern1) 4270**]
MEDQUIST36
D: [**2176-11-11**] 10:54
T: [**2176-11-12**] 04:18
JOB#: [**Job Number 53968**]
ICD9 Codes: 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3754
} | Medical Text: Admission Date: [**2159-11-8**] Discharge Date: [**2159-12-6**]
Date of Birth: [**2118-5-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Pollen/Hayfever
Attending:[**Last Name (NamePattern1) 1561**]
Chief Complaint:
esophageal cancer and has
received neoadjuvant chemoradiation. He presents now for
surgical treatment.
Major Surgical or Invasive Procedure:
Minimally-invasive combined thoracoscopic and
laparoscopic total esophagogastrectomy.
2. Laparoscopic-assisted/open jejunostomy tube placement.
History of Present Illness:
41 y/o delightful,young gentleman who underwent CT scan
evaluation of his chest
for an ascending aortic aneurysm and was found to have distal
thickening of his esophagus. Further evaluation confirmed the
presence of a large distal esophageal cancer, stage T3, N1.
He underwent neoadjuvant chemoradiotherapy and then
restaging. He had a reasonable response and was, therefore,
taken forward for a minimally-invasive esophagogastrectomy.
Past Medical History:
Diverticulitis w/ colovesicle fistula s/p repair, ventral
hernia, dilated aortic root, s/p T&A
Social History:
lives with wife and 2 daughters. Employed by [**Company 33655**]
Physical Exam:
General: obese male in NAD
HEENT: PERRL, EOMI, no cervical lymph adenopathy, neck supple.
Resp-lungs CTA bilat
Cor: RRR S1, S2
Abd: Obses w/ large incisional hernia-easily reduced. No
hepatosplenomegally.
Ext: no LE edema
Neuro: A+OX3
Pertinent Results:
[**2159-11-8**] 06:30PM GLUCOSE-128* UREA N-16 CREAT-1.0 SODIUM-139
POTASSIUM-4.9 CHLORIDE-108 TOTAL CO2-17* ANION GAP-19
[**2159-11-8**] 06:30PM CALCIUM-8.4 PHOSPHATE-3.9 MAGNESIUM-1.1*
[**2159-11-8**] 06:30PM WBC-8.2 RBC-3.05* HGB-10.5* HCT-29.1* MCV-95
MCH-34.3* MCHC-36.0* RDW-15.0
[**2159-11-8**] 06:30PM PLT COUNT-231
[**2159-11-8**] 06:30PM PT-12.8 PTT-23.6 INR(PT)-1.1
[**2159-11-8**] 05:49PM LACTATE-6.5*
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2159-11-16**] 09:10AM 8.6 3.05* 10.2* 29.9* 98 33.3* 33.9 14.8
408
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2159-11-16**] 09:10AM 408
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2159-11-27**] 09:50AM 11.0 3.18* 10.1* 29.4* 92 31.7 34.4 15.6*
641*
[**2159-11-26**] 06:15AM 9.5 3.14* 9.9* 29.2* 93 31.6 33.9 15.6*
670*
[**2159-11-25**] 12:32AM 10.3 3.34* 10.5* 30.5* 92 31.3 34.3 15.8*
771*
[**2159-11-24**] 04:40AM 10.3 3.20* 9.9* 29.1* 91 30.8 33.8 15.7*
648*
[**2159-11-23**] 07:00AM 10.6 3.06* 9.3* 27.8* 91 30.4 33.5 16.1*
577*
[**2159-11-22**] 07:24PM 9.9 3.22* 10.0* 28.9* 90 31.0 34.5 16.1*
558*
[**2159-11-22**] 08:59AM 11.9* 2.88* 8.8* 25.4* 88 30.4 34.5 16.6*
553*
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2159-11-15**] 10:20AM 90 25* 0.8 145 4.0 104 321 13
1 NOTE UPDATED REFERENCE RANGE AS OF [**2159-6-1**]
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2159-11-15**] 10:20AM 8.7 4.2 2.1
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2159-11-27**] 09:50AM 128* 69* 4.0* 138 4.8 104 231 16
1 NOTE UPDATED REFERENCE RANGE AS OF [**2159-6-1**]
[**2159-11-26**] 03:35PM 109* 70* 4.2* 139 5.0 103 241 17
1 NOTE UPDATED REFERENCE RANGE AS OF [**2159-6-1**]
[**2159-11-26**] 06:15AM 105 70* 4.4* 141 5.1 104 241 18
1 NOTE UPDATED REFERENCE RANGE AS OF [**2159-6-1**]
[**2159-11-25**] 01:50PM 119* 68* 4.9* 139 5.1 104 231 17
1 NOTE UPDATED REFERENCE RANGE AS OF [**2159-6-1**]
[**2159-11-25**] 12:32AM 164* 71* 4.9* 137 4.7 104 221 16
1 NOTE UPDATED REFERENCE RANGE AS OF [**2159-6-1**]
[**2159-11-24**] 07:35PM 69* 5.0* 5.3*
[**2159-11-24**] 04:40AM 107* 68* 5.1* 139 4.4 102 231 18
1 NOTE UPDATED REFERENCE RANGE AS OF [**2159-6-1**]
[**2159-11-23**] 07:00AM 110* 63* 5.2* 136 4.1 101 241 15
1 NOTE UPDATED REFERENCE RANGE AS OF [**2159-6-1**]
[**2159-11-23**] 12:30AM 62* 5.0*
[**2159-11-22**] 07:24PM 131* 60* 4.9* 134 4.8 99 231 17
1 NOTE UPDATED REFERENCE RANGE AS OF [**2159-6-1**]
[**2159-11-22**] 08:59AM 146* 58* 4.7* 132* 4.7 98 251 14
1 NOTE UPDATED REFERENCE RANGE AS OF [**2159-6-1**]
[**2159-11-21**] 10:18PM 113* 51* 4.4* 4.7 97 221
1 NOTE UPDATED REFERENCE RANGE AS OF [**2159-6-1**]
[**2159-11-21**] 10:40AM 125* 45* 3.7* 132* 4.5 98 231 16
1 NOTE UPDATED REFERENCE RANGE AS OF [**2159-6-1**]
[**2159-11-21**] 06:45AM 118* 42* 3.4*# 130* 4.8 97 241 14
RADIOLOGY Final Report
BAS/UGI AIR/SBFT [**2159-11-15**] 10:34 AM
Reason: THIN BARIUM contrast to look at anastomotic leak
[**Hospital 93**] MEDICAL CONDITION:
41 year old man with esophagogastrectomy
REASON FOR THIS EXAMINATION:
THIN BARIUM contrast to look at anastomotic leak
INDICATION: Status post esophagogastrectomy.
PROCEDURE: Exam was performed with Conray, water soluble
contrast followed by thin barium. Multiple obliquities of the
esophagus were obtained following administration of oral
contrast. Barium passes freely through the esophagus, through
the esophagogastrectomy into the intrathoracic stomach. There is
a less than 1 cm long, approximately 1 mm high outpouching of
contrast from the GI tract at the upper thoracic level
consistent with a small leak. No extravasation of contrast
beyond this point is seen. Contrast passes through the stomach
into the proximal small bowel in a delayed fashion. After
approximately 5-10 minutes, contrast is still present within the
stomach.
IMPRESSION: Less than 1 cm x 1 mm thin outpouching of the GI
tract at the upper thoracic level in the region of the presumed
esophagogastrectomy that is consistent with a tiny leak. No free
extravasation of contrast is seen beyond this finding.
RADIOLOGY Preliminary Report
UNILAT LOWER EXT VEINS LEFT [**2159-11-16**] 12:26 AM
[**Hospital 93**] MEDICAL CONDITION:
41 year old man pod #7 s/p lap esophagogastrectomy now with
unilateral L leg redness, pain
REASON FOR THIS EXAMINATION:
?DVT
INDICATION: 41-year-old man postop day 7 status post
esophagogastrectomy, now with unilateral left leg redness.
Evaluate.
COMPARISON: None.
IMPRESSION: Negative left lower extremity DVT study.
Brief Hospital Course:
Patiet admitted SDA for above procedure. Patient tolerated
procedure well, transferred to PACU intubated, stable, right
chest tube x1 to suction, neck JP drain to bulb suction, NGtube,
J- tube. PACU course overnight significant for: intubation and
sedation- propofol, IVF for low u/o;pain control Fentanyl gtt,
electrolyte management; HR rate control w/ b blocker.
POD#1-Pt in PACU all day; propofol weaned to off, vent weaned
and extubated @10am w/o complication, followed by close resp
management- IS, pulmonary toilet;Fentanyl gtt weaned to off,
dilaudid IV PCA for pain control; hemodynamic/fluid managment;
Patient transferred to floor late evening. B blocker increased.
POD#2- Pain control w/ PCA; NGT> LCS; NPO; Jtube clamped; OOB>
chair; course BS, CT > SC no leak to w/s at 12noon;IVHL> lasix
iv x1 w/ good response; weaning O2; ST 104-114- b blocker
increased to 37q6h.
POD#3- Pain control w/Dilaudid PCA; right chest tube to water
seal, no leak; NGT LCS,NPO, tube feedings via J- tube @10cc/hr;;
Hct 24, tx 1U PRBC; lasix 20 mg IVx1 w/ goal 1.5L negative;
Physical therapy consulted.
POD#4- Pain control w/ PCA; CT to w/s; TF 10/hr and adv10cc q4
hr to goal 50/hr; lasix 20 mg IVx1 w/ goal 1.5L negative.
Weaning O2 6L-94% chair.
POD#5-1L negative overnight; NGT> LCS;J tube feedings tolerated
well- Deliver 2.0 @50/hr=goal; OOB> chair and ambulation;
weaning O2 3L-93%; 6L w/ ambulation
POD#6- 94% RA> chair; LLE swelling, and erythema at ankle, hx
gout, LENI- negative.
POD#7-Toleratating tube feeds well, + BS; Swallow study passed,
NGT d/c, no sips today; Character of CT drainage- yellow/milky-
Triglyceride level=15, CT placed to suction; WBC-8.6. Pain
control w/ Dilaudid PCA.
POD#8-T 100.4, CT drainage ?concern for kylothorax- stable, no
leak on suction; tolerating clears, + BS no stool; + peripheral
edema>diuresis;
POD#[**8-10**]-T-102, cx blood, urine, pleural fluid- gram + cocci,
placed on Vanco and Zosyn;CT remains to suction- CXRY(new right
apical pneumothorax) and Chest CT obtained- fluid collection
right lower lung. Pt consented for CT placement/drainage for
Right pleural effusion; WBC 17,Started Vanco/zosyn empirically;
PO intake reversed to NPO.
POD#11 ([**2159-11-18**])-To OR for VATs for evacuation right pleural
effusion. MIld hypotension intra-op. IVF given w/ resolution.
Fluid/tissue cx sent.
POD#[**11-13**]- Pleural fluid-CX-coag + staph [**Last Name (un) 36**] to levo/clinda/ox;
[**11-18**] tissue cx: rare coag + Staph. Creat- rising 4.4-4.7, Renal
consult obtained. Vanco/Zosyn d/c per Renal consult, changed to
Clinda per C&S results. Renal ultrasound normal.
POD#15- CT to w/s w/ no leak, moderate drainage, murky quality.
Cr 5.0, IVF [**Month (only) **]'d. Small amts po intake tolerated marginally.
Episodes of nausea and vomitting 50-100/day.
POD#16-17- Vomitting not improved; [**Doctor First Name 4663**] leak not improving. NPO
and TPN started, cont. CR decreasing <5.0. CT & [**Doctor Last Name **] remains to
w/s. WBC 10K; Clinda cont.
POD#18-19-TPN advanced to goal, lipids added. clears only; Cr.
4.2, WBC 9.0; R angle CT clamped, +leakage around site> [**Doctor Last Name 406**] to
waterseal.
POD#20 CXR> no ptx, CT d/c'd, [**Doctor Last Name **] to bulb sx. Gastrographin
swallow to eval anastamosis leak and gastric emptying shows no
leak but persistant delayed emptying.
TPN cont'd.
POD#21 temp spike-pan cultured; all neg. Noted to have
pericardial effusion- eval by cardiology but since effusion w/o
change and no hemodynamic compromise will follow up as out pt.
Creat returned to baseline.
POD#21 taken to the OR for bronch, pylorus balloon dilation.
POD#22-25 continued to progress w/ activity. decreased episodes
of emesis.
TPN weaning, clears restarted and tube feed 8pm-8am. [**Doctor Last Name 406**] drain
d/c'd.
POD#26 pt d/c'd to home w/ supportive services.
Medications on Admission:
atenolol 50'
Discharge Medications:
1. tube feedings
Tubefeeding: Fiber source HN Starting rate:90cc/hr from 8pm to
8am.Hold tube feeding for nausea/vomiting
Flush w/200ccl water qid.
Other instructions: do not check residuals
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed: crush and give via j-tube.
Disp:*60 Tablet(s)* Refills:*1*
3. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours): crush and give via j-tube.
Disp:*240 Tablet(s)* Refills:*2*
4. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
Disp:*900 ml* Refills:*2*
5. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed.
6. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
Disp:*600 ML(s)* Refills:*0*
7. Heparin Lock Flush (Porcine) 10 unit/mL Solution Sig: Five
(5) ML Intravenous PRN (as needed): to by done by VNA .
8. Acetaminophen 500 mg/5 mL Liquid Sig: One (1) PO every [**3-6**]
hours as needed.
Disp:*600 ml* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
Assisted Daily Living< Inc
Discharge Diagnosis:
Esophogeal cancer
Diverticulitis w/ colovesicle fistula s/p repair, ventral
hernia, dilated aortic root, s/p T&A
Blood loss anemia- post-op
Heart Failure
Pericardial effusion
acute renal failure
pyloroplasty
j-tube
double lumen port a cath
Discharge Condition:
good
Discharge Instructions:
Call Dr.[**Name (NI) 1816**]/Thoracic surgery office for ([**Telephone/Fax (1) 170**]):
fever, chills, shortness of breath, chest pain, persistant
nausea, vomiting, diarrhea, or inability to take food orally.
Also call for tan, foul smelling discharge from chest tube
sites.
Take all medications as directed. After showering on friday,
remove your chest tube dressings and cover them daily with clean
bandaids until healed.
Take clear and full liquids as tolerated and you may trial soft
foods as directed by Dr. [**Last Name (STitle) 952**].
No tub baths for 3-4 weeks
Followup Instructions:
Call Dr.[**Name (NI) 1816**]/ Thoracic Surgery office for an appointment in
3 weeks. [**Telephone/Fax (1) 170**].
Completed by:[**2159-12-10**]
ICD9 Codes: 4280, 5845, 2851, 2762, 4241 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3755
} | Medical Text: Admission Date: [**2132-7-19**] Discharge Date: [**2132-7-24**]
Date of Birth: [**2061-9-24**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Oxacillin / Heparin Agents
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Sepsis and hypoxic respiratory failure
Major Surgical or Invasive Procedure:
Right dialysis catheter change over wire
Dialysis
History of Present Illness:
Pt is a 70 year-old M with ESRD on HD, HTN, afib, CAD, multiple
MRSA line infections, L UE DVT (on Coumadin) and multiple other
medical problems, who was recently ([**2132-7-11**]) discharged from
[**Hospital1 18**] MICU with sepsis that began on [**6-5**] and presents from
[**Hospital3 672**] Hospital today with fevers to 104 and
Hypotension. Patient had been dishcarged from the MICU to trach
facility on Vancomycin and Imipenem for MRSA pneumonia and
bacteremia. On the evening PTA, patient had been transferred to
[**Hospital3 672**] Hospital from trach facility in respiratory
distress with ABG 7.33/52/54 on FIO2 40%. Bright red blood was
also noted on trach suction, and patient reportedly had
supratherapeutic INR. At rehab, patient's urine grew out VRE,
but patient did not have foley cath and he did not receive
treatment.
.
Pt was admitted to [**Hospital1 18**] in the setting of sepsis and hypoxic
respiratory failure.
.
In the ED, patient received Ceftriaxone 1g IV, Vancomycin 1g IV,
and Azithromycin 500mg IV, along qith 1.5 L of fluids. His VS in
the Ed were T 102, HR 68, BP 130/53, RR 18, and O2 sat 100% on
?. EKG showed no ST/T changes. CXR showed significant decrease
in left retrocardiac effusion/density. Loculated left pleural
effusion and small right pleural effusion. Patient also received
CT Chest/Abd/Pelvis which showed multifocal bilateral patchy
lung opacities which could be infectious in origin, slightly
worsened compared to earlier study. Bilateral small pleural
effusions L > R, L slightly increased compared to [**2132-5-23**].
Dependent atelectasis b/l. Heavy calcifications of aorta and
coronary arteries. Calcifications at R lung apex similar to [**2131**]
study. No pericardial effusion. Metallic L subclavian stent.
Liver, spleen, pancreas, adrenal glands, and native kidneys
unchanged compared to prior study. G-tube in stomach. Sigmoid
diverticulosis without definite evidence of diverticulitis.
Past Medical History:
1. As above
2. ESRD (unclear etiology) on HD M/W/F s/p R cadaveric tx '[**19**] at
[**Hospital1 2177**], failed '[**29**], removed [**6-26**]
3. Staph aureus (sensitive to Ox, resistant to PCN) sepsis,
recent line infections; [**2131-5-24**] micro data
4. HTN
5. AFib
6. DDD Pacemaker
7. CAD - mild 40% prox LAD on cath '[**27**]
8. LUE DVT
9. Left TKR '[**23**]
10. Hypothyroidism
11. Hx of TB as child, PPD neg
12. PEG tube placed [**6-18**].
Social History:
Retired dentist, was living in [**Location (un) **] with wife, kids, and
[**Name2 (NI) 7337**], denies etoh/tob.
Family History:
Both parents died in 90's, healthy.
Physical Exam:
VS: afebrile, HR 67, BP 120/56, RR 16, O2 100, FiO2 100
GEN; NAD, responsive with eyes
Neck: tracheostomy in place
CV: RRR, S1S2 normal, no m/r/g
Lung: anterior: coarse rhonchi b/l
Abd: soft, nt, nd, +BS, G-tube in place
Extrema: - edema, DP 2+ b/l, femoral catheter in place
Pertinent Results:
[**2132-7-19**] 12:50PM NEUTS-86.4* LYMPHS-8.6* MONOS-4.2 EOS-0.3
BASOS-0.5
[**2132-7-19**] 12:50PM WBC-9.7 RBC-3.38* HGB-9.8* HCT-31.4* MCV-93
MCH-29.1 MCHC-31.2 RDW-16.3*
[**2132-7-19**] 12:50PM CALCIUM-8.7 PHOSPHATE-2.5* MAGNESIUM-2.7*
[**2132-7-19**] 12:50PM GLUCOSE-175* UREA N-45* CREAT-3.0* SODIUM-136
POTASSIUM-4.7 CHLORIDE-100 TOTAL CO2-26 ANION GAP-15
[**2132-7-19**] 12:58PM LACTATE-1.6
[**2132-7-19**] 02:50PM TYPE-ART RATES-/12 TIDAL VOL-500 O2-100
PO2-370* PCO2-43 PH-7.39 TOTAL CO2-27 BASE XS-1 AADO2-307 REQ
O2-57 -ASSIST/CON INTUBATED
.
CT abdomen: [**7-19**]
1. Multifocal patchy opacities within the lungs that have
slightly worsened since [**2132-5-23**]. An infectious etiology is
considered.
2. Bilateral small pleural effusions, left greater than right.
The left has slightly increased since [**Month (only) 205**], while the right is
decreased. There is
dependent atelectasis bilaterally.
3. Relatively unchanged appearance of the abdomen and pelvis
compared to
[**7-1**]. There are multiple small mesenteric lymph nodes of
undetermined significance.
4. Sigmoid diverticulosis, without evidence of diverticulitis.
5. Coronary artery calcifications and heavy vascular
calcifications.
.
CXR [**7-19**]
1. Interval improvement in left retrocardiac opacity.
2. Loculated left pleural effusion and small right pleural
effusion persists.
3. Interval stable appearance of interstitial edema, pleural
thickening, and apical scarring.
.
Brief Hospital Course:
Impression/Plan: 70 year-old M with ESRD on HD, HTN, afib, CAD,
multiple MRSA line infections, L UE DVT (on Coumadin) and
multiple other medical problems admitted for respiratory
failure.
.
# Respiratory failure: secondary to pneumonia gievn fevers,
infitrate, white count and eventually sputum grew seratia and
acitenobacter. He was covered with azotreonam given oxacillin
allergy and sensitivies to both. He will need to complete a 14
day course on [**2132-8-4**]. He also had componant of fluid overload
which was contributing and was dialiazed her with good output
which he tolerated and respiratory status improved. HE will
continue his regular HD schedule. He was initially started on
vanc/levoquin, but changed to azotreonam/linezolid given
mosocomial concerns given his stay at rehab and hopitals for
last 6 weeks. He was on AC most of his stay and prior to eaving
PEEP down to 5 with good oxygenation. Did not pass RSBI, but
tolerated spurts of Pressure support at 18/5 and passy muir
valve trials. Ventilator can continue to be weaned at rehab.
.
# Hypotension: possibly related to hypovolemia, did improve with
fluid boluses and blood. Also noted to be c.diff positive and
likley some degree of sepsis contributing to hypotension. Much
improved over course of stay.
.
# C. diff colitis: c. diff positive stool here, likey related to
antibiotics he has received. He was started on flagyl and his
diarrhea improved. He will complete 2 weeks course on [**8-3**].
.
# ESRD: had dialysis on M/T/W to help get fluid off after
initial resucitation, but can now go back to regular M/W/F
schedule. Procrit does was increased and transfused total of
4units of blood. Because he only has tremporary HD catheter in
place, it was changed over wire by IR because he is difficult
access. More permanat HD options should continue to be
evalauated as an outpateint.
.
# Anemia: likley just chronic disease, guiaic negative, epogen
increased and transfused with HD. Cotn to follow closely.
.
# L UE DVT stable restarted anticoagulation after line re-placed
over wire. Goal INR [**12-27**].
.
# F/E/N: continued tube feeds
.
# Access: Right subclavian temporary hemodialysis catheter with
extra port for abx, placed [**7-23**]
.
# Communication: Wife
Medications on Admission:
MVI
Iron Sulfate 325mg GT qd
Folic Acid 1mg GT qd
Vitamin B12 GT qd
Senna 1 tab GT qd
Amiodarone 200mg GT qd
Renagel 80
Protonix 40
Ativan 1mg q4
Coumadin on hold
Vancomycin 1000mg IV with HD
Imipenem 500mg IV after HD
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed: Hold for sedation.
5. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
6. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) PO DAILY (Daily).
7. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q4-6H
(every 4 to 6 hours) as needed.
8. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
9. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
10. Warfarin Sodium 2 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime): Adjust for therapeutic INR.
11. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
12. Morphine Sulfate 1-5 mg IV Q4-6H:PRN
13. Aztreonam 1 g Recon Soln Sig: One (1) Recon Soln Injection
Q8H (every 8 hours) for 11 days: -on HD days, please DO NOT give
before dialysis
-Continue through [**2132-8-4**] (last day).
14. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 10 days: Continue through [**2132-8-2**] (last day).
15. Insulin Regular Human 100 unit/mL Solution Sig: Regular
Insulin Sliding Scale Injection ASDIR (AS DIRECTED): Breakfast,
Lunch, Dinner, Bedtime
151-200 2 units
201-250 4 units
251-300 6 units
301-350 8 units
351-400 10 units
>400- [**Name8 (MD) **] MD.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 672**] Hospital
Discharge Diagnosis:
Primary diagnosis:
Respiratory Failure
Pneumonia
Pulmonary edema
C. Difficile
Secondary diagnosis:
End stage renal disease on hemodialysis
Anemia
Left upper extremity DVT
Hypertension
Atrial Fibrillation
Coronary artery disease
Hypothyroidism
Discharge Condition:
Pt is doing better. He is not in respiratory distress and his
ventilator settings have been weaned down. He has received
dialysis and is subjectively feeling better and afebrile.
Ventilator settings upon transfer to Rehab:
Tv: 500/ RR: 12/ FiO2: 40%/ PEEP 5
Also tolerated PS 18/5/40% for times as well.
Discharge Instructions:
-Call your doctor (or be evaulated) or go to the emegency room
if you have increase trouble breathing not being handled, chest
pain, dizziness, or any other health concern.
-Take your medications as prescribed.
-Resume dialysis per your normal schedule.
Followup Instructions:
-You should follow up with your primary care doctor in the next
2 days at rehab.
-Dialysis per schedule
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2132-7-24**]
ICD9 Codes: 5070, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3756
} | Medical Text: Admission Date: [**2148-10-25**] Discharge Date: [**2148-11-2**]
Service: Surgery, Purple Team
ADMISSION DIAGNOSIS: Colon cancer, status post right
colectomy.
HISTORY OF PRESENT ILLNESS: This is an 81-year-old man who
was found to have a cecal lesion during colonoscopy for
anemia. Given the lesion which was consistent with
adenocarcinoma of the colon, he was scheduled for a right
colectomy by Dr. [**Last Name (STitle) **]. However, this patient does
have a significant coronary artery disease history, so his
main issue preoperatively was evaluation and cardiac
clearance.
His cardiac history is significant for a myocardial
infarction in [**2131**] for which he subsequently underwent bypass
surgery. He did undergo repeat catheterizations, most
recently in [**Month (only) **] with stenting of a single artery.
Echocardiograms in the past revealed an ejection fraction
of 50% with an inferior posterior wall motion abnormality.
The patient did have significant dyspnea on exertion
preoperatively and is only able to walk up one flight of
stairs, sometimes not even able to achieve this. He had a
Holter monitor examination which revealed ventricular ectopy,
nonsustained ventricular tachycardia, episodes of AV nodal
Wenckebach for which he underwent an exercise echocardiogram
which demonstrated that the patient could only exercise for
two minutes and again had premature ventricular contractions,
nonsustained ventricular tachycardia, and sinus bradycardia
with Wenckebach.
Given all of this, it was felt that the patient had a sick
sinus syndrome and AV nodal disease with significant
chronotropic incompetence, for which he underwent
Electrophysiology evaluation for pacemaker placement.
However, given the fact that he needed a colon resection in
the near future, Electrophysiology did not want to place a
pacemaker in him prior to the resection because of concerns
related to infection with the pacemaker. Hence, he was
managed medically.
PAST MEDICAL HISTORY: (His past medical history is
significant for the following)
1. Coronary artery disease, status post coronary artery
bypass graft in [**2141**] (saphenous vein graft to obtuse
marginal), status post percutaneous transluminal coronary
angioplasty stent.
2. Sick sinus syndrome.
3. Valvular disease.
4. Hypertension.
5. Insulin-dependent diabetes mellitus.
6. Hyperlipidemia.
7. Arthritis.
8. Carotid artery stenosis of 80% to 90% bilaterally.
9. Angina.
MEDICATIONS ON DISCHARGE: His medications on admission
included Lopressor 25 mg p.o. b.i.d., lisinopril 70 mg p.o.
q.d., Imdur 30 mg p.o. q.d., Plavix 75 mg p.o. q.d., Mevacor,
Prevacid, aspirin, glyburide, probenecid, and folate.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: No smoking or alcohol.
FAMILY HISTORY: His family history was noncontributory.
PHYSICAL EXAMINATION ON PRESENTATION: On physical
examination prior to his procedure, he was healthy-appearing.
Clear to auscultation. His abdomen revealed no masses,
tenderness, hernias, or ascites.
HOSPITAL COURSE: He was given a Fleets preparation kit the
day prior to surgery and was admitted to the [**Hospital1 346**] on [**10-25**] for a colectomy.
On [**10-25**], the patient underwent a right colectomy for
right colon cancer by Dr. [**Last Name (STitle) **], assisted by Dr. [**First Name (STitle) **].
The findings were a right ascending colon mass. There was
100 cc of estimated blood loss, 1 liter of crystalloid was
given intraoperatively. The patient had a Swan-Ganz catheter
placed postoperatively in the Postanesthesia Care Unit and
was transferred to the Intensive Care Unit for monitoring
given concerns over his cardiac status, as well as the fact
that intraoperatively the patient had bradycardia to the 30s.
He was also hypertensive requiring a nitroglycerin drip for
control of his blood pressure.
The patient had a 5-day Intensive Care Unit stay.
Immediately postoperatively, he was on a nitroglycerin drip
for control of his blood pressure. He was transfused while
in the Intensive Care Unit to maintain hematocrit in the 30
range. He was also ruled out for acute myocardial
infarction. He was maintained n.p.o. until return of bowel
function was noted with nasogastric tube decompression of his
stomach.
He received a Cardiology consultation while in the Intensive
Care Unit for assistance of evaluation of his cardiac status.
Cardiology recommendations were for beta blockers and
conversion to nitroglycerin paste from nitroglycerin, as well
as the addition of aspirin and Accupril for control of his
blood pressure. Recommendations were also to maintain
hematocrit above 30 and for implantable
cardioverter-defibrillator placement in the future.
By postoperative day four he was off of his nitroglycerin.
On postoperative day four his nasogastric tube was also
removed, and by postoperative day five he was transferred to
the floor.
On the floor he did very well. He was maintained n.p.o.
until return of bowel function. He did begin having flatus
by postoperative day seven and was begun on p.o. His diet
was advanced which he tolerated very well. His Foley was
removed, and he was screened for rehabilitation.
However, on the night between postoperative days seven and
eight, he did slip and fall out of bed while attempting to
stand up to urinate. He did not sustain and significant
injuries from this.
By postoperative day eight, given the fact that he was
tolerating a regular diet, hemodynamically stable with good
urine output with an abdomen that was soft, with an incision
that was clean, dry, and intact without any erythema, edema,
or induration, it was felt that he was stable for discharge.
DISCHARGE DIAGNOSES:
1. Adenocarcinoma of the cecum, status post right colectomy.
2. Coronary artery disease, status post coronary artery
bypass graft and multiple stents.
3. Sick sinus syndrome with tachy arrhythmias including
nonsustained ventricular tachycardia.
4. Carotid artery disease.
5. Gastroesophageal reflux disease.
6. Diabetes.
7. Hypertension.
8. Hyperlipidemia.
9. Arthritis.
DISCHARGE DIET: He diet on discharge was cardiac diet.
MEDICATIONS ON DISCHARGE:
1. Hydralazine 10 mg p.o. q.i.d.
2. Colace 100 mg p.o. b.i.d.
3. Ambien 5 mg p.o. q.h.s. p.r.n.
4. Probenecid 500 mg p.o. b.i.d.
5. Heparin 5000 units subcutaneous b.i.d.
6. Imdur 30 mg p.o. q.d.
7. Accupril 40 mg p.o. q.d.
8. Aspirin 81 mg p.o. q.d.
9. Sliding-scale insulin.
10. Metoprolol 25 mg p.o. b.i.d.
11. Protonix 40 mg p.o. q.d.
12. Tylenol 650 mg p.o. q.4-6h. p.r.n.
DISCHARGE INSTRUCTIONS: (His discharge instructions included
the follow)
1. To follow up with his cardiologist and primary care
[**Provider Number 34259**]. To follow up with Dr. [**Last Name (STitle) **] within one week for
removal of his staples.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D.
[**MD Number(1) 11126**]
Dictated By:[**Name8 (MD) 4720**]
MEDQUIST36
D: [**2148-11-2**] 21:58
T: [**2148-11-2**] 10:31
JOB#: [**Job Number 102233**]
(cclist)
ICD9 Codes: 4271, 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3757
} | Medical Text: Unit No: [**Numeric Identifier 70499**]
Admission Date: [**2116-10-6**]
Discharge Date: [**2116-10-13**]
Date of Birth: [**2116-10-6**]
Sex: F
Service: NB
HISTORY: Baby Girl [**Known lastname 1528**] was born at 35-1/7-weeks
gestation and admitted to the NICU with respiratory distress
and prematurity. She was born to a 39-year-old G2, P1 now 2
mother with an [**Name (NI) 37516**] of [**2116-11-9**]. Prenatal labs
included blood type A-negative, antibody negative, RPR
nonreactive, rubella immune, HBsAg negative, and GBS unknown.
This pregnancy was complicated by intermittent vaginal
bleeding and concern for chronic abruption.
The mother presented the day prior to delivery with recurrent
vaginal bleeding. Given the gestational age, she was admitted
for induction of labor. Fetal testing was reassuring. The
biophysical profile was [**6-23**] with a normal AFI. This pregnancy
was otherwise unremarkable with a normal fetal survey. The
mother delivered vaginally after Pitocin induction. Rupture
of membranes was 3 hours prior to delivery. Mother was
treated with penicillin 6 hours prior to delivery. There was
no fever noted.
At delivery, the infant emerged with moderate tone and poor
respiratory effort responding gradually to stimulation and
brief positive pressure ventilation. The heart rate was
greater than 100 at 1 minute. Apgars were 6 and 8, and the
infant was brought to the NICU for further care. Of note,there
was a moderate-sized clot of blood in the placenta.
PHYSICAL EXAM ON ADMISSION: Birth weight 2,490 grams which
is 50th-75th percentile, head circumference 33.25 cm which is
75th percentile, length of 47.5 cm which is 50th-75th
percentile. General physical exam: Warm and dry infant,
responsive to exam with moderate increased work of breathing
at rest. Skin: Pale, pink, warm, cool extremities. Sluggish
capillary refill. No rash. HEENT showed fontanelle soft and
flat. Ears: Normal. Positive red reflex bilaterally. Intact
palate. Neck: Supple, no lesions. Chest: Coarse moderately
aerated breath sounds with retractions and nasal flaring.
Cardiac showed a normal rate and rhythm, no murmur, normal
femoral pulses, and distal pulses. Abdomen: Soft, no
hepatosplenomegaly, no mass, 3-vessel cord, quiet bowel
sounds. GU: Normal female with a patent anus. Extremities:
Hips mildly lax, but stable, normal back. Neuro: Mildly
diminished tone and activity, intact Moro and grasp.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: Respiratory: The
infant was initially on room air, but placed on nasal cannula
oxygen for mild grunting and mild respiratory distress. The
infant weaned to room air on day of life 1 and has remained
on room air since that time. She had intermittent apnea and
bradycardic episodes none requiring methylxanthine therapy. She
is now 5 days spell free.
Cardiovascular: The infant was given a single normal saline
bolus for initial hypovolemia. Blood pressure and heart rate
have been normal since that time. There have been no further
issues. There is no murmur.
Fluid, electrolytes, and nutrition: IV fluids were initiated
on admission to the NICU. The infant was started on enteral
feedings on day of life 1 and progressed to ad-lib p.o.
feeding. IV fluid was discontinued on day of life 2. The
infant is taking all feedings p.o. of either breast milk or
Similac 20 with iron at this time. The most recent weight is
on [**10-16**] of 2365g. The most recent set of electrolytes was drawn
at 24 hours of life: Sodium of 138, potassium of 4.9, chloride
107, CO2 of 20.
GI: The infant had hyperbilirubinemia and was been treated
with 3 days of phototherapy for peak bilirubin level of
14.1/0.4. A rebound bilirubin on day of life 6, [**2116-10-12**]
and that result was 9.5/0.3. A repeat bili was 0.2 on [**10-14**].
Hematology: Infant's hematocrit at birth was 43.4. The
hematocrit at 24 hours of life was 39. The infant has had no
further hematocrits measured.
Infectious disease: A CBC and blood culture were screened on
admission. The CBC remained benign. The infant received 48
hours of ampicillin and gentamicin which were subsequently
discontinued when the blood culture remained negative at 48
hours.
Neurology: The infant has maintained a normal neurologic exam
for gestational age.
Sensory: Hearing screen passed.
CONDITION AT DISCHARGE: Fair.
DISCHARGE DISPOSITION: To home.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1968**], [**Hospital 70500**] Medical
Associates
CARE RECOMMENDATIONS:
1. Feeds: Ad-lib p.o. feeds of breast milk or Similac 20
with iron.
2. Medications: None.
3. Car seat screening: Car seat position screening passed
4. State newborn screen was sent on [**10-9**] and [**10-15**], [**2115**].
Results are pending.
5. Immunizations received: The infant has received the
hepatitis B vaccine on [**2116-10-8**].
6. Immunizations recommended: Synagis RSV prophylaxis should
be considered from [**Month (only) **] through [**Month (only) 958**] for infants who
meet any of the following 3 criteria: 1) born at less
than 32-weeks gestation; 2) born between 32-35 weeks
gestation with 2 of the following either daycare during
RSV season, a smoker in the household, neuromuscular
disease, airway abnormalities, or school-age siblings; or
3) with chronic lung disease.
Influenza immunization is recommended annually in the fall
for all infants once they reach 6 months of age. Before this
age and for the 1st 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out-of-home caregivers.
FOLLOW-UP APPOINTMENTS:
1) Pediatrician Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1968**] on Monday
2) VNA follow up on Tuesday.
DISCHARGE DIAGNOSES:
Prematurity born at 35-weeks gestation,
sepsis ruled out,
respiratory distress resolved,
hyperbilirubinemia, resolved,
apnea of prematurity, resolved.
hypovolemia treated.
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 31759**], MD [**MD Number(1) 43886**]
Dictated By:[**Name8 (MD) 62299**]
MEDQUIST36
D: [**2116-10-12**] 20:24:29
T: [**2116-10-13**] 04:35:51
Job#: [**Job Number 70501**]
ICD9 Codes: 7742, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3758
} | Medical Text: Admission Date: [**2136-4-18**] Discharge Date: [**2136-4-20**]
Date of Birth: [**2093-12-9**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Found down
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 42 y.o. man with past medical history of traumatic
subdural hemorrhage from a bar fight in [**2132**] and right handed
boxers fracture during a bar fight in [**2133-9-20**] who was
brought in on transfer after being found down and taken to
[**Hospital3 1196**]. Per the patient, he remembers being
out to a bar and drinking perhaps 12 beers, which he says is
more than his usual. He also admitted to having taken some of
his wife's alprazolam for recreational purposes. He was found
down with significant facial trauma and then vomited and was
intubated for airway protection. Given concern for head injury
from the extent of facial trauma, he was transferred to [**Hospital1 18**]
for trauma center services.
He was extubated without incident and his mental status resolved
to baseline quickly.
Past Medical History:
-Traumatic subdural hematoma secondary to bar fight
-History of boxers fracture
Social History:
He has a history of alcohol abuse. Per his report, he used to
drink >10 beers per day but no longer drinks every day though he
continues to binge drink on the weekends. On night leading to
admission he had about 12 beers (slightly more than baseline) as
well as wife's alprazolam. He also report smoking one and half
packs per day of cigarettes.
Family History:
Notable for diabetes mellitus in his mother.
Physical Exam:
On transfer from ICU:
VS: T 98.7, BP 102/72, P 86, RR 20, O2 96% on RA
Gen: Middle aged male with obvious facial contusions and
abrasions, NAD
HEENT: Multiple facial abrasions w/ dried blood, OP benign w/o
lesions (broken tooth not visible), sclerae anicteric
Neck: No masses or lymphadenopathy, no thyroid nodules
appreciated
CV: RRR, no M/R/G; there is no jugular venous distension
appreciated; PT and radial pulses 2+ bilaterally
Pulm: Breathing is unlabored, expansion equal bilaterally,
scattered coarse wheezes
Abd: Soft, NT, ND, BS+, no organomegaly or masses appreciated
Extrem: Warm and well perfused, no C/C/E
Neuro: A and O*2 (misses date), CNII-XII grossly intact,
strength 5/5 in all extremities
Psych: Pleasant, cooperative, denies any SI/HI or depressed
mood, frankly denies any attempt at self harm
Pertinent Results:
LABORATORY RESULTS
==================
On Presentation:
WBC-15.1* RBC-5.38 Hgb-16.2 Hct-46.6 MCV-87 RDW-12.5 Plt Ct-186
PT-13.9* PTT-26.6 INR(PT)-1.2* Fibrino-211
Glucose-99 UreaN-10 Creat-0.6 Na-138 K-5.3* Cl-104 HCO3-22
ALT-47* AST-26 CK(CPK)-122 AlkPhos-47 TotBili-0.4 Lipase-20
Calcium-7.8* Phos-2.3*
Serum Tox: ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-POS
On Discharge:
BLOOD WBC-12.2* RBC-4.42* Hgb-13.5* Hct-38.2* MCV-87 RDW-12.5
Plt Ct-188
[**2136-4-19**] 03:59PM BLOOD Calcium-9.0 Phos-1.7* Mg-2.2
OTHER STUDIES
===============
CT Facial:
IMPRESSION:
1. Lucency at C2 as indicated above. This finding is not well
seen in other planes and my represent a vascular channel ( most
likely) and less likely a fracture . Recommend comparison with
physical exam and if concern exists for injury at that site,
recommend further evaluation with MRI.
2. Extensive paranasal sinus opacification and fluid in the oral
and
nasopharynx as detailed above.
CT Chest, Abdomen, and Pelvis w/ Contrast:
IMPRESSION:
1. Bilateral pulmonary consolidations, possibly aspirational in
etiology.
2. Endotracheal tube with overinflation of the cuff.
3. Nasogastric tube with side port positioned too high, this
tube should be advanced.
CT Head w/o Contrast:
IMPRESSION: No acute intracranial process.
Brief Hospital Course:
42 year old male with history of alcohol abuse presents after
being found down with facial trauma for trauma evaluation.
1) Found down/Facial trauma: The exact events leading to the
patient being found down and having facial trauma are unknown as
he does not remember them and there are no reliable witnesses to
what happened. Given his extensive facial trauma when he was
found and his altered mental status there was considerable
concern for more extensive and/or intracranial injuries.
Extensive imaging here revealed only a broken tooth and no other
significant traumatic injuries. Most likely the patient simply
suffered a mechanical fall while intoxicated and facial
contusions.
2) Altered Mental Status: The patient was not responding
purposefully when he was found and was vomiting extensively,
therefore, he was intubated for airway protection and
transferred to [**Hospital1 18**] sedated. Imaging revealed no intracranial
bleed or skull fracture. After extubation his mental status
returned to baseline suggesting that his intoxication was the
primary etiology of his altered mental status.
3) Aspiration Pneumonitis: On imaging of the chest the patient
was noted to have bilateral pulmonary infiltrates. Given his
vomiting and intubation this was thought to be most likely due
to aspiration pneumonitis. He never developed fevers, O2
requirement, or severe cough so he was not treated for
aspiration pneumonia. His pneumonitis should resolve without
antibiotic therapy.
4)Alcohol Abuse: The patient has a history of alcohol abuse and
significant injuries secondary to alcohol use. This
presentation occurred with injuries in the context of abusing
alcohol and benzodiazepines. When asked, the patient denied any
suicidal intent and specified that he only took the
benzodiazepines with recreational intent. The patient met with
social work twice who discussed alcohol treatment programs. It
is unclear if the patient will pursue this.
5) Leukocytosis: The patient had a leukocytosis at presentation
presumably due to trauma and pneumonitis. This was improving at
time of discharge and there were no signs of another locus of
infection.
The patient initially received IV H2 blocker for GI prophylaxis
but this was discontinued after extubation. He received SC
heparin for DVT prophylaxis. He was full code.
Medications on Admission:
None
Discharge Medications:
None
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
Alcohol Abuse
Aspiration Pneumonitis
Mechanical Fall
Discharge Condition:
Stable, not hypoxic on room air at rest or with ambulation
Discharge Instructions:
You were admitted because you were found unconscious and
bleeding with injuries to your face. There was concern you had
a serious head injury so you were transferred to [**Hospital1 18**] for
evaluation by the trauma services. They imaged your head,
chest, abdomen, and spine and found no injuries except bumps and
bruises to your face and a broken tooth. You had a tube placed
down your throat because of concerns about your poor mental
status and vomiting leading to vomit going into your lungs,
which can cause a life threatening pneumonia. Unfortunately,
you did have some inflammation in your lungs suggesting a degree
of aspiration, but as you were not having shortness of breath or
needing oxygen this is fairly mild and should resolve on its
own. As you had the tube removed without incident and did not
seem to have any other major issues your are being discharged to
complete your recovery.
You have not been started on any medications during this
hospitalization. WE STRONGLY RECOMMEND THAT YOU STOP USING
ALCOHOL. You have multiple life threatening hospital admissions
related to drinking. We strongly encourage you to discuss
strategies to reduce your drinking with your PCP [**Name Initial (PRE) **]/or in
outpatient rehab.
Please return to your local ED or call your doctor if you have
fevers, chills, night sweats, increasing shortness of breath,
chest pain, severe headache, or any other changes in your
health.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] in [**12-23**] weeks to discuss your
health. His office can be contact[**Name (NI) **] at [**Telephone/Fax (1) 30445**].
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
ICD9 Codes: 5070 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3759
} | Medical Text: Admission Date: [**2103-3-5**] Discharge Date: [**2103-3-12**]
Service: MEDICINE
Allergies:
Morphine
Attending:[**First Name3 (LF) 13329**]
Chief Complaint:
Vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a [**Age over 90 **]yo F with a history of dementia, COPD, and
dysphagia, DNR/DNI, presented to the ED from nursing home with
several episodes of bilious emesis earlier today. She had one
episode where she was witnessed to be choking after emesis. She
appeared pale and diaphoretic in some respiratory distress.
Reportedly she had an O2 sat in the 60s at the nursing home, so
was brought to the emergency department.
.
In the ED, initial vs were: T 101.8 P 100-110 BP 130/70 R 32 O2
sat 75% on RA-->92% on 4L. CT Abdomen/Pelvis was performed,
which confirmed bibasilar opacities concerning for aspiration
pneumonia, but no other abdominal pathology that would cause
vomiting. Patient was given Zofran 4mg, Tylenol 650mg PR, Ativan
2mg IV, Zosyn and Vancomycin. She received 1L IV fluids. Vitals
prior to transfer HR 94 BP 108/48 RR 26 92% NRB.
On arrival to the floor, the patient was sedated.
Past Medical History:
dementia
dysphagia
pacer
COPD
asthma
chronic UTI
HTN
angina
HL
s/p chole
s/p appy
esophageal diverticula
Social History:
She has been living in a nursing home for 3.5 years, before that
she lived on her own in an apartment. She had an episode 6 or 7
years ago when she was attacked on the street by a mugger and
(used to be a doctor) and she fell and hit her head, and after
that, was never quite the same. She worked as a pulmonologist
Family History:
Non contributory in this [**Age over 90 **] yo woman
Physical Exam:
ADMISSION EXAM:
Vitals: T: BP: 99/50 P: 85 R: 18 O2: 98% on NRB
General: somulent, GCS 11, localize stimuli,inapropriate words
opens eye to voice
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: course rhonchi and crackles throughout
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
DISCHARGE EXAM:
Vitals: 96.1 97(m) 176/100 (138-176/80-100) 73 (73-95) 20
90-95% RA
General: Elderly woman, sleeping, but arousable
Neck: supple, no LAD
Lungs: clear anteriorly, coarse in bases
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
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Admission Labs:
[**2103-3-5**] 06:27PM BLOOD WBC-11.8*# RBC-4.97 Hgb-15.0 Hct-45.6
MCV-92 MCH-30.2 MCHC-32.9 RDW-14.7 Plt Ct-559*
[**2103-3-6**] 07:35AM BLOOD WBC-27.5*# RBC-4.25 Hgb-13.3 Hct-40.1
MCV-94 MCH-31.3 MCHC-33.2 RDW-15.0 Plt Ct-467*
[**2103-3-8**] 09:57AM BLOOD WBC-11.6* RBC-3.78* Hgb-11.6* Hct-35.6*
MCV-94 MCH-30.6 MCHC-32.5 RDW-15.4 Plt Ct-471*
[**2103-3-5**] 06:27PM BLOOD PT-13.1 PTT-23.3 INR(PT)-1.1
[**2103-3-8**] 09:57AM BLOOD Plt Ct-471*
[**2103-3-5**] 06:27PM BLOOD Glucose-141* UreaN-26* Creat-1.2* Na-138
K-4.6 Cl-100 HCO3-26 AnGap-17
[**2103-3-8**] 09:57AM BLOOD Glucose-156* UreaN-14 Creat-1.1 Na-142
K-3.9 Cl-110* HCO3-25 AnGap-11
[**2103-3-6**] 07:35AM BLOOD ALT-29 AST-35 AlkPhos-116* TotBili-1.1
[**2103-3-8**] 10:39AM BLOOD Type-ART pO2-48* pCO2-52* pH-7.29*
calTCO2-26 Base XS--1
Discharge Labs:
[**2103-3-11**] 09:20AM BLOOD WBC-8.7 RBC-4.76 Hgb-14.4 Hct-42.6 MCV-89
MCH-30.2 MCHC-33.8 RDW-15.4 Plt Ct-621*
[**2103-3-11**] 09:20AM BLOOD Glucose-129* UreaN-14 Creat-1.0 Na-138
K-3.2* Cl-97 HCO3-29 AnGap-15
[**2103-3-11**] 09:20AM BLOOD Calcium-10.0 Phos-1.1* Mg-1.8
Cultures:
[**3-5**] Urine culture negative
[**3-7**] and [**3-10**] C diff negative
[**3-6**] Blood cultures- NGTD (pending on discharge)
[**3-7**] Blood cultures pending
Imaging:
CT CHEST/ABDOMEN [**2103-3-5**]:
1. Bibasilar opacities, concerning for aspiration or pneumonia.
2. Descending and sigmoid colon diverticulosis without
diverticulitis. No bowel obstruction.
3. Areas of lucency in the left iliac bone with suggestion of
increased
trabeculation could relate to Paget's disease, focal osteopenia,
metastatic disease not entirely excluded. No cortical disruption
seen. Focal area of lucency in the right sacrum, without
definite cortical destruction, may relate to osteopenia,
although underlying metastatic disease can not be entirely
excluded. Consider further evaluation with bone scan.
4. 9 x 8 mm hypodense lesion in the pancreatic head, possible
representing intraductal papillary mucinous neoplasm (IPMN). If
clinically appropriate given patient age, MRCP for further
evaluation.
5. 2 cm right ovarian hypodense lesion. If clinically warranted,
pelvic US can be obtained for further characterization.
CXR [**2103-3-5**]:
Unchanged right middle lobe atelectatic changes, as noted on the
prior CT, raising concern for underlying malignancy. There is an
unchanged small left pleural effusion and bibasilar atelectasis.
Cardiomediastinal silhouette and hila are stable. There is no
pneumothorax.
CXR [**2103-3-8**]:
1. Stable right base opacity and increasing left base opacity.
Probable pneumonia with superimposed atelectasis or worsening
infection.
2. Increasing mild vascular congestion.
3. Stable mild cardiomegaly.
4. Intact pacemaker leads in unchanged position.
Brief Hospital Course:
Ms. [**Last Name (Titles) 110916**] [**Age over 90 **] yo F with multiple medical problems who
presented with vomiting, with subsequent hypoxia and respiratory
distress, concerning for aspiration pneumonia.
ACTIVE PROBLEMS:
1. ASPIRATION PNEUMONIA: She presented from her nursing home
with significant emesis, and subsequently became febrile with
oxygen desaturations to the 60s-70s on room air. Initial CXR and
CT chest/abdomen both showed bilateral basilar opacities, which
was felt to be consistent with an aspiration event. She was
started on vancomycin with levaquin and cefepime dual therapy
for additive GNR coverage, and her oxygen saturations slowly
improved over her ICU stay. She did not require invasive
ventilation or BIPAP during her hospitalization. Speech and
swallow saw her, and recommended continuation of her previous
nectar thickened liquids and pureed solids. She will completed
7 days of antibiotic treatment with vancomycin and cefepime on
[**3-11**]. She was discharged with oxygen saturations in the low-mid
90s on room air. She had intermittent wheezing treated with
nebs, steroids withheld due to agitation and deliriogenic
effect. Her wheezing had largely resolved at the time of
discharge.
2. DEMENTIA/DELIRIUM: Patient had initially been quite agitated
with sundowning and insomnia. She was initially managed with
haldol with poor effect. Geriatrics team was consulted and
recommended use of home seroquel, which fostered significant
improvement. Her nighttime dose was increased to 75mg Q5pm
which prevented sundowning. She received intermittent 12.5mg
prn doses which helped control intermittent agitation. She has
baseline dementia, and this behavior is at her baseline. She
also was continued on her aricept, celexa, and namenda.
3. GOALS OF CARE: Patient was DNR/DNI during hospital stay.
Brief meeting was held to discuss avoidance of further
hospitalization, though family was unprepared to make decision
at the time. This will need to be addressed again in the future.
4. ACUTE RENAL FAILURE: Presented with a Cr 1.2. Unclear
baseline, but she likely was slightly prerenal in the setting of
vomiting and infection. Cr improved to 1.0 with fluids.
5. VOMITING: Nausea and vomiting had resolved at the time of
admission.
6. Concern for underlying malignancy: Patient has history of
lung nodule. CT abdomen shows lytic lesions of iliac bone,
concerning for metastases. The family has decided not to pursue
further work up.
7. H/o Angina: No active issues. Continued plavix, Simvastatin,
Metoprolol.
Pending on Discharge:
[**3-7**] Blood Culture- NGTD
Medications on Admission:
1. Colace 100 mg po bid
2. trazodone 50 mg po qhs
3. Acidophilus po bid
4. Aricept 10 mg po qhs
5. gabapentin 300 mg po qhs
6. acetaminophen 650 mg po tid
7. Spiriva 18 mcg inh daily
8. loratadine 10 mg po daily
9. Namenda 10 mg po daily
10. Plavix 75 mg po daily
11. simvastatin 20 mg po daily
12. metoprolol tartrate 25 mg po bid
13. Seroquel 50 mg po bid
14. Seroquel 12.5 mg po bid PRN agitation
15. DuoNeb inh q6h PRN SOB
16. Cranberry Concentrate Capsule Sig: One (1) Capsule PO
once a day.
17. Prilosec 20 mg po dailyl
18. Celexa 15 mg po daily
19. Atrovent 2 puffs inh [**Hospital1 **] PRN SOB
20. Milk of Magnesia 30mL po q4h
Discharge Medications:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. quetiapine 25 mg Tablet Sig: Three (3) Tablet PO QPM (once a
day (in the evening)): Liquid form is peferable if available.
4. quetiapine 50 mg Tablet Sig: One (1) Tablet PO qAM: Liquid
form preferable if available.
5. quetiapine 25 mg Tablet Sig: 0.5 Tablet PO twice a day as
needed for agitation.
6. docusate sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
7. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. donepezil 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
9. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): Hold for SBP<100, HR<60.
10. memantine 5 mg Tablet Sig: Two (2) Tablet PO daily ().
11. citalopram 10 mg/5 mL Solution Sig: Fifteen (15) mg PO DAILY
(Daily).
12. 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.
13. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
14. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
15. loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day.
16. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) puff Inhalation once a day.
17. gabapentin 300 mg Capsule Sig: One (1) Capsule PO at
bedtime.
18. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every eight
(8) hours as needed for fever or pain.
19. ipratropium-albuterol 0.5 mg-3 mg(2.5 mg base)/3 mL Solution
for Nebulization Sig: One (1) neb Inhalation every six (6) hours
as needed for shortness of breath or wheezing.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Aspiration Pneumonia
Agitation
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. [**Known lastname 110917**],
It was a pleasure taking care of you in the hospital. You were
admitted for aspiration pneumonia and treated with antibiotics
in the medical ICU. You improved on antibiotics and were ready
to go back to your nursing home. You were agitated during your
stay and this was treated with Seroquel and Haldol.
.
We made the following changes to your medications:
- Please increase your evening dose of seroquel to 75 mg
Please continue to take your other medications as you were
previously.
We wish you a speedy recovery.
Followup Instructions:
Please followup with your PCP at your nursing home.
Completed by:[**2103-3-12**]
ICD9 Codes: 5070, 5180, 5119, 5849, 2930, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3760
} | Medical Text: Admission Date: [**2138-8-30**] Discharge Date: [**2138-9-26**]
Date of Birth: [**2069-4-18**] Sex: M
Service: MEDICINE
Allergies:
Dilaudid
Attending:[**Last Name (un) 11974**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
Thoracentesis
History of Present Illness:
69yo M PMHx Severe aortic stenosis ([**Location (un) 109**] 0.9cm2), s/dCHF (EF 20%
[**8-/2138**]), recurrent L-sided pleural effusion attributed to CHF,
AV node dysfunction s/p PPM ([**2-/2138**]), COPD, CKD, and multiple
recent hospital stays for shortness of breath, notable for
CABG/AVR w/u but subsequent refusal of surgical intervention,
now presenting with SOB. Patient reports SOB has been worsening
since discharge 1d prior to this presentation. He denies CP,
palpitations, nausea/vomitting/diarrhea, HA, weakness.
.
Initial vital signs in the ED were 98.5 74 120/60 16 95%. Exam
was notable for crackles throughout lung fields. Labs were
significant for WCC 11.5 (6.1 at discharge), Hct 31.1, Cr 3.8
(3.7 at discharge), CXR demonstrated fluid overload w stable
large L pleural effusion. CT [**Doctor First Name **] was consulted but given
patient's refusal of surgical interventions in the past they
recommended medicine admission. Patient was admitted to medicine
for further management of shortness of breath. Vitals at time of
transfer were 98.6 77 131/76 22 100%2LNC.
.
On arrival to the floor, initial vital signs were 96.3 143/70 73
28 93%4L. Patient denied any pain or discomfort, but his
tachypnea interfered w conducting a full review of systems. On
the day of admission the pt was transferred to the CCU due to
concern for evolving sepsis in the setting of likely PNA and CHF
exacerbation.
Past Medical History:
CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
CARDIAC HISTORY:[**3-/2138**] cath 30% prox LAD. 100% first diagonal,
50% mid LCx, 40% OM1, 100% ostial RCA
OTHER PAST MEDICAL HISTORY:
- Chronic Diastolic and Systolic Congestive Heart Failure
- Aortic Stenosis
- Coronary Artery Disease
- Chronic Renal Insufficiency (baseline Cr 2.5)
- Chronic Obstructive Pulmonary Disease
- Cerebrovascular event ([**2097**], per pt no residual deficits)
- Type II Diabetes Mellitus (IDDM)
- Post-traumatic stress disorder
- Chronic Pain ( fractured lumbar vertebra)
- Osteoarthritis left shoulder and leg
- Benign prostatic hypertrophy
- Left hand neuropathy
- Glaucoma in left eye
- Colon polyps
- Recurrent left pleural effusion
4. PAST SURGICAL HISTORY
- Permanent Pacemaker [**2138-3-10**]
- C4-C7 spinal surgery
- Right lower extremity vein stripping
- Nasal surgery
Social History:
Tobacco: 1.5 ppd ( 75 PYHx); trying to quit
ETOH: 2 per month
Lives: Alone, has daughter who spends a lot of time hopitalized
for psychiatric reasons
Occupation: retired engineer
Last Dental Exam: has 6 remaining teeth, uses partials
Family History:
Brother died of MI at 69.
Physical Exam:
ADMISSION EXAM:
VS: T 98 BP 91/52 HR 84 RR 14 O2 Sat 93% 3L NC
GENERAL: Resting comfortably in bed. Unarousable.
HEENT: NCAT. Sclera anicteric. PERRL. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa.
NECK: Supple, JVP to the angle of the mandible
CARDIAC: PMI not palpable. RR, harsh crescendo/decrescendo
systolic murmur best heard at the R 2nd intercostal space
radiating to the carotids.
LUNGS: Absent breath sounds and dullness to percussion at the L
base. Scattered crackles. Using accessory abdominal muscles.
ABDOMEN: Soft, NTND. No HSM or tenderness. AS murmur heard in
the abdominal aorta.
EXTREMITIES: 2+ pitting edema to the shin, 1+ pitting edema to
the patellas bilaterally. Pulses 1+.
SKIN: Bilateral abrasions of the forearms, confluent ecchymoses
of the forearms
PULSES:
Right: Carotid 2+ Femoral 2+ Radial 2+
Left: Carotid 2+ Femoral 2+ Radial 2+
NEURO: Pupils 1-2mm bilaterally, equally round and reactive to
light. Otherwise unable to participate [**3-12**] sedation.
.
DISCHARGE EXAM:
GENERAL: 69 yo M sitting in bed in no acute distress
HEENT: supple, no JVD sitting upright
CHEST: Crackles bibasilar 1/2 up
CV: S1 S2 Normal in quality and intensity with
crescendo-decrescendo systolic murmur throughout precordium.
ABD: firm, non-tender, distended with mild ecchymosis. Pos BS.
EXT: wwp, 2+ edema 1/2 up calf. DPs, PTs 1+.
NEURO: sleepy, arousable but quickly falls back asleep. Able to
answer simple questions.
SKIN: no rash, PICC d/c'ed
PSYCH: lethargic, not agitated but restless.
Pertinent Results:
ADMISSION LABS:
[**2138-8-31**] 09:15AM BLOOD WBC-20.3*# RBC-3.82* Hgb-11.4* Hct-36.0*
MCV-94 MCH-30.0 MCHC-31.8 RDW-14.4 Plt Ct-386
[**2138-8-31**] 09:15AM BLOOD Glucose-146* UreaN-85* Creat-3.8* Na-146*
K-4.1 Cl-97 HCO3-28 AnGap-25*
[**2138-8-30**] 06:45PM BLOOD cTropnT-0.36*
[**2138-8-31**] 09:15AM BLOOD CK-MB-8 cTropnT-0.49*
[**2138-8-31**] 09:15AM BLOOD Calcium-9.1 Phos-4.8* Mg-2.3
[**2138-8-31**] 09:18PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2138-8-31**] 08:18PM BLOOD Type-ART Temp-36.7 pO2-50* pCO2-28*
pH-7.46* calTCO2-21 Base XS--1 Intubat-NOT INTUBA
[**2138-8-31**] 08:18PM BLOOD Lactate-8.7*
[**2138-9-1**] 08:18AM BLOOD Lactate-1.4
.
Pleural Fluid Analysis:
[**2138-9-2**] 05:59PM PLEURAL WBC-70* RBC-1230* Polys-6* Lymphs-63*
Monos-8* Meso-4* Macro-15* Other-4*
[**2138-9-2**] 05:59PM PLEURAL TotProt-1.3 Glucose-211 LD(LDH)-120
Albumin-LESS THAN Cholest-17
DISCHARGE LABS:
.
Microbiology:
No growth on multiple blood, urine, or pleural fluid cultures.
PERTINENT REPORTS:
.
CXR ([**2138-9-1**]): Interval increase in size of a now large left
pleural effusion with associated bilateral lower lobe
atelectasis and moderate edema.
CXR [**2138-9-14**]: Lines and catheters are in satisfactory position.
There is pulmonary edema which may be slightly increased. Right
lung is well aerated with persistent left basilar opacity,
probably a combination of pleural effusion and atelectasis or
consolidation. This has remained unchanged.
IMPRESSION:
1. Persistent opacity at the left lung base with mild increase
in pulmonary edema.
TTE [**2138-9-8**]:
The left atrium is moderately dilated. The estimated right
atrial pressure is at least 15 mmHg. Left ventricular wall
thicknesses are normal. The left ventricular cavity is
moderately dilated. There is moderate to severe global left
ventricular hypokinesis with relative preservation of anterior
septal and basal inferolateral contraction. The remaining
segments are severely hypokinetic (LVEF = 25 %). [Intrinsic left
ventricular systolic function is likely more depressed given the
severity of valvular regurgitation.] No masses or thrombi are
seen in the left ventricle. Right ventricular chamber size is
normal with depressed free wall contractility. There is severe
aortic valve stenosis (valve area 0.9cm2). Moderate (2+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Moderate (2+) mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is a very
small pericardial effusion.
IMPRESSION: Left ventricular cavity enlargement with global
hypokinesis c/w diffuse process (multivessel CAD, toxin,
metabolic, etc.). Severe aortic valve stenosis. Moderate aortic
regurgitation. Pulmonary artery systolic hypertension. Moderate
mitral regurgitation.
Compared with the prior study (images reviewed), anterior septal
motion is improved. The gradient across the aortic valve is
increased with similar aortic valve area. The severity of mitral
regurgitation is slightly increased.
Brief Hospital Course:
PRIMARY REASON FOR ADMISSION: 69yo M PMHx Severe aortic stenosis
([**Location (un) 109**] 0.8cm2, peak gradient 66mmHg), s/dCHF (EF 20%), recurrent
L-sided pleural effusion attributed to CHF, AV node dysfunction
s/p PPM ([**2-/2138**]), COPD, CKD, and multiple recent hospital stays
for shortness of breath, notable for CABG/AVR w/u but subsequent
refusal of surgical intervention, now presenting with SOB.
.
ACTIVE DIAGNOSES:
# Shortness of Breath: Pt with s/d CHF (EF 20% [**8-/2138**]), critical
AS (valve area 0.9 cm2), as well as recurrent L pleural effusion
that has previously been attributed to CHF, presenting w
worsening SOB, CXR significant for volume overloaded appearance;
most likely etiology is complication of AS. On HD 1 he was
transfered to the CCU for progressive hypoxia. In the CCU, his
pleural effusion was tapped (chemistry consistent with
transudative nature with negative statin, culture and cytology).
He was started broad spectrum coverage with
vancomycin/cefepime/flagyl for multifocal pneumonia and diuresed
with significant improvement in his respiratory symptoms.
Cultures both sputum and blood cultures were negative. In total
he received 6 days of vancomycin and flagyl and 8 days of
cefepime. He was tranferred to the floor but required
readmission to the CCU the following day after an apneic episode
believed to be due to ativan. In the CCU his respirtory status
continued to decline and he required CPAP. Effusion
reaccumulated on HD10, drained (2L) with pigtail catheter
placed. Once again the fluid was noted to be transudative in
nature. After drainage his respiratory status markedly improved
and he was weaned to room air. Once patient was made comfort
measures only, dyspnea was managed with oral morphine as needed.
.
#Critical Aortic stenosis- EF 20%, maintaining BP. Pt meets
criteria for NYHA class III/IV. The patient was started on
milrinone in the setting of decling renal function which
resulted in an EF increase to 25%. However, renal function
continued to decrease and the patient required CVVHD. CT
surgery was consulted and felt that the patient was not a
candidate for surgical intervention. His milrinone was
discontinued as was CVVHD, and patient was symptomatically
managed for volume overload with lasix and morphine.
# Acute on chronic renal failure: Renal failure has been
worsened in the setting of improved cardiac output with very
decreased urine output. Patient showed signs of uremia with
decreased mental status and twitching. Pt failed a diuretic
challenge. Renal was consulted for possible dialysis. His urine
sediment showed muddy brown casts suggesting ATN. Per renal
recommendations patient was started on CVVHD via a R IJ dialysis
line with marked improvement in his mental status and uremia.
However, the patient expressed to renal that he did not desire
to have further dialysis. Additionally concerns were raised
about the patients compliance with outpatient dialysis and it
was determined that he would be a poor candidate for long term
dialysis. His IJ line was removed as there was no further plan
for dialysis.
# AMS/Agitation: Patient's initial agitation was controlled with
standing haldol 1mg PO TID. Changes in mental status were
thought to be multifocal in nature, including baseline dementia,
hospital delirium, uremia in setting of worsening renal function
and poor CNS perfusion in setting of severe AS. As patient
became more somnolent, uremia appeared to be a controllable
factor as creatinine was climbing with decreasing UOP. Patient
was started on CVVHD and mental status markedly improved.
However, patient refused CVVHD and it was discontinued on HD14.
At baseline, pt is combative, so there was to be an underlying
psych component superimposed on any organic cause of AMS. He
was continued on PRN haloperidol 0.5 mg PO, with increasing
frequency.
# Medical Decision Making: Patient exhibited delirium, and per
evaluation by psychiatry service did not demonstrate capacity to
make medical decisions. His daughter [**Name (NI) 803**] expressed
interest in pursuing guardianship for pt, but it was not certain
whether this was appropriate since at times the patient had
expresed that he did not want to see his daughter and did not
want her participating in his care (although he was disoriented
when he made these remarks). At the time of discharge his
daughter was in the process of attempting to gain guardianship
through the courts.
# Goals of Care: Pt was evaluated by CT surgery who felt that he
was not a surgical candidate. Pt initially started on CVVH,
when mental status improved he stated that he did not wish to
continue dialysis. Dialysis was discontinued to respect his
wishes and his HD catheter line was removed. A meeting was held
with primary team, palliative care team, SW, and pt's daughter.
(Patient was agitated and disoriented at that time so was unable
to participate.) It was agreed that since patient is not a
candidate for surgery and had requested that dialysis be
stopped, that it was appropriate to change his goals of care to
focus on comfort measures only.
# Leukocytosis: Resolved without antibiotics, etiology unclear.
[**Name2 (NI) **] remained afebrile, and cultures from pleural fluid, urine,
stool, and blood showed no growth.
INACTIVE DIAGNOSES:
# HTN: Patient's home prazosin and metoprol were initally
continued. His pressure was labile throughout admission
requiring a short period of pressure support with phenylephrine.
His home metoprolol and prazosin were held during this period
and pressures improved. He subsequently resumed his home dose of
metoprolol, but prazosin was not restarted.
# CAD: Stable throughout admission without acute EKG changes.
Patient was continued on ASA 325mg daily.
# DM: Patient's blood sugars were controlled with home glargine
and sliding scale of insulin. Patient frequently refused
fingersticks and insulin, and so when he was made comfort
measures only, glargine and insulin were discontinued as were
fingerstick checks.
#TRANSITIONAL ISSUES
- Per discussion with patient and family, his code status was
changed to DNR/DNI.
Medications on Admission:
- aspirin 81mg daily
- metoprolol succinate 25mg daily
- famotidine 20mg q24hrs
- clonazepam 2mg Tablet daily
- lactulose 10 gram/15 mL daily
- prazosin 1mg qhs
- Lasix 40mg [**Hospital1 **]
- Zocor 20mg daily
- glargine 20units qAM
Discharge Medications:
1. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
2. ipratropium bromide 0.02 % Solution Sig: One (1) vial
Inhalation Q6H (every 6 hours) as needed for wheeze.
3. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) vial Inhalation Q2H (every 2 hours) as
needed for SOB, wheeze.
4. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever; pain.
5. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
8. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig:
2.5-5.0 mg PO Q1H (every hour) as needed for SOB or pain.
9. haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for agitation.
10. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day): i9f not having daily BM's.
11. prochlorperazine 25 mg Suppository Sig: One (1) Suppository
Rectal Q12H (every 12 hours) as needed for nausea.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Severe aortic stenosis
Acute on chronic systolic congestive heart failure
Acute kidney injury requiring temporary dialysis
Coronary artery disease
Left pleural effusion
Chronic obstructive pulmonary disease
Post traumatic stress 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:
You were admitted with pneumonia and congestive heart failure
and needed to be on a ventilator to help you breathe while you
received antibiotics and diuretics. Your kidney function
deteriorated and you received 24hour dialysis for a few days.
AFter speaking with you, the kidney doctors and the cardiac
surgeons, it was decided that surgery or long term dialysis
would not be an appropriate treatment plan. Therefore, the goal
of your care will to keep you as comfortable as possible. We
have discontinued all aggressive medicines and most regular
monitoring.
.
We made the following changes to your medicines:
1. Stop taking famotidine, clonazepam, prazosin, lasix, glargine
and zocor
2. Start albuterol/Ipratroprium nebulizers for your breathing
3. change metoprolol to short acting and take twice daily
4. Increase aspirin to 325 mg daily
5. Start colace, senna and lactulose
6. STart morphine for pain or trouble breathing
7. Start haldol as needed for agitation
8. Start compazine for nausea
Followup Instructions:
Pulmonary: Please cancel if this appt is not appropriate:
Department: WEST [**Hospital 2002**] CLINIC
When: TUESDAY [**2138-10-7**] at 8:45 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 3020**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 11975**]
ICD9 Codes: 5845, 4280, 4241, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3761
} | Medical Text: Admission Date: [**2194-12-20**] Discharge Date: [**2194-12-31**]
Date of Birth: [**2120-3-4**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5606**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
EGD with small bowel enteroscopy
Colonoscopy
Intubation
SMA angiography
History of Present Illness:
74 y/o gentleman with the hx of diverticualr disease, GERD and
Parkinson disease who intially presented with melena and
weakness that led to a fall.
.
He intially noticed dark stool X 2, without red blood, normal
consistency. He didn't have any abdominal pain, nausea or
vomiting. . On Saturday was in the shower he started feeling
weekness and nausea and slid down without hitting his head. His
wife was there and helped him to stand up. She says he didn't
loose his consiousness. After she stood him up, he slid down
again. After that she was able to stand him up and he didn't
have any more nausea. He denies weight loss or dyspepsia. He had
similar episode in [**2189**] when it turned out to be lower GI
bleeeding b/o diverticulosis.
.
On the floor he was noted to have guaiac pos brown stool, he was
noted to be orthostatic (133/66 supine to 78/47 standing), and
had one small and 1 large volume maroon colored stool, noted to
have BUN 42. Given one unit red cells on floor, temp with
RBC's,and treated with tylenol.
.
On arrival to the MICU, he was asymptomatic and the above hx was
obtained from himself and his wife.
.
s/p: 11 unit of blood, hct not bump, maroon melanotic stool. 1
unit of FFP and 1 bag of plaletes, calcium is being followed.
[**Hospital1 656**] (neurologist) has been following. Surgery aware. IR
aware. CTA: active arterial extravasation in the small bowel.
10am SMA anguiography. No extravasation on non selective and
selective runs supplying the small bowel with active
extravasation on CT. Manual pressure applied.
.
VS: HR 53 sinus, 92/56 on neo at 1, 99% on AC 500/14/5/0.4
.
Past Medical History:
Parkinson's disease
seizures
plantar fascitis
depression,
gout
lower GI Bleed in [**2189**]
GERD
Social History:
lives with his wife at home, does't smoke or drink alcohol.
Family History:
father had MI at the age of 57
Mother dementia when she was 75 yo
Physical Exam:
Vitals: afebrile 139/78, P-93, 100% RA
General: Alert, oriented, no acute distress . Oriented X2, does
not know the president and has very poor short term memory
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU:foley in place
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
Rectal: light Brown stool with black specks. External hemmrhoids
non bleeding visualized.
Pertinent Results:
Admission Labs:
[**2194-12-20**] 08:55AM BLOOD WBC-13.1* RBC-2.92*# Hgb-9.3*# Hct-27.5*#
MCV-94 MCH-31.8 MCHC-33.7 RDW-13.4 Plt Ct-252
[**2194-12-20**] 08:55AM BLOOD Neuts-81.7* Bands-0 Lymphs-11.5*
Monos-2.4 Eos-3.8 Baso-0.6
[**2194-12-20**] 08:55AM BLOOD Glucose-111* UreaN-41* Creat-1.3* Na-145
K-4.3 Cl-111* HCO3-25 AnGap-13
[**2194-12-20**] 08:55AM BLOOD LD(LDH)-119 Amylase-63 TotBili-0.2
[**2194-12-20**] 08:55AM BLOOD Iron-103
[**2194-12-20**] 08:55AM BLOOD calTIBC-319 Hapto-169 Ferritn-24* TRF-245
Imaging:
EGD: Erythema and erosion in the gastroesophageal junction
Mild friability and erythema in the stomach
Polyps in the fundus
Gastric mass
Normal mucosa in the duodenum
Small hiatal hernia
Otherwise normal EGD to third part of the duodenum
Recommendations: Serial hcts. Allow clears. Prep for [**Last Name (un) **]
tomorrow. Should have repeat egd in [**5-8**] weeks to evaluate lesion
in the stomach body as well as the GE junction. [**Hospital1 **] PPI.
[**2194-12-22**] Small Bowel Enteroscopy:
Impression: Diverticula in the proximal jejunum and mid jejunum
(injection)
The presence of jejunal diverticuli and the CT angiographic
findings are highly suggestive, but not diagnostic, of small
bowel diverticular bleeding.
[**12-23**] Small bowel enteroscopy:
Impression: Multiple large divertiula noted in the mid jejunum.
Multiple small ulcers noted between diverticula and on
diverticular edges
No active bleeding or bleeding site noted
The point of maximum reach of the enteroscope was tattooed
Otherwise normal small bowel enteroscopy to mid jejunum
[**2194-12-24**] 12:37 pm SPUTUM Site: ENDOTRACHEAL
Source: Endotracheal.
**FINAL REPORT [**2194-12-27**]**
GRAM STAIN (Final [**2194-12-24**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS, CHAINS, AND
CLUSTERS.
RESPIRATORY CULTURE (Final [**2194-12-27**]):
MODERATE GROWTH Commensal Respiratory Flora.
KLEBSIELLA PNEUMONIAE. SPARSE GROWTH.
IDENTIFICATION AND SENSITIVITIES PER DR.
[**Last Name (STitle) **],[**First Name3 (LF) **] PAGER
[**Numeric Identifier 97652**] [**2194-12-26**].
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
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Urine cultures negative
Blood cultures negative to date
Colonoscopy:Large internal hemorrhoids with stigmata of recent
bleeding were noted [ overlying clot ].
Diverticulosis of the sigmoid colon and descending [**Last Name (un) **]
Otherwise normal colonoscopy to cecum
Brief Hospital Course:
74 y/o gentleman with the h/o diverticular disease, GERD and
Parkinson disease presents with melena and weakness that led to
a fall.
.
# GI Bleed: The patient had a history of dark stools/melena for
3 days. On rectal exam, he has brown stool with black specks. We
initially suspected lower GI bleed due to diverticulosis and
given painless nature, however upper GI bleed thought possible
too. Hct dropped from baseline 44 in [**3-/2194**] to 25.0 on
admission. Patient required massive transfusion protocol for
first 2 days in the ICU. GI was consulted. Started on IV PPI,
electively intubated for EGD, which was negative for bleed.
Given the multiple transfusions without appropriate increase in
Hct, CTA performed to attempt localization of bleed. CTA of the
abdomen noted blush in mid-jejunum, suspicious for jejunal
source of bleed. Attempted IR embolization failed. Push
enteroscopy showed multiple diverticula in the small bowel
without active bleeding. Patient then had a balloon enteroscopy,
which again showed many jejunal diverticula with some
ulceration/friability the edges but did not have any active
bleeding. Colorectal surgery was consulted and recommended
laparoscopic small bowel resection as a possible definitive
treatment, however his bleeding appeared to be stabilized at
that time, so this was not pursued urgently. Bleeding slowed on
the hospital days 4 and 5, allowing for transfer to the medical
floor. Colonoscopy performed, showed large internal hemorrhoids
with stigmata of recent bleeding were noted [overlying clot].
Diverticulosis of the sigmoid colon and descending colon,
Otherwise normal colonoscopy to cecum. Hct remained stable. He
was continued on a PPI. He should follow up in colorectal
surgery for evaluation of hemorrhoidectomy.
.
# Pneumonia: While intubated electively for EGD, patient
experienced fevers and increasing leukocytosis. Started having
increasing secretions and CXR concerning for pneumonia, so
started on cefepime, cipro and vancomycin on [**2194-12-24**]. Sputum
culture grew Klebsiella. The pt was extubated with no
difficulty. CXR and fevers improved after start antibiotics.
Sputum cultures were positive for Klebsiella sensitive to
ciprofloxacin so antibiotics were narrowed on [**2194-12-28**]. He did
receive a day of ceftriaxone on [**2194-12-30**] when his WBC rose from
[**10-12**] but he remained afebrile. The patient was discussed with
ID who felt that ciprofloxacin was likely adequate but that it
would not be unreasonable to treat with levofloxacin for better
respiratory coverage. I would recommend completing 14 days of
antibiotics.
.
# Agitation/Delirium: The patient became increasingly agitated
while in the ICU and was given small doses of ativan and
seroquel with good results. On the floor, the family felt the
Seroquel did not help so it was d/ced. He did require ativan on
the floor at night for intermittent agitation but his
neurologist recommended avoiding psychotropic meds. The patient
was re-oriented as much as possible.
.
# Weakness and fall: Very likely due to the anemia with GI
bleed, with underlying Parkinsons. PT evaluated the patient and
recommended rehab.
.
# Parkinson disease: Treated by Dr. [**Last Name (STitle) 1693**] in the outpatient.
Continued home medication. Dr. [**Last Name (STitle) 1693**] followed the patient while
in house. The patient has been delirious given his ICU
hospitalization, infection etc., but seems to be making slow
improvement. His neurologist predicts slow but gradual
improvement.
.
# Gout -His last attack more than 10 years ago. Continued home
allopurinol
.
# Seizure: last one in [**2190**]. Continued home levitiracetam .
.
#Hypernatremia - the patient had Na of 148 and was given D5W
overnight and his sodium normalized.
.
#CODE - FULL
Medications on Admission:
Allopurinol 100 mg PO/NG DAILY
MEMAntine 10 mg Oral [**Hospital1 **]
Escitalopram Oxalate 5 mg
LeVETiracetam 250 mg PO/NG DAILY
Multivitamins 1 TAB PO/NG DAILY
Ranitidine 150 mg PO/NG HS
Discharge Medications:
1. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. escitalopram 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for rash.
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
6. levetiracetam 250 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. memantine 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q 4 HR PRN () as needed for shortness of breath or wheezing.
9. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 7 days: until [**1-6**]. Tablet(s)
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] Senior Healthcare of [**Location (un) 55**]
Discharge Diagnosis:
Upper GI Bleed
VAP
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were hospitalized for a GI bleed. You received blood
transfusions and underwent a colonoscopy. You likely had
jejunal bleeding prior to admission which now appears to have
stopped. You also had evidence of possible bleeding from your
hemorrhoids. Your blood counts are now stable. You also
developed a pneumonia while in the hospital and was treated with
antibiotics. Because you are now weak from your acute
illnesses, you are being discharged to a rehab facility.
Followup Instructions:
You should follow up with your PCP [**Last Name (NamePattern4) **] [**1-2**] weeks or after you
leave the rehab.
You also have the following appointments in gastroenterology.
You should also follow up with colorectal surgery to be
evaluated for hemorrhoidectomy. You can call [**Telephone/Fax (1) 160**] to
schedule an appointment.
Department: DIGESTIVE DISEASE CENTER
When: MONDAY [**2195-2-2**] at 11:30 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 463**]
Building: [**First Name8 (NamePattern2) **] [**Hospital Ward Name 1950**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 1951**]
Campus: EAST Best Parking: Main Garage
Department: ENDO SUITES
When: MONDAY [**2195-2-2**] at 11:30 AM
ICD9 Codes: 486, 2760, 2762, 5859, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3762
} | Medical Text: Admission Date: [**2132-2-14**] Discharge Date: [**2132-2-14**]
Date of Birth: [**2073-11-22**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
facial and laryngeal swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 58 year-old male with a history of hyperlipidemia who
presents with laryngeal edema after endoscopy. The patient
reports that throughtout his life he would have episodes of
swelling during viral or other illness. These would include
swelling of the lip, throat, hand, arm or leg. He was able to
take benadryl and his symptoms would resolved. He has never
been hospitalized or intubated for these episodes.
Interestingly, the patients twin brother also has similar
symptoms. The patient was in his usual state of health when he
went for an outpatient endoscopy to follow-up prior ulcers. He
states that after the procedure he noticed his eyes swelling and
on the car ride home he could feel his neck and throat swelling.
They presented to the [**Location (un) 620**] ED in respiratory distress and
was having difficulty handling his secreations. He was given
125mg solumedrol, 50mg benadryl, pepcid 20mg, and epi-pen x2.
He was also evaluated by ENT who saw significant laryngeal
edema. His symptoms improved after the 2 epi-pens, but was
transferred to [**Hospital1 18**] for further management.
.
In the ED, 96.8 159/107 95 20 94% 2L. He was given 1L NS and
transferred to the ICU for closer monitoring.
.
On arrival to the ICU the patient continues to have hoarse
voice, but reports that his breathing is more comfortable.
.
ROS: The patient denies any fevers, chills, weight change,
nausea, vomiting, abdominal pain, diarrhea, constipation,
melena, hematochezia, chest pain, shortness of breath,
orthopnea, PND, lower extremity oedema, cough, urinary
frequency, urgency, dysuria, lightheadedness, gait unsteadiness,
focal weakness, vision changes, headache, rash or skin changes.
.
Past Medical History:
Hyperlipidemia
GERD/ Ulcers
Social History:
Lives in [**Location 620**] with wife and son.
[**Name (NI) 1139**]: neg
EtOH: socially, ~2/week
Denies drugs
Family History:
Brother: recurrent angioedema
Strong h/o autoimmune disorders
Physical Exam:
GEN: Well-appearing, well-nourished, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, slight swelling of the lower lip, tongue is
mildy enlarged; able to clearly visualize the airway. Improved
vocal hoarseness
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, improved expiratory wheeze, no R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 5/5 in upper
and lower extremities. Patellar DTR +1. Plantar reflex
downgoing.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
[**2132-2-14**] 02:14AM WBC-8.0 RBC-4.46* HGB-13.6* HCT-38.9* MCV-87
MCH-30.5 MCHC-34.9 RDW-13.7
[**2132-2-14**] 02:14AM PLT COUNT-255
[**2132-2-14**] 02:14AM NEUTS-91.4* LYMPHS-7.4* MONOS-0.7* EOS-0.2
BASOS-0.3
[**2132-2-14**] 02:14AM GLUCOSE-153* UREA N-17 CREAT-1.1 SODIUM-142
POTASSIUM-4.3 CHLORIDE-108 TOTAL CO2-24 ANION GAP-14
[**2132-2-14**] 02:14AM ALT(SGPT)-135* AST(SGOT)-55* LD(LDH)-160 ALK
PHOS-89 TOT BILI-0.4
[**2132-2-14**] 02:14AM ALBUMIN-4.7
[**2132-2-14**] 02:14AM CRP-3.0
[**2132-2-14**] 02:14AM C3-172 C4-48*
[**2132-2-14**] 02:14AM SED RATE-28*
ALT: 135 AP: 89 Tbili: 0.4 Alb: 4.7
C3: 172
C4: 48
[**2132-2-14**] C1 ESTERASE INHIBITOR, FUNCTIONAL ASSAY: pending
[**2132-2-14**] TRYPTASE: pending
Brief Hospital Course:
This is a 58 year-old male with a history of recurrent
angioedema who presents with facial swelling.
.
#. Laryngeal Edema: The patient with a history of prior episodes
of swelling which typically occur in setting of viral illness.
[**Name (NI) **] brother also with similar episodes raising the
possibility to of an hereditary angioedema. This last episode,
incurred after endoscopy, has been the most severe and caused
significant laryngeal edema and airway compromise. It is likely
that the endoscopy caused irritation that lead to the edema
though it has been reported that oral-pharyngeal
trauma/manipulation can precipitate episodes of hereditay
angioedema, such as C1 esterase inhibitor. Also question if
recent medication, such as Augmentin, may have spurred allergic
reaction. Patient received a total of epi-pen x2, IV
methylprednisone 125mg x2, benadryl x3, famotidine with
improvement in breathing and near complete resolution of
swelling. Patient discharged on 5 day prednisone taper as well
as Pepcid [**Hospital1 **] for 5 days for further treatment of edema as well
as instruction to discontinue Augmentin. Prescribed epi-pen x2
in case of emergency. C1 inhibitor level, complement levels,
ESR, CRP as well as tryptase levels were drawn. ESR mildly
elevated, CRP wnl. Remaining labs pending at time of discharge.
Patient will follow-up with PCP and from there be referred to an
allergist for further work-up of what appears to be recurrent
angioedema.
.
# Transaminitis. On admission ALT/AST found to be mildly
elevated at ; unknown baseline. Patient without h/o liver
disease of heavy EtOH use. Patient has been on current statin
therapy at current dose for years. Patient does endorse recent
URI therefore strong possibility mild abnl is secondary to viral
illness.
Will follow as outpatient.
#. Hyperlipidemia: Continued home statin
.
#. Dispo: Patient discharged to from from the ICU after near
complete resolution of symptoms. He will plan to follow-up with
PCP [**Last Name (NamePattern4) **] 1 week.
Medications on Admission:
MVI
Prilosec
Pravastatin
ASA 81
MVI
Calcium supplementation
Discharge Medications:
1. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*10 Tablet(s)* Refills:*0*
2. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO daily ().
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. epinephrine 0.3 mg/0.3 mL Pen Injector Sig: One (1) ML
Intramuscular PRN (as needed) as needed for angiedema.
Disp:*2 ML(s)* Refills:*0*
5. Prilosec Oral
6. prednisone 10 mg Tablet Sig: per taper Tablet PO once a day
for 5 days: Taper:
Day 1: 60mg; Day2: 50mg; Day 3: 40mg, Day 4: 30mg; Day 5: 20mg.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Laryngeal edema
.
Secondary
Gastric Ulcers
Discharge Condition:
Mental status: clear and coherent
Ambulates without assistance
Discharge Instructions:
Dear Mr [**Known lastname 49965**] it was a pleasure taking care of you.
.
You were admitted to [**Hospital1 18**] for treatment and evaluation of your
upper airway and facial swelling after endoscopy. You received
IV steroids as well as benadryl and pepcid. You facial swelling
lessened, your breathing and swallowing improved. Tests were
sent off to determine a cause of your recurrent swelling. These
were pending at time of discharge. It will be important to
follow-up these results with both your primary care physician as
well as an allergist.
.
CHANGES TO YOUR MEDICATIONS
- Stop taking Augmentin as it is unclear if this medication
contributed to your episode of swelling
To treat your swelling start taking:
- Prednisone - this medication will be administered on a taper
for 5 days: 60mg day one, 50mg day 2, 40mg day 3, 30mg day 4,
20mg day 5
- Pepcid 20mg twice daily for 5 days.
- Epi-pen prescription to be used as needed
.
Again it was a pleasure taking care of you. Please do not
hesitate to contact with any questions or concerns
Followup Instructions:
Please follow-up with your PCP in next week.
Your PCP will arrange allergy follow-up for you.
Completed by:[**2132-2-14**]
ICD9 Codes: 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3763
} | Medical Text: Admission Date: [**2147-8-19**] Discharge Date: [**2147-8-30**]
Date of Birth: [**2077-11-4**] Sex: F
Service: MEDICINE
Allergies:
Plavix / Heparin Agents
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
fever, abdominal distension, drainage from GJ tube site
Major Surgical or Invasive Procedure:
Interventional Radiology placement of G-J tube
History of Present Illness:
(All hx from chart as pt aphasic and unable to discuss with
family members. 69 y/o F w/ a h/o pansensitive TB on 3 drug
regimen, MDS with pancytopenia, respiratory failure s/p trach
placement and revision [**5-/2147**], recently admitted [**Date range (1) 102694**] with
sepsis presumed [**12-23**] PNA (by MDR E coli, pseudomonas) who comes
in from [**Hospital3 **] with increasing abdominal distension,
drainage from GJ tube site and fever. On last admission pts
sputum grew out pan sensitive serratia and two strains of
psudomonas. 3 wk course of inhaled tobramycin and ciprofloxacin.
completed [**8-11**]. ARF, UTI complicated course. Two days ago the
patient's G-tube fell out and she had it was replaced.
Presented today with a firm distended abdomen, fever to 100.8
and GJ site draining copious amounts of green yellow fluid.
Lowest BP noted at 90/53. Given vancomycin and ceftaz. Attempted
subclavian, unsuccesful. Of note plts at 14. Large amounts of
blood from trach site, requiring frequent suction. 2 L NS also
given. Pt sent to [**Hospital Unit Name 153**].
.
In the [**Hospital Unit Name 102695**] 90/40. Temp to 100.5. Started on meropenem and
ceftaz as per ID. Fluid bolus given. Blood cx, coags, chem 7, UA
and cx ordered. 2 bags platelets given.
.
Recent ID course:
Prior cultures significant for MDR pseudomonas sensitive to
Cipro from sputum [**6-10**] and MDR E coli sensitive (ESBL) to
Meropenem from sputum [**6-9**]. Also, VRE from cath tip on [**6-21**],
started on Daptomycin, however, daptomycin was discontinued due
to negative blood cx for VRE on [**6-23**]. Tobramycin was added on
[**6-19**] for double coverage of resistent pseudomonas given poor
lung penetration of Cipro. The full course of meropenem was
completed on [**7-2**] and of tobramycin on [**7-3**]. On last
admission, sputum grew out pan sensitive serratia and two
strains of pseudomonas. 3 wk course of inhaled tobramycin and
ciprofloxacin. completed [**8-11**].
Past Medical History:
-[**Date range (1) 102693**] admission for presumed PNA sepsis. ID course as above
-Pulm TB (pan sensitive) with liver/spleen granulomas
- s/p R sided vats, r supraclavic LN, liver bx +
- h/o +PPD w/o tx
- AFB on BAL [**2147-1-2**]
- tx continuous since 2/1 per prior dc summ
- Diabetes mellitus
- OSA - previously on BiPAP
- Cataract left eye
- CVA/TIA (positive MRI)[**11-27**] - right frontal with L arm/hand
hemiparesis; etiology likely moderate degree stenosis of the ICA
in the cavernous region, stable on recent CTA, hx of watershed
infarcts during acute illness in the setting of acute disease
- Asthma
- Hypercholesterolemia
- Seizure- uncertain diagnosis - L arm involuntary movements
[**2144**], not on anti-seizure medications
- Chronic renal insufficiency due to recurrent exposures to
nephrotocxic medications/ contrast and hemodynamic instability
in the context of recurrent sepsis, Creat on last discharge 2.6.
- Likely anoxic brain injury: nonverbal, withdraws to pain, eyes
open; presumptively from recurrent hypotensive insults
- MDS: on bone marrow biopsy with borderline transformation to
AML
- hx of HIT
Social History:
(Per last discharge summary) Has been living in [**Hospital **] rehab
getting tx for disseminated TB. Previosly lived alone in
[**Location (un) 86**]. Supportive family nearby. Remote history of tobacco use.
One-two glasses of alcohol per week. Retired, used to work in a
post office.
.
Family History:
(Per last discharge summary) Diabetes in son, sister, and
brother. [**Name (NI) 102689**] with epilepsy. [**Name (NI) **] brother with
possible lung cancer. Uncle with TB.
Physical Exam:
VS: 100.1, HR 110, BP 95/45, RR 36 (36-41)
GEN: NAD, unresponsive, not following commands
NEURO: nonverbal, minimally withdraws to pain, eyes open,
reflexes
HEENT: PEERLA, 4mm pupils, L cataract, mmm, Dry mucous membranes
CARDS: S1S2, RR, tachycardic, no m/r/g
CHEST: rhonchorus breath sounds throughout, expiratory wheeze.
ABD: s/nt/nd/scarse positive bowel sounds, PEG in place with
bilious secretions, erythema surrounding. Distended. Hypoactive
bowel sounds
EXT: +DP, warm, minimal movement with pain, reflexes, 2+ edema
Skin: Edematous, PICC line Right arm, erythema. 2+ LE and UE
edema. Warm to touch. No skin mottling.
Pertinent Results:
ABG 7.41, 28, 351
.
146 120 40 71 AGap=13
5.1 18 1.1
Ca: 7.3 Mg: 2.1 P: 4.3
ALT: 4 AP: 87 Tbili: 0.6
AST: 19 LDH: 275
[**Doctor First Name **]: 39 Lip: 20
.
10.1
7.3 Pnd
29.4
N:Pnd L:Pnd M:Pnd E:Pnd Bas:Pnd
.
PT: 15.0 PTT: 33.1 INR: 1.3
.
KUB [**2147-8-19**] GJ-tube is present, the tip of which is
probably in the distal duodenum or proximal jejunum. There is a
non- specific bowel gas pattern. Heterotopic bone formation is
seen involving the left hip.Degenerative changes in the lower
lumbar spine are again noted.
.
CXR [**2147-8-19**] No pneumothorax is identified. A right-sided
subpulmonic effusion is unchanged. There is bibasilar
atelectasis. A right-sided PICC with the tip in the superior SVC
is unchanged. The tracheostomy tube is unchanged.
.
EKG- Sinus tach 106, low voltages, Q III AVF, T wave flattening
.
CT Abd/Pelvis:
IMPRESSION:
1. Fluid and air tracking along the GJ tube site consistent
with known
clinical leak. No evidence of intra-abdominal abscess or
extraluminal
contrast extravasation. No evidence of obstruction.
2. Bibasilar airspace opacity is likely consolidation with
small bilateral
pleural effusions.
3. Unchanged splenic infarcts of unknown etiology.
4. Moderate amount of ascites and severe anasarca.
5. Right renal hemorrhagic cyst.
6. Foley catheter balloon is inflated within the urethra and
should be
repositioned.
7. Heterotopic bone formation associated with the left proximal
femur may
relate to myositis ossificans related to prior trauma. This
heterotopic bone has slowly increased in size and prominence
since [**2147-1-2**], at which time there was an
intramuscular hematoma in this region.
Brief Hospital Course:
69 yo female with a history of disseminated TB, GJ tube
placement after CVA with recent replacement, Serratia and
Pseudomonas PNA and persistent intermittent fevers presenting
with abdominal distension and fever, increased drainage from
adjacent to GJ tube site and bloody secretions from trach site.
.
#Pseudomonas pneumonia: Chronic low grade fever intermittently
on multiple hospitalizations with unclear etiology. Recent hx of
pneumonia including pseudomonas, serratia - with recent ([**2147-7-23**])
sputum culture showing strain of pseudomonas resistant to
meropenem and cefepime - sensitive only to tobramycin - received
treatment at that time. Now with new fever spike to 102,
increased white sputum production and cough. Subsequent sputum
culture revealed pseudomonas pneumonia with sensitivities
identical to prior hospitalizations. Was treated with
tobramycin and ciprofloxacin per culture sensitivities. Mild
improvement, but the day prior to death, had an aspiration event
after vomiting with likely resultant aspiration pneumonitis.
.
#G-J tube dysfunction - Admitted with nonfunctional G-J tubes,
with copious draining from site (stomach secretions). CT scan
negative for abscess or ileus. KUB with no evidence of
pneumoperitoneam. IR replaced the tube. She continued to have
1.5-2L of fluid output daily via the G-tube. Additionally, the
J-tube had no drainage, but resultant lab data after medication
administration indicated her small intestine was not absorbing
properly. She was reimaged on [**2147-8-24**] with increased concern
for an evolving intraabdominal process given worsening abdominal
distension and sepsis. CT Scan again revealed no
intra-abdominal abscess or fluid collections. The day she
expired, she again became septic following aspiration
necessitating multiple fluid boluses. Despite aggressive
resuscitation, her pressures continued to drop. Intrabladder
pressure was measured at 45, likely resultant from bowel edema,
giving evidence of likely intra-abdominal compartment syndrome,
however, given her tenuous blood pressure surgical decompression
was not an option.
.
#Bleeding from trach site: Pt with platelets 14 on admission.
Bleeding with suction. Hx of TB. Hx of hemoptysis. [**5-30**] with
hemoptysis considered likely due to obstruction of the
tracheostomy tube and hemoptysis most likely related to
granulation tissue or tracheal stenosis at the tracheostomy
site. Bleeding slowed significantly with PLT transfusion.
However, PLT level initially bumps with repeated platelet
transfusion but comes back to teens. Throughout hospital stay
was transfused with multiple units of platelets when either her
level was <10 or she developed oozing at trach or G-J site.
.
#DMII-Initially hypoglycemic on admission after several days
without tube feeds. Tube feeds were resumed. While initially
septic she was started on an insulin drip for tight glycemic
control but later transitioned to a sliding scale once more
stable.
.
#Tachycardia: Baseline tachycardia of low 100s. Intermittently
throughout stay would be tachycardic to 130s during episodes of
fever, pain or profound infection. The day of death, her heart
rate advanced to 150s but we were unable to slow her rate given
concern for worsening hypotension. Within the last hour of
life, her heart rate precipitously dropped until she developed
asystole necessitating CPR.
.
#MDS: Thrombocytopenia and anemia persisted throughout her
hospitalization. Prior biopsy in [**2146-11-21**] showed
progression with concern of impending AML conversion. While
inpatient, peripheral blood smear analysis gave no evidence for
new leukemia. Repeat CT Scan revealed progressive
lymphadenopathy throughout the abdomen and thorax. Thoracic
surgery was consulted concerning potential biopsy, but we were
ultimately unable to have this done as she was too unstable for
the operating room.
.
#Disseminated TB: Continued on four drug regimen while
inpatient. Began pursuing biopsy of lymph nodes, but were
ultimately unable due to the severity of her illness.
.
#Code Status - While inpatient, her status remained FULL CODE.
Several meetings were held with her son [**Name (NI) **] [**Name (NI) **] (HCP) who
reaffirmed this wish.
.
.
The day of expiration, Ms. [**Known lastname **] was in septic shock, likely due
to progressive pseudomonas pneumonia and aspiration pneumonitis.
She was treated aggressively with fluid resuscitation,
antibiotics and pressors to maintain her blood pressure. The
day of death, at approximately 0400, she began dropping her BP
despite being maximally dosed on 3 pressors. As her BP
decreased to SBP 40s, she went into asystole. CPR was
initiated. She was treated with chest compressions, epinephrine
and atropine, however she failed to regain a sustainable rhythm
and she was pronounced dead.
Addendum: Note: the patient had progressive abdominal distention
the evening prior to her death. This compromised diaphragmatic
motion and ventilation, further worsening acid-base status. Due
to patient's critical condition, no diagnostic tests to assess
for intra-abdominal pathology were feasible.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD
Medications on Admission:
Lansoprazole 30 mg PO DAILY
Albuterol 90 mcg/Actuation Aerosol 1-2 Puffs Q6H as needed
Ipratropium Bromide 17 mcg/Actuation 2 Puff Inhalation QID
Insulin QID per sliding scale
Insulin Glargine 7 units Subcutaneous at bedtime
Isoniazid 300 mg PO DAILY
Pyrazinamide 500 mg PO DAILY
Pyridoxine 50 mg PO DAILY
Sucralfate 1 g PO QID
Ethambutol 400 mg 3tbl PO Q36H
Nystatin S+S
Acetaminophen 160 mg/5 mL Solution [**Last Name (NamePattern4) **] PO Q6H
Lactulose 10 g/15 mL 30ml PO Q8H as needed for constipation.
Senna 8.6 mg PO BID as needed for constipation.
Docusate Sodium 100 mg PO BID
Sodium Bicarbonate 650 mg PO Q6H (every 6 hours).
Fentanyl Citrate 25-100 mcg IV Q6H:PRN
Midazolam 2-4 mg IV Q4H:PRN
reglan 5 mg Q8 GJ tube
Sodium bicarbonate 650 mg q 12 hr
KCL 40 meq daily
free water- via feeding tube 400 ml q6 hr
MVI
morphine s2 mg q 4 hr PRN
Discharge Medications:
None - expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Pseudomonas pneumonia, sepsis, Mycobacterium Tuberculosis,
Diabetes mellitis type two, myelodysplastic syndrome
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
ICD9 Codes: 0389, 5849, 2762, 2875, 4275 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3764
} | Medical Text: Admission Date: [**2150-2-21**] Discharge Date: [**2150-2-24**]
Date of Birth: [**2080-5-6**] Sex: M
Service: MEDICINE
Allergies:
Mevacor / Pravachol / Bactrim / Adhesive Tape
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
left leg cellulitis
Major Surgical or Invasive Procedure:
LENI
CT Head
History of Present Illness:
Mr. [**Known lastname **] is a 69 y/o M with PMH significant for ESRD s/p
cadaveric renal transplant in [**2145**] with CKD, afib, and recurrent
cellulitis who presented with cellulitis and hypotension. He was
admitted [**Date range (1) **] for cellutis and had right great toe
debridement and was discharged on ciprofloxacin and vancomycin
to treat osteomyelitis. He presented to [**Hospital **] clinic on day
PTA who felt his toe looked well post debridement. At home he
noted poor glucose control and fever so presented to the ED.
In the ED, he had a fever to 103.3 orally, HR 107, BP 153/69
with elevated lactate at 4.5. He received 1700 cc of NS and 650
mg of tylenol. Per ID recommendations he was given 2.25 g of
Zosyn IV X 1 and vancomycin and had good urine output with UA
and CXR clear. Due to elevated lactate and tachycardia decision
was made to admit the patient to the ICU.
While in the ICU he was continued on vancomycin and Zosyn per
ID. Renal was consulted and decreased cellcept to 500 [**Hospital1 **],
prednisone to 5, with plan to check Cyclosporin level in AM.
LENIs were negative and [**Hospital1 **] was consulted.
Past Medical History:
1. Atrial fibrillation- s/p cardioversion and initiation of
amiodarone on [**1-7**].
2. Atrial flutter s/p ablation in [**3-/2145**] with resultant atrial
fibrillation
3. S/P cadaveric renal transplant in 07/[**2145**]. Complicated by
delayed graft rejection. Pt's ESRD secondary to autoimmune
glomerulonephritis.
4. [**Name (NI) **] Pt is s/p MI x2 and CABG in [**2138**]. No cath or stress
results in our system.
5. [**Name (NI) 4964**] Pt's most recent echo was [**1-/2148**] with EF 40% and mild
dilated LV and LV mild hypokinesis, post akinesis, 1+ MR.
6. H/O pulmonary nocardiosis in [**10/2144**]
7. H/O bladder cancer s/p surgery and BCG treatment in [**2136**]
8. S/P GI bleed while on heparin
9. H/O line related DVT
10. Stable right adrenal lesion
11. Type 2 diabetes mellitus complicated by neuropathy, on
insulin, followed at [**Last Name (un) **]
12. BL leg cellulitis: RLE cellulitis began after a board fell
on his leg in the beginning of [**Month (only) 1096**]. Swab MRSA +, treated
with IV vancomycin and unasyn & d/c'd on linezolid and augmentin
(14 day course). Re-presented one week later with fevers (felt
to NOT be related to the cellulits), completed remainder of the
14 day course with vancomycin and unasyn. Next admission treated
with cipro/linezolid. Developed diarrhea while on linezolid
([**Month (only) 404**]), so changed to doxycycline.
13. Chronic Kidney Disease
14. elevated triglycerides
15. Pseudogout
Social History:
Patient is married and lives with his wife. [**Name (NI) **] is a former
illustrator. Denies drugs/alcohol. Smoked 1.5 ppd X 25 years.
Quit 20 years ago. Has 2 daughters.
Family History:
Mother with diabetes
Physical Exam:
T: 98.9, 144/74, 84, 20, 96%
Gen: Pleasant male in NAD. Lying in bed.
HEENT: periocular left eye ecchymosis
CV: irreg irreg, S1 S2 [**2-3**] HSM at RUSB
LUNGS: CTA bilat
ABD: soft, NT, mod distended, no HSM
EXT: absent dp pulses [**Last Name (un) **], severe hyperpigmentation changes of
RLE chronic venous stasis changes, 1+ pitting edema to knees
bilat, markedly improved erythema of LLE now well inside
demarcated line, markedly improved tenderness to palpation in
posterior calf
NEURO: CNII-XII intact, [**4-4**] UE and LE strength, distal sensation
diminished in [**Month/Day (1) 104785**] distrubution bilat, A and Ox3
Pertinent Results:
[**2150-2-24**] 09:15AM BLOOD WBC-7.0 RBC-4.04* Hgb-9.3* Hct-29.5*
MCV-73* MCH-22.9* MCHC-31.3 RDW-19.6* Plt Ct-261
[**2150-2-21**] 09:45PM BLOOD WBC-16.7*# RBC-4.72 Hgb-11.1* Hct-34.6*
MCV-73* MCH-23.5* MCHC-32.1 RDW-19.2* Plt Ct-313
[**2150-2-21**] 09:45PM BLOOD Neuts-80.1* Lymphs-15.8* Monos-3.4
Eos-0.4 Baso-0.2
[**2150-2-23**] 06:15AM BLOOD PT-20.1* PTT-37.1* INR(PT)-1.9*
[**2150-2-24**] 09:15AM BLOOD Glucose-173* UreaN-58* Creat-3.2* Na-141
K-3.5 Cl-102 HCO3-28 AnGap-15
[**2150-2-20**] 12:30PM BLOOD UreaN-71* Creat-3.9* Na-141 K-4.7 Cl-105
HCO3-23 AnGap-18
[**2150-2-23**] 06:15AM BLOOD TotBili-1.6*
[**2150-2-21**] 09:45PM BLOOD CK(CPK)-79
[**2150-2-21**] 09:45PM BLOOD CK-MB-NotDone cTropnT-0.08*
[**2150-2-22**] 03:05AM BLOOD Acetone-NEGATIVE
[**2150-2-23**] 06:15AM BLOOD Vanco-18.4
[**2150-2-22**] 06:52PM BLOOD Vanco-21.5*
[**2150-2-22**] 06:24AM BLOOD Vanco-26.4*
[**2150-2-20**] 12:30PM BLOOD Vanco-35.0*
[**2150-2-24**] 09:15AM BLOOD Cyclspr-46*
[**2150-2-21**] 11:58PM BLOOD Lactate-1.2
[**2150-2-21**] 09:44PM BLOOD Lactate-4.5* K-4.6
[**2150-2-21**] CT HEAD: No evidence of acute intracranial hemorrhage.
.
[**2150-2-21**] CXR: No evidence of pneumonia.
.
[**2150-2-21**] ECG: Sinus tachycardia. P-R interval is prolonged. Left
axis deviation. Left anterior fascicular block. Right
bundle-branch block with left anterior ascicular block/ Since
the previous tracing the rate is increased.
.
[**2150-2-22**] UNLAT LE VEINS: No DVT in the left lower extremity.
.
Brief Hospital Course:
A/P: Mr. [**Known lastname **] is a 69 y/o M with PMH significant for ESRD s/p
renal transplant in [**2145**] with persistent CKD, afib, and
recurrent cellulitis who presented with cellulitis and
septicemia.
.
# LLE post-procedure Cellulitis with septicemia
Markedly improved with zosyn and vancomycin
ID Consultation
- Continue vanc/zosyn total of 14 days
- Re consult [**Year (4 digits) **] felt surgical wound clean, not
osteomyelitis
- ID consult to follow vanco levels as outpatient
# CKD Stage 5 s/p Transplant:
Patient's creatinine increased from previous discharge.
Renal transplant consultation following
- Continue usual doses of cyclosporine and decreased cellcept
and prednisone per renal consult
They will continue to follow this in the outpatient setting
- Continue calcitriol, folplex vitamin.
.
# Gout: Continue allopurinol and prednisone at 10 mg daily.
.
# DM Type 2 uncontrolled with complications:
Cont usual NPH regimen 20 U [**Hospital1 **] with sliding scale.
- Continue neurontin for neuropathy
.
# Hypertension - benign:
Continue toprol and [**Hospital1 **]
.
# CHF - Systolic:
EF 35%
Continue toprol and bumex
.
# yeast balanitis:
clotrimazole cream
.
# Atrial fibrillation:
Continue toprol, amiodarone for rate control
coumadin for anticoagulation and monitor INR.
.
# Microcytic anemia of CKD:
Hct slightly below baseline but likely dilutional. Baseline
anemia due to CRI. [**Month (only) 116**] benefit from Epogen. Fe studies may
suggest mild iron deficiency with neg colonoscopy [**2144**].
Medications on Admission:
1. Mycophenolate Mofetil 1000 mg [**Hospital1 **]
2. Amiodarone 100 mg daily
3. Warfarin 2 mg daily
4. Cyclosporine Modified 50 mg QAM, 25 mg QPM
5. Bumetanide 1 mg [**Hospital1 **]
6. Sarna lotion
7. Allopurinol 100 mg daily
8. Calcitriol 0.25 mcg daily
9. Docusate Sodium 100 mg [**Hospital1 **]
10. B Complex-Vitamin C-Folic Acid 1 cap daily
11. Atorvastatin 5 mg Q3 days
12. Prilosec 40 mg daily
13. Toprol XL 50 mg daily
14. NPH 20 U [**Hospital1 **] with sliding scale regular insulin
15. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed.
16. Nystatin ointment
17. Vancomycin 750 mg daily
18. Cipro 500 mg [**Hospital1 **]
19. Gabapentin 300 mg daily
20. Prednisone 10 mg daily
Discharge Medications:
1. Cyclosporine Modified 25 mg Capsule Sig: Two (2) Capsule PO
QAM (once a day (in the morning)).
2. Cyclosporine Modified 25 mg Capsule Sig: One (1) Capsule PO
QPM (once a day (in the evening)).
3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q24H (every
24 hours).
4. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
5. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
7. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Pyridoxine 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
10. Atorvastatin 10 mg Tablet Sig: 0.5 Tablet PO 3X/WEEK
(MO,WE,FR).
11. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
12. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Bumetanide 0.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
14. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
16. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
17. Piperacillin-Tazobactam 2.25 g Recon Soln Sig: One (1) Recon
Soln Intravenous Q8H (every 8 hours) for 11 days.
Disp:*33 Recon Soln(s)* Refills:*0*
18. Vancomycin 1,000 mg Recon Soln Sig: Seven [**Age over 90 1230**]y
(750) mg Intravenous once a day for 11 days: Note: Not full
dose!.
Disp:*11 Doses* Refills:*0*
19. PICC CARE
PICC Care per NEHT Protocol
20. Outpatient [**Age over 90 **] Work
Please Draw Weekly (Every Wednesday)
Vancomycin Level
CBC
Basic Metabolic Profile
To be followed by Dr. [**First Name4 (NamePattern1) 4850**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 1419**]. Tel:
[**Telephone/Fax (1) 457**]
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Post-Procedure Cellulitis of the Leg
Chronic Kidney DIsease s/p renal transplant
Type 2 DM uncontrolled with complications
CAD
Systolic CHF
Gout
Atrial Fibrillation
Discharge Condition:
Good
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1500ml
If you are unable to walk, increasing pain in the calf, notable
leg swelling, fever/chills, weight gain
Note your cyclosporine level has been reduced and will be
controlled by Dr. [**Last Name (STitle) 118**]
You will be on a total of 2 weeks of IV Zosyn and Vancomycin,
you will need to finish ALL doses. It may take up to a week to
see the majority of the redness to disappear from your leg.
Followup Instructions:
1. Provider: [**Name10 (NameIs) 1947**] CLINIC (SB) Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2150-3-6**] 10:30
2. Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2150-3-23**] 10:30
3. Dr. [**First Name4 (NamePattern1) 4850**] [**Last Name (NamePattern1) **] has re-scheduled your follow-up appointment
with her. It is now on [**2150-3-5**] at 9:30.
Your vancomycin levels will be sent to Dr. [**First Name (STitle) **] to follow.
ICD9 Codes: 0389, 4280, 3572, 4019, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3765
} | Medical Text: Admission Date: [**2175-9-13**] Discharge Date: [**2175-9-20**]
Date of Birth: [**2095-10-1**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Left upper lobe lung cancer.
Major Surgical or Invasive Procedure:
[**2175-9-14**]: VATS exploration, left thoracotomy and left upper
lobectomy, thoracic lymphadenectomy, flexible bronchoscopy with
aspiration.
History of Present Illness:
Mr. [**Known lastname 80151**] is a 79-year-old gentleman with a biopsy-proven left
upper lobe lung cancer. He also had proximal hilar adenopathy.
Past Medical History:
Lyme Disease
TB
Social History:
A 15-pack-year smoker, discontinued 40 years ago. Occupation:
Publisher. Lives with his wife. [**Name (NI) **] drinks occasionally and
denies any exposure history.
Family History:
Mother had brain cancer. Father had questionable lung cancer
versus benign tumor, and he has a sister with rectal cancer.
Pertinent Results:
[**2175-9-19**] WBC-8.8 RBC-3.38* Hgb-10.1* Hct-30.1* Plt Ct-252
[**2175-9-16**] WBC-14.7* RBC-3.42* Hgb-10.3* Hct-29.2* Plt Ct-239
[**2175-9-13**] WBC-10.3 RBC-3.36* Hgb-10.6* Hct-28.5* Plt Ct-158
[**2175-9-19**] Glucose-109* UreaN-12 Creat-1.0 Na-137 K-4.4 Cl-102
HCO3-27
[**2175-9-17**] Glucose-130* UreaN-12 Creat-0.9 Na-136 K-4.1 Cl-102
HCO3-29
[**2175-9-13**] Glucose-171* UreaN-15 Creat-0.8 Na-131* K-4.2 Cl-106
HCO3-24
CXR:
[**2175-9-19**] left pneumothorax is still minimal.
[**2175-9-18**] Unchanged small left apical pneumothorax after removal
of the
left chest tube.
[**2175-9-14**]: Small left apical pneumothorax has developed.
Postoperative volume loss is present following left upper lung
resection. Patchy and linear atelectasis is present at right
lung base as well as minimal
atelectasis at the left base. Marked gastric distension has
developed.
[**2175-9-15**]: PICC terminating in the expected location of the mid
to lower superior vena cava.
[**2175-9-17**] Upper Extremity Duplex
The right cephalic vein is thrombosed as visualized. Right
basilic vein is thrombosed from the lower one-third of the upper
arm to the antecubital fossa. PICC line is identified in the
right basilic vein.
3. Of the two-paired right brachial veins, one is patent
throughout the upper arm. The second is visualized only to the
lower half of the upper arm. Non- visualization of the lower
portion may be due to small size, although thrombosis cannot be
excluded.
Brief Hospital Course:
Mr. [**Known lastname 80151**] was admitted on [**2175-9-13**] for VATS exploration, left
thoracotomy and left upper lobectomy, thoracic lymphadenectomy,
flexible bronchoscopy with aspiration which was complicated by
staples that had torn out of the distal PA resulting in bleeding
requiring 5 Units packed red blood cells, 2 units of fresh
frozen plasma, and 4 liters of crystalloid, and a Phenylephrine
drip intraoperatively. He was transferred to the SICU intubated
on Phenylephrine for further management. The 2 left chest-tube
were to suction with serosanguinous drainage, a foley and
Bupivacaine Epidural for pain control managed by the acute pain
service. On POD #1 he was extubated without difficulty, the
pressors were stopped, he was started on beta-blockers for brief
episodes of atrial fibrillation in the 100s-140s. Hydromorphone
was added to the epidural for better pain control. He tolerated
a clear liquid diet which was advanced as tolerated. On POD #2
the atrial fibrillation increased with episodes of hypotension.
An amiodarone bolus/drip was started with better rate control.
The Phenylephrine was restarted for hypotension while in atrial
fibrillation. Serial chest x-rays showed decreased left lung
volume consistent with surgery and right lower lobe atelectasis.
On POD #3 he converted to sinus rhythm, the chest-tube was
placed to water-seal without air leak. The left anterior chest
tube was removed Oxygen saturations 98% 2.5 Liter nasal cannula.
A PICC line was placed. The epidural was removed and his pain
was managed with PO pain medication. On POD #4 the pressors
were wean off, he transferred to the floor. The PICC line was
removed secondary to Right basilic vein is thrombosed from the
lower one-third of the upper arm to the antecubital fossa
confirmed by ultrasound. The remainder chest-tube was removed
with stable small apical pneumothorax. On POD #5 the
beta-blockers were increased for persistent paroxysmal atrial
fibrillation. Cardiology recommended aspirin 325 mg daily for
anticoagulation. He continued to make steady progress and was
discharged to home with VNA. He will follow-up with Dr.
[**Last Name (STitle) **] as an outpatient.
Medications on Admission:
None
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day
for 7 days: then one tablet daily for 30 days.
Disp:*14 Tablet(s)* Refills:*0*
2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day
for 30 days.
Disp:*30 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day).
5. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed.
Disp:*75 Tablet(s)* Refills:*0*
6. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*135 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Left upper lobe squamous cell carcinoma.
Paroxysmal atrial fibrillation
Lyme Disease
TB
Discharge Condition:
stable
Discharge Instructions:
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if experience:
-Fever > 101 or chills
-Increased shortness of breath, cough or sputum production
-Incision develops drainage.
Chest-tube site cover with a bandaid
You may shower on thursday. No tub bathing or swimming for 6
weeks
No driving while taking narcotics. Take stool softners with
narcotics
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] on [**2175-10-5**] at 2:30pm on the [**Hospital Ward Name **] clinical center [**Location (un) **]. Please arrive 45 minutes to
your appointment and report to the [**Location (un) 470**] radiology for a
chest XRAY.
Schedule a follow up appointment with your primary care doctor
to review some new medications that you were sent home with from
the hospital- aspirin, lopressor, amiodarone.
Completed by:[**2175-9-20**]
ICD9 Codes: 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3766
} | Medical Text: Admission Date: [**2160-4-25**] Discharge Date: [**2160-4-30**]
Service: MEDICINE
Allergies:
Amoxicillin
Attending:[**First Name3 (LF) 2751**]
Chief Complaint:
Low Hct
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] yo M with Hx of Autoimmune hemolytic anemia and GI bleeds,
CAD, CKD, Mechanical Aortic valve on coumadin with recent
admission to [**Hospital1 18**] for anemia felt to be secondary to GI bleed
([**Date range (1) 66606**]), who was sent to the ED from [**Hospital 100**] Rehab for
persistently low Hct. Per the patient, he has been in his usual
state of health and has not experienced any dizziness, syncope,
CP, SOB or other symptoms in the last several days, but has felt
generally tired. His NH has been closely monitoring his Hct,
which has been low but stable for the past several days. He
received 2 units prbcs at rehab on [**4-18**] for Hct 22, and did not
have an adequate response (Hct [**4-23**] was 23.8 and [**4-25**] was 22.3
with INR 2.2). Patient was also reportedly noted to have a
small amount of BRBPR yesterday, but he states he never saw the
blood.
.
Of note, the patient has had extensive workup in the past for GI
bleed(EGD x4, [**Last Name (un) **] x2, capsule x3, CT abd/pelvis, bleeding scan)
without clear source or site, and felt to be most likely
bleeding from an UGI source that is not possible to reach
endoscopically. On prior admissions, further invasive testing
was discussed, and the patient and HCP opted for more
conservative measures including transfusions and iron
supplementation.
.
In the ED, initial vs were: 97.0 86 95/51 14 97% RA, pain 0/10.
Labs were significant for Hct 20.5 (down from 22.3 at NH), INR
3.0. He was found to have black guaiac positive stool. No NG
lavage was performed given patient's stability and multiple
prior similar presentations. Patient was given a protonix bolus
and started on a drip. He was typed and crossed 2 units but did
not receive any blood prior to transfer. He was admitted to the
ICU for further management.
.
On the floor, patient reports feeling generally tired and
thirstly, but otherwise well. Specifically denies dizziness,
chest pain, SOB, palpitations or other symptoms currently.
.
Review of systems:
(+) Per HPI, also reports several days of burning with
urination. Incontinent of urine and stool at baseline. Also
reports left arm pain when his arm "gets cold," which is
responsive to tylenol and has been present for several weeks.
Does not walk or move much at baseline.
(-) 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 arthralgias or myalgias.
Denies rashes or skin changes.
Past Medical History:
# Anemia, multifactorial as below, baseline HCT 28
# Autoimmune hemolytic anemia (Coomb's +, warm autoantibody),
on prednisone 10mg Po daily
# Listeria Endocarditis s/p AVR, suppressive amoxicillin stopped
due to hemolytic anemia
# Aortic mechanical valve, recently Coumadin resistant so
intermittently on Lovenox bridge, followed by Dr. [**Last Name (STitle) **]
# hx recent GI bleeds: colonoscopy [**1-10**]: noted normal colon
with melanotic stool in terminal ileum
# GERD: EGD [**12/2159**] Polyp in the area of the papilla; found on
the wall opposite the ampulla. Small hiatal hernia. Otherwise
normal EGD to third part of the duodenum.
# H/o presyncope
# CKD Cr 1.6-2.0 Stage III
# CAD s/p NSTEMI [**7-10**]
# Chronic CHF, likely diastolic, ([**9-9**] EF=50%)
# Hyperlipidemia
# Hypertension
# Depression vs adjustment disorder after death of brother
# Prostate cancer- s/p radiation
# Bladder/bowel incontinence
# Right lateral malleolus stage 1 pressure ulcer
# Dementia
Social History:
Never smoked, no EtOH or other drugs. Currently living at
[**Hospital 100**] Rehab. Uses wheelchair typically. Requires a
significant degree of assistance in all his ADLs and IADLs. Has
2 sons and 4 grandchildren.
Family History:
No bleeding diatheses. Father had stomach cancer. No other
cancers including colon.
Physical Exam:
Vitals: T: 96 BP: 92/41 P:69 R: 18 O2: 99% on RA
General: pale, tired-appearing elderly male, lying in bed in
NAD, alert and oriented (although later appeared confused)
HEENT: NCAT, PERRL, right ptosis (chronic per patient), sclera
anicteric, dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally (anterior only)
CV: Regular rate and rhythm, S1 + S2, mechanical ao valve sounds
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Admission Labs:
[**2160-4-25**] 06:45PM BLOOD WBC-4.3 RBC-2.05*# Hgb-7.0*# Hct-20.5*#
MCV-100* MCH-34.1* MCHC-34.0 RDW-22.2* Plt Ct-159
[**2160-4-25**] 06:45PM BLOOD PT-30.4* PTT-29.8 INR(PT)-3.0*
[**2160-4-25**] 06:45PM BLOOD Glucose-183* UreaN-50* Creat-1.4* Na-138
K-4.4 Cl-106 HCO3-23 AnGap-13
[**2160-4-25**] 06:45PM BLOOD Albumin-3.0* Calcium-7.7* Phos-3.0 Mg-2.1
[**2160-4-26**] 09:05AM BLOOD WBC-4.6 RBC-2.58*# Hgb-8.4* Hct-24.4*
MCV-95 MCH-32.5* MCHC-34.3 RDW-22.1* Plt Ct-108*
[**2160-4-26**] 02:48PM BLOOD WBC-4.0 RBC-2.76* Hgb-9.1* Hct-25.7*
MCV-93 MCH-33.0* MCHC-35.4* RDW-21.7* Plt Ct-110*
[**2160-4-27**] 02:54AM BLOOD WBC-3.6* RBC-2.62* Hgb-8.2* Hct-25.5*
MCV-98 MCH-31.4 MCHC-32.2 RDW-22.1* Plt Ct-108*
[**2160-4-28**] 04:10AM BLOOD WBC-3.5* RBC-2.71* Hgb-8.7* Hct-26.5*
MCV-98 MCH-31.9 MCHC-32.6 RDW-21.6* Plt Ct-118*
[**2160-4-29**] 04:28AM BLOOD WBC-4.1 RBC-2.78* Hgb-9.0* Hct-26.5*
MCV-95 MCH-32.4* MCHC-34.0 RDW-21.5* Plt Ct-125*
[**2160-4-30**] 05:18AM BLOOD WBC-5.1 RBC-3.24* Hgb-10.7* Hct-30.9*
MCV-95 MCH-33.0* MCHC-34.6 RDW-20.6* Plt Ct-134*
[**2160-4-30**] 05:18AM BLOOD Glucose-86 UreaN-13 Creat-1.3* Na-144
K-3.7 Cl-112* HCO3-25 AnGap-11
[**2160-4-25**] 06:45PM BLOOD Albumin-3.0* Calcium-7.7* Phos-3.0 Mg-2.1
[**2160-4-25**] 06:45PM BLOOD LD(LDH)-182 TotBili-0.2 DirBili-0.1
IndBili-0.1
[**2160-4-30**] 05:18AM BLOOD LD(LDH)-198
[**2160-4-26**] 3:00 pm URINE Source: Catheter.
URINE CULTURE (Preliminary):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH FECAL
CONTAMINATION.
INTERPRET RESULTS WITH CAUTION.
GRAM NEGATIVE ROD(S). >100,000 ORGANISMS/ML..
PREDOMINATING ORGANISM.
CARDIAC ECHO [**2160-4-29**]:
Poor image quality. The left atrium is moderately dilated. The
right atrium is moderately dilated. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is probably
mildly depressed (LVEF= 45 %) with a suggesiton of more
prominent inferior hypokinesis (difficult to assess due to poor
image quality). There is no ventricular septal defect. The
ascending aorta is mildly dilated. The aortic arch is mildly
dilated. A mechanical aortic valve prosthesis is present. The
aortic valve prosthesis appears well seated, with normal
leaflet/disc motion and transvalvular gradients. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Mild to moderate ([**2-3**]+) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of [**2159-1-30**],
no definite change.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2160-4-29**] 16:28
PORTABLE CHEST, [**2160-4-27**]
CLINICAL INFORMATION: Falling hematocrit, question change.
FINDINGS:
Frontal view of the chest compared to multiple prior
examinations. There are
low lung volumes. PICC on the right is unchanged. Small
left-sided pleural
effusion with left lower lobe atelectasis unchanged. Mild
congestive failure.
Brief Hospital Course:
[**Age over 90 **]M with autoimmune hemolytic anemia, mechanical aortic valve on
coumadin and recurrent GIB, who presents with low HCT and guaiac
positive stool.
.
#. Anemia: Most likely multifactorial, and mostly from recurrent
ongoing GIB. Hemolysis not thought to be a significant factor
given the Coombs test was negative and he had a normal LDH. He
had dark guaiac pos stools, but has had work up in past
including colonoscopy and capsule endoscopy without finding
source of bleed. GI was consulted and felt as though, while he
is anticoagulated, there is nothing to do. If his
anticoagulation could be stopped they would recommend monitoring
his HCT over a few months time to evaluate stability. His HCT
was 20.7 on admission and he received 2 units PRBCs in the ED
and his HCT had an appropriate bump to 25 and remained stable at
25 thereafter. Hematology recommended transfusing to >30 and so
he received one more unit on the medical floor. CBC should be
monitored periodically as well as stool output for recurrent
bleeding. GI team was aware of him, but since prior
EGD/Colonoscopy has failed to reveal a source, decided
conservative treatment was the best. In the past, blood has
been noted in the terminal ileum so a small bowel lesion is
suspected. Capsule studies have not revealed a source, though
was incomplete (in [**2159-12-3**]). Patient on brdiging IV
Hep/Warfarin.
.
# Mechanical Aortic valve: The patient has a goal INR of [**3-6**]
(ideally 2.5). Heme/onc wanted to consider stopping
anticoagulation as pt frequently in hospital. Cardiology felt
the risk was not well definable and not worth it, so he was
continued on anticoagulation. His INR was reveresed in the ICU
with Vit K and he was restarted on IV heparin drip (wt based
protocol without bolus) to bridge until therapeutic INR on
warfarin. Per cardiology, the hep gtt should not be stopped
until the INR level is therapeutic at around 2.2. He is
discharged to [**Hospital 100**] Rehab where this can be followed
appropriately. A TTE was updated and showed no change from
prior (see report in results section).
# UTI: The patient complained of dysuria on admission and he had
a positive U/A. He was started on cipro 500mg Q12H with plans
for a 7 day course. He had questionable delerium after ICU stay,
and so Cipro was changed to Ceftriaxone. Urine culture [**2160-4-26**]
is growing >100K organisms with a predominant GNR, not yet
speciated with sensitivities. This needs to be followed by
[**Hospital 100**] Rehab by calling [**Hospital1 18**] Micro Lab [**Telephone/Fax (1) 4645**] for
results.
.
# Delerium vs. Hospital Psychosis: When out of ICU on medical
floor, he had vivid hallucinations of being visited by Chinese
Immigration, and then by 2 men from the mafia who were after his
patents. He was otherwise not inattentive as usually seen with
acute delierum, and his psychosis was not agitated. He received
one nightime dose of Haldol 0.25mg on [**2160-4-29**] and slept very
well without PM or [**2160-4-30**] AM recurrent hallucinations (though
patient has good recollection of the hallucinations). This
should be followed by his medical team and geriatrician at
[**Hospital 100**] Rehab. [**Name (NI) **] son [**Name (NI) **] ([**Name2 (NI) **]) is aware.
.
# Autoimmune Hemolytic Anemia: Chronic - is on Prednisone for
this. Not acutely hemolyzing here. At the time this diagnosis
was originally made, the patient was on Amoxicillin, so there
was some concern at that time that Penicillin associated drug
hemolyis was possible. While very unlikely, since he is on
Ceftriaxone, hematolgoy team recommends checking LDH
periodically while he is taking this drug.
.
# CKD: On admission his creatinine was at his baseline
(1.2-1.5). Medications were renally dosed as needed. Creatinine
varied 1.0 to 1.4 during hosptialization.
.
# GERD: Initially he was treated with PPI IV BID and
subsequently transitioned to PO.
.
# CAD/Hyperlipidemia/HTN: Continued statin. Held carvedilol in
setting of GIB and stable blood pressures.
.
CODE: FULL
HCP: [**Name (NI) **] ([**Doctor Last Name **]) [**Known lastname 66590**] Phone number: [**Telephone/Fax (1) 66592**] Cell phone:
[**Telephone/Fax (1) 66591**]
Medications on Admission:
-oxycodone 2.5 mg TID prn
-warfarin 3 mg daily
-tylenol 650 mg q6h prn
-Vitamin B12 [**2149**] mcg daily
-folic acid 4 mg po daily
-omeprazole 40 mg [**Hospital1 **]
-simvastatin 40 mg daily
-carvedilol 3.125 [**Hospital1 **]
-Bactrim SS daily (400-80)
-clindamycin 600 mg prn po
-levothyroxine 75 mcg daily
-senna daily
-prednisone 10 mg daily
-acetaminophen 1000 mg [**Hospital1 **]
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for fever or pain.
2. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: Four (4)
Tablet PO DAILY (Daily).
3. folic acid 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily): give 1 hour prior to meals and PPI in the morning.
10. warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at
4 PM.
11. heparin (porcine) in NS 10 unit/mL Kit Sig: wt based units
Intravenous continuous: until therapeutic INR 2.2.
12. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
13. ceftriaxone in dextrose,iso-os 1 gram/50 mL Piggyback Sig:
One (1) gram Intravenous Q24H (every 24 hours) as needed for UTI
for 6 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Acute blood loss Anemia
GI Hemorrhage
MEchanical Heart Valve
Delerium vs. Hospital psychosis
Chronic Systolic Heart Failure
Autoimmune Hemolytic Anemia (chronic)
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:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
You were admitted with recurrent GI bleed from suspected small
bowel source. Your warfarin was held and reversed, you recevied
a total of 3 units of blood with appropriate bump. You are on
IV heparin bridge while back on coumadin until therapeutic to
protect your heart valve.
You had mild delerium vs. Hospital psychosis which will be
followed by your team at [**Hospital 100**] Rehab.
Followup Instructions:
By Geriatrician Dr. [**Last Name (STitle) **] at [**Hospital 100**] Rehab.
ICD9 Codes: 5789, 2851, 5990, 4280, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3767
} | Medical Text: Admission Date: [**2109-7-17**] Discharge Date: [**2109-7-22**]
Date of Birth: [**2062-9-18**] Sex: M
Service: MEDICINE
Allergies:
Clindamycin
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
SOB, increasing pedal edema
Major Surgical or Invasive Procedure:
Intubation, with successful extubation.
History of Present Illness:
[**Known firstname 94522**] [**Known lastname 94523**] is a 46-year-old gentleman with h/o DMI, ESRD on HD,
HIV (VL <50, CD4 393 [**2-13**]), recently diagnosed PE, and multiple
ED admissions for HTN urgency who presented to the ED with
complaints of SOB and LE that had progressed throughout the
evening. Sicne 11PM night PTA, dyspnea increased and patient
sought eval in ED. In [**Last Name (LF) **], [**First Name3 (LF) **] report, patient was 89% RA, and
100% on a 4L NC, appeared comfortable. EKG showed mildly peaked
Ts, and he was treated with calcium, bicarb, and D50/insulin.
Approximately 1/2 hour later, patient became acutely dyspneic
and tachypneic. Repeat EKG showed anterolateral ST segment
elevations. SBP was in 240s at that time. EKG was reviewed with
cardiology attending and cath lab was activated. Patient was
started on Bipap, nitro gtt, nipride gtt, and given lasix 100mg
IV. Breathing status looked poor, he was intubated using
Rocuronium for paralysis given ESRD. He was given heparin and
integrillin boluses for presumed ACS. Repeact CXR showed acute
pulmonary edema. Repeat EKG showed that ST segment elevations
had resolved with BP control. Bedside ECHO was done by
cardiology fellow and no wall motion abnormalities were noted.
Cath was deferred, and patient was admitted to MICU for further
management.
Past Medical History:
- Type 1 diabetes
- HIV (boosted atazanavir, lamivudine, stavudine), dx'd [**2096**]
VL <50, CD4 393 [**2-13**])
- ESRD previously on HD, attempted on PD
on transplant list (clinical study for HIV/solid organ
transplant)
- Malignant Hypertension
- hx Serratia bacteremia (presumed AV graft) tx 6 wks meropenem
- Hx schistosomiasis
- Restless leg syndrome
- Peripheral neuropathy on gabapentin
- S/p cholecystectomy
- s/p R nephrectomy in [**2092**] secondary renal nephrolithiasis
Social History:
Moved from [**Country 4812**] in [**2091**]. Lives with wife in [**Location (un) 538**].
Works in support services for a law firm. Denies any alcohol or
IV drug use. Quit smoking last year; previous 30 pack-year
history.
Family History:
Non-contributory
Physical Exam:
T: 98.7; HR 64; BP 120/75; RR 24; O2 Sat 100%
GEN: alert and oriented, ambulating freely
HEENT: NCAT. MMM. OP clear.
NECK: Supple, No LAD.
CV: S1S2 RRR. Grade II/VI systolic murmur
LUNGS: CTAB
ABD: NABS. Soft, NT, ND.
EXT: WWP, NO CCE. 2+ DP pulses BL
SKIN: No rashes/lesions, ecchymoses.
Pertinent Results:
ECHO [**6-15**]: [**6-/2109**] shows The left atrium is mildly dilated. The
estimated right atrial pressure is 11-15mmHg. There is mild
symmetric left ventricular hypertrophy. Overall left ventricular
systolic function is normal (LVEF 60%). There is severe mitral
annular
calcification.
.
[**2109-7-17**] CXR
IMPRESSION: New air space process in both mid-lungs, most
suggestive of early pulmonary edema.
.
[**2109-7-17**] 06:05AM TYPE-ART TEMP-35.2 O2-100 PO2-188* PCO2-60*
PH-7.30* TOTAL CO2-31* BASE XS-2 AADO2-479 REQ O2-80
INTUBATED-INTUBATED
.
[**2109-7-17**] 05:49AM GLUCOSE-98 UREA N-52* CREAT-8.8* SODIUM-136
POTASSIUM-7.3* CHLORIDE-94* TOTAL CO2-25 ANION GAP-24*
.
[**2109-7-17**] 05:49AM CALCIUM-9.9 PHOSPHATE-11.6*# MAGNESIUM-3.5*
.
[**2109-7-17**] 05:49AM WBC-12.6*# RBC-3.40* HGB-12.7* HCT-36.7*
MCV-108* MCH-37.3* MCHC-34.6 RDW-16.4* NEUTS-84.8* LYMPHS-8.5*
MONOS-4.9 EOS-1.7 BASOS-0.1
.
[**2109-7-17**] 02:05AM CK(CPK)-89
[**2109-7-17**] 02:05AM cTropnT-0.26*
[**2109-7-17**] 02:05AM CK-MB-NotDone proBNP-[**Numeric Identifier **]*
Brief Hospital Course:
46M HIV, ESRD on HD p/w shortness of breath, intubated for
respiratory distress.
.
# RESPIRATORY DISTRESS Initially presented in an event that
appears that most recent event is secondary to acute pulmonary
edema. CXR with new pulmonary edema that developed over 1 hour.
Was emergently intubated and given nitroglycerin gtt.
Siginficantly improved with dialysis but had focal infiltrate on
post-dialysis cxr thought due to pneumonia (as well as fever).
Thus was initially started on vanc/meropenem that was changed to
just vancomycin qhd once sputum culture showed GPCs. Was
extubated without event on [**2109-7-19**] and continued to saturate
well, ultimately sating 97% on RA. Was continued on vancomycin
for presumed CAP, was discharge on day 5 of 7 with continued
dosing per HD. Volume status was continually monitored by I/Os
and daily weights. He had HD on the day of discharge and
tolerated it well. He will continue with his MWF HD where they
will monitor both his fluid status and vancomycin dosing.
.
# Benign Hypertension No history of CAD, ruled out for ACS upon
admit. Transitory EKG changes with admit hypertension, resolved
with BP control. On multiple meds [**Date Range 3782**] with recurrent admits
for HTN urgency. Simplified medications while inpatient. Upon
discharge his morning antiHTN meds included Nifedipine CR 30mg,
lisinpril 30mg, metoprolol XL 12.5mg. These differed
significantly from his admit medications. During his stay, his
atenolol and valsartan were discontinued. Nifedipine was
changed from 90 mg to CR 30 mg and Lisinopril was increased from
20 mg to 30 mg. Metoprolol 12.5 mg daily was added for
additional cardio-protection. We also changed his clonidine to a
patch instead of taking po clonidine. He was instructed to
follow-up with both his PCP and renal physicians to adjust these
medications as needed.
.
# ESRD on HD. Appreciate renal input. Urgent HD x 3 last week,
with total volume decrease of 9kg. This aided greatly in the
resolution of his pulmonary edema. He will resume his normal
MWF HD this week. His [**Date Range 766**] dialysis was peformed while
inpatient without incident. Discharged on Cinacalcet and
Lanthanum per Renal recommendations.
.
# HIV/AIDS (VL <50, CD4 393 [**2-13**]) Was maintained on his [**Month/Year (2) 3782**]
HAART medication without interuptions while inpatient. Was
discharged without altering these medications.
.
# H/O Pulmonary Embolus Diagnosed [**6-24**] and with a newly
discovered clot on [**7-7**]. Supratherapeutic in ICU, for which
coumadin was briefly held. Upon admission to the floor, was
restarted on warfarin 4mg po daily. INR was monitored and was
therapeutic on discharge. Will be followed in HD for continued
monitoring and adjustments as need.
.
# DM Type II Controlled - Last HbA1c [**2109-2-12**] 5.7. Checked
with QAC and QHS finger sticks while inpatient. The patient
actually did not receive any insulin for 5 days, and did not get
any signs or sx of DKA. He reports at home that his AM FS is
80-90 and then post-prandial goes up to 100-115, after which he
then takes his NPH. States he takes both long-acting insulin
and short-acting with meals. Given this, we strongly believe his
initial diagnosis of Type 1 DM was incorrect and in fact was a
very poorly controlled type 2. Upon discharge it was recommended
that he not take insulin unless his finger sticks were elevated
>200. At that point, if his FS >200, he was instructed to call
his primary care doctor to seek advice for continued insulin
management. Given this change, we established follow-up for Mr.
[**Known lastname 94523**] with the [**Hospital **] Clinic for [**7-26**] at 3 pm where this
will be addressed. At the recommendation of the [**Name8 (MD) **] NP, we
also drew C-PEPTIDE and INSULIN ANTIBODIES which were pending at
time of discharge and will be followed up at [**Last Name (un) **].
FULL CODE
Medications on Admission:
1. Warfarin 2 mg Tablet Sig: Three (3) Tablets PO HS (at
bedtime).
2. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day). Capsule(s)
3. Lanthanum 500 mg Tablet, Chewable Sig: Four (4) Tablet,
Chewable PO TID (3 times a day).
4. Cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Valsartan 160 mg Tablet Sig: One (1) Tablet PO BID
8. Prochlorperazine 20mg PRN nausea
9. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1)
Tablet PO QSAT (every Saturday).
10. Ritonavir 100 mg PO qd
11. Atazanavir 300mg PO qd
12. Stavudine 20 mg PO qd
13. Lamivudine 25 PO qd
14. Metoclopramide 10 mg IV Q6H
15. Albuterol Sulfate 0.083 % q6h
16. Clonidine 0.2 mg PO BID
17. Nifedipine 90 mg PO qd
Discharge Medications:
1. Lanthanum 500 mg Tablet, Chewable Sig: Four (4) Tablet,
Chewable PO TID (3 times a day).
2. Cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Ritonavir 80 mg/mL Solution Sig: 1.25 mL PO DAILY (Daily).
5. Atazanavir 150 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
6. Stavudine 20 mg Capsule Sig: One (1) Capsule PO Q24H (every
24 hours).
7. Lamivudine 10 mg/mL Solution Sig: 2.5 mL PO DAILY (Daily).
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QFRI (every Friday).
Disp:*4 Patch Weekly(s)* Refills:*2*
10. Nifedipine 30 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO DAILY (Daily).
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
11. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*0*
12. Lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
13. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*15 Tablet Sustained Release 24 hr(s)* Refills:*2*
14. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) g
Intravenous HD PROTOCOL (HD Protochol).
15. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
inhalation Inhalation every six (6) hours as needed for
shortness of breath or wheezing.
16. Prochlorperazine 10 mg Tablet Sig: 1-2 Tablets PO twice a
day as needed for nausea.
17. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO three
times a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Hypertensive crisis, acute respiratory failure
secondary to pulmonary edema, pneumonia
Secondary: ESRD requiring hemodialysis, HTN, HIV, DM, history of
PE on coumadin therapy
Discharge Condition:
Good. Hemodynamically stable and afebrile.
Discharge Instructions:
Please take all medications as directed. There have been several
changes to your medications. First, you have not required
insulin during this hospitalization. We reccomend that you do
not take insulin unless you notice that your finger sticks are
elevated >200. If your sugar is >200, call your primary care
doctor and he will advise you what to do with your insulin. We
have set you up with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Diabetes [**Last Name (NamePattern4) 648**] for [**7-26**] at 3 pm where this will be addressed. We also changed your
blood pressure medications. You should stop taking your atenolol
and valsartan. We decreased your nifedipine from 90 mg to 30 mg
and increased your lisinopril from 20 mg to 30 mg. We also added
metoprolol 12.5 mg daily. We also changed clonidine to a patch
which you should change every Friday instead of taking clonidine
by mouth. Your coumadin was decreased from 6 mg daily to 4 mg
daily.
Please follow-up with all outpatient appointments.
Take daily weights, return to ED or your PCP if you should
notice increasing shortness of breath or lower extremity
swelling.
Followup Instructions:
You should follow-up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 4026**] after discharge.
Please call the office at [**Telephone/Fax (1) 250**] to schedule an
[**Telephone/Fax (1) 648**].
We also scheduled [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Diabetes [**Last Name (NamePattern4) 648**] to better assess
your diabetes. You have [**Last Name (NamePattern4) 648**] on Friday [**7-26**] at 3
pm with Dr. [**Last Name (STitle) 978**].
1. Hemodialysis [**Last Name (STitle) 766**], Wednesday and Friday. You should have
your PT and INR checked to assess whether your coumadin dose is
correct. Dr. [**Last Name (STitle) 1366**] will follow-up on this blood test.
1. Provider: [**Name10 (NameIs) 2975**] [**Name8 (MD) 2976**], MD Phone:[**Telephone/Fax (1) 2309**]
Date/Time:[**2109-7-25**] 10:45
2. Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2109-8-20**] 9:10
3. Provider: [**First Name4 (NamePattern1) 3520**] [**Last Name (NamePattern1) 3521**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2109-8-27**] 9:40
ICD9 Codes: 4280, 5856, 5070 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3768
} | Medical Text: Admission Date: [**2141-6-29**] Discharge Date: [**2141-7-2**]
Date of Birth: [**2083-2-20**] Sex: F
Service: GYN
HISTORY OF PRESENT ILLNESS: This is a 58-year-old G4, P2,
who has a history of dysfunctional uterine bleeding which was
refractory to medications and endometrial ablation who is
seen for planned vaginal hysterectomy, anterior/posterior
colporrhaphy, and left salpingo-oophorectomy for both
dysfunctional uterine bleeding and left ovarian cyst.
PAST MEDICAL HISTORY: Pulmonary embolus in [**2130**], on Coumadin
since.
Hypothyroidism.
Hypertension.
Congestive heart failure.
Pulmonary hypertension.
Morbid obesity.
Sleep apnea.
Restrictive lung disease.
Positive PPD.
PAST SURGICAL HISTORY: None.
PAST OB HISTORY: G4, P2.
PAST GYN HISTORY: Irregular vaginal bleeding since [**2140**]. No
history of blood transfusions or STDs. Last normal mammogram
is [**11/2136**], last normal Pap smear was [**11-28**]. The patient had a
previous Thermachoice endometrial ablation.
SOCIAL HISTORY: The patient denies tobacco, alcohol or
drugs.
FAMILY HISTORY: Hypertension, diabetes.
ALLERGIES: Heparin agents.
MEDICATIONS:
1. Lasix 80 mg p.o. b.i.d. as needed.
2. Coumadin 7.5 mg on Monday, Wednesday, Friday, and 10 mg on
the other days.
3. Ferrous gluconate tablets.
4. Megace.
5. Flexeril.
6. Folic acid.
7. Beclomethasone.
8. Synthroid 112 mcg q.d.
HOSPITAL COURSE: On hospital day 0, the patient underwent a
total vaginal hysterectomy and left salpingo-oophorectomy for
dysfunctional uterine bleeding. The procedure was
significant for difficulty placing IV lines preoperatively
with failed A-line and placement of a Swan-Ganz catheter in
the right internal jugular, 1200 cc of blood loss, 2 units of
packed red blood cells transfused, a fibroid uterus, and a
large left ovarian cyst, which ruptured serous fluid, normal
right ovary, and anterior and posterior repair were not
performed. Please see operative note dictation for further
details.
POSTOPERATIVE COURSE: Postop day 0, the patient remained
intubated postoperatively and brought to the medical ICU
overnight for monitoring and continued intubation given the
patient's morbid obesity and 3-hour surgery in a
Trendelenburg position. She remained hemodynamically stable
overnight and was extubated on postoperative day 1 without
difficulty. On postoperative day 1, she was started on
liquid and solid diet. Her pain was well tolerated on p.o.
pain medications. She could not ambulate; however, had
pneumoboots placed for DVT prophylaxis. She had electrolytes
checked and replaced as needed, and her Lasix was held due to
low blood pressures. The patient's hematocrit was 28.5 and
after the 2 units 32.3. The remainder of her hospital course
is discussed in systems:
Pulmonary. By postoperative day 1, the patient was extubated
and at her pulmonary baseline with O2 supplementation needed
for exertion. The patient is on home O2 as well. The
patient's Lasix was held until postoperative day 3 given her
borderline blood pressure; however, her blood pressure on
postoperative day 3 was 120/70, and the patient was restarted
on her Lasix p.o. A chest x-ray performed to evaluate line
placement showed normal chest x-ray, just mild evidence of
fluid overload. On discharge, the patient was saturating
well on room air and at her baseline.
Cardiovascular. The patient remained cardiovascularly
stable. She had some mild tachycardia, which was resolving
prior to discharge, likely secondary to her mild anemia. She
had an episode of chest pain on postop day 3 that was not
felt to be cardiac with a normal EKG when compared to her
prior EKG and partial resolution with Maalox.
Heme. The patient had been receiving a heparin alternative
for the 4 days prior to her surgery under the direction of
her hematologist. Postoperatively, she was started on her
regular Coumadin regimen by postop day 1, and her INR was
followed. On the day of discharge, her INR was 1.5, and plan
was made to have it checked in 2 days at home with visiting
nurse. She was kept on pneumoboots throughout her
hospitalization for DVT prophylaxis, and she had no signs or
symptoms of clinical pulmonary embolus while in the hospital.
Her hematocrit was 32.5 after her 2 units of blood
postoperatively and was unstable at 29 prior to discharge.
Endocrine. The patient was continued on her thyroid
medicine.
Postop. The patient was ambulating by postoperative day 2.
Her Foley was also discontinued on postoperative day 2. She
was tolerating a regular diet with good pain control with
p.o. pain medications and had no evidence of vaginal
bleeding.
ID. The patient had no signs or symptoms of infection;
however, did receive ampicillin, gentamicin, Flagyl for 48
hours postoperatively as prophylaxis.
Hypertension. The patient had history of hypertension per
report; however, had normal to low blood pressures throughout
her admission and did not require any antihypertensives.
Line. The patient had a right internal jugular line
replaced, Swan-Ganz catheter, which was removed on postop day
1, and a central line was placed. This was removed on the
day of discharge on postoperative day 3.
DISCHARGE DIAGNOSIS: Dysfunctional uterine bleeding status
post total vaginal hysterectomy and left salpingo-
oophorectomy, with pathology pending.
DISCHARGE STATUS: Stable.
DISCHARGE PLAN: The patient will follow up with Dr. [**Last Name (STitle) 94042**]
in 2 weeks and will have followup blood draws in 48 hours, to
be followed by Dr. [**Last Name (STitle) **] for her medical conditions.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 94043**], [**MD Number(1) 94044**]
Dictated By:[**Last Name (NamePattern4) 94045**]
MEDQUIST36
D: [**2141-7-2**] 17:44:26
T: [**2141-7-3**] 07:43:48
Job#: [**Job Number **]
ICD9 Codes: 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3769
} | Medical Text: Admission Date: [**2182-9-24**] Discharge Date: [**2182-9-25**]
Date of Birth: [**2104-2-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Cardiac arrest
Major Surgical or Invasive Procedure:
[**2182-9-24**] Emergency cannulation for extracorporeal membrane
oxygenation and institution of ECMO.
History of Present Illness:
Mr. [**Known lastname 3311**] is a 78-year-old male who presented from an outside
hospital for a cardiac catheterization with a history of chest
pain and a troponin leak. We were called to the catheterization
laboratory emergently after the initial diagnostic injection. He
was seen to have worsening hemodynamics and went into fulminant
cardiac arrest. We were called emergently to the cath lab while
the patient was in the midst of CPR for institution of
extracorporeal membrane oxygenation in an effort to salvage the
situation.
Past Medical History:
Hypertension, Hypercholesterolemia
Social History:
Denies excessive ETOH and illicit drugs. Remote history of
tobacco.
Family History:
No premature CAD
Physical Exam:
BP 160/94, HR 86, RR 20, SAT 95% on 2L
General: Diaphoretic, elderly male in NAD
HEENT: OP benign, PERRL
Neck: slightly elevated JVP
Heart: RRR, no murmur or rub
Lungs: decreased bilaterally at bases
Abdomen: benign
Ext: warm, no edema
Neuro: grossly intact
Pertinent Results:
[**2182-9-25**] 03:09AM BLOOD WBC-17.3* RBC-3.75* Hgb-11.7* Hct-32.4*
MCV-86 MCH-31.3 MCHC-36.3* RDW-13.8 Plt Ct-152
[**2182-9-25**] 03:09AM BLOOD PT-16.3* PTT-101.6* INR(PT)-1.8
[**2182-9-25**] 03:09AM BLOOD Plt Ct-152
[**2182-9-25**] 03:09AM BLOOD Glucose-141* UreaN-31* Creat-0.8# Na-140
Cl-104 HCO3-21*
[**2182-9-25**] 03:09AM BLOOD CK(CPK)-735*
[**2182-9-24**] 10:22PM BLOOD ALT-64* AST-122* AlkPhos-32* Amylase-266*
TotBili-1.0
[**2182-9-24**] 10:22PM BLOOD CK-MB-46* cTropnT-0.70*
[**2182-9-25**] 03:09AM BLOOD CK-MB-277* MB Indx-37.7* cTropnT-17.37*
[**2182-9-25**] 12:27PM BLOOD Type-ART pO2-234* pCO2-38 pH-7.37
calHCO3-23 Base XS--2
Brief Hospital Course:
After the first angiogram, the patient became short of breath
and complained of throat pain. He became progressively
hypotensive and PEA arrested. Cardiopulmonary resuscitation was
initiated and a 9F 40cc IABP was promply placed in the right
common femoral artery. Following successful intubation, Cardiac
surgery was called and the patient was placed on ECMO with
optimal flow rates ([**3-19**] Lt/min) within 25
minutes of the initial event. Of note, the patient's rhythm
degenerated into VF and he was shocked twice with 200 joules and
reverted to sinus rhythm. He was stabilized, sedated and
transferred to the cardiothoracic ICU for further management
including potential CABG depending on the patient's neurological
status. Over the next 24 hours, patients clinical status
steadily deteriorated. Patient was taken off ECMO, became
asystolic and expired with his family present.
Medications on Admission:
Aspirin, IV Nitro, IV Heparin, Vasotec 10 qd, Lasix 40 qd,
Plavix 75 qd, Atenolol 50 qd, Levaquin
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Cardiac arrest, cardiogenic shock, probable multivessel CAD
Discharge Condition:
Deceased, expired
Discharge Instructions:
None
Followup Instructions:
None
Completed by:[**2183-4-9**]
ICD9 Codes: 4275, 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3770
} | Medical Text: Admission Date: [**2184-2-10**] Discharge Date: [**2184-3-12**]
Date of Birth: Sex: M
Service:
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 37724**] is a 76 year old
man who was brought to the Trauma Bay as a trauma plus after
he had been hit by a car as a pedestrian. He had loss of
consciousness at the scene and was found to be combative at
the scene with a frontal laceration. He had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2611**] coma
scale of 13 on arrival and was extremely combative and had no
recall of the event. He was also hypertensive to systolic of
180s on arrival.
PAST MEDICAL HISTORY: Macular degeneration.
MEDICATIONS: None.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: Examination on arrival revealed
temperature of 96.8, pulse 120, pressure 174/palpable.
Oxygen saturation was 100% nonrebreather. Pupils are equal
and reactive. Extraocular movements intact. Face is
midline. Tympanic membranes are clear and trachea is
midline. There is a laceration above the right eye
approximately 2 cm and left orbital bruising. His heart is
regular but tachycardiac. Lungs are clear. Abdomen is soft,
flat and nontender. Pelvis is stable. Rectal is normal with
a normal tone, heme is guaiac negative. There were no
stepoffs in the back. Neurological examination is
significant for [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2611**] coma scale of 13. There are
abrasions in the right knee with no deformities of the
extremities in the Trauma Bay.
Physical examination at discharge revealed a temperature of
97.3, pulse 72, pressure 132/80, respirations 20s and oxygen
95% on face mask. This is an elderly man in no acute
distress who when given glasses smiles and tries to converse.
His heart is regular, his lungs are clear. His abdomen is
soft and nontender. The percutaneous endoscopic jejunostomy
tube site is clean. His extremities are frail and have boots
to protect from pressure ulcers.
LABORATORY DATA: Laboratory data on discharge revealed a
white count of 13.6, hematocrit of 30, platelet count 643,
sodium 140, potassium 3.9, chloride 102, bicarbonate 29, BUN
19, creatinine 0.5, glucose 114, magnesium 1.9. Radiological
studies, trauma series on arrival on [**2-10**] shows normal
heart size without mediastinal widening. Lungs are
hyperinflated. There is no evidence of pneumothorax or
pleural effusion. The AP view of the pelvis shows fracture
of the right pubic bone.
Computerized tomography scan of the head on arrival shows
question of small subarachnoid hemorrhage in the frontal
area. Computerized tomography scan also shows multiple
fractures including fracture of the right zygomatic arch,
bilateral fracture superior, posterior and lateral portions
of the maxillary sinuses, bilateral fracture through the
anterior walls of the maxillary sinuses, air fluid levels in
the maxillary sinuses. There is a small pneumocephalus.
Facial computerized tomography scan shows the fractures as
described above in the head computerized tomography scan.
The mandible is intact. There are bilateral frontal
contusions. Repeat head computerized tomography scan within
a day of arrival shows hemorrhages in the frontal, right
parietal and left occipital lobes and small hemorrhage of
blood in the subarachnoid space. Also a small amount of gas
anterior to the left temporal lobe associated with sphenoid
[**Doctor First Name 362**] fracture. Computerized tomography scan of the abdomen
on arrival shows fracture of the left inferior pubic ramus,
extensive pancreatic calcification consistent with chronic
pancreatitis, ectatic infrarenal abdominal aorta measuring
2.4 cm.
Magnetic resonance imaging scan of the cervical spine shows
no evidence of ligamentous injury. There is moderate
degenerative change. There are no apparent fractures on the
cervical spine studies.
Left hand films show fractures at the base of the first and
second metacarpals. Thoracolumbar spine films show diffuse
osteopenia, however, no evidence of thoracic or lumbar spine.
There is lumbar spine scoliosis with degenerative changes.
HOSPITAL COURSE: Mr. [**Name14 (STitle) 37725**] was admitted to the Intensive
Care Unit after suffering extensive head and facial trauma
when he was hit by a car on [**2184-2-10**]. He received
an orthopedic, neurosurgery, plastics and ophthalmology
consultation for a full evaluation. Relevant details of his
hospital course are described by systems below:
Neurological - Mr. [**Name14 (STitle) 37725**] suffered multiple intracranial
hemorrhages and subarachnoid bleed as evident on computerized
tomography scans which were repeated serially through his
hospital course. His hemorrhages evolved over the first day
and then were stable throughout the course. Neurosurgery was
consulted and no operative management was indicated. For
this reason, Mr. [**Name14 (STitle) 37725**] was observed off his Dilantin
regimen in the hospital. His mental status is not at
baseline due to his cranial injuries. Currently he is awake,
is able to communicate slightly, however, in a
noncomprehensive fashion. He shows no signs of agitation and
seems to understand what he is being told. Once his
hemorrhages were found to be stable he was started on
subcutaneous heparin and was cleared by Neurosurgery for
rehabilitation. His cervical spine was cleared with an
magnetic resonance imaging scan after which the collar was
taken off. His thoracolumbar spine was cleared by thoracic
films obtained during his visit. At discharge, he is
cooperative, pleasant, somewhat communicative, unable to
perform activities of daily living and is only on Tylenol prn
for pain medications. His Dilantin was discontinued during
his hospital course without problems.
Cardiac - Mr. [**Name14 (STitle) 37725**] has remained stable throughout his
hospital course from a cardiovascular perspective. Initially
his blood pressure was controlled as per guidelines
established by Neurosurgery. Through his hospital course it
became evident that he has some component of high blood
pressure which is now being treated by Lopressor which is
currently at 50 mg b.i.d. He has been on this dose for
several weeks and has a stable blood pressure and heartrate
without any signs of arrhythmia.
Respiratory - Mr. [**Name14 (STitle) 37725**] did not suffer any direct injury
to the lung, however, approximately on [**2-29**], he was found
to have an aspiration event. For this, he had to be
transferred to the Intensive Care Unit and was intubated. He
received a full course of treatment of Vancomycin,
Levofloxacin and Flagyl for any aspiration pneumonia. He was
extubated around [**3-8**] and since then has been stable on
the floor. He is off all antibiotics. He requires
suctioning and chest physical therapy to prevent further
episodes of pneumonia.
Gastrointestinal - Mr. [**Name14 (STitle) 37725**] on hospital day #10 after
tolerating nasogastric feeds received a percutaneous
endoscopic gastrostomy tube placement. He has tolerated
these tube feeds at goal for most of his hospital course.
Due to an aspiration event, around [**2-29**], his tube feeds
were stopped and his percutaneous endoscopic gastrostomy tube
was converted to a percutaneous endoscopic jejunostomy tube.
Now he is tolerating tube feeds again at goal. He is having
bowel movements and has a soft, nondistended abdomen.
During his hospital course Mr. [**Name14 (STitle) 37725**] also had an episode
of lower gastrointestinal bleed. He received multiple units
of transfusions for his lower gastrointestinal bleed which
when assessed by angiogram was rectal bleed, reachable in the
operating room. He was taken to the Operating Room on [**2-28**] and his rectal ulcer that was bleeding was oversewn using
three stitches. Since then he has remained stable and shows
no signs of gastrointestinal bleed. His hematocrit is stable
at 30 on discharge.
Also on discharge, Mr. [**Name14 (STitle) 37725**] is on Zantac and Colace and
Reglan for prophylaxis.
Infectious disease - Mr. [**Name14 (STitle) 37725**] was treated for a full
course of Vancomycin, Levofloxacin and Flagyl for aspiration
pneumonia from which he recovered. One of the cultures
through an arterial line during his course had an
enterococcus resistant to Vancomycin which was treated with
linezolid. Infectious disease consult was obtained for which
linezolid was given for seven days. On discharge he has
finished his course of linezolid and there are no signs of
any more enterococcus infection. His white count at
discharge is coming down and is at 13. During his aspiration
pneumonia course his white count maxed at about approximately
25.
Hematology - Mr. [**Name14 (STitle) 37725**] lost a significant amount of blood
during his lower gastrointestinal bleed in the middle of his
hospitalization. This gastrointestinal bleed was stopped in
the Operating Room by placing three stitches in his rectum.
He was placed on Epogen for a short term to recover his
hematocrit. On discharge he has a stable hematocrit of 30.
He is no longer on Epogen.
Renal - Mr. [**Name14 (STitle) 37725**] has made adequate urine throughout his
hospital course and has a normal creatinine. He has a condom
catheter in place to monitor his urine output.
Prophylaxis - Once cleared by Neurosurgery, Mr. [**Name14 (STitle) 37725**] was
placed on heparin subcutaneous prophylaxis. He also received
Zantac for prophylaxis. He has multiporous boots on his feet
to prevent pressure ulcers to his heels.
Ophthalmology - Mr. [**Name14 (STitle) 37725**] was seen by Ophthalmology early
in his hospital course after his trauma and was cleared to
have no entrapment. He is recommended to have a follow up
for routine examination after his discharge.
Plastics - Mr. [**Name14 (STitle) 37725**] received a plastic surgeon for
multiple facial fractures as described in the head
computerized tomography scan. He was found to have
nonoperative fractures and did not receive any plastic
surgery operations.
Orthopedics - Mr. [**Name14 (STitle) 37725**] was taken to the Operating Room on
[**2-20**], for repair of fracture in his left first metacarpal.
This fracture was repaired and is currently splinted in a
cast. He is to follow up with Plastic Surgery as an
outpatient for this.
In summary Mr. [**Name14 (STitle) 37725**] is an unfortunate 76 year old man who
was brought to the Trauma Bay on [**2184-2-10**] after he
was struck by a car at which time he suffered multiple facial
fractures and intracranial hemorrhages. He also had a
fracture of his left first metacarpal and the left pubic
rami. His hospital course was complicated by a slow recovery
from his cranial bleeds which have left him below his
baseline for his neurological function. He also received
repair of his left metacarpal and percutaneous endoscopic
gastrostomy tube placement which was later converted to a
percutaneous endoscopic jejunostomy tube. His hospital
course was also complicated by an episode of lower
gastrointestinal bleed which was repaired by placing stitches
in the rectum at the site of the bleed and a course of
aspiration pneumonia which he recovered from with a course of
antibiotics.
On discharge Mr. [**Name14 (STitle) 37725**] is stable, is able to communicate
slightly but noncomprehensively and has a tube feed through
which he is tolerating tube feeds at goal, he is having bowel
movements and is voiding through his condom catheter. His
functional status is out of bed with assist. He does not
have any family in contact, however, does have a legal
guardian and friends.
MEDICATIONS ON DISCHARGE:
1. Zantac 150 mg per jejunostomy tube b.i.d.
2. Reglan 10 mg per jejunostomy tube t.i.d.
3. Lopressor 50 mg per jejunostomy tube b.i.d.
4. Colace 100 mg per jejunostomy tube b.i.d.
5. Heparin 5000 units subcutaneously b.i.d.
6. Tube feeds, ProMod with fiber at 60 cc/hr
7. Free water 100 cc per jejunostomy tube t.i.d.
ADDENDUM: Mr. [**Name14 (STitle) 37725**] will be followed by [**Hospital **]
Rehabilitation at [**Hospital6 256**] which
also serve [**Hospital3 7**].
FOLLOW UP: Trauma Clinic in two weeks. Follow up in
plastics with Dr. [**Last Name (STitle) 24130**] at [**Hospital6 2018**] in two weeks.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: To Rehabilitation.
DISCHARGE DIAGNOSIS:
1. Pedestrian struck by car.
2. Multiple intracranial hemorrhages.
3. Left first metacarpal fracture.
4. Left pubic rami fracture, nonoperable.
5. Hypertension.
6. Recovery from lower gastrointestinal bleed in the rectum.
7. Recovery from aspiration pneumonia.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D.
[**MD Number(1) 6066**]
Dictated By:[**Name8 (MD) 180**]
MEDQUIST36
D: [**2184-3-12**] 15:06
T: [**2184-3-12**] 16:07
JOB#: [**Job Number 37726**]
ICD9 Codes: 5070, 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3771
} | Medical Text: Admission Date: [**2106-4-2**] Discharge Date: [**2106-4-11**]
Date of Birth: [**2037-4-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
CHEST PRESSURE / SOB
Major Surgical or Invasive Procedure:
Coronary artery bypass grafting x4 with the left
internal mammary artery to left anterior descending artery
and reverse saphenous vein graft to the first obtuse marginal
artery, diagonal artery and posterior descending artery.
History of Present Illness:
68 year old Albanian speaking male presented to PCP reporting
increasing frequency of chest pressue and dyspnea on exertion.
He reported taking NTG Sl with increasing frequency. His PCP
sent him to the ED with unstable angina. Cardiac cath was done
and multivessel coronary disease was revealed. Cardiac surgery
was consulted for coronary revascularization.
Past Medical History:
DM, HTN, HYPERLIPIDEMIA, CHF (EF UNKWN), HX
KIDNEY STONES, OSETOPOROSIS, HYPOTHYROIDISM
Past Surgical History: KIDNEY STONES REQUIRING UNKWN SURGICAL
INTERVENTION
Social History:
Race: ALBANIAN
Last Dental Exam: NOT KNOWN
Lives with:
Occupation:
Tobacco: POS SMOKER
ETOH: SOCIAL
Family History:
NC
Physical Exam:
Physical Exam
Pulse: 68 Resp: 18 O2 sat: 98% RA
B/P Right: 122/ 67 Left:
Height: Weight: 84.8 kg
General:
Skin: Dry [X] intact [X]
HEENT: PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X]
Chest: DIMINISHED AT BASES
Heart: RRR [X] Irregular [] Murmur
Abdomen: Soft [X] slightly distended [x] non-tender [x] bowel
sounds + [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: p Left: p
DP Right: p Left: p
PT [**Name (NI) 167**]: p Left: p
Radial Right: p Left: p
Carotid Bruit Right: none Left: none
Pertinent Results:
[**2106-4-2**] 10:35AM BLOOD WBC-10.2 RBC-4.91 Hgb-15.2 Hct-43.7
MCV-89 MCH-31.0 MCHC-34.8 RDW-14.4 Plt Ct-227
[**2106-4-10**] 12:35PM BLOOD PT-19.9* INR(PT)-1.8*
[**2106-4-2**] 10:35AM BLOOD PT-14.2* PTT-22.9 INR(PT)-1.2*
[**2106-4-10**] 12:35PM BLOOD UreaN-21* Creat-1.1 Na-137 K-3.9 Cl-96
[**2106-4-2**] 10:35AM BLOOD Glucose-268* UreaN-23* Creat-1.0 Na-139
K-4.1 Cl-98 HCO3-27 AnGap-18
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 90039**], [**Known firstname 90040**] [**Hospital1 18**] [**Numeric Identifier 90041**] (Complete)
Done [**2106-4-6**] at 9:34:12 AM PRELIMINARY
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]
[**Last Name (NamePattern4) 18**] - Department of Cardiac S
[**Last Name (NamePattern1) 439**], 2A
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2037-4-11**]
Age (years): 68 M Hgt (in): 67
BP (mm Hg): 122/69 Wgt (lb): 187
HR (bpm): 67 BSA (m2): 1.97 m2
Indication: Intraop CABG Evaluate valves, ventricular function,
wall motion, aortic contours
ICD-9 Codes: 786.05, 786.51, 424.1, 424.0, 424.2
Test Information
Date/Time: [**2106-4-6**] at 09:34 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2011AW1-: Machine: u/s 3
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Peak Pulm Vein S: 0.2 m/s
Left Atrium - Peak Pulm Vein D: 0.6 m/s
Left Atrium - Peak Pulm Vein A: *0.4 m/s < 0.4 m/s
Left Ventricle - Ejection Fraction: 25% to 30% >= 55%
Aortic Valve - Valve Area: *2.6 cm2 >= 3.0 cm2
Findings
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Lipomatous
hypertrophy of the interatrial septum. No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Normal LV wall thickness and cavity size.
Severely depressed LVEF.
RIGHT VENTRICLE: Indeterminate RV cavity size.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Normal ascending aorta diameter.
Simple atheroma in ascending aorta. Normal aortic arch diameter.
Complex (>4mm) atheroma in the aortic arch. Normal descending
aorta diameter. Complex (>4mm) atheroma in the descending
thoracic aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets. No AS.
Trace AR. AR vena contracta is <0.3cm.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Eccentric
MR jet. Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate [2+]
TR.
PULMONIC VALVE/PULMONARY ARTERY: PVR not well seen. Physiologic
(normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. No TEE related complications.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
I certify that I was present for this procedure in compliance
with HCFA regulations.
Interpretation assigned to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, Interpreting
physician
Brief Hospital Course:
On [**2106-4-6**] Mr.[**Known lastname **] was taken to the operating room and
underwent Coronary artery bypass grafting x4 (left internal
mammary artery to left anterior descending artery
and reverse saphenous vein graft to the first obtuse marginal
artery, diagonal artery and posterior descending artery) with
Dr.[**Last Name (STitle) **].
Please see operative report for further details. Cross clamp
time: 91 minutes. Cardiopulmonary Bypass time:104 minutes. He
tolerated the procedure well and was transferred to the CVICU
sedated and intubated for further monitoring. He awoke
neurologically intact and was extubated without incident. All
lines and drains were discontinued in a timely fashion.
Beta-blocker/Statin/Aspirin and diuresis were initiated. He
continued to progress and was transferred to [**Hospital Ward Name 121**] 6 for further
monitoring. On POD# 2 he went into rapid atrial fibrillation and
was administered Amiodarone and Beta-blocker. Anticoagulation
was started after 24 hours of postoperative atrial fibrillation.
His rhythm converted to normal sinus rhythm. Physical therapy
was consulted for evaluation of strength of mobility. He
continued to progress and was cleared for discharge to home on
POD# 5. All follow up appointments were advised.
Medications on Admission:
ATENOLOOL 100 MG, SL NTG PRN ([**6-18**] X DAY),
COLACE 100 MG PRN, MVI, METFORMIN 850 MG [**Hospital1 **], ASA 325 MG,
ENALAPRIL 20 MG, LASIX 40 MG, SYNTHROID 25 MCGMS
Discharge Medications:
1. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
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:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
7. metformin 850 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
8. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 2 tabs po bid x 5 days, then decrease to 1 tab po bid x
7 days, then decrease to 1 tab po daily.
Disp:*120 Tablet(s)* Refills:*2*
9. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO DAILY (Daily) for 14 days.
Disp:*28 Tablet Extended Release(s)* Refills:*0*
10. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 14 days.
Disp:*14 Tablet(s)* Refills:*0*
11. warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day for 2
days: 1 tab po today [**2106-4-11**], then 1 tab po Mon,[**2106-4-12**].
Disp:*2 Tablet(s)* Refills:*0*
12. warfarin 1 mg Tablet Sig: [**Name8 (MD) **] MD Tablet PO once a day: INR
goal=[**3-18**], indication=postop Atrial Fibrillation.
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
coronary artery disease
Secondary:
DM, HTN, HYPERLIPIDEMIA, CHF (EF UNKWN), HX
KIDNEY STONES, OSETOPOROSIS, HYPOTHYROIDISM
Past Surgical History: KIDNEY STONES REQUIRING UNKWN SURGICAL
INTERVENTION
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesia
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage. Trace
edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Recommended Follow-up:
You are scheduled for the following appointments
Surgeon:
Cardiologist:
Please call to schedule appointments with your
Primary Care Dr..... in [**2-14**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication
Goal INR
First draw
Results to phone fax
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] # [**Telephone/Fax (1) 170**] office will call you to
arrange appointment
Cardiologist: To be recommended by your PCP
Please call to schedule appointments with your
Primary Care Dr.[**Last Name (STitle) 86612**],[**First Name3 (LF) **], [**Telephone/Fax (1) 17465**] in [**2-14**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication :postoperative Atrial
fibrillation
Goal INR :[**3-18**]
First draw; Tuea, [**2106-4-13**]
Results to phone Dr.[**Last Name (STitle) 86612**],[**First Name3 (LF) **], [**Telephone/Fax (1) 17465**]
Completed by:[**2106-4-11**]
ICD9 Codes: 4280, 4168, 4111, 4019, 2724, 2449, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3772
} | Medical Text: Admission Date: [**2133-11-20**] Discharge Date: [**2133-11-25**]
Date of Birth: [**2054-5-17**] Sex: F
Service: MEDICINE
Allergies:
Iodine / Beta-Adrenergic Blocking Agents
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
s/p diagnostic cardiac cath
History of Present Illness:
79 yo female with PMH DM, hyperlipidemia, HTN admitted with one
week history of chest pain and EKG changes. Pt states that CP
started on Monday. It is intermittent and occurring with
exertion. Sharp, substernal, radiating to right chest and back,
[**10-25**], associated with SOB. Initially relieved with BenGay. This
AM, severe pain not relieved with BenGay. States pain is
different from anginal pain. +peripheral edema at baseline.
+PND. -orthopnea.
Past Medical History:
asthma
DM2
hypercholesterolemia
hypertension
CAD
s/p cholecystectomy
Social History:
Denies tobacco, ETOH, drugs.
Lives alone, but has family in the area - she has 13 children
Family History:
Denies CAD
+HTN
Physical Exam:
p63, rr18, 100%2L
Vitals: afebrile, HR = 63 , BP = , RR =18 , SaO2 = 100% on 2L.
General: female sleeping, appears comfortable, NAD.
HEENT: Normocephalic and atraumatic head, no nuchal rigidity,
anicteric sclera, moist mucous membranes. Alopecia.
Neck: No thyromegaly, no lymphadenopathy, no carotid bruits.
Chest: Her chest rose and fell with equal size, shape and
symmetry, her lungs were clear to auscultation bilaterally. No
erythema around Hickmann line, non tender.
CV: PMI appreciated in the fifth ICS in the midclavicular line
without heaves or thrills, RRR, normal S1 and S1 no murmurs rubs
or gallops.
Abd: Normoactive BS, NT and ND. No masses or organomegaly
Back: No spinal or CVA tenderness.
Ext: NO cyanosis, no clubbing or edema with 2+ dorsalis pedis
pulses bilaterally
Integument: no rash
Neuro: CN II-XII symmetrically intact, PERRLA.
Pertinent Results:
[**2133-11-20**] 07:20PM WBC-3.4* RBC-2.98* HGB-9.6* HCT-27.5* MCV-92
MCH-32.3* MCHC-35.1* RDW-12.5
[**2133-11-20**] 07:20PM PLT COUNT-156
[**2133-11-20**] 07:20PM PT-13.7* PTT-133.3* INR(PT)-1.2
.
[**2133-11-20**] 07:20PM GLUCOSE-141* UREA N-29* CREAT-1.5* SODIUM-139
POTASSIUM-3.7 CHLORIDE-102 TOTAL CO2-28 ANION GAP-13
[**2133-11-20**] 09:07PM CALCIUM-9.1 PHOSPHATE-3.4 MAGNESIUM-1.8
[**2133-11-20**] 07:20PM ALT(SGPT)-17 AST(SGOT)-25 ALK PHOS-68 TOT
BILI-0.3
[**2133-11-20**] 09:07PM LIPASE-65*
[**2133-11-20**] 07:20PM ALBUMIN-3.5
.
[**2133-11-20**] 09:07PM CK-MB-5 cTropnT-<0.01
.
[**2133-11-20**] 10:59PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.005
[**2133-11-20**] 10:59PM URINE BLOOD-LGE NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2133-11-20**] 09:07PM GLUCOSE-133* UREA N-28* CREAT-1.5* SODIUM-138
POTASSIUM-3.8 CHLORIDE-102 TOTAL CO2-30* ANION GAP-10
Brief Hospital Course:
Assessment and Plan: 79 yo female with PMH DM, hyperlipidemia,
HTN admitted with one week history of chest pain and EKG
changes. S/p cardiac catherization with diagnosis of 3vd.
Potential CABG candidate but had cath instead because of anemia
and no transfusion. The patient was admitted to the CCU.
1. CAD: Cardiac cath findings: LMCA 50% distal; LAD 80-90%; LCx
OM 80-90%, RCA 100%. Attempt to open occluded RCA, unable to
perform. Recommended consideration of CABG and no PTCA completed
on the first cath. Left ventriculography: LVEF 50%, inferior
hypokinesis. No significant MR. Pt seen by CT surgery but was
unsure of her CABG potential given her Jehovahs Witness beliefs
and her anemia. All caring for the patient explained to her that
given her age and anemia, she would have a very high chance of
needing a life-saving blood transfusion during the CABG. The
patient accepted that this was a risk and decided to undergo a
high risk cath instead of CABG. On [**11-23**] she returned to cath for
intervention - stents to LAD. During her entire stay, she
continued to have intermittent chest pain without changes in
vital signs, cardiac enzymes, or EKG changes. Her Imdur was
titrated up because of this. She was discharged on Imdur,
aspirin, Plavix, Lipitor, avapro, and cardizem, (BB cause
wheezing).
2. DM: continued humalin 25u qam
3. CRI: given mucomyst peri-cath
4. Anemia: Likely iron deficiency anemia. Started on Epogen and
iron.
5. Code status: FULL code. No blood products (Jehovah's witness)
6. Social: The patient has a large family whom she relies on
heavily for decision making. The discussion about CABG vs. cath
was difficult because her family insisted that there were places
in the country that would do CABG without blood transfusions.
However, it was explained to them by all members of the medical
team, including CT surgery, that her risk was of morbidity or
mortality without blood transfusions was unacceptably high.
Medications on Admission:
Plavix 75 mg qd
Singulair 10mg qd
Cardizem LA 180 mg qd
Folic acid 1mg qd
Avapro 150mg qd
Lasix 20mg qd
Humalin 25 u qAM
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
4. Irbesartan 150 mg Tablet Sig: 1.5 Tablets PO qd ().
Disp:*45 Tablet(s)* Refills:*2*
5. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
6. Humulin N 100 unit/mL Suspension Sig: 25 units Subcutaneous
qAM.
7. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain:
Take one if you have chest pain. You may take another in 5
minutes if your pain does not resolve. Then call your
cardiologist.
Disp:*10 Tablet, Sublingual(s)* Refills:*0*
10. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Partners
Discharge Diagnosis:
unstable angina
anemia
Discharge Condition:
good
Discharge Instructions:
Call Dr. [**Last Name (STitle) 43511**] if you have any chest pain or shortness of
breath.
Followup Instructions:
You have an appointment with Dr. [**Last Name (STitle) 43511**] on [**11-30**] at
1:00PM.
Call [**Telephone/Fax (1) 105952**] if you cannot make this appointment.
Follow up with your cardiologist in 2 - 4 weeks. You need to
call to make this appointment.
ICD9 Codes: 4111, 4019, 2724, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3773
} | Medical Text: Admission Date: [**2200-6-2**] Discharge Date: [**2200-6-9**]
Date of Birth: [**2127-2-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Known firstname 1283**]
Chief Complaint:
Asymptomatic with +stress test
Major Surgical or Invasive Procedure:
[**6-2**] Coronary Artery Bypass Graft x 4 (LIMA to LAD, SVG to OM1,
SVG to PDA, OM2)
History of Present Illness:
73 y/o asymptomatic male who had an abnormal stress test.
Referred for cath which revealed 3 vessel disease. Then referred
for surgical intervention.
Past Medical History:
Diabetes Mellitus, Permanent [**Month/Year (2) **] [**2196**], Hypertension,
Hyperlipidemia, Chronic Renal Insufficency (1.1-1.5), h/o
Melanoma s/p excision, s/p tonsillectomy, h/o scarlet fever,
Osteoarthritis
Social History:
Retired. Quit smoking 30-40 yrs ago. [**2-15**] drinks/wk. Live with
wife.
Family History:
Brother had CABG at age 70
Physical Exam:
VS: 57 15 150/77 6'1" 95.3kg
HEENT: EOMI, PERRL, NCAT
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/varicosities
Neuro: A&Ox3, MAE, non-focal
Pertinent Results:
Echo [**6-2**]: PREBYPASS: There is moderate symmetric left
ventricular hypertrophy. There is mild regional left ventricular
systolic dysfunction. Overall left ventricular systolic function
is mildly depressed. Resting regional wall motion abnormalities
include mild hypokinesis of the apex and distal lateral and
distal septal walls. The remaining left ventricular segments
contract normally. LVEF~45%. The right ventricular cavity is
mildly dilated. Right ventricular systolic function is normal.
The descending thoracic aorta is mildly dilated. No aortic
regurgitation is seen. Trivial mitral regurgitation is seen.
POST BYPASS: LV systolic function is slightly improved compared
to prebypass LVEF~55%. Previous wall motion abnormalities
persist however remaining walls are more hyperdynamic. The
remaining study is unchanged from prebpass.
CXR [**6-6**]: Stable appearance of the cardiomediastinal silhouette.
Bibasilar atelectasis slightly increased on the left. Bilateral
small pleural effusion.
[**2200-6-2**] 10:38AM BLOOD WBC-12.1*# RBC-2.73* Hgb-8.9* Hct-25.4*
MCV-93 MCH-32.5* MCHC-34.9 RDW-14.7 Plt Ct-100*
[**2200-6-8**] 05:22AM BLOOD WBC-9.0 RBC-2.76* Hgb-8.9* Hct-25.8*
MCV-94 MCH-32.3* MCHC-34.5 RDW-14.6 Plt Ct-220
[**2200-6-9**] 06:35AM BLOOD Hct-27.0*
[**2200-6-2**] 11:44AM BLOOD PT-13.7* PTT-26.1 INR(PT)-1.2*
[**2200-6-2**] 11:44AM BLOOD UreaN-33* Creat-1.5* Cl-109* HCO3-24
[**2200-6-8**] 05:22AM BLOOD Glucose-166* UreaN-19 Creat-1.0 Na-137
K-3.9 Cl-99 HCO3-28 AnGap-14
[**2200-6-9**] 06:35AM BLOOD UreaN-20 Creat-1.1 K-4.3
[**2200-6-4**] 03:22PM URINE Blood-LG Nitrite-NEG Protein-NEG
Glucose-100 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2200-6-4**] 03:22PM URINE RBC-21-50* WBC-[**2-16**] Bacteri-FEW Yeast-NONE
Epi-0-2
Brief Hospital Course:
Pt was seen following her cardiac cath which revealed three
vessel disease. She went home and returned on [**2200-6-2**] and was
brought directly to the operating room where she underwent a
coronary artery bypass graft x 4. Please see op note for
surgical details. She tolerated the procedure well and was
transferred to the CSRU for invasive monitoring in stable
condition. Later on op day she was weaned from sedation, awoke
neurologically intact and was extubated. Chest tubes were
removed on post-op day two and she was started on beta blockers
and diuretics. She was gently diuresed towards he pre-op weight.
On this day she appeared to be doing well and was transferred to
the telemetry floor. Her post-operative blood sugars remained
elevated and Endocrine was consulted for better DM management.
Initially on the floor she desaturated (O2) and required 6L via
NC. Overtime her pulmonary status improved with ongoing
toilet/diuresis. Her Epicardal pacing wires and Foley were
removed on post-op day three and four, respectively. Her beta
blockers were titrated for maximum BP and heart rate control (an
ace inhibitor was also added). Physical Therapy followed patient
during entire post-op course for strength and mobility. Over the
next several days she continued to improve without
complications. Her vital signs at time of discharge were: 96
156/81 20 96% at RA.
Medications on Admission:
Clonidin Patch, Actos 45mg qd, Glucotrol 10mg [**Hospital1 **], Glucophage
1000mg [**Hospital1 **], Norvasc 5mg [**Hospital1 **], Cozaar 50mg [**Hospital1 **], Lopressor 150mg
[**Hospital1 **], HCTZ 50mg qAM and 75mg qPM, Vasotec 20mg [**Hospital1 **], ASA 81mg qd,
Lipitor 80mg qd, Lorazepam 1mg qd, Fish Oil, Garlic Suppl, MVI,
Osteo Biflex, MVI, Vitamin C, Beta-Car.
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. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*0*
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Glipizide 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
5. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
7. 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*
8. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*0*
9. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q2H (every 2
hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
10. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO
twice a day.
Disp:*180 Tablet(s)* Refills:*0*
11. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
12. Enalapril Maleate 20 mg Tablet Sig: One (1) Tablet PO twice
a day.
Disp:*60 Tablet(s)* Refills:*0*
13. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 1 weeks: 20 mg [**Hospital1 **] x 1 week, then 20 mg QD until
stopped by cardiologist.
Disp:*50 Tablet(s)* Refills:*0*
14. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for
1 weeks: 20 meq [**Hospital1 **] x 1 week then QD until stopped by
cardiologist.
Disp:*50 Capsule, Sustained Release(s)* Refills:*0*
15. Insulin Glargine 100 unit/mL Cartridge Sig: Fifteen (15)
units Subcutaneous at bedtime.
Disp:*QS 1 month* Refills:*0*
16. Insulin Lispro (Human) 100 unit/mL Cartridge Sig: per
sliding scale units Subcutaneous QACHS.
Disp:*QS 1 month* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 2203**] VNA
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4
PMH: Diabetes Mellitus, Permanent [**Location (un) **] [**2196**], Hypertension,
Hyperlipidemia, Chronic Renal Insufficency (1.1-1.5), h/o
Melanoma s/p excision, s/p tonsillectomy, h/o scarlet fever,
Osteoarthritis
Discharge Condition:
Good
Discharge Instructions:
Call with fever, redness or drainage from incision, or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds, or driving until follow up with
surgeon.
[**Last Name (NamePattern4) 2138**]p Instructions:
Dr. [**Last Name (STitle) 1007**] 2 weeks
Dr. [**Last Name (STitle) 11649**]
Dr. [**Last Name (Prefixes) **] 4 weeks
Dr. [**Last Name (STitle) 29213**] at [**Last Name (un) **] for DM follow up.
The following appointments were already scheduled:
Provider: [**Name10 (NameIs) **] CALL Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2200-7-8**]
5:00
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2200-9-11**]
10:30
Provider: [**Name10 (NameIs) 1918**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 902**]
Date/Time:[**2200-9-11**] 11:00
Completed by:[**2200-6-30**]
ICD9 Codes: 5859, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3774
} | Medical Text: Admission Date: [**2142-2-4**] Discharge Date: [**2142-2-8**]
Date of Birth: [**2084-1-7**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 297**]
Chief Complaint:
stroke
Major Surgical or Invasive Procedure:
none
History of Present Illness:
58 YO M resident [**Last Name (un) 2224**] prison, HTN, post. circ stroke,
meniere disease, transferred w/altered MS, hypoxia required
admission in ER. Per notes, patient had fall (vs syncopal event)
[**1-30**] while in prison after episode of coughing. A code was
called, but no thought of cardiac event. Presented to neuro
clinic on [**2-2**] with gait instability, right sided hearing loss,
vertigo. Originally thought 2nd to Menieres therefore given
prednisone. MRi/MRA on 25th showed multiple infarcts in
cerebellum, pons, pica (?new). He was transferred to ICU, given
ASA, Plavix and placed on nitro drip to titrate BP. On [**2-3**] in
pm worsening dysarthria, right sided dysmetteria, decreased gag,
right-sided facial droop. ? aspiration on [**2-4**] with increased o2
requirement therefore transferred . 02 sat in 80s. (of note,
attempted intubation unsuccessful in ambo. HR 106, 104/34
Past Medical History:
DM, HTN, cerebellar strokes/hemorrage in past, BG stroke,
menieres disease, vertigo, history of hearing loss
Social History:
incarcerated, drug/etoh/tobacco history not listed
Family History:
noncontributory
Physical Exam:
Neuro: Eyes open spontaneously. Mimics commands. PERRL. Right
gaze with nystagmus. Difficulty tracking to left. Absent
corneals. +gag. Postures right arm to pain. Moves left arm well.
Brisk reflexes left arm, both legs.
Pertinent Results:
[**2142-2-4**] 02:30PM BLOOD WBC-30.0* RBC-4.57* Hgb-14.5 Hct-42.3
MCV-93 MCH-31.6 MCHC-34.2 RDW-13.4 Plt Ct-396
[**2142-2-4**] 02:30PM BLOOD PT-14.9* PTT-26.4 INR(PT)-1.4
[**2142-2-5**] 04:26AM BLOOD Glucose-181* UreaN-21* Creat-0.9 Na-142
K-3.9 Cl-113* HCO3-22 AnGap-11
[**2142-2-4**] 02:30PM BLOOD ALT-13 AST-21 AlkPhos-112 Amylase-33
TotBili-1.6*
[**2142-2-4**] 02:30PM BLOOD Lipase-30
[**2142-2-5**] 04:26AM BLOOD Calcium-8.4 Phos-3.4 Mg-2.0
[**2142-2-4**] 02:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2142-2-4**] 02:38PM BLOOD pO2-82* pCO2-96* pH-7.04* calHCO3-28 Base
XS--7 Comment-NEW SPECIM
[**2142-2-4**] 04:58PM BLOOD Type-ART Temp-38.9 Rates-/15 pO2-427*
pCO2-47* pH-7.27* calHCO3-23 Base XS--5 Intubat-INTUBATED
Vent-CONTROLLED
[**2142-2-4**] 03:38PM BLOOD Lactate-1.8
.
MRI on admission: Findings consistent with an enormous, subacute
infarct within the cerebellum. Multiple chronic infarcts
elsewhere within the brain
.
MRA on admission: There appears to be negligible flow within the
visualized segments of the distal vertebral artery as well as
the basilar artery except for possible residual flow in
proximity to the basilar artery summit. This extensive vascular
flow abnormality, consistent with occlusive disease, certainly
correlates with the massive cerebellar infarction described
above.
.
TEE: Complex atheromatous plaque of the aorta.No vegetations or
atrial
septal defect identified.
Brief Hospital Course:
58 M w/history of DM, HTN, history of stroke, presents with
mental status changes, respiratory failure, fever. The patient
was found to have a massive stroke involving most of the
cerebellum and some of the pons. He was intubated for
respiratory failure. Neurosurgery and neurology were consulted.
Neurology recommended initiation of a mannitol drip to decrease
the risk of brain edema and herniation. A TEE showed a large
atheromatous plaque in the aorta which is the likely source of
the stroke. Pt spiked a fever and grew out MSSA in his sputum
so was started on a course of oxacillin. Over the next several
days, pt's head CT showed no change and neurosurgery recommended
no further intervention. Neurology and neurosurgery, along with
the MICU team, agreed that the pt's prognosis was extremely poor
and this was communicated to the pt's cousin, his health care
proxy. On HD #5, the pt's cousin decided to withdraw care and
the pt was extubated. He expired several hours later.
Medications on Admission:
asa, plavix, enalapril, motrin, meclazine, RISS, protonix, nitro
drip, glipizide, zocor, amlodipine
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
expired from large stroke, respiratory failure
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
ICD9 Codes: 5070, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3775
} | Medical Text: Admission Date: [**2169-6-14**] Discharge Date: [**2169-7-7**]
Date of Birth: [**2096-6-30**] Sex: F
Service: [**Last Name (un) **]
HISTORY OF PRESENT ILLNESS: The patient is a 72-year-old
female, who was transferred from an outside hospital for an
infected pancreatic pseudocyst. She has a history of
gallstone pancreatitis for which she came to [**Hospital1 **] Hospital in [**2169-4-10**]. In [**Month (only) 547**], she developed
a pseudocyst, which was felt to have decreased in size on
followup CT. However, the patient presented to her primary
care physician [**Last Name (NamePattern4) **] [**2169-6-12**] with a complaint of 10 days of
malaise and decreased appetite. She was admitted to the
outside hospital on [**6-13**] and started on IV antibiotics. A
preliminary CT scan report showed "evidence of pancreatic
abscess with pockets of air."
On admission to [**Hospital1 **] Hospital, the patient
reports feeling weak and tired without a desire to eat. She
denies abdominal pain, shortness of breath, chest pain,
nausea, vomiting, diarrhea, constipation, or fevers.
PAST MEDICAL HISTORY: Hypertension.
Non-insulin dependent-diabetes mellitus.
Gallstone pancreatitis (03/[**2169**]).
Remote history of seizure disorder.
Renal cell carcinoma ([**2167**]).
COPD.
PAST SURGICAL HISTORY: Status post left nephrectomy in [**2167**].
Status post appendectomy at age 16.
ALLERGIES: No known drug allergies.
MEDICATIONS AT HOME:
1. Dilantin 200 mg b.i.d.
2. Lopressor 50 mg b.i.d.
3. Metformin 500 mg q.d.
4. Protonix.
PHYSICAL EXAMINATION: Vital signs - 99.2, 79, 140/60, 14,
and 94 percent on room air. General - pale, tired. Heart -
regular, rate, and rhythm without murmur, gallop, or rub.
Pulmonary - CTAB. Abdomen - soft, obese, nontender,
nondistended, no rigidity, no rebound, no guarding, no masses
palpable, abdomen full. Extremities - no clubbing, cyanosis,
minimal pitting edema.
LABORATORIES FROM OUTSIDE HOSPITAL: Sodium 137, potassium
4.4, chloride 104, bicarbonate 20.6, BUN 22, creatinine 1.0,
glucose 90, calcium 7.7, magnesium 1.8, phosphorus 2.7.
White blood cells 14.6, hematocrit 27, platelets 41. AST 50,
ALT 69, total bilirubin 0.6, alkaline phosphatase 229,
amylase 69, lipase 210. Dilantin 1.3.
HOSPITAL COURSE: The patient was admitted for a pancreatic
abscess status post gallstone pancreatitis, made NPO, placed
on IV fluids, and Zosyn was started. Blood cultures were
also drawn, which were subsequently negative. The patient's
laboratories on admission included a hematocrit of 24.4, for
which the patient received 1 unit of packed red blood cells.
The patient also had Dilantin levels drawn, which were
initially 2.9. She was loaded with Dilantin, and over the
course of the remainder of her hospital stay she remained in
the 10-20 range, the last Dilantin level being 12.8 on [**7-1**].
On hospital day three, the patient received a PICC line and
began receiving TPN with the expectation that she would go to
the OR once her nutritional status was improved. The patient
continued to be afebrile with Zosyn and TPN until she was
taken to the OR on hospital day 11 ([**2169-6-20**]). The
patient's hematocrit had remained stable up to that point and
was 28.8 on the day of her surgery.
On [**2169-6-20**], the patient underwent an open cholecystectomy
along with open drainage of the pancreatic pseudocyst.
Patient tolerated the procedure well. Please see dictated OP
note for further details. Intraoperatively, two swabs and a
tissue culture were taken and sent. They later came back
with vancomycin-sensitive Enterococcus. The patient was
presumptively treated with Zosyn and fluconazole
postoperatively.
In the course of the operation, the patient required a total
of 10 liters of fluid and due to low urine output
postoperatively, the patient continued to require ongoing
fluids to maintain her urine output. The patient, on the day
of the operation, positive 6 liters on postoperative day one.
On postoperative day two, the fluid requirement decreased and
the patient was net 0 fluids. Because of the large quantity
of fluids required, patient was kept intubated and sedated
for several days.
On postoperative day two with a hematocrit of 27, the patient
received 1 unit of packed red blood cells. This brought her
hematocrit only up to 29.
On postoperative day three, the patient's TPN was restarted
and the patient was begun on vancomycin along with Zosyn and
fluconazole. The patient's white blood cell count
postoperatively had been elevated up to 23.6, but by [**6-25**]
was down to 12.7, and continued to trend down from there
until two days prior to discharge when her white blood cell
count had leveled out at 7.5.
On postoperative day three, diuresis was begun and the
patient was a net negative 2 liters for the day. This level
of diuresis continued to through postoperative day nine as
the patient remained in the ICU, that is to say she lost
approximately 1.5 to 2 liters per day during that period.
On [**6-26**], a routine rectal swab showed vancomycin-resistant
Enterococcus in the patient's rectum, however, it was not
thought that the patient required any change in her
antibiotics, so she was kept on Zosyn and vancomycin, the
fluconazole haven been stopped a few days prior.
The patient continued to be difficult to extubate and on
[**7-1**], underwent a bronch with a culture that was ultimately
negative. On postoperative day 13, the patient's wound was
noted to have a bit of cellulitis on the right and was
therefore opened and packed with wet-to-dry dressing. The
patient was finally extubated on postoperative day 13 after a
very long vent wean. Wound cultures were sent from the open
wound and later came back as showing rare growth of gram-
positive cocci. Patient was continued on her TPN and tube
feeds were begun. However, those tube feeds were relatively
short-lived and the patient was started on a clear diet on
postoperative day 14 and sent to a floor. Also all of her
oral medications were restarted. She continued, however, on
TPN.
The other side of the patient's wound was later opened and
packed wet-to-dry so that both sides were ultimately opened
on the patient's discharge. The two sides were opened
approximately 3 cm with the left side draining a greater
amount of fluid than the right.
On the floor, the patient did well, tolerated her clear diet,
and was advanced to a regular diet without difficulty. Her
TPN was ended on the day of her discharge, and a repeat
surveillance CT was obtained. Please see the CT report for
details. The patient was discharged to a rehab facility on
[**2169-7-7**].
DISCHARGE CONDITION: Good.
DISPOSITION: To rehab facility.
DISCHARGE DIAGNOSES: Hypertension.
Non-insulin dependent-diabetes mellitus.
Gallstone pancreatitis (03/[**2169**]).
Remote history of seizure disorder.
Renal cell carcinoma ([**2167**]).
Chronic obstructive pulmonary disease.
Status post debridement and drainage of pancreatic
pseudocyst.
DISCHARGE MEDICATIONS:
1. Dilantin 100 mg p.o. t.i.d.
2. Metoprolol 25 mg p.o. b.i.d.
3. Glucophage XR 500 mg p.o. q.d.
4. Protonix 40 mg p.o. q.d.
5. Albuterol inhaler 1-2 puffs q.6h.
6. Atrovent inhaler two puffs q.6h.
7. Insulin-sliding scale.
FOLLOW-UP PLANS: The patient is to call Dr.[**Name (NI) 2829**] office
to arrange a follow-up appointment in [**2-10**] weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**MD Number(2) 11162**]
Dictated By:[**Last Name (NamePattern1) 15517**]
MEDQUIST36
D: [**2169-7-6**] 12:46:51
T: [**2169-7-6**] 13:23:36
Job#: [**Job Number 53292**]
ICD9 Codes: 496, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3776
} | Medical Text: Admission Date: [**2199-4-5**] Discharge Date: [**2199-4-11**]
Date of Birth: [**2170-4-19**] Sex: M
Service: MEDICINE
Allergies:
Erythromycin Base
Attending:[**First Name3 (LF) 2932**]
Chief Complaint:
Nausea/vomiting
Major Surgical or Invasive Procedure:
Central line placement
History of Present Illness:
28 year old male with DM1 complicated by nephropathy,
retinopathy, and severe gastroparesis requiring multiple
admissions and gastric pacer placement, who presented to ER on
[**2199-4-5**] with c/o nausea and vomiting x 3-4 days. He denied
fevers, chills, hemetemesis, and reported that his symptoms were
identical to prior flares of gastroparesis (last in 11/[**2198**]). He
was admitted to the general medical floor. While on the floor,
he continued to have marked nausea and vomiting, associated with
labile blood sugars, ranging 300-400 (no anion gap to suggest
DKA). He was evaluated by both gastroenterology and the [**Last Name (un) **]
diabetes service, who recommended an insulin gtt to allow
improved glucose control. For this reason, he was transferred to
the ICU on [**2199-4-7**]
Past Medical History:
1) Type 1 Diabetes Mellitus: Diagnosed at age 2, complicated by
retinopathy (blind in left eye), nephropathy, and gastroparesis.
Followed by Dr. [**Last Name (STitle) 3617**] at [**Last Name (un) **].
2) Chronic renal insufficency: baseline Cr ~ 1.6-2; +
proteinuria
3) Gastroparesis: Since [**2194**]. Received Botox injection to the
pylorus in 3/[**2197**]. Had Gastric stimulator placed on [**2197-11-10**] by
Dr. [**Last Name (STitle) **]. Flare regimen includes reglan, Zelnorm,
phenergan, compazine, and anzemet. Pacer last interrogated
06/[**2198**].
4) History of hypoglycemic seizure
5) Hypertension
6) Migraines
7) Depression
8) Anemia
9) Gastritis/esophagitis
Social History:
Patient lives with his wife who is very dedicated to his care.
Denies tobacco, alcohol, and illicit drug use. He is currently
unemployed and on disability.
Family History:
Paternal grandfather with [**Name (NI) 59282**]
Mother and sister with thyroid disease
Physical Exam:
VS: T 100.7 HR 130 BP 130/57 RR O2Sat 96% RA
Gen: Patient nauseous, with rigors, looks uncomfortable
Heent: PERRL, OP clear, MM dry
Lungs: CTA B/L
Cardiac: tachy, RRR S1/S2 no murmurs
Abd: soft, NT, supressed bowel sounds
Ext: no edema
Neuro: AAOx3
Pertinent Results:
Laboratory studies on admission:
[**2199-4-5**]
WBC-6.9 HGB-11.9 HCT-35.1 MCV-77 RDW-13.1 PLT COUNT-341
NEUTS-70.3* LYMPHS-20.6 MONOS-5.3 EOS-3.3 BASOS-0.6
LACTATE-1.8
GLUCOSE-266* UREA N-30* CREAT-2.3* SODIUM-139 POTASSIUM-4.4
CHLORIDE-103 TOTAL CO2-24
ALT(SGPT)-22 AST(SGOT)-22 ALK PHOS-101 AMYLASE-101* TOT BILI-0.3
CALCIUM-10.1 PHOSPHATE-1.9*# MAGNESIUM-2.4
U/A: URINE BLOOD-TR NITRITE-NEG PROTEIN-TR GLUCOSE-250
KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG
Laboratory studies on discharge:
[**2199-4-10**]
WBC-9.6 Hgb-9.9 Hct-29.2 MCV-77 RDW-13.0 Plt Ct-295
Glucose-226* UreaN-14 Creat-1.7* Na-141 K-4.1 Cl-104 HCO3-26
[**4-5**] EKG: Sinus tachycardia. No significant change compared to
the previous tracing of [**2198-11-11**]. There continues to show rapid
heart rate and right axis deviation
Radiology
[**4-5**] CXR: Two views of the chest are markedly limited secondary
to technique. Linear left retrocardiac opacities may represent
atelectasis or may be secondary to poor technique. No definite
airspace consolidation is present. No dilated bowel loops are
identified within the visualized abdomen. Gastric stimulation
device is unchanged in position.
[**3-7**] KUB: Again visualized is a neurostimulating device
projecting over the thoracolumbar spine. Gas is seen in the
stomach and in the colon. Stool is seen throughout the colon.
There is a paucity of small bowel gas, but no dilated loops are
seen. There is no free air.
Brief Hospital Course:
28 year old male with Type I diabetes and gastroparesis presents
with exacerbation of gastroparesis. His course was complicated
by acute renal failure and persistent hyperglycemia requiring
transfer to the ICU for an insulin drip.
1) Gastroparesis: The patient's symptoms improved with improved
glucose control in the ICU. He was initially NPO with IV
anti-emetics, however, as his symptoms improved, his diet was
gradually advanced. He was transferred to the general medical
floor the evening of [**2199-4-10**], after which he remained
asymptomatic off IV anti-emetics. At time of discharge, he was
tolerating a regular diabetic diet without difficulty.
2) Type I diabetes, poorly controlled with complications: As
mentioned above, the patient was transferred to the ICU for an
insulin drip. He was subsequently transitioned to glargine and,
at time of discharge, was on his home dose of glargine (although
this was qAM rather than qhs). He will follow-up with Dr. [**Last Name (STitle) 3617**]
as an outpatient. The precipitant of the patient's hyperglycemia
is unclear; infectious work-up (urine culture, blood cultures,
CXR) was unrevealing and EKG was without acute change.
3) Possible coffee ground emesis: Following the admission to the
floor, the patient had an episode of emesis with possible coffee
grounds. The gastroenterology service was consulted, who did not
recommend EGD given his hematocrit was stable at 29. They felt
that this was most likely related to gastritis (as visualized on
prior EGD). He will continue PPI [**Hospital1 **] and will follow-up with
gastroenterology as an outpatient.
4) Acute on chronic renal failure: The patient's creatinine was
2.3, which improved to his baseline 1.7 on discharge with
hydration, indicating likely pre-renal etiology.
5) Hypertension: The patient was continued on his home doses of
metoprolol and valsartan.
6) Iron deficiency anemia: At time of discharge the patient's
hematocrit was stable at 29.2 (within baseline 27-31). His
admission hematocrit of 35 likely represented hemoconcentration
in the setting of nausea/vomiting. He will follow-up with
gastroenterology as an outpatient for further work-up.
Outpatient iron supplementation may be considered if his GI
symptoms remain stable.
Full Code.
Medications on Admission:
1. Tegaserod Hydrogen Maleate 6 mg PO BID
2. Valsartan 80 mg PO BID
3. Metoprolol Tartrate 25 mg PO BID
4. Pantoprazole 40 mg PO Q12H
5. Metoclopramide 10 mg PO Q6H
6. Prochlorperazine 10 mg PO Q6H prn
7. Promethazine 25 mg PO Q6H prn
8. Insulin Glargine 30U qhs
9. Insulin Lispro per sliding scale
10. Clonidine patch QWednesday, unknown dose
Discharge Medications:
1. Tegaserod Hydrogen Maleate 6 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
2. Valsartan 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. 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*
5. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
6. Promethazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for nausea.
7. Insulin Glargine 100 unit/mL Solution Sig: Thirty (30) units
Subcutaneous QAM.
8. Insulin Lispro (Human) 100 unit/mL Solution Sig: sliding
scale/carb counting Subcutaneous QAC and QHS.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Type I diabetes, poorly controlled with complications
Secondary: Gastroparesis, iron-deficiency anemia, hypertension,
acute on chronic renal failure
Discharge Condition:
Tolerating food well, on oral medications
Discharge Instructions:
You were admitted with high blood sugars and a flare of
gastroparesis. You were treated with an insulin drip and IV
hydration/medications with improvement, and are now doing well
on your home medication regimen.
1) Please follow-up as indicated below.
2) Please take all medications as prescribed.
3) Please see your primary care physician or come to the
emergency room if you develop worsening nausea/vomiting, unable
to tolerate oral medications, fevers, chills, abdominal pain, or
other symptoms that concern you.
Followup Instructions:
1) Primary Care: Please follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
([**Telephone/Fax (1) 250**]) Thursday [**2202-5-3**]:10 a.m.
2) [**Last Name (un) **]: Dr. [**Last Name (STitle) 3617**] ([**Telephone/Fax (1) 2378**]) [**5-17**] at 3:30 p.m.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2937**]
Completed by:[**2199-4-11**]
ICD9 Codes: 5849, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3777
} | Medical Text: Admission Date: [**2176-11-26**] Discharge Date: [**2176-12-9**]
Date of Birth: [**2146-7-19**] Sex: M
Service: PLASTIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5667**]
Chief Complaint:
traumatic left ankle/foot amputation and degloving below the
knee
Major Surgical or Invasive Procedure:
1. left above the knee amputation
2. irrigation and debridement of left lower extremity wound.
3. muscle flap advancement for closure of abdominal wound.
4. full-thickness skin graft measuring 40 x 9 cm.
5. split-thickness skin graft measuring 20 x 8 cm.
6. Local tissue rearrangement of proximally based
fasciocutaneous flap.
7. irrigation and debridement of left lower extremity wound
and nonviable tissues.
8. split-thickness skin graft coverage of wound measuring
26 x 19 cm.
History of Present Illness:
30yo male who reports riding a backhoe at work and was hit by a
car at a high speed while working on the highway. Per patient
he may have gotten out of the backhoe and been walking when he
was hit, but the details are unclear. [**Name2 (NI) **] was found to have a L
ankle amputation with degloving distal to the knee. His tissue
was recovered at the seen and was bagged and iced. He was
transported by air to [**Hospital1 18**]. Patient complaining of back pain
and left lower extremity pain.
Past Medical History:
3 prior back surgeries
chronic pain
Social History:
works in construction, + tobacco use, occasional alcohol use,
denies other drug use.
Family History:
non-contributory
Physical Exam:
PHYSICAL EXAM [**2176-11-26**]:
99.0 118 125/76 24 100% NRB --> 2L NC
Gen: Pt. lying on stretcher, in acute pain
HEENT: PERRL
CV: RRR
PULM: CTAB
ABD: protuberant, soft NT/ND, pelvis is stable on exam by
trauma
team, normal rectal exam by trauma team.
EXT: LLE with ankle amputation and degloving below the knee with
large laceration proximal to the knee joint. Most of the soft
tissue below the knee is gone leaving only tibia. Painful
sensation of the proximal thigh. Pulses intact on right lower
extremity, sensation intact right lower extremity. Bleeding
controlled after tourniquet released.
Pertinent Results:
RADIOLOGY [**2176-11-26**]:
.
CT SPINE
IMPRESSION: No evidence of fractures or abnormal alignment at
the cervical
spine.
.
CT HEAD
IMPRESSION:
1. No acute intracranial traumatic injury.
2. Small linear nondisplaced fracture at the right zygomatic
bone, of
indeterminate age. Clinical correlation is indicated.
.
CT TORSO
IMPRESSION:
Mild fat stranding in the left renal hilum, which may indicate
hematoma,
related to acute injury. Question possible underlying trauma to
the left
renal artery, however, the kidneys enhance symmetrically with
normal
excretion. Followup is recommended to evaluate renal artery for
trauamtic
dissection after acute presentation resolves.
.
X-ray left wrist ([**12-8**])
IMPRESSION:
lucency and cortical distruption at the base of ulnar styloid
process likely representing non-displaced ulnar styloid
fracture.
.
BLOOD WORK:
CBC
[**2176-11-26**] 11:45AM BLOOD WBC-37.0* RBC-4.60 Hgb-13.4* Hct-38.9*
MCV-85 MCH-29.2 MCHC-34.5 RDW-13.5 Plt Ct-467*
[**2176-11-26**] 01:58PM BLOOD WBC-27.4* RBC-3.95* Hgb-11.7* Hct-32.4*
MCV-82 MCH-29.7 MCHC-36.1* RDW-13.4 Plt Ct-356
[**2176-11-27**] 02:20AM BLOOD WBC-14.9* RBC-3.10* Hgb-9.1* Hct-25.9*
MCV-83 MCH-29.3 MCHC-35.1* RDW-14.3 Plt Ct-283
[**2176-11-27**] 03:35PM BLOOD WBC-13.0* RBC-2.56* Hgb-7.5* Hct-21.5*
MCV-84 MCH-29.3 MCHC-34.9 RDW-14.4 Plt Ct-209
[**2176-11-28**] 02:17AM BLOOD WBC-12.3* RBC-2.24* Hgb-6.4* Hct-18.4*
MCV-82 MCH-28.5 MCHC-34.8 RDW-13.6 Plt Ct-187
[**2176-11-28**] 07:22AM BLOOD WBC-12.2* RBC-2.59* Hgb-7.6* Hct-21.2*
MCV-82 MCH-29.2 MCHC-35.6* RDW-13.7 Plt Ct-182
[**2176-11-28**] 12:45PM BLOOD Hct-20.8*
[**2176-11-29**] 06:00AM BLOOD WBC-13.2* RBC-3.08* Hgb-9.0* Hct-25.8*
MCV-84 MCH-29.3 MCHC-34.9 RDW-14.5 Plt Ct-174
[**2176-11-30**] 08:30AM BLOOD WBC-11.5* RBC-3.20* Hgb-9.3* Hct-27.1*
MCV-85 MCH-29.0 MCHC-34.3 RDW-15.0 Plt Ct-261
[**2176-11-30**] 08:30AM BLOOD Neuts-74.2* Lymphs-20.1 Monos-4.6 Eos-0.9
Baso-0.2
[**2176-12-4**] 07:15AM BLOOD WBC-15.0* RBC-3.46* Hgb-9.7* Hct-29.9*
MCV-87 MCH-28.0 MCHC-32.4 RDW-14.5 Plt Ct-424#
.
COAGS
[**2176-11-26**] 11:45AM BLOOD PT-12.5 PTT-21.6* INR(PT)-1.1
[**2176-11-29**] 06:00AM BLOOD Plt Ct-174
[**2176-11-30**] 08:30AM BLOOD Plt Ct-261
[**2176-12-4**] 07:15AM BLOOD Plt Ct-424#
.
CHEMISTRIES
[**2176-11-26**] 11:45AM BLOOD UreaN-14 Creat-1.1
[**2176-11-26**] 01:58PM BLOOD Glucose-128* UreaN-13 Creat-0.8 Na-140
K-4.0 Cl-109* HCO3-21* AnGap-14
[**2176-11-26**] 01:58PM BLOOD Calcium-8.1* Phos-2.4* Mg-1.7
[**2176-11-27**] 02:20AM BLOOD Glucose-142* UreaN-11 Creat-0.7 Na-137
K-4.7 Cl-107 HCO3-22 AnGap-13
[**2176-11-27**] 02:20AM BLOOD Calcium-8.2* Phos-3.8 Mg-1.6
[**2176-11-28**] 02:17AM BLOOD Glucose-111* UreaN-11 Creat-0.8 Na-132*
K-4.3 Cl-101 HCO3-26 AnGap-9
[**2176-11-28**] 02:17AM BLOOD Calcium-7.8* Phos-2.4* Mg-2.0
[**2176-11-29**] 06:00AM BLOOD Glucose-83 UreaN-9 Creat-0.7 Na-141 K-4.0
Cl-103 HCO3-29 AnGap-13
[**2176-11-29**] 06:00AM BLOOD Calcium-8.1* Phos-2.6* Mg-2.3
[**2176-12-4**] 07:15AM BLOOD Glucose-95 UreaN-11 Creat-0.7 Na-136
K-4.5 Cl-99 HCO3-30 AnGap-12
[**2176-12-4**] 07:15AM BLOOD Calcium-9.1 Phos-4.4# Mg-2.3
.
BLOOD GASES
[**2176-11-26**] 06:09PM BLOOD Type-ART Temp-37.6 pO2-197* pCO2-33*
pH-7.41 calTCO2-22 Base XS--2
[**2176-11-28**] 02:44AM BLOOD Type-ART pO2-96 pCO2-37 pH-7.48*
calTCO2-28 Base XS-3
Brief Hospital Course:
The patient was transported to [**Hospital1 18**] via [**Location (un) 7622**]. In the
Emergency Room he was thoroughly evaluated by the Trauma team,
Vascular surgery, and Plastic surgery. He underwent CT imaging
of the head, neck, and torso. After review of these films
patient was cleared to go to the OR. The patient was initially
admitted to the Trauma service on [**2176-11-26**] and then transferred
to the plastic surgery service on [**2176-11-28**]. On [**2176-11-26**], he
underwent an above the left knee amputation by the Vascular
service and then had a full-thickness skin graft measuring 40 x
9 cm, a Split-thickness skin graft measuring 20 x 8 cm, and
local tissue rearrangement of proximally based fasciocutaneous
flap by Plastic Surgery. A wound vac was applied to skin graft
sites per protocol. The patient tolerated the procedure well
and was transferred to the PACU for post-operative recovery and
then to the Trauma SICU for close monitoring. On POD#2, the
patient was transferred out of the Trauma SICU and onto the
floor on telemetry monitoring. On [**2176-12-2**], patient returned to
OR for irrigation and debridement of left lower extremity wound
and nonviable tissues. a split-thickness skin graft was taken
from left lower extremity upper thigh area to cover stump wound
measuring 26 x 19 cm.
.
Neuro: In the ED, pain was controlled with IV Fentanyl, Dilaudid
and Methadone. Post-operatively, the patient was evaluated by
the Acute Pain Service (APS) and started on Bupivacaine sciatic
catheter infusion and Bupivacaine femoral catheter infusion as
well as a dilaudid PCA. APS also started the patient PO
methadone. Patient's pain escalated on [**2176-11-27**] dilaudid PCA was
increased and APS added neurontin and tizanidine to his pain
regimen. On [**2176-11-28**], APS discontinued the tizanidine, and
decreased neurontin and dilaudid dosages for episodes of
increased sedation. Bupivicaine catheters infusions and
Dilaudid PCA were discontinued on [**2176-11-30**]. The patient was
started on PO Dilaudid and his Neurontin was increased to 600 mg
TID. Patient maintained on Methadone 40 mg Q6h. This regimen
was very effective until patient returned to OR on [**2176-12-2**] for
skin grafting to left stump sites. Skin graft donor sites were
very painful for patient and he felt they were 'on fire'. A
dilaudid PCA was re-started to provide relief in the setting of
acute pain. This PCA was discontinued on [**2176-12-8**] per Chronic
Pain Service recommendations and he was given a home analgesia
regimen prior to discharge consisting of oral dilaudid,
methadone, and neurontin.
.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
.
GI/GU: Post-operatively, the patient was given IV fluids until
tolerating oral intake. His diet was advanced when appropriate,
which was tolerated well. He was also started on a bowel regimen
to encourage bowel movement. Foley catheter was removed on
POD#2. Intake and output were closely monitored. CT Torso on
[**2176-11-26**] showed mild fat stranding in the left renal hilum,
indicating question of hematoma and question of trauma to left
renal artery. Patient continued with good urine output, stable
Creatinine, and normal blood pressures so Vascular felt there
was no need for further intervention.
.
ID: Patient was given IV Gentamcin and Cefazolin upon arrival to
the ED. Post-operatively, the patient was started on IV
cefazolin, then switched to PO cephalexin on POD#2. Cephalexin
was discontinued on POD#13. The patient's temperature was
closely watched for signs of infection.
.
Musculoskeletal: Patient was noted to have a left non-displaced
ulnar styloid fracture on x-ray and was placed in an ulnar
gutter splint.
.
Prophylaxis: The patient received subcutaneous heparin during
this stay, and was encouraged to get up and ambulate as early as
possible.
.
At the time of discharge on POD#14, the patient was doing well,
afebrile with stable vital signs, tolerating a regular diet,
ambulating, voiding without assistance, and pain was well
controlled.
Medications on Admission:
Methadone 80 mg QD
Discharge Medications:
1. Wheelchair Device Sig: One (1) unit Miscellaneous for
patient mobility: wheelchair with elevating leg rests.
Disp:*1 wheelchair* Refills:*0*
2. commode Sig: One (1) unit for patient use.
Disp:*1 unit* Refills:*0*
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
Disp:*60 Tablet(s)* Refills:*2*
4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation.
Disp:*60 Capsule(s)* Refills:*2*
6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
Disp:*500 ML(s)* Refills:*4*
7. Methadone 40 mg Tablet, Soluble Sig: One (1) Tablet, Soluble
PO Q6H (every 6 hours) as needed for pain.
Disp:*120 Tablet, Soluble(s)* Refills:*0*
8. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
Disp:*180 Capsule(s)* Refills:*2*
9. Hydromorphone 4 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*120 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
1. left lower extremity trauma with traumatic amputation of left
ankle/foot and below the knee degloving
2. left non-displaced ulnar styloid fracture
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:
Activity: non-weight beaing left lower extremity and non-weight
bearing left wrist
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness, swelling or
discharge from incision, chest pain, shortness of breath, or
anything else that is troubling you.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
This information provided is designed as a guideline to assist
you in a speedy recovery from your surgery. Please follow these
guidelines unless your physician has specifically instructed you
otherwise. Please call our office nurse if you have any
questions. Dial 911 if you have any medical emergency.
.
ACTIVITY:
There are restrictions on activity. On the side of your
amputation you are non weight bearing until cleared by your
surgeon. You should keep this amputation site elevated when ever
possible.
.
You may use the other leg to assist in transferring and pivots.
But try not to exert to much pressure on the amputation site
when transferring and or pivoting.
.
No driving until cleared by your surgeon.
.
PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:
1. Redness in or drainage from your leg wound(s).
2. Watch for signs and symptoms of infection. These are: a fever
greater than 101 degrees, chills, increased redness, or pus
draining from the incision site. If you experience any of these
or bleeding at the incision site, CALL THE DOCTOR.
.
Exercise:
Limit strenuous activity for 6 weeks.
.
BATHING/SHOWERING:
.
You may shower immediately upon coming home. No bathing.
.
WOUND CARE:
daily dressing changes with xeroform and kerlix to amputation
site
keep skin graft donor skin clean and dry.
.
Avoid taking a tub bath, swimming, or soaking in a hot tub for
four weeks after surgery.
.
MEDICATIONS:
Unless told otherwise you should resume taking all of the
medications you were taking before surgery.
.
Remember that narcotic pain meds can be constipating and you
should increase the fluid and bulk foods in your diet. (Check
with your physician if you have fluid restrictions.) If you feel
that you are constipated, do not strain at the toilet. You may
use over the counter Metamucil or Milk of Magnesia. Appetite
suppression may occur; this will improve with time. Eat small
balanced meals throughout the day.
.
CAUTIONS:
.
NO SMOKING! We know you've heard this before, but it really is
an important step to your recovery. Smoking causes narrowing of
your blood vessels which in turn decreases circulation. If you
smoke you will need to stop as soon as possible. Ask your nurse
or doctor for information on smoking cessation.
.
Avoid pressure to your amputation site.
.
No strenuous activity for 6 weeks after surgery.
.
DIET :
There are no special restrictions on your diet postoperatively.
Poor appetite is expected for several weeks and small, frequent
meals may be preferred.
.
FOLLOW-UP APPOINTMENT:
.
Please call the office on the first working day after your
discharge from the hospital to schedule a follow-up visit. This
should be scheduled on the calendar for seven to fourteen days
after discharge.
.
PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR
QUESTIONS THAT MIGHT ARISE
.
You may page Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] by going through the Page
Operator at ([**Telephone/Fax (1) 83886**], with any questions or concerns.
Followup Instructions:
please call [**Telephone/Fax (1) 5343**] to schedule a follow-up appointment
with plastic surgery (Dr [**First Name (STitle) **] as well as follow-up x-ray for
your left wrist
please call vascular surgery (Dr [**Last Name (STitle) **] at [**Telephone/Fax (1) 2625**]
as needed
Completed by:[**2176-12-9**]
ICD9 Codes: 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3778
} | Medical Text: Admission Date: [**2132-1-13**] Discharge Date: [**2132-1-15**]
Date of Birth: [**2080-11-23**] Sex: M
Service: MEDICINE
Allergies:
Reglan / Protonix
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
Nausea/Vomiting
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a 50 year old male who presented to the ED with
nausea/vomiting consistent with known gastroparesis and DKA. On
Wednesday evening, 4 days PTA, he began feeling weak with
minimal strength. This continued and on Thursday he was unable
to take PO's, including liquids. Because of this, he stopped
taking all of his insulin, including baseline lantus. He states
that he is extremely sensitive to insulin and is very concerned
about hypoglycemia. He reports his highest sugar to be 169. He
had small amounts to drink yesterday and today, but nothing else
by mouth. He relates nausea beginning on Thursday, but no emesis
until today. Urine output has decreased in conjunction with
fluid intake, no dysuria. + thirst. No abdominal pain but did
have one episode of loose stools last evening. No melena,
hematochezia. No fevers, chills, sick contacts, recent travel.
No URI sxs. Came to ED because he believed he was dehydration
(has been dehydrated on 4 prior occasions, requiring IV fluids).
.
In the ED vitals were 96.4, HR 89, BP 121/66, RR 18, 98% RA.
Chem 7 demonstrated AG of 24 (last known albumin 3.6), glucose
213, UA not done. Presumed diagnosis of DKA and given 1L NS and
second liter hung. Patient was given 6 units insulin SQ and
insulin gtt was started at 1 unit/hr. Was given 1 amp calcium
gluconate and 1 amp bicarb for potassium of 6. Also recieved
phenergan 12.5 IV.
.
ROS: no fevers, chills, chest pain, SOB, jaw pain, abd pain,
frequency, urgency, dysuria, sick contacts
.
Past Medical History:
# Insulin dependent diabetes type I - complications of
neuropathy, retinopathy, gastroparesis (somewhat responsive to
erthromycin)
# Renal transplant, [**2119**] - followed by Dr [**First Name (STitle) 805**]
# CAD - 3VD, DES to OM [**3-26**], following MI (deferred placing
multiple stents d/t excessive dye load in setting of renal
insufficiency. Echo [**5-24**]: EF 25-30%, akinesis of apex, lateral
wall, inferior wall.
# Polycythemia [**Doctor First Name **]
# PVD
# HTN
# Osteomyelitis of 5th metatarsal
# Eosinophilic gastritis
# Stoke in [**2123**] with right hand weakness, resolved on its own
# UTI - MRSA
# Dehydration d/t gastroparesis
Social History:
Lives with his wife, has two children (17,21), worked as a
mechanic.
Currently not working and on disability. He denies EtOH,
tobacco, illicit drugs.
Family History:
Father - died of head and neck cancer
Sister - ? liver CA
PGF - DM
Physical Exam:
96.3, 106, 172/102, 15, 99% on RA
HEENT: PERRL, EOMI, anicteric sclera, MM dry, OP clear
Skin: ecchymosis on belly from insulin injections
Neck: supple, no LAD, no thyromegaly
Cardiac: tachy, regular rhythm, NL S1 and S2, no MRGs
Lungs: CTAB, no wheezes, rhonchi, crackles
Abd: soft, NTND, NABS, no HSM, no rebound or guarding
Ext: warm, 2+ DP pulses, no C/C/E, +neuropathy with touch in
feet
Neuro: CN III-XII intact, MAE
Pertinent Results:
[**2132-1-13**] 01:00PM BLOOD WBC-4.9 RBC-5.20 Hgb-14.5 Hct-43.0 MCV-83
MCH-27.9 MCHC-33.8 RDW-17.3* Plt Ct-205
[**2132-1-14**] 05:36AM BLOOD WBC-4.8 RBC-3.81*# Hgb-10.6*# Hct-30.7*#
MCV-81* MCH-27.8 MCHC-34.5 RDW-17.3* Plt Ct-152
[**2132-1-14**] 12:14PM BLOOD WBC-5.4 RBC-4.20* Hgb-11.7* Hct-34.3*
MCV-82 MCH-27.9 MCHC-34.2 RDW-17.6* Plt Ct-160
[**2132-1-15**] 06:00AM BLOOD WBC-4.7 RBC-4.07* Hgb-11.3* Hct-32.9*
MCV-81* MCH-27.8 MCHC-34.4 RDW-17.4* Plt Ct-169
[**2132-1-13**] 01:00PM BLOOD Neuts-79.5* Lymphs-17.7* Monos-1.3*
Eos-0.4 Baso-1.0
[**2132-1-13**] 01:00PM BLOOD PT-12.9 PTT-28.7 INR(PT)-1.1
[**2132-1-13**] 01:00PM BLOOD Glucose-213* UreaN-83* Creat-4.9* Na-134
K-6.0* Cl-98 HCO3-12* AnGap-30*
[**2132-1-14**] 05:36AM BLOOD Glucose-116* UreaN-81* Creat-3.9* Na-138
K-4.8 Cl-109* HCO3-18* AnGap-16
[**2132-1-15**] 06:00AM BLOOD Glucose-125* UreaN-74* Creat-3.7* Na-138
K-4.4 Cl-110* HCO3-17* AnGap-15
[**2132-1-13**] 04:57PM BLOOD ALT-9 AST-25 LD(LDH)-168 TotBili-0.4
[**2132-1-13**] 04:57PM BLOOD CK-MB-8 cTropnT-0.18*
[**2132-1-14**] 05:36AM BLOOD CK-MB-NotDone cTropnT-0.14*
[**2132-1-13**] 01:00PM BLOOD Calcium-9.1
[**2132-1-15**] 06:00AM BLOOD Calcium-7.9* Phos-3.3 Mg-2.1
[**2132-1-14**] 12:14PM BLOOD calTIBC-203* Ferritn-149 TRF-156*
[**2132-1-14**] 12:14PM BLOOD PTH-494*
[**2132-1-14**] 05:39PM BLOOD Cyclspr-103
[**2132-1-15**] 06:00AM BLOOD Cyclspr-97*
CXR [**1-13**]: IMPRESSION: No acute cardiopulmonary process.
Brief Hospital Course:
50 year old male with type I diabetes who presented with
dehydration, nausea, vomiting, found to be in DKA.
.
# DKA - the pt presented with AG of 24, urine ketones. Lactate
was normal. The patient was started on insulin drip, admitted
to ICU. Overnight, his AG closed to 11. He received fluid
resuscitation with 4L of NS, his K was 6.0 initially with some
peaked T waves and widened QRS on EKG, which resolved with
calcium gluconate and bicarbonate. His potassium stabilized
with improvement of his acidosis.
Infectious work-up including u/a, cxr was negative. The patient
may have had worsening of his gastroparesis of a viral
gastroenteritis leading to poor PO intake and discontinuation of
his insulin as a cause of his DKA. He was transitioned from
insulin drip to his regular dose of glargine (12U in AM). He
was also given a prescription to use humalog rather than his
previous regular insulin for home use.
.
# CAD - Significant CAD history. He never had chest pain,
although the nausea was suspicious. Cardiac enzymes were
trended with CK remaining flat and troponing trending down.
Continued his aspirin, plavix, BB.
.
# Acute on Chronic Renal Failure - Creatinine improved with
hydration, with return to 3.7 prior to discharge.
Renal saw the patient, recommended starting hectorol for
secondary hyperparathyroidism and sensipar as well.
.
# S/P renal transplant - continued cyclosporin and prednisone.
Cyclosporine level was checked, found to be 97 as an AM trough.
Patient had missed a few doses. Recommend continuing current
dose and to recheck at next f/u.
.
# HTN - Initially very hypertensive on arrival to floor, but
stabilized, remianing on regular home meds of toprol and
hydralazine.
.
full code
Medications on Admission:
Aspirin 325 QD
Plavix 75 QD
Hydralazine 10 QID
Cyclosporin 50 [**Hospital1 **]
Lipitor 40 QD - stopped one week ago d/t leg cramps
Toprol 25 QD
Prednsione 5 mg qd
SSI
Lantus 12 units QAM
ALL: Reglan, Protonix
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Cyclosporine Modified 25 mg Capsule Sig: Two (2) Capsule PO
Q12H (every 12 hours).
3. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
4. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
5. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Doxercalciferol 0.5 mcg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
9. Insulin Glargine 100 unit/mL Cartridge Sig: Twelve (12) unit
Subcutaneous at bedtime.
10. Humalog 100 unit/mL Solution Sig: as directed by MD
Subcutaneous three times a day: please use per your sliding
scale with meals.
Disp:*1 vial* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Diabetic Ketoacidosis
Discharge Condition:
stable
Discharge Instructions:
Please cal your doctor or return to ED if you have nausea,
vomiting, unable to eat/take pills, chest pain, shortness of
breath or if there are any concerns at all.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4450**], M.D. Phone:[**Telephone/Fax (1) 4451**]
Date/Time:[**2132-2-27**] 10:40
Please f/u with your primary care doctor or your diabetes doctor
within a week.
Completed by:[**2132-1-15**]
ICD9 Codes: 5849, 2767, 3572 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3779
} | Medical Text: Admission Date: [**2188-4-1**] Discharge Date: [**2188-4-18**]
Date of Birth: [**2120-7-17**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
ERCP
EUS
History of Present Illness:
This is a 67 year old female, well known to the HPB service with
a history of necrotizing gallstone pancreatits c/b pancreatic
necrosis/pseudocyst. She also had ARF/ARDS and a prolonged ICU
stay. She ultimately went to the OR on [**2187-8-3**] for pseudocyst
drainage, but this was not done because the pseudocyst was
smaller in size. She had an Ex Lap., IOC, CCY, and Gastrotmy.
She recovered from this and has been followed by Alphoso Brown.
She presents with 5 days of mid-epgastric pain, N/V x 1 day. She
has intermittent loose stools and no report of fever/chills.
Past Medical History:
1. HTN
2. Diverticulitis
3. ETOH Abuse
4. GERD
5. Renal Insufficiency
6. Severe Necrotizing Gallstone Pancreatitis
7. Respiratory Failure s/p tracheosotomy [**2187-5-10**]
PSH:
Open CCY, IOC, Gastrotomy ([**7-14**])
Social History:
Used to drink alcohol heavily until [**2174**]. Smoked [**1-12**] cigs/day,
quit years ago. Lives in [**Location 2624**] with her daughter and
son-in-law. Does not work. Came here from [**First Name8 (NamePattern2) 466**] [**Country 467**] ~ [**2181**].
Family History:
NC
Physical Exam:
VS: 99.2, 98.4, 75, 160/82, 98% RA
HEENT: mild scleral icterus, MM dry, no JVD, no bruits
CV: Reg S1, S2, no murmur
Pulm: decreased BS, R>L, clear
Abd: soft, minimally tender
Ext: no C/C/E, +2 bilat., warm
Rectal:
Pertinent Results:
CT PERITINEAL DRAIN EXCLUDING APPENDICEAL [**2188-4-3**] 2:59 PM
IMPRESSION: Successful CT-guided aspiration of a large
subhepatic fluid collection revealing 400 mL of
greeenish-brownish nonpurulent fluid. It was sent for various
lab tests, which are currently pending. Findings discussed with
Dr. [**Last Name (STitle) **] by Dr. [**First Name (STitle) **] at completion of the examination.
.
ERCP BILIARY&PANCREAS BY GI UNIT [**2188-4-4**] 8:51 AM
Cholangiogram demonstrates a dilated biliary tree. Narrowing is
seen in the distal third of the CBD. The pancreatic duct is
normal in course and caliber. Final images demonstrate placement
of a biliary stent.
IMPRESSION: Dilated biliary tree with narrowing in the lower
third of the common bile duct.
.
EUS: A 5 cm X 8 cm cyst was noted in the region of the head of
the pancreas. The cyst walls were thin and well-defined. The
distance between the gastric wall and the cyst was 3 mm.
Moderate amount of debris was noted within the cyst. No
intrinsic mass or septations were noted within the cyst.
A 4 cm X 8 cm cyst was noted in the region of the pancreas body
/ tail [corresponding to sub-hepatic fluid collection on CT
scan] . The cyst walls were thin and well-defined. The distance
between the gastric wall and the cyst was 3 mm. Moderate amount
of debris was noted within the cyst. No intrinsic mass or
septations were noted within the cyst.
Small amout of pancreatic parenchyma was noted in the pancreas
body. The pancreatic duct was tortuous and measured 3 mm in
diameter.
Impression: Two large peri-pancreatic fluid collections with
well-defined wall and moderate amount of debis were noted.
.
CTA ABD W&W/O C & RECONS [**2188-4-8**] 1:15 PM
IMPRESSION:
1. Decreased size of large pancreatic pseudocyst replacing the
neck, body, and medial tail of the pancreas. Pancreatic
parenchyma within the head and uncinate process abnormally
enhances but there is normal enhancing pancreas within the tail.
2. Persistent splenic vein occlusion with collateral formation.
Portal vein is narrowed at the portal venous confluence to only
a few mm, but remains patent. The SMV, IMV, IVC, and renal veins
are patent.
3. No pseudoaneurysm evident. Normal arterial vasculature within
the abdomen and pelvis.
4. Decreased size slightly of subhepatic fluid collection.
5. Decreased size of intrahepatic bile ducts with appropriate
position of extrahepatic bile duct stent.
.
[**2188-4-9**] 09:30AM BLOOD WBC-12.7*# RBC-3.38* Hgb-8.4* Hct-26.1*
MCV-77* MCH-24.9* MCHC-32.3 RDW-15.9* Plt Ct-406
[**2188-4-9**] 09:30AM BLOOD Glucose-151* UreaN-7 Creat-1.0 Na-136
K-3.4 Cl-99 HCO3-29 AnGap-11
[**2188-4-8**] 09:55AM BLOOD ALT-75* AST-19 AlkPhos-292* Amylase-99
TotBili-1.2
[**2188-4-4**] 06:20AM BLOOD ALT-346* AST-206* AlkPhos-639*
Amylase-125* TotBili-8.0*
[**2188-4-8**] 09:55AM BLOOD Lipase-27
[**2188-4-1**] 12:55AM BLOOD Lipase-673*
[**2188-4-9**] 09:30AM BLOOD Calcium-8.5 Phos-3.6 Mg-1.7
Brief Hospital Course:
She was admitted on [**2188-4-1**].
She was NPO and started on IVF. A CT was obtained on [**2188-4-2**]
showed:
1. Intrahepatic bile duct dilatation and common bile duct
dilatation.
2. Subhepatic collection, measuring almost 10 cm in diameter.
3. Pancreatic pseudocyst, measuring 10.3 cm x 7.1 cm.
4. Bilateral inguinal hernias.
5. Free fluid in the pelvis.
6. Significant inflammation in the peripancreatic area,
consistent with the patient's history of necrotizing
pancreatitis with low attenuation areas in pancreas which may
represent necrosis.
[**4-3**]: CT aspiration: 400cc drawn off. Studies/cytology sent/P.
Her abdomen softened and her pain improved somewhat.
[**4-4**]: ERCP: stent placed (no drainage of pseudocyst)-no
spincterotomy. Her Tbili began to fall from a high of 8.0 to 1.4
on [**2188-4-7**].
On [**4-6**], she was having crampy pain, loose stools, foul odor.
She was started back on her Creon, and the diarrhea resolved.
[**4-8**]: EUS: Two large peri-pancreatic fluid collections with
well-defined wall and moderate amount of debis were noted.
She had a baseline CT on [**4-8**] and this showed decreased size of
large pancreatic pseudocyst replacing the neck, body, and medial
tail of the pancreas. Pancreatic parenchyma within the head and
uncinate process abnormally enhances but there is normal
enhancing pancreas within the tail. Persistent splenic vein
occlusion with collateral formation. Portal vein is narrowed at
the portal venous confluence to only a few mm, but remains
patent. The SMV, IMV, IVC, and renal veins are patent.
No pseudoaneurysm evident. Normal arterial vasculature within
the abdomen and pelvis.
Decreased size slightly of subhepatic fluid collection.
Decreased size of intrahepatic bile ducts with appropriate
position of extrahepatic bile duct stent.
.
She complained of LUQ pain on HD 8 and this seemed to resolve.
Overall, she felt better and her LFT's, pancreatic enzymes
decreased. She was tolerating a regular diet and her abdomen was
softer and mildly tender. She was taking Creon with meals. She
will return to the OR next week for drainage of the cyst.
Medications on Admission:
enalapril, atenolol, protonix, FeSO4, Creon-20, Ca/VitD, MVI
Discharge Medications:
1. Enalapril Maleate 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Amylase-Lipase-Protease 33,200-10,000- 37,500 unit Capsule,
Delayed Release(E.C.) Sig: Eight (8) Cap PO TID W/MEALS (3 TIMES
A DAY WITH MEALS).
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for 2 weeks.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal Pain
Pancreatic Pseudocysts
Discharge Condition:
Good
Tolerating Diet
Abdomen soft, nondistended.
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomitting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomitting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
=
=
=
=
=
================================================================
Please resume all regular home medications.
.
Continue to ambulate several times per day.
.
Contninue to eat and drink plenty of fluids.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] on Thursday, [**2188-4-17**].
Call ([**Telephone/Fax (1) 2363**] to schedule an appointment.
You should have nothing to eat or drink 6 hours before surgery.
Provider: [**First Name4 (NamePattern1) 1386**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2188-4-21**] 10:00
Completed by:[**2188-4-9**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3780
} | Medical Text: Admission Date: [**2138-7-3**] Discharge Date: [**2138-7-30**]
Date of Birth: [**2059-9-28**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor Last Name 1350**]
Chief Complaint:
Neck pain s/p fall
Major Surgical or Invasive Procedure:
1. Posterior cervical laminectomy C3-C7.
2. Posterior cervical arthrodesis C2-T1.
3. Posterior cervical instrumentation C2-T1
4. Allograft supplementation.
History of Present Illness:
Mr. [**Known lastname **] is a 78 year old male who fell out of bed and hit
cervical spine and loss function of both upper and lower
extremities. Mr. [**Known lastname **] was brought to [**Hospital1 18**] emergency via
ambulance.
Past Medical History:
Borderline Diabetes
Social History:
Currently lives with wife in [**Name (NI) 651**]
Family History:
None
Physical Exam:
A+O x3
Breathing on own and stable
Able to elevate shoulders.
C-spin in collar.
On admission: B/UE & B/LE 0/5 strength, no sensation
On discharge: B/LE: 4+/5 strength with mild decrease in
sensation. B/UE: Delt, tricept [**2-4**], bicep [**3-5**] left & [**2-4**] right,
decreased sensory throughout
rectal tone intact
distal pulses intact
Abd: soft non-tender
Pertinent Results:
[**7-3**] CT C-spine: IMPRESSION: Severe ossification of the posterior
longitudinal ligament at C2 through C4 with up to 75% narrowing
of the spinal canal. With the correct mechanism injury to the
spinal cord is likely and given the clinical scenario, MRI of
the cervical spine is strongly recommended to evaluate for
spinal cord injury.
[**7-3**] MRI C-spine:
IMPRESSION: 1. Severe spinal canal stenosis due to bulky
ossification of the posterior longitudinal ligament, with spinal
cord contusion extending from C2 through C4-5 level, with spinal
cord edema, but no evidence of hemorrhage. 2. No definite
evidence of ligamentous injury.
[**2138-7-3**] 06:19AM BLOOD WBC-12.5*# RBC-4.57* Hgb-14.6 Hct-41.9
MCV-92 MCH-31.9 MCHC-34.8 RDW-13.5 Plt Ct-234
[**2138-7-3**] 03:26PM BLOOD Hct-38.4*
[**2138-7-4**] 05:15AM BLOOD WBC-15.3* RBC-3.76* Hgb-11.8* Hct-34.1*
MCV-91 MCH-31.5 MCHC-34.7 RDW-13.7 Plt Ct-214
[**2138-7-5**] 02:45AM BLOOD WBC-12.8* RBC-3.34* Hgb-10.9* Hct-30.3*
MCV-91 MCH-32.7* MCHC-36.1* RDW-12.9 Plt Ct-176
[**2138-7-6**] 01:46AM BLOOD WBC-9.9 RBC-3.28* Hgb-10.7* Hct-29.8*
MCV-91 MCH-32.6* MCHC-35.9* RDW-12.7 Plt Ct-181
[**2138-7-7**] 02:00AM BLOOD WBC-10.4 RBC-3.43* Hgb-10.9* Hct-31.0*
MCV-91 MCH-31.9 MCHC-35.2* RDW-13.7 Plt Ct-214
[**2138-7-8**] 03:44AM BLOOD WBC-9.8 RBC-3.53* Hgb-11.2* Hct-32.0*
MCV-91 MCH-31.7 MCHC-35.0 RDW-12.8 Plt Ct-294
[**2138-7-9**] 06:00AM BLOOD WBC-11.0 RBC-3.60* Hgb-11.6* Hct-32.5*
MCV-90 MCH-32.3* MCHC-35.7* RDW-13.3 Plt Ct-284
[**2138-7-3**] 02:36AM BLOOD Glucose-193* UreaN-31* Creat-1.4* Na-139
K-4.0 Cl-106 HCO3-25 AnGap-12
[**2138-7-3**] 06:19AM BLOOD Glucose-187* UreaN-30* Creat-1.3* Na-137
K-4.4 Cl-106 HCO3-23 AnGap-12
[**2138-7-3**] 03:26PM BLOOD Glucose-183* UreaN-28* Creat-1.3* Na-138
K-4.4 Cl-105 HCO3-21* AnGap-16
[**2138-7-4**] 05:15AM BLOOD Glucose-155* UreaN-32* Creat-1.2 Na-139
K-4.3 Cl-108 HCO3-23 AnGap-12
[**2138-7-7**] 02:00AM BLOOD Glucose-168* UreaN-24* Creat-1.0 Na-138
K-4.2 Cl-105 HCO3-27 AnGap-10
[**2138-7-8**] 03:44AM BLOOD Glucose-166* UreaN-27* Creat-1.0 Na-135
K-4.3 Cl-102 HCO3-25 AnGap-12
[**2138-7-9**] 06:00AM BLOOD Glucose-134* UreaN-27* Creat-1.1 Na-139
K-4.3 Cl-104 HCO3-28 AnGap-11
Brief Hospital Course:
Mr. [**Known lastname **] was brought to [**Hospital1 18**] after a fall from bed resulting in
loss of function of both upper and lower extremities. He was
brought to the TSICU in stable condition and breathing on his
own. After explaining his situation to both his wife and his
daughter, he was consented for a posterior cervical
decompression and fusion. He tolerated the procedure well.
After his procedure he was brought back to the TSICU and then
transfered to the general floor five days post op.
1. Cervical cord compression: Mr [**Known lastname **] experienced cervical cord
compression s/p fall from bed. Cervical decompression and
fusion was performed to stabilize his cervical spine. He did
have a second procedure for removal of C2 cervical screw and
further decompression of C2 lamina. He tolerated the procedure
well.
2. Acute post operative anemia: Mr. [**Known lastname **] became acutely anemic
as the result of his surgical procedure. He was asymptomatic
and did not require blood transfusion.
3. IVC filter placement. Mr. [**Known lastname **] [**Last Name (Titles) 1834**] placement with IVC
filter for prevention of pulmonary embolism. He tolerated the
procedure well.
Mr. [**Known lastname **] did work with physical therapy who recommended
discharge to rehab facility. The rest of his course was
unremarkable.
Medications on Admission:
None
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
5. Oxycodone 5 mg/5 mL Solution Sig: One (1) PO Q6H (every 6
hours) as needed for pain.
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
7. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed.
10. Glyburide Micronized-Metformin 2.5-500 mg Tablet Sig: Two
(2) Tablet PO BREAKFAST (Breakfast).
11. Glyburide Micronized-Metformin 2.5-500 mg Tablet Sig: One
(1) Tablet PO DINNER (Dinner).
12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
1. Cervical spinal cord injury.
2. Ossification of the posterior longitudinal ligament (OPLL).
3. Cervical spine fracture C3-C4.
Discharge Condition:
Stable to ECF
Discharge Instructions:
Please keep incision clean and dry. You may shower in 48 hours,
but please do not soak the incision. Change the dressing daily
with clean dry gauze. If you notice drainage or redness around
the incision, or if you have a fever greater than 100.5, please
call the office at [**Telephone/Fax (1) **]. Please resume all home
mediciation as prescribed by your primary care physician. [**Name10 (NameIs) **]
have been given additional medication to control pain. Please
allow 72 hours for refills of this medication. Please plan
accordingly. You can either have this prescription mailed to
your home or you may pick this up at the clinic located on
[**Hospital Ward Name 23**] 2. We are not allowed to call in prescriptions for
narcotics to the pharmacy. If you have questions concerning
activity, please refer to the activity sheet.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 1007**] at two weeks from the date of
discharge. You can call [**Telephone/Fax (1) **] to make this appointment.
Completed by:[**2138-7-29**]
ICD9 Codes: 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3781
} | Medical Text: Admission Date: [**2136-7-18**] Discharge Date: [**2136-7-23**]
Date of Birth: [**2073-9-29**] Sex: M
Service: MEDICINE
Allergies:
Bee Pollens
Attending:[**First Name3 (LF) 10293**]
Chief Complaint:
post-operative pain
HCT monitoring
Major Surgical or Invasive Procedure:
liver biopsy
radiofrequency ablation
History of Present Illness:
62yo M with history of alcoholic cirrhosis complicated by
encephalopathy and ascites with three HCC liver lesions who is
admitted for monitoring after scheduled RFA. He underwent RFA
by IR to the three lesions this afternoon and had liver biopsy.
After ablation of the third lesion, active mild extravasation
was noted but the tract was ablated. He was hemodynamically
stable throughout. His Hct after procedure 33 from baseline of
39 two days prior.
.
On the floor, he complains of some RUQ pain over biopsy area
that is starting to come back after pain meds he received in
PACU. Otherwise, he has been in his normal state of health and
feels fine.
Past Medical History:
-ETOH cirrhosis (MELD 12 in [**11-16**]) with history of
decompensations with hepatic encephalopathy, ascites, and
varices. Currently listed for transplant at [**Hospital1 18**].
-Osteoarthritis
-S/p multiple back/neck surgeries for "disc disease"
-S/p bowel resection & anastamosis ~15 yrs ago for perforation
Social History:
Married. Retired. Former smoker. No EtOH currently. Hobbies
include fly fishing and golf.
Family History:
Father and brother with prostate CA. Two brothers with DM type 2
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 97.8 BP: 103/64 P: 54 R: 18 O2: 100% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, 3/6 systolic murmur
loudest over L upper sternal border
Abdomen: soft, RUQ tenderness with mild guarding, non-distended,
bowel sounds present, no rebound tenderness, hepatomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: No asterixis
.
DISCHARGE PHYSICAL EXAM:
O: Tc 98.8/99.8, 120/70, 67, 18, 96% RA, I/O: 960/820+ (32h), BM
x 3 x 24h
General: appears sad, NAD
HEENT: Sclera icteric, MMM
Lungs: pleural rub over RLL but no crackles, wheezes, or rhonchi
throughout rest of lung
CV: Regular rate and rhythm, normal S1 + S2, 3/6 systolic
ejection murmur heard best over RUSB
Abdomen: soft, NT, distended, normoactive bowel sounds
Ext: trace edema in LE bilat at ankles
Neuro: AAOx3, can say DOW backward, no asterixis
Pertinent Results:
Admission Labs:
[**2136-7-18**] 10:11PM BLOOD WBC-9.2# RBC-2.36* Hgb-8.7* Hct-25.0*
MCV-106* MCH-37.1* MCHC-35.0 RDW-14.1 Plt Ct-79*
[**2136-7-18**] 10:11PM BLOOD PT-18.7* PTT-39.3* INR(PT)-1.7*
[**2136-7-18**] 10:11PM BLOOD Glucose-137* UreaN-16 Creat-1.0 Na-133
K-6.8* Cl-105 HCO3-24 AnGap-11
[**2136-7-18**] 09:20PM BLOOD ALT-53* AST-174* AlkPhos-73 TotBili-4.6*
[**2136-7-18**] 10:11PM BLOOD Calcium-7.5* Phos-4.0# Mg-1.6
CTA AP [**2136-7-19**]
1. Moderate right hemothorax along with progression of
previously visualized perihepatic hemorrhage. There is no
evidence of active arterial
extravasation. These findings are likely related to venous
bleeding, either from post-procedure or from variceal rupture.
2. Evidence of cirrhosis with varices and a recanalized
periumbilical vein.
3. The patient is status post RFA of three hepatic sites.
CXR [**2136-7-19**]:
Right side chest tube is seen with its tip approximately at
posterior 6th rib but the side hole is located at the level of
the intercostal space. Minimal air is seen in the right
subcutaneous region, likely following the recent chest tube
placement. Right hemothrax better demonstrated on prior chest CT
dated [**2136-7-18**] is mild-to-moderate in quantity. There is no
pneumothorax. Left lung is clear. Heart size, mediastinum and
hilar contours are normal.
ABD U/S [**2136-7-20**]:
1. Shrunken nodular liver consistent with cirrhosis. Limited
evaluation of
known hepatic lesions.
2. Patent main portal vein with hepatopetal flow. Evaluation of
the portal
branches is limited.
3. Evidence of portal hypertension including splenomegaly and
moderate
intra-abdominal ascites.
4. Gallbladder sludge.
CXR [**2136-7-22**]:
As compared to the previous radiograph, there is an improvement.
The linear opacities along the right minor fissure have almost
completely
resolved. A small gas bubble in the right soft tissues, at the
site of the
previous chest tube insertion, is also resolved. There is no
evidence of
pneumothorax or of pleural effusion. The appearance of the left
hemithorax is unchanged. Unchanged left axillary clips.
DISCHARGE LABS:
[**2136-7-23**] 05:50AM BLOOD WBC-6.7 RBC-3.23* Hgb-11.2* Hct-31.0*
MCV-96 MCH-34.5* MCHC-36.0* RDW-17.3* Plt Ct-70*
[**2136-7-23**] 05:50AM BLOOD PT-18.7* PTT-35.4* INR(PT)-1.7*
[**2136-7-23**] 05:50AM BLOOD Glucose-104* UreaN-10 Creat-0.6 Na-136
K-4.1 Cl-101 HCO3-28 AnGap-11
[**2136-7-23**] 05:50AM BLOOD ALT-61* AST-75* AlkPhos-69 TotBili-7.0*
[**2136-7-23**] 05:50AM BLOOD Calcium-8.2* Phos-1.6* Mg-1.7
Brief Hospital Course:
62yo M with history of alcoholic cirrhosis complicated by
encephalopathy and ascites who was initially admitted to the
medical floor for observation after schedule radiofrequency
ablation of three HCC liver lesions and liver biopsy,
complicated by right hemothorax.
# hemothorax: Post procedure Hct was 33 down from 39 prior to
the RFA. On the floor the evening of admission, he became
hypotensive to the 70s. He was noted to have low UOP with
concentrated urine, dry-appearing, and cool to the touch. He
recieved 3L NS with improvement in pressures to 100s and better
UOP. Hct was 25 upon recheck. After discussion with IR, pt was
sent emergently to CT given concern for intra-abdominal bleeding
and was found to have a right-sided hemothorax. He got one unit
of PRBC's at this time and labs also showed K 6.8. He was given
insulin/D50 and calcium; no significant ECG changes were seen.
In the MICU, a chest tube was placed by thoracics on [**2136-7-19**]. He
got a total 6 units pRBCs, 3 units FFP, and 1 unit plts while in
the MICU. Pt was on an octreotide gtt in the MICU at the request
of liver. His Hct stabilized near 31 and he was transferred to
the general medicine service to be followed by the liver
attending. On the floor, he was continued on octreotide
subcutaneously for another 2d. On the evening of [**2136-7-21**] the
chest tube had minimal output and Hct was stable and the tube
was removed by thoracics. His Hct remained stable and a repeat
CXR showed near resolution of hemothorax. He was discharged on
oxycodone 5mg po q6h prn for pain in addition to his home dose
of tramadol 50mg po BID. He was instructed not to drive while
on narcotics.
# cirrhosis: diuretics were held after patient developed
hemothorax, but pt was continued on rifaximin, lactulose, and
pantoprazole during admission. Nadolol was held initially but
was restarted upon transfer to the general medicine floor on
[**2136-7-20**]. he began to develop trace edema in his LE on [**2136-7-23**];
his volume status and Hct were stable at this time so his
diuretics were restarted. His LFT's remained stable throughout
admission. He was also placed on levofloxacin for 5d for
infection prophylaxis. His home medication regimen included
both omeprazole and pantoproazole, which was thought to be
redundant, so pantoprazole was discontinued on discharge and pt
was instructed to take only omeprazole 20mg po BID with plans to
further discuss this with Dr. [**Last Name (STitle) 497**].
# tachycardia: on [**2136-7-22**] pt developed tachycardia to the 160s.
He did not have symptoms. He had not yet received his AM
nadolol and was given this medication, after which his
tachycardia resolved, but nadolol has little systemic effect so
it is more likely that the tachycardia resolved spontaneously.
He said he had a similar episode in the past 7-8 years ago. He
denied a history of afib or being treated for a heart condition,
and an EKG taken at the time revealed multifocal atrial
tachycardia, so no further work up or treatment was pursued.
TRANSITIONAL ISSUES:
# follow up with liver specialist in one week
# discuss PPI regimen with Dr. [**Last Name (STitle) 497**] (pantoprazole was DC'ed and
omeprazole was continued)
# repeat CT scan in 1 month
Medications on Admission:
Alprazolam 0.25 mg PO PRN nightly
Calcipotriene ointment
Clobetasol ointment
EpiPen PRN
Furosemide 40 mg PO QD
Lactulose 10gm/15ml solution 30 ml TID PO
Nadolol 20 mg PO QD
Omeprazole 20 mg PO BID
Pantoprazole 40 mg PO QD
Rifaximin 550 mg PO BID
Spironolactone 100 mg PO BID
Tramadol 50 mg PO BID
MVI
Discharge Medications:
1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO QID (4 times a day).
6. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day): titrate to [**2-10**] bowel movements per day.
7. spironolactone 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO at bedtime
as needed for insomnia.
9. calcipotriene 0.005 % Ointment Sig: One (1) application
Topical twice a day: Apply to hands and feet twice daily Monday
through Friday. .
10. clobetasol 0.05 % Ointment Sig: One (1) application Topical
twice a day: Apply to hands and feet twice daily. Use 2
wks/month. Do not apply to face, skin folds, armpits, groin. .
11. EpiPen 0.3 mg/0.3 mL Pen Injector Sig: One (1) injection
Intramuscular once as needed for anaphylaxis.
12. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
13. tramadol 50 mg Tablet Sig: One (1) Tablet PO twice a day.
14. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 3 days: Last Dose [**2136-7-26**].
Disp:*3 Tablet(s)* Refills:*0*
15. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
16. spironolactone 100 mg Tablet Sig: One (1) Tablet PO twice a
day.
17. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*28 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
acute post-procedure bleeding/hemothorax
radiofrequency ablation
Secondary Diagnoses:
hepatocellular carcinoma
alcoholic cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Dear Mr. [**Known lastname 976**],
It was a pleasure taking care of you in the hospital. You had
radiofrequency ablation of parts of your liver. After the
procedure, you were admitted for close observation to control
post-operative pain and ensure that you were not actively
bleeding. You developed a bleed into your chest cavity and you
received 6 units of blood cells, 3 units of fresh frozen plasma,
and 1 unit of platelets to control your bleeding. You also had
a chest tube placed to drain the blood that had collected there.
Your blood counts stabilized and the chest tube was removed.
Change the dressing daily over the chest tube site and keep the
area dry. Avoid baths until scab has completely formed over the
area. You may shower starting on [**2136-7-24**].
We reviewed your medications and noticed that you were on both
Pantoprazole and Omeprazole which have a similar mechanism of
action. It is unnecessary to take both of these; we recommend
that you take omeprazole only and discuss this with Dr. [**Last Name (STitle) 497**] at
your next visit.
The following changes were made to your medications:
STOP Pantoprazole and discuss at your next appointment with Dr.
[**Last Name (STitle) 497**]
START levofloxacin 750mg by mouth daily for three days (last
dose [**2136-7-26**])
START oxycodone 5mg by mouth every 6 hours as needed for pain
Followup Instructions:
1. TRANSPLANT [**Hospital 1389**] CLINIC
Phone: [**Telephone/Fax (1) 673**]
Date/Time: [**2136-8-1**] @ 8:00
2. CAT SCAN
Phone:[**Telephone/Fax (1) 327**]
Date/Time: [**2136-8-20**] @ 11:30
ICD9 Codes: 2851, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3782
} | Medical Text: Admission Date: [**2188-2-19**] Discharge Date: [**2188-2-28**]
Date of Birth: [**2122-11-18**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
Esophageal cancer
Major Surgical or Invasive Procedure:
s/p transhiatal esophagectomy for adenocarcinoma of esophogas
[**2-19**]
History of Present Illness:
This is a 65 year old gentleman who has a history of known
Barrett's esophagus who has developed invasive carcinoma. He has
had reflux symptoms for years and surveillance biopsies in [**2186**]
revealed high-grade dysplasia. Endoscopic mucosal resection but
there was persistant invasive cancer. Endoscopic ultrasound
showed no dominant tumor mass, staging him at TxNoMo. He had a
PET scan demonstrating hypermetobolic uptake at the tumor site
but not elsewhere.
Past Medical History:
Diabetes Mellitus
Hypertension
Hyperlipidemia
CAD s/p CABG x 5 '[**84**]
Gangrenous omentum s/p ex-lap
GERD
Social History:
He smoked a pack and a half a day for 25 years, but quit 15
years ago. He is a recovering alcoholic with no recent binges.
Family History:
non-contributory
Physical Exam:
on admission:
Afebrile, vital signs stable, weight 217 pounds
Gen: well-developed middle-aged male
HEENT: moist mucous membranes, no scleral icterus
Neck:no lymphadenopathy in the neck
CV: RRR, no murmurs
Pulm: clear to auscultation bilaterally
Abd: soft, NT/ND, normoactive bowel sounds
Extr: warm, well-perfused
Neuro: grossly intact
Pertinent Results:
[**2188-2-19**] 03:26PM BLOOD WBC-10.3 RBC-3.89* Hgb-11.7* Hct-32.3*
MCV-83 MCH-30.2 MCHC-36.4* RDW-14.2 Plt Ct-256
[**2188-2-20**] 02:20AM BLOOD WBC-12.2* RBC-3.82* Hgb-11.3* Hct-32.4*
MCV-85 MCH-29.6 MCHC-34.9 RDW-14.4 Plt Ct-238
[**2188-2-21**] 01:55AM BLOOD WBC-15.3* RBC-3.63* Hgb-10.7* Hct-30.4*
MCV-84 MCH-29.3 MCHC-35.0 RDW-14.4 Plt Ct-193
[**2188-2-22**] 03:08AM BLOOD WBC-14.7* RBC-3.48* Hgb-10.2* Hct-29.6*
MCV-85 MCH-29.4 MCHC-34.5 RDW-14.3 Plt Ct-214
[**2188-2-23**] 05:37AM BLOOD WBC-13.0* RBC-3.64* Hgb-10.9* Hct-31.4*
MCV-86 MCH-29.9 MCHC-34.7 RDW-14.6 Plt Ct-255
[**2188-2-24**] 05:30AM BLOOD WBC-11.1* RBC-3.77* Hgb-11.2* Hct-32.6*
MCV-86 MCH-29.7 MCHC-34.3 RDW-14.4 Plt Ct-271
[**2188-2-25**] 09:47AM BLOOD WBC-13.2* RBC-3.83* Hgb-11.3* Hct-32.9*
MCV-86 MCH-29.4 MCHC-34.2 RDW-14.7 Plt Ct-300
[**2188-2-27**] 08:30AM BLOOD WBC-11.1* RBC-3.77* Hgb-11.1* Hct-32.7*
MCV-87 MCH-29.6 MCHC-34.0 RDW-15.0 Plt Ct-346
[**2188-2-19**] 03:26PM BLOOD PT-14.5* PTT-24.4 INR(PT)-1.3*
[**2188-2-21**] 01:55AM BLOOD Glucose-148* UreaN-13 Creat-1.0 Na-137
K-3.6 Cl-102 HCO3-26 AnGap-13
[**2188-2-22**] 03:08AM BLOOD Glucose-113* UreaN-17 Creat-0.9 Na-141
K-4.0 Cl-104 HCO3-28 AnGap-13
[**2188-2-24**] 05:30AM BLOOD Glucose-144* UreaN-19 Creat-0.7 Na-142
K-4.1 Cl-108 HCO3-25 AnGap-13
[**2188-2-26**] 08:04AM BLOOD Glucose-185* UreaN-19 Creat-0.8 Na-141
K-4.2 Cl-104 HCO3-27 AnGap-14
[**2188-2-27**] 08:30AM BLOOD Glucose-180* UreaN-17 Creat-0.8 Na-139
K-4.8 Cl-104 HCO3-27 AnGap-13
[**2188-2-19**] 03:26PM BLOOD Albumin-3.3* Calcium-8.5 Phos-6.2*
Mg-1.0* Iron-105
[**2188-2-26**] 08:04AM BLOOD Calcium-9.0 Phos-2.7 Mg-1.5*
[**2188-2-27**] 08:30AM BLOOD Calcium-8.8 Phos-2.9 Mg-1.7
RADIOLOGY:
[**2-19**] post-op CXR: The patient is status post transhiatal
esophagectomy. The tip of the endotracheal tube is identified 2
cm above the carina. The right jugular Swan-Ganz catheter
terminates in the right main PA. A nasogastric tube terminates
in the intrathoracic stomach.
There is mild congestive heart failure with cardiomegaly. Patchy
atelectasis is seen at the lung bases. There is no evidence of
pneumothorax.
[**2-21**] CXR: Cardiac and mediastinal contours are stable. There has
been removal of a nasogastric tube. Surgical drains remain in
place in the upper mediastinum.
There is an air collection present adjacent to the drain which
may relate to air within the proximal neoesophagus or
postoperative extraluminal air
collection. There is mild perihilar haziness suggestive of mild
perihilar
edema, and note is made of small bilateral pleural effusions,
slightly
improved in the interval.
[**2-26**] Barrium Swallow eval: Barium passes freely through the
esophagus. An
end-to-side anastomosis is noted within the upper mediastinum.
There is no
evidence of anastomotic leak. A drain is seen within the
superior
mediastinum.
IMPRESSION: No evidence of anastomotic leak.
PATHOLOGY:
I. Esophagogastrectomy (A-AH,CA-CK ):
1. Barrett's esophagus with extensive low grade and foci of high
grade glandular dysplasia (see note).
2. Hiatal hernia.
3. Gastric segment and regional lymph nodes, within normal
limits.
4. Esophageal squamous epithelium at proximal margin and gastric
corpus mucosa at distal margin.
5. There is no carcinoma.
II. Left gastric lymph nodes (BA-BK):
1. Hyperplasia of lymph nodes.
2. No tumor.
Note: The glandular dysplasia is low grade in the more proximal
part of the esophageal segment, and high grade in the lower
part. The entire columnar-lined esophagus is sampled, and there
is no residual carcinoma.
Brief Hospital Course:
This is a 65 year old gentleman with high-grade Barrett's
esophagus with adenocarcinoma who presented for esophagectomy.
He underwent transhiatal esophagectomy without complication on
[**2188-2-19**] (please see the operative note of Dr. [**First Name (STitle) **] [**Doctor Last Name **] for
full details). He had an uncomplicated post-operative course. He
was extubated on post-operative day 1 and diuresed gently. He
received perioperative antibiotics. Tube feeds were started on
post-op day 2. His pain was well controlled with an epidural
catheter. The patient accidentally removed his nasogastric tube
on post-op day 2. He had flatus on post-op day 5 and tube feeds
were advanced to goal. He underwent a swallow eval on post-op
day 7 which he passed and a diet was started; he was tolerating
a regular diet by post-op day 8 and had good pain control on
oral pain medications. His JP drain and staples were removed on
post-op day 8. He was discharged to home on post-op day 9 with
planned visiting nurse [**First Name (Titles) **] [**Last Name (Titles) **] with tube feeding. Allq
uestions were answered to his satisfaction upon discharge.
Medications on Admission:
Aspirin 325 mg po qdaily
Lopressor 150 mg po qdaily
Protonix 40 mg po qdaily
lipitor 80 mg po qdaily
lisinopril 40 mg po qdaily
Glipizide 10 mg PO BID
Metformin 1000 mg po BID
Norvasc 5 mg po Qdaily
Prozac 20 mg po qdaily
Discharge Medications:
1. tube feeding
probalance 80cc/hr x24hours, cycle as per tolerance
[**5-28**] cans/day
2. tube feeding supplies
kangaroo pump
iv pole
feeding bags
60cc catheter tip syringes
tube feeding extension tubing
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
4. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day): crush and take by mouth.
Disp:*120 Tablet(s)* Refills:*1*
5. Fluoxetine 20 mg/5 mL Solution Sig: Five (5) cc PO DAILY
(Daily).
Disp:*100 cc* Refills:*2*
6. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*1*
8. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*1*
9. Glipizide 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*1*
10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. 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:*1*
12. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
Disp:*120 ML(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Diabetes Mellitus, Hypertension, Hyperlipidemia, Coronary artery
disease, s/p Coronary artert bypass graft x 5 '[**84**], gangrenous
omentum s/p exploratory-laparoscopy, Gastric esophogeal reflux
disease, [**1-28**]- cardiac ejection fraction 37%, adenocarcinoma of
esophogas
Discharge Condition:
good
Discharge Instructions:
Call Dr.[**Doctor Last Name 4738**]/Thoracic Surgery office ([**Telephone/Fax (1) 170**])
for:fever, shortness of breath, chest pain, difficulty
swallowing, excessive nausea, vommitting, J- tube clogging and
inability to unclog w/ cola, meat tenderizer, redness, drainage
and new pain at j-tube site or incision site.
REsume regular medications as listed in discharge instructions.
You may shower when you return home.
Change j-tube dressing every day-keep dressing dry, change if
wet.
TUBE FEEDING-ProBalance formula- cycle schedule
110cc/hr for 18 hours/day; 120cc/hr for 16 hours/day; 140cc/hr
for 14 hours/day; 160cc/hr for 12 hours/day.
VNA Services-[**Last Name (un) 2646**] VNA- [**Telephone/Fax (2) 62697**]
Tube feeding support with-[**Telephone/Fax (1) 43291**]
Followup Instructions:
Call Dr.[**Doctor Last Name 4738**]/Thoracic Surgery office ([**Telephone/Fax (1) 170**]) for
appointment in [**10-4**] days.
Completed by:[**2188-2-28**]
ICD9 Codes: 4280, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3783
} | Medical Text: Admission Date: [**2177-7-3**] Discharge Date: [**2177-8-1**]
Date of Birth: [**2107-11-9**] Sex: F
HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname **] is a 59 year old
woman who presented with a chief complaint of shortness of
breath. She has a past medical history of breast cancer,
DCIS, diagnosed in [**2175-6-10**]. She is status post total
positive, Stage II, N0 M0 with no radiation therapy,
previously on Tamoxifen. She also has a history of
hypertension, chronic obstructive pulmonary disease, diabetes
mellitus type 2 on oral hypoglycemics, chronic renal
insufficiency secondary to diabetes mellitus with nephrotic
proteinuria. She has a history of increased creatinine on
ACE inhibitors. She also has a history of thalassemia trait,
ALLERGIES: She has no known drug allergies.
SOCIAL HISTORY: She has remote tobacco use. No alcohol
consumption. She lives with her son.
Nine days prior to her admission to [**Hospital1 190**] she was discharged from [**Hospital1 190**] where she was admitted for a chronic
obstructive pulmonary disease flare and bilateral pleural
effusions and a pericardial effusion with tamponade which was
tapped under ultrasound there, showing an exudative effusion
and cytologies were negative. Serum [**Doctor First Name **] was positive for
1:160; a 2D echocardiogram there also showed right
ventricular wall clot/tumor, but a normal ejection fraction
of 60%. She was treated with Levofloxacin at the time.
Upon arriving to the Emergency Department at [**Hospital1 346**] she was short of breath.
PHYSICAL EXAMINATION: On examination, she was tachypneic
with respirations of 25 to 35, saturating at 65% on room air.
She remained hypoxic on 100% face mask and arterial blood gas
showed a respiratory acidosis of 7.32/66/55. Her left eye is
blind, abducted. Her right eye has equal and reactive pupil.
Oropharynx is clear. Neck was supple with no jugular venous
pressure. Lungs were dull at the left base with decreased
breath sounds on the left, fine crackles, bibasilar. There
was no wheezing but was rhonchorous. Cardiovascular: She
had regular tachycardic rhythm with a faint pericardial rub.
Abdomen was unremarkable.
LABORATORY: Her labs on presentation were significant for a
white blood cell count of 19.4, with left shift, neutrophils
of 93%. Her hematocrit was 40.8 with an MCV of 77. Her
hemoglobin A1C was 7.6% and her blood gas revealed a pH of
7.32, a pO2 of 66 and a pCO2 of 55 on Bi-PAP 5/5 with an FIO2
of 35%.
Her EKG showed normal sinus rhythm. ST elevation of 1 mm in
the anterior V1 through V3 leads; no change from [**2175-6-10**].
HOSPITAL COURSE: The patient was initially thought to have a
chronic obstructive pulmonary disease flare and was treated
with nebs, Lasix and Solu-Medrol. The patient was found to
have tamponade physiology on PTE. She was taken for a
balloon pericardiotomy and required intubation for airway
protection at that time. She also received an ultrasound
guided thoracentesis on [**7-4**] for a left pleural effusion
which turned out to be a transudative effusion. She was
successfully intubated after this procedure.
Unfortunately, pulmonary and pericardial effusions
reaccumulated. The patient had respiratory failure requiring
re-intubation on [**7-9**], at which time she was taken to
the Operating Room for a pericardial window, a left chest
tube placement and a left pleurodesis. Post-procedure
extubation attempts were unsuccessful and the patient was
transferred to the Medical Intensive Care Unit.
In the Medical Intensive Care Unit, the patient was failing
to wean from the ventilator due to many factors. Most
notably, the patient was found to have diaphragmatic weakness
with poor negative inspiratory pressures, gastric balloon
studies were nonrevealing and diaphragm ultrasound was
suggestive of a diaphragmatic weakness. She was also found
to have critical care polyneuropathy and myopathy as well
which probably contributed significantly to her failure from
weaning. She also has a component of bronchoconstriction on
top of a restrictive lung disease which responds to Albuterol
nebulizers. Due to the failure to wean, the patient was
trached on [**2177-7-17**].
From a cardiovascular standpoint, the patient was diuresed
for congestive heart failure, titrated on afterload reducing
medications for systolic hypertension including Metoprolol
and Lisinopril. Her initial serial PTE's showed
reaccumulation of pericardial fluid which was loculated but
did not show any signs of tamponade.
The patient required treatment for a Candiduria and was given
Diflucan for five days and then Foley catheter was changed.
She was also treated with Levofloxacin for five days for a
urinary tract infection between [**7-19**] and [**7-24**]. The
patient had increasing white blood counts starting [**7-21**]
with no determined source until [**7-27**] when her urine cultures
grew out Vancomycin resistant enterococcus. She was
previously given a course of Vancomycin for Gram positive
cocci in one out of four bottles of blood culture, but was
discontinued when the urine cultures revealed Vancomycin
resistant enterococcus. She was started on Linezolid.
Her hospital course was also complicated by a contrast
induced nephropathy which is resolving. As mentioned
previously, the patient had an EMG which showed evidence of
critical care neuromyopathy. Since starting the Linezolid,
the patient has had decrease in fever spikes and falling
white blood cell counts. She has responded accordingly from
a Pulmonary standpoint where she is able to tolerate a
T-piece.
The patient had a PEG tube placed on [**2177-7-28**].
CONDITION AT DISCHARGE: The patient's cause of recurrent
pericardial and pleural effusions are still unknown to date.
Her pleural effusions are transudative in nature.
Rheumatology has evaluated her and determined that this is
not a rheumatologic cause since her [**Doctor First Name **] was negative at the
time of admission. Repeated pleural and pericardial effusion
cytologies never showed any evidence of malignant cells nor
did the pericardial biopsy from the pericardial window
procedure.
The patient's current Pulmonary status is improving,
progressing from a ventilatory support of 25/7.5 at an FIO2
of 0.4 and tidal volumes of 200 to 400 cc, has
diminished to tolerating T-piece during the day. She
continues to require Albuterol and Atrovent nebulizers to
help with her reactive airway disease. Her pulmonary
effusions are also decreasing and her pericardial effusions
appear to be stable. No repeat of the pericardial effusion
echocardiogram is required unless clinically indicated.
Other cardiovascular issues include her blood pressure which
has stabilized as well on Metoprolol and Lisinopril. Her
renal function contrast induced nephropathy is also resolving
and her creatinine is returning to baseline.
From an Infectious Disease standpoint, the patient has a
Vancomycin resistant enterococcus in her urine being treated
with Linezolid requiring a seven day course. She is
currently on day number four at time of discharge on
[**2177-7-30**].
From an Endocrine perspective, the patient is on insulin
sliding scale and 8 units of NPH a day, split 4 units in the
morning and 4 units before dinner. From a hemodynamic
standpoint, the patient has required several units of blood,
but the hematocrit is stable at 28 on [**7-29**] and is currently
on Epogen 3 times a week to maintain her reticulocyte count.
The patient may require other units of packed red blood cells
to keep her hematocrit above 27.
She was also found to have an SPEP with 2% gamma band. This
result is not significant for myeloma; most likely consistent
with MGUS. Her urinary PEP is still pending.
From a gastrointestinal standpoint, she currently has a PEG
tube in place requiring tube feeds of ProMod with fiber. She
is still a full code and communications are with her son.
The patient is ready for discharge to a Vent Core Unit to
wean her off of her tracheostomy.
DISCHARGE MEDICATIONS:
1. Calcium carbonate 500 mg p.o. three times a day for
phosphate binding.
2. Linezolid 600 mg p.o. q. 12 hours for her VRE infection
which is to be continued for another three days for a full
course of seven days.
3. Lisinopril 20 mg p.o. twice a day.
4. Metoprolol 50 mg p.o. three times a day.
5. Ipratropium bromide nebulizer, one to two nebs q. four
hours.
6. Insulin sliding scale that begins at a glucose value of
120 mg per deciliter giving 2 units for each increment of 40
mg per deciliter. The starting point is also 2 units.
7. Insulin NPH 4 units twice a day.
8. Epoetin alpha 5000 units subcutaneously three times a
week.
9. Furosemide 80 mg p.o. twice a day.
10. Ranitidine 150 mg p.o. q. day elixir.
11. Folic acid 1 mg p.o. q. day.
12. Aspirin 325 mg p.o. q. day.
13. Lorazepam 1 mg p.o. three times a day.
14. Docusate sodium 100 mg p.o. twice a day.
15. Amlodipine 10 mg p.o. q. day.
16. Three ophthalmic solutions: First one, Latanoprost
0.005% ophthalmic solution, one drop in the right eye q. day;
Dorzolamide 2% ophthalmic solution one drop in the right eye
three times a day; and Brimonidine tartrate 0.2% one drop in
the right eye three times a day.
DISCHARGE DIAGNOSES:
1. Recurrent pleural pericardial effusions of unknown
etiology.
2. Restrictive lung disease with reactive airway disease.
3. Critical care neuromyopathy.
4. Urinary tract infection.
5. Hypertension.
6. Contrast induced nephropathy.
7. Anemia.
8. Thalassemia trait.
9. Osteogenesis imperfecta.
10. Diabetes mellitus type 2.
11. Chronic renal insufficiency with nephrotic range
proteinuria.
12. Status post breast cancer DCIS with total mastectomy.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-426
Dictated By:[**Name8 (MD) 1020**]
MEDQUIST36
D: [**2177-7-29**] 15:48
T: [**2177-7-29**] 16:08
JOB#: [**Job Number 12115**]
ICD9 Codes: 2762, 4280, 5990, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3784
} | Medical Text: Admission Date: [**2147-2-7**] Discharge Date: [**2147-2-17**]
Date of Birth: [**2093-10-4**] Sex: F
Service: NEUROLOGY
Allergies:
Shellfish / Insulin,Beef / Insulin Zinc,Pork / Compazine /
Droperidol / Ivp Dye, Iodine Containing
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
transferred for cerebellar infarct
Major Surgical or Invasive Procedure:
Extraventricular drain placement
Intubation
History of Present Illness:
Pt. is a 53 y/o with a hx of Type II DM, CAD s/p CABG x 3 and
multiple stenting procedures, obesity, hypertension,
hyperlipidemia who is transferred for further management of a L
cerebellar infarct.
Pt. reports that she was in her USOH until Thursday [**2-2**], when
she noticed that her speech was slurred. Then early in the
morning on Friday ([**2-3**]) around 4 AM she got up off the couch and
fell to the floor due to imbalance. She did not notice any
weakness or numbness at that time. She reports she vomited once
and felt very nauseated. She stayed on the floor because she
felt too off balance to stand, and eventually around 6AM her
husband found her and helped her back to bed. She slept for a
few hours, and then tried to get up to go to the bathroom with
the aid of a walker, but fell again. At this point he called
EMS and she was transferred to [**Hospital3 **].
At [**First Name11 (Name Pattern1) 46**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) 430**] CT was performed, and was read as 3 cm density
in the L cerebellar hemisphere with surrounding edema, shift of
the 4th ventricle on the R, and partial effacement of hte
paramesencephalic cistern at the level of the pons on the left.
She was admitted for a metastatic work up for brain mass and
started on Decadron 4 mg Q6 given concern for mass effect. A CT
Torso was performed and showed several tiny pulmonary nodules on
the right and an adrenal nodule on the left. CEs were monitored
and were elevated (peaked at 4.33, normal range 0.0-0.04, on [**2-3**]
at 2100, then trended down) and she was seen by Cardiology, who
recommended medical management. She was seen by Neurosurgery
there on [**2-5**], and their exam was significant for intact
strength and normal cranial nerve exam and L sided dysmetria.
They recommended MRI head for further work up. MRI was
performed today (delayed [**1-27**] pt. claustrophobia, required open
MRI at Shields), and was read as a 3 cm area of restricted
diffusion in the L cerebellum with mass effect on the 4th and
medulla, more c/w acute to subacute infarct. Decadron was
d/ced. She was seen by Neurology there this morning, and they
reviewed her MRI.
Their exam was similar to Neurosurgery's exam, and showed intact
strength and cranial nerves and L sided dysmetria. She was
transferred to [**Hospital1 18**] given concern for mass effect on the
brainstem.
Symptomatically she reports that she has continued to feel
nauseated but has not thrown up since Friday. Today, around the
time she was examined by Neurology, she noticed some
intermittent vertical diplopia (although she did not have
diplopia on their exam). She denies any numbness or weakness.
She feels very clumsy on her left side and has been unable to
walk without assistance. She feels that her speech is still
slurred, but denies any problems with word finding or
comprehension. No dysphagia. No change in bowel or bladder
movements. She has had a pounding bitemporal headache on and
off since Friday (has one now) which is similar to her normal
migraine headaches.
Past Medical History:
CAD, s/p CABG x 3, mult caths and stenting procedures, many
angina admissions, EF >=60% on echo from [**2-27**]; most recent
stenting in [**12/2146**]
DM2-insulin dependent with neuropathy
COPD
obesity
hyperlipidemia
HTN
anemia of chronic disease followed by a hematologist
GERD
Diverticulitis
OSA
chronic migraine headaches
chronic pain/arthritis
depression
anxiety
s/p appy, s/p ccy
benign bladder tumor
Social History:
Lives at home with husband. children are grown. No tobacco
currently (10 PY history), no alcohol, no recreational drugs.
Used to work as sales clerk. On disability since CABG in [**2140**].
Family History:
Mother deceased at 69 with diabetes, renal failure, and one MI
in 50s. Father deceased at 57 from alcoholic liver disease, had
1st MI at 52. No family history of stroke or migraines.
Physical Exam:
On admission:
T- 96.4 BP- 149/80 HR- 62 RR- 9 O2Sat- 100% on 3L
Gen: Lying in bed, NAD, obese
HEENT: NC/AT, moist oral mucosa
Neck: No tenderness to palpation, normal ROM, supple, no carotid
bruit
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema
Neurologic examination:
Mental status: Awake and alert, cooperative with exam, normal
affect. Oriented to person, place, and date. Attentive, says
[**Doctor Last Name 1841**] backwards. Speech is fluent with normal comprehension and
repetition; naming intact. Mild dysarthria but speech easily
understandable. Registers [**2-25**], recalls [**2-25**] in 5 minutes. No
right left confusion. No evidence of apraxia or neglect.
Cranial Nerves:
Pupils equally round and reactive to light, 4 to 2 mm
bilaterally. Visual fields are full to confrontation.
Extraocular movements intact bilaterally, no nystagmus. Some
horizontal diplopia at midline, worse with left gaze, better
with right gaze. Sensation intact V1- V3. Facial movement
symmetric. Hearing intact to finger rub bilaterally. Palate
elevation symmetrical. Sternocleidomastoid and trapezius normal
bilaterally. Tongue midline, movements intact
Motor:
Normal bulk bilaterally. Tone normal. No observed myoclonus or
tremor. L arm bobs with testing for drift.
[**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IP H Q DF PF TE TF
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
L 4+ 4 4+ 5 5- 4+ 5 4+ 4 5 5 5 5 5
Sensation: Intact to light touch and pinprick throughout,
decreased to vibration and proprioception to ankles. No
extinction to DSS
Reflexes:
Trace in patella and achilles bilaterally. 1+ in biceps and
triceps and BR bilaterally. Toes mute bilaterally
Coordination: marked dysmetria on FNF on left, intact on R
Gait: not assessed
On discharge:
Mental status: intact
Cranial nerves: minimal nystagmus on left, right, and upgaze.
Numbness in right face sparing medial cheek, with paresthesias
worst in the right ear.
Motor: strength full bilaterally.
Sensation: intact
Reflexes: as above
Coordination: improved, with mild dysmetria on left
Gait: steady, narrow based, with walker.
Pertinent Results:
OSH labs from [**2-15**]:
WBC 12.7 Hct 39.1 Plt 162 Hgb 12.9 Na 134 K 4.7 Cl 99 HCO3 23
BUN 26 Cr 0.9 Glucose 317
Imaging:
Head CT from OSH:
- new 3 cm area of density within the left cerebellar hemisphere
with surrounding edema with mass effect and shift of the 4th
ventricle to hte R of midline and partial effaceemtn of the
paramesencephalic cisterns at the level of the pons
- 3rd and lateral ventricles symmetric and not enlarged
MRI from OSH (per Neurology consult note):
- 3 cm area of restricted diffusion in the L cerebellum with
mass effect on the 4th and medulla, more c/w acute to subacute
infarct (no report available)
Head CT noncontrast [**2147-2-7**]: A large area of hypodensity
centered in the right cerebellum measuring approximately 47 x 46
mm, with a laterally centered region of higher density measuring
28 x 32 mm is seen, probably representing the known left
cerebellar infarct. This infarct has mass effect on the
midbrain and superior medulla, with compression of the fourth
ventricle rightward. The vermis is displaced rightward,
approximately 7 mm. The cerebellopontine angle cistern and
superior medullary cisterns are effaced.
The lateral ventricles are more prominent than they were in the
[**2145-3-18**] CT scan, concerning for noncommunicating
hydrocephalus. There is no evidence of transependymal edema.
Hypodensities in both corona radiata, especially surrounding the
frontal lobes and in the subinsular white matter on the left
indicate chronic microvascular changes. Imaged sinuses are
clear. No fractures are seen.
IMPRESSION: Left cerebellar edema causing compression and
rightward shift of fourth ventricle and effacement of posterior
fossa cisterns.
MRI/MRA with contrast brain [**2147-2-7**]:
FINDINGS: MR HEAD: Within the left cerebellar hemisphere, there
is a large rounded lesion measuring approximately 3 cm in
greatest diameter, which is heterogeneous in signal on T2 and
slightly hyperintense on T1 weighted images. There is
susceptibility artifact noted on the gradient-echo sequence. On
the post- gadolinium images, there is mild peripheral
enhancement identified. There is T2 hyperintensity surrounding
the lesion extending into the superior aspect of the cerebellum,
consistent with surrounding edema. The lesion is hyperintense on
diffusion-weighted images, which could be due to the blood
products. This lesion could represent a subacute infarct with
hemorrhagic transformation. However, an underlying hemorrhagic
mass cannot be entirely excluded, although the clinical history
includes vascular risk factors predisposing to infarction of the
brain. A follow-up study in several weeks to determine lesion
evolution may be helpful in distinguishing these entities.
There is a ventricular shunt catheter which enters through the
right frontal region and terminates in the region of the right
foramen of [**Last Name (un) 2044**]. There is no evidence of hydrocephalus. There
are scattered areas of T2 hyperintensity within the cerebral
periventricular white matter that were present on the prior
study and are not changed, consistent with chronic small vessel
infarction.
MRA HEAD: There is termination of the right vertebral artery as
a right posterior inferior cerebellar atery. The anterior and
posterior intracranial circulations are otherwise normal. There
is no evidence of aneurysm greater than 3 mm or focal stenosis.
No AV malformations are noted.
MRA NECK: The left vertebral artery is dominant. The right
vertebral artery terminates as a posterior inferior cerebellar
artery . The carotid arterial systems are normal. There is no
evidence of stenosis.
IMPRESSION:
1. Large area of hemorrhage in the left cerebellar hemisphere
2. Unremarkable MR angiogram of the head/neck.
Head CT Noncontrast:
FINDINGS: Since the prior CT examination, there has been
interval placement of a right ventricular shunt catheter with
its tip terminating in the region of the foramen of [**Last Name (un) 2044**] on the
right. The ventricles have decreased in size as compared to the
prior CT scan.
As before, there is a large area of hypodensity within the left
cerebellar
hemisphere with a slightly more dense structure centered within
the area of hypodensity. This lesion could represent an area of
infarction with
hemorrhagic transformation. However, underlying hemorrhagic
lesion cannot be entirely excluded. There is mass effect with
rightward displacement of the cerebellar vermis as well as
compression of the fourth ventricle. There is also effacement
of the cerebellopontine angle cisterns. There is no new
intracranial hemorrhage. There is no shift of the normally
midline
structures.
IMPRESSION:
1. No change from [**2147-2-7**] scan, regarding the left cerebellar
hemisphere lesion which may represent a subacute infarct with
hemorrhagic transformation. However, underlying hemorrhagic mass
cannot be entirely excluded. Nevertheless, given the history of
diabetes, hypertension, and severe cardiac disease, cerebellar
infarction would seem a reasonable diagnostic consideration.
Additionally, a prior MR study from [**2145-2-26**] disclosed two chronic
lacunar infarcts within the inferior aspect of the left
cerebellar hemisphere, suggesting prior vascular disease in some
proximity to the new, much larger lesion.
2. Interval placement of ventricular shunt catheter, with
decompression of the ventricular system.
HCT [**2-15**]:
Since [**2147-2-8**], there has been improvement in the
amount of mass effect within the left cerebellar hemisphere with
less mass effect upon the fourth ventricle.
Status post removal of the right frontal ventriculostomy
catheter with unchanged configuration of the lateral ventricles.
There is still a possibility of mild hydrocephalus as the
frontal horns of the lateral ventricles remain rounded, in
contrast to the [**2-8**] study.
Brief Hospital Course:
Impression: 53 y/o with a long-standing history of CAD s/p CABG
x 3 and multiple stenting procedures (last [**12/2146**]), HTN, DM,
Hyperlipidemia, obesity, who presented with a 3 cm L cerebellar
infarct and concern for mass effect and pressure on the medulla.
Hospital course is reviewed below by system:
NEURO: Ms. [**Known lastname 1662**] was admitted to NeuroICU service. By history
the infarct most likely occurred on early Friday, [**2-3**] (4 days
PTA). Exam was significant for marked L sided dysmetria,
diplopia on L gaze but full EOM and mild L hemiparesis, which
was not seen by Neurology at OSH. Stat head CT was performed
which showed left cerebellar edema causing compression and
rightward shift of fourth ventricle and effacement of posterior
fossa cisterns. Given the new deficits found on neuro exam and
neuroimaging results, the patient was taken emergently to the OR
for placement of an external ventricular drain. She was given
50mg IV mannitol, 10mg IV Decadron and 6 bags of platelets due
to ASA and Plavix inactivation. Cardiology was consulted prior
to procedure for evaluation of risk factors and management of
anti-platelet medications peri-operatively. The EVD was placed
in the OR without complications.
As patient did not tolerated MRI, she was taken post-operatively
while intubated and sedated for MRI of brain and neck which was
suggestive of either a subacute infarct with hemorrhagic
transformation or an underlying hemorrhagic mass. The
ventricular shunt catheter entered through the right frontal
region and terminated in the region of the right foramen of
[**Last Name (un) 2044**]. There was periventricular chronic small vessel
infarction without evidence of hydrocephalus. MRA revealed a
dominant left vertebral artery and right vertebral artery
terminating as a right posterior inferior cerebellar atery.
Carotids were normal. There was no evidence of stenosis,
aneurysm or AV malformation. A follow-up study in several weeks
to determine lesion evolution was recommended.
Sedating medications were held, including Xanax and Ambien.
Topamax and Effexor were continued for migraine prophylaxis.
She was continued on neurontin per home regimen for chronic pain
and arthritis; oxycontin was changed to fentanyl and dilaudid.
Ms. [**Known lastname 1662**] improved clinically through her hospital course. On
[**2-10**], she had sudden onset of headache, followed by R face
numbness (top of head to ear to right face, sparing chin),
followed by moving diagonal lines across her vision. A repeat
head CT was unchanged. The facial numbness was persistent on
discharge and thought to be due to irritation from the EVD
intervention.
The EVD remained in until [**2-14**]; a repeat head CT was performed
after removal and was stable, reviewed by neurosurgery. Mannitol
was discontinued on [**2-13**]. Decadron was tapered and discontinued
just prior to discharge. Aspirin and plavix were restarted on
[**2-15**]. She will follow up with neurosurgery for further
evaluation of the cerebellar lesion (infarct vs mass), as well
as in neurology clinic.
CV: ASA and Plavix were held throughout the hospitalization
while the EVD was in place. Her statin was restarted. BP was
initially allowed to autoregulate to maximize cerebral
perfusion, though Metoprolol and Isordil were continued given
her history of severe CAD. Her BP and HR were optimized with HR
in the 60s and SBP generally <120.
PULM: She has a history of COPD and sleep apnea. She is on home
O2. She was electively intubated for EVD placement on [**2-7**] and
was subsequently extubated on [**2-8**] without complication. She
was stable on 3L NC (her home dose).
ID: Patient was continued on Cefazolin IV until EVD was
discontinued. She was clinically diagnosed with a UTI and was
treated with ciprofloxacin x 3 day course. A urinalysis was
negative.
ENDO: Patient was on insulin drip while in the ICU and was
switched to fixed dose glargine then NPH once transferred out of
the ICU. She was also covered with ISS. As the decadron was
weaned off prior to discharge, she was discharged on her home
insulin regimen.
FEN: Patient was hyponatremic Na 128-130 and received 500cc
hypertonic saline with good correction. Urine Na and Osm were
checked to evaluate for SIADH. Serum osm ranged 300 or less.
She was fluid restricted while hyponatremic with good response;
this was loosened as the mannitol was weaned off and she was
normonatremic at discharge.
Medications on Admission:
Home Meds (from OSH records)
Aspirin 325 mg PO DAILY, Xanax 1 mg [**Hospital1 **] (8A and 12P), Ca
Carbonate, Clopidogrel 75 mg PO DAILY, Venlafaxine 225 mg QD,
Atorvastatin 40 mg PO HS, Zolpidem 10 mg PO HS, Metoprolol
Tartrate 50 QD, Isordil 40 TID, Topiramate 75 mg PO BID,
Pantoprazole 40 mg [**Hospital1 **], Gabapentin 600 [**Hospital1 **] (8A and 12P),
Oxycontin 60 mg TID
Docusate Sodium 100 mg PO BID, Actos 30 mg PO once a day, Lantus
42 units QHS
Diltiazem HCl 120 PO DAILY, Naproxen 500 mg PO BID NTG PRN chest
pain, Miralax 17 g daily PRN, Humalog sliding scale
Meds on Transfer
Aspirin 325 mg PO DAILY, Xanax 1 mg Q6H, Dexamethasone 4 mg PO
Q6H, Ca Carbonate, Clopidogrel 75 mg PO DAILY, Venlafaxine 225
mg QD, Atorvastatin 40 mg PO HS, Zolpidem 10 mg PO HS,
Metoprolol Tartrate 50 QD, Isordil 40 TID
Topiramate 75 mg PO BID, Pantoprazole 40 mg [**Hospital1 **], Gabapentin 600
[**Hospital1 **] (8A and 12P)
Oxycontin 60 mg TID, Docusate Sodium 100 mg PO BID, Actos 30 mg
PO once a day, Lantus 21 units QHS HISS, Diltiazem HCl 120 PO
DAILY, Naproxen 500 mg PO BID
NTG PRN chest pain, Ondansetron 4 mg IV Q4H PRN nausea, Humalog
sliding scale
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Calcium Carbonate Oral
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Venlafaxine 75 mg Capsule, Sust. Release 24HR Sig: Three (3)
Capsule, Sust. Release 24HR PO DAILY (Daily).
5. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*135 Tablet(s)* Refills:*0*
7. Isosorbide Dinitrate 20 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
8. Topiramate 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*0*
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
10. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO Q6H (every
6 hours).
Disp:*240 Capsule(s)* Refills:*0*
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
13. Actos 30 mg Tablet Sig: One (1) Tablet PO once a day.
14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
15. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 2 doses.
Disp:*2 Tablet(s)* Refills:*0*
16. Humalog Subcutaneous
17. Lantus 100 unit/mL Cartridge Sig: Forty Two (42) units
Subcutaneous at bedtime.
18. Fentanyl 100 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
Disp:*10 Patch 72HR(s)* Refills:*0*
19. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
20. MRI
MRI head with and without contrast to evaluate cerebellar lesion
seen on MR [**2-7**] (?infarct vs mass)
Please send report to Dr. [**First Name (STitle) **] ([**Telephone/Fax (1) 2574**]) and Dr. [**Last Name (STitle) **]
(617-63-BRAIN).
Discharge Disposition:
Home With Service
Facility:
VNA Assoc. of [**Hospital3 **]
Discharge Diagnosis:
Left cerebellar lesion, likely infarct
Hyponatremia
Coronary artery disease
Hypertension
Diabetes mellitus
Urinary tract infection
Discharge Condition:
Stable. Improving examination with mild left sided dysmetria,
nystagmus, and baseline gait. No chest pain or dyspnea.
Discharge Instructions:
Take all medications as prescribed.
Follow up with Dr. [**Last Name (STitle) 5311**] and Dr. [**First Name (STitle) **] as scheduled. Call
63-BRAIN to make an appointment with Dr. [**Last Name (STitle) **] in 4 weeks.
Please get your MRI performed in 3 weeks. Bring copies of the
MRI to your appointments.
Call your doctor or go to the emergency room if you have any
worsening of your walking, speaking, or hand incoordination, or
if you have any new symptoms, including weakness, numbness, loss
of consciousness, visual problems, chest pain, difficulty
breathing, nausea, vomiting, or any other concerning symptoms.
Followup Instructions:
Please call Dr. [**Last Name (STitle) 5311**] ([**Telephone/Fax (1) 5317**]) to follow up in the next
week.
Get your MRI performed in 3 weeks and bring the results to your
appointments with Dr. [**Last Name (STitle) **] and Dr. [**First Name (STitle) **].
Please call Dr.[**Name (NI) 9034**] office (617-63-BRAIN) to make a follow
up appointment for 3-4 weeks from now.
Follow up in the neurology clinic:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2147-3-20**] 3:00
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
ICD9 Codes: 431, 5990, 2761, 496, 3572, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3785
} | Medical Text: Admission Date: [**2126-11-14**] Discharge Date: [**2126-11-25**]
Date of Birth: Sex:
Service:
CHIEF COMPLAINT: Right sided weakness.
HISTORY OF PRESENT ILLNESS: This is an 84 year old lady with
a past medical history of hypertension and dementia, who
presents to the Emergency Room for evaluation of fall. She
was in her usual state of health today except for fatigue,
when she fell in her bedroom. Her son went into the room,
finding her on the floor with a large bruise on the right
side of her face. She was slurring her speech and not making
sense but her son does not remember anything about her limb
movements. She became progressively more sleepy. EMS was
notified and she was brought to an outside Emergency Room for
further evaluation. Because that Emergency Room did not have
a functioning CT scanner, she was sent to [**Hospital1 346**] for further work-up.
Her systolic blood pressure upon arrival was 268. While in
the Emergency Room, the neurology resident witnessed two
episodes of focal shaking of her arms, lasting 30 seconds and
resolving spontaneously.
PAST MEDICAL HISTORY: Hypertension. Dementia.
MEDICATIONS:
Captopril 25 mg p.o. twice a day.
Evista 60 mg p.o. q. week.
Wellbutrin 150 mg p.o. q. day.
Dyazide 37.5/25 one tablet p.o. q. day.
Aspirin 81 mg p.o. q. day.
Colace.
Multi-vitamin.
Caltrate 600 mg p.o. twice a day.
Xalatan eye drops.
ALLERGIES: Penicillin.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: The patient lives with her son. She walks
with a cane/walker. She is independent in her activities of
daily living. There is no history of tobacco, alcohol or
drug use.
PHYSICAL EXAMINATION: Upon admission, temperature was 97.4;
pulse 98; blood pressure 233/91; respiratory rate 15; 100% on
room air. General: Uncommunicative elderly woman, lying in
bed, looking towards the left. HEAD, EYES, EARS, NOSE AND
THROAT shows right facial hematoma. Lungs are clear to
auscultation bilaterally. Cardiovascular: Regular rate and
rhythm. No murmurs, rubs or gallops noted. Abdomen soft,
nontender, nondistended. Normoactive bowel sounds.
Extremities: 2+ pulses with no edema. Neurologic
examination: She is awake but not following commands. She
does not attempt to speak. She is uncooperative with
examiner. She would not let the examiner assess pupils or
extraocular movements; however, a left gaze preference was
noted. The right side withdraws less to painful stimuli than
the left side. Her reflexes were brisk throughout. Her toes
were upgoing bilaterally.
LABORATORY DATA: White count of 11.9; hematocrit of 39.1;
platelets 313. Sodium of 135; potassium of 4.1; chloride
102; bicarbonate 24; BUN 15; creatinine 0.8; glucose 164; ALT
20; AST 17; alkaline phosphatase 73; total bilirubin 0.1.
Amylase 98; lipase 41.
Non contrast head CT showed left thalamic hemorrhage,
measuring about 2.5 by 2.5 by 3 cm with white midline shift.
There is a large amount of periventricular white matter
disease and generalized atrophy.
HOSPITAL COURSE: Neurology: Left thalamic bleed. Given the
patient's hemorrhage, INR was checked and found to be normal
at 1.0. She did not require any blood products to correct
her INR. She was put on Dilantin for seizure prophylaxis.
Corrected Dilantin level was quite high, despite being on
Dilantin 100 mg p.o. three times a day so free Dilantin was
checked and found to be at 2. Given that this level is at
the upper end of normal, her Dilantin was decreased to 100 mg
twice a day. A Dilantin level was checked on [**2126-11-25**] but is
still pending. Her blood pressure was controlled with
Labetalol and Captopril during her hospitalization. She was
ruled out for a myocardial infarction which may have led to
this bleed.
Infectious disease: Urinary tract infection. The patient
had an elevated white count that was unaccounted for. A
urine culture was obtained showing Proteus mirabilis which
was sensitive to Cefuroxime. She was placed on the
cephalosporins for seven days and her urinalysis cleared
along with a white count that decreased. She had no
intravenous access so a central line was left in place. Blood
cultures were obtained from the central line and only showed
contaminant with staph coagulase negative organisms. A
Clostridium difficile toxin was checked and was found to be
negative.
Congestive heart failure: The patient's sodium was noted to
decrease from 135 upon admission to 128. A chest x-ray was
obtained showing no evidence of pneumonia but did show
congestive heart failure. The patient was diuresed and her
sodium came back up. However, she was diuresed a little bit
too far given the rising BUN so she was gently replenished
with free water boluses through her nasogastric tube.
Gastroenterology: The patient had a nasogastric tube placed
for nutrition but it was thought that the percutaneous
endoscopic gastrostomy would be needed to replace the
temporary nasogastric tube. The son will decide on whether a
percutaneous endoscopic gastrostomy would be called for. The
rest of the dictation will be dictated by Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 16188**].
DR.[**Last Name (STitle) **],[**First Name3 (LF) 4224**] 13-303
Dictated By:[**Last Name (NamePattern1) 4270**]
MEDQUIST36
D: [**2126-11-25**] 11:12
T: [**2126-11-26**] 04:24
JOB#: [**Job Number 98215**]
ICD9 Codes: 431, 5990, 4280, 2761, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3786
} | Medical Text: Admission Date: [**2145-12-28**] Discharge Date: [**2146-1-6**]
Date of Birth: [**2068-10-11**] Sex: M
Service: NEUROLOGY
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 2090**]
Chief Complaint:
bilateral ophthalmoplegia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
77 yo man with Alzheimer's disease, myelodysplastic syndrome
and papilledema admitted [**2145-12-28**] with diplopia. Neurology was
consulted regarding bilateral ophthalmoplegia.
Patient was being seen by ophthalmology starting [**2145-11-23**] for
papilledema, OU. LP was done in [**2145-12-7**] to rule out increased IC
pressure. LP results then showed Total Protein, CSF 66* mg/dL,
WBC 1, and OP 145 mm H20. MRI performed showed chronic left
parietal stroke and no mass lesion. Patient went to Aruba with
his wife. On [**2145-12-22**], patient was diagnosed with bronchitis in
Aruba, presenting with nonproductive cough, no fever, no nausea
and vomiting, no other complaints. Patient was given Zithromax x
5 days.
6 days PTA, patient complained of diplopia, both eyes, even when
either one is covered, persistent, worse on downward gaze but
present in all directions. His wife also noted a progressive
change in the quality of his voice, which was becoming more
nasal
and generalized weakness more on the lower extremities but also
involving the face. He also reported numbness and tingling at
his
fingertips. He was brought to a hospital in Aruba but diagnosis
was not made. Patient flew back home with his wife for
assessment
and management of symptoms. 1 day PTA, patient fell on his right
side while walking to the bathroom. No loss of consciousness. No
convulsive activity. Laceration noted left eyebrow with multiple
hematomas and ecchymoses more on the left. He was then brought
to
[**Hospital1 18**] for admission. Day after admission, bilateral
ophthalmoplegia noted.
PMH:
Alzheimer's Disease
MDS
Papilledema
Past Medical History:
Alzheimer's Disease
MDS
Papilledema
Social History:
Deferred
Family History:
Noncontributory.
Physical Exam:
VS: 97.9 / 103/56 / 18 / 94% RA
GEN: Multiple bruises to L eye/face, L side of body, fatigued,
not speaking
HEENT: JVD flat, no LAD, OP clear, muscle weakness around mouth
LUNGS: CTA B
HEART: RRR, no m/r/g
ABD: NABS. Soft, NT, ND. No HSM
EXT: WWP, NO CCE. 2+ DP pulses BL
SKIN: No rashes/lesions, ecchymoses.
NEURO: CN 3-6, [**8-15**] abnormal, ophthalmoplegia. Gait not tested.
0-1+ reflexes.
SKIN: Hematomas throughout, esp L side of body
Pertinent Results:
MR head:
1. No evidence of acute infarction.
2. Unremarkable MRA and MRI of the internal auditory canals.
Brief Hospital Course:
The patient was admitted to the oncology service after a fall
and opthalmoplegia noted. Neurology was consulted and made the
diagnosis of [**Doctor First Name **]-[**Doctor Last Name **] variant of guillain-[**Location (un) **] syndrome
(acute inflammatory demyelinating polyneuropathy) and the
patient was transferred to the neurology service and treated
with a 5-day course of IVIG. He recovered swallowing function
and was able to eat. He recovered some up and downgaze by the
time of discharge.
At present, he remains areflexic. Ataxia on finger-to-nose is
slight now.
Hematology was consulted during his hospital stay regarding his
cell counts, particularly his decreaesing platelets. They felt
his MDS was stable and platelets were decreasing due to
heparin-induced thrombocytopenia, as his titers were borderline
positive. HE SHOULD THEREFORE NOT RECEIVE HEPARIN PRODUCTS -
THIS WILL REQUIRE VIGILANT CARE TO PREVENT DVT'S BY OTHER MEANS
(boots, exercises, etc).
Heparin products were discontinued. The condition carries a 50%
risk in the first month of clots anywere (from DVT/PE, MI,
stroke, etc). However, given his fall risk due to severe
dementia, and dysfunctional platelets due to MDS, and given the
borderline positivity, anticoagulation with argatroban/coumadin
was deferred, as the risk of bleeding was considered
substantial.
Course was also complicated by hypernatremia, thought to be due
to decreased hydration. He was put on IVF with subsequent
improvement.
Neurologically, it remains to be seen how much more improvement
is to be expected, as this variant of GBS does not improve as
reliably. He should be monitored for signs of urinary retention
and constipation. At baseline, he is severely demented but
pleasant - he requires his wife's assistance for ADLs. Neuro
exam shows slight up and down gaze, reactive pupils, areflexia
and slight ataxia on finger-to-nose, in addition to the expected
mental status findings given his dementia.
He will be seen as an outpatient urology - we recommend avoiding
anticholinergics if possible, for fear of worsening dementia.
Medications on Admission:
TraMADOL (Ultram) 50 mg PO Q4-6H:PRN pain
Acetaminophen 325-650 mg PO Q4-6H:PRN
Danazol 200 mg PO TID
PredniSONE 20 mg PO DAILY
FoLIC Acid 1 mg PO DAILY
Famotidine 20 mg PO BID
Heparin 5000 UNIT SC TID
Discharge Medications:
1. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Danazol 200 mg Capsule Sig: One (1) Capsule PO TID (3 times a
day).
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q12 () as needed
for pain.
7. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
8. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): Sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
[**Doctor First Name 1557**]-[**Doctor Last Name **] variant of guillain-[**Location (un) **] syndrome
Probable alzheimer dementia
myelodysplasia syndrome (anemia, thrombocytopenia)
Discharge Condition:
Improved
Discharge Instructions:
Please continue to take all medications as planned.
Followup Instructions:
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 65792**], MD Phone:[**Telephone/Fax (1) 1690**]
Date/Time:[**2146-1-14**] 8:30
Provider: [**Name10 (NameIs) 6131**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2146-2-1**]
8:30
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43**] MD [**MD Number(1) 2107**]
Completed by:[**2146-1-6**]
ICD9 Codes: 2760 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3787
} | Medical Text: Admission Date: [**2136-7-15**] Discharge Date: [**2136-7-15**]
Date of Birth: [**2058-6-25**] Sex:
Service: CCU
HISTORY OF PRESENT ILLNESS: The patient is a 78-year-old
female transferred directly to the [**Hospital1 18**] CCU from the
[**Hospital 26200**] Hospital for possible further evaluation and
treatment of shock. The patient was admitted to [**Hospital1 **]-
[**Last Name (un) 4068**] on [**7-14**] with two weeks' history of malaise,
dizziness, fatigue at [**Location (un) 1036**]. Her systolic blood
pressure was reportedly in the 70s. The patient complained
of feeling "hot" to family.
REVIEW OF SYSTEMS: Her review of systems is negative for
fevers, nausea, vomiting, diarrhea, skin changes. Of note,
the patient was recently admitted to [**Hospital3 20445**] on [**2136-7-2**] for lower extremity cellulitis with
cultures positive for pansensitive Pseudomonas, was just
treated with ciprofloxacin and Zosyn. The course was
complicated by Clostridium difficile, for which the patient
was treated with Flagyl as well as acute renal failure, which
was attributed to mild ATN and prerenal azotemia. On
[**2136-7-12**], the patient was noted to have bandemia and elevated
BNP. The patient was treated with dopamine, ceftriaxone,
vancomycin, levofloxacin, Flagyl but became progressively
hypertensive and dyspneic despite Levophed, dobutamine,
BiPAP. Therefore, the patient was transferred here to [**Hospital1 18**]
for further evaluation.
ALLERGIES: SULFA, unknown reaction; ASPIRIN, possible
reaction with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] disease.
MEDICATIONS ON TRANSFER FROM [**Hospital1 **]:
1. Dopamine 2.5 mcg/kg/minute.
2. Vancomycin.
3. Ceftriaxone.
4. Remeron.
5. Vitamin C.
6. Protonix.
7. Zinc.
8. Zyprexa.
9. Multivitamin.
10. Lasix.
11. Levofloxacin.
12. Flagyl.
PAST MEDICAL HISTORY: Right ventricular heart failure
secondary to anthracycline toxicity.
CLL with transformation to B-cell large lymphoma.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] disease.
Mitral valve prolapse.
Acute renal failure.
Status post appendectomy.
Status post cholecystectomy.
SOCIAL HISTORY: The patient denies cigarettes or alcohol.
She lives at [**Hospital 1036**] Nursing Home.
REVIEW OF SYSTEMS ON TRANSFER TO [**Hospital1 18**]: Her constitutional
symptoms were abnormal. She was short of breath. She had
abdominal pain. She denied chest pain. She complained of
dyspnea on exertion. She complained of dyspnea with lying
flat and orthopnea, and complained of edema.
PHYSICAL EXAMINATION: General: She was somnolent but
arousable, cachetic and frail, in no apparent distress. She
appeared comfortable with diffuse anasarca. Vital signs: On
admission her temperature was 98.2 degrees p.o. Her blood
pressure was 89/50, respiratory rate was 14, oxygen
saturation was 84 percent on nonrebreather at the outside
hospital. We are unable to obtain her oxygen saturation by
seeing their oximetry. Urine output had been zero since
midnight. HEENT: Temporal wasting. Sclerae anicteric.
Pupils equal, round and reactive to light and accommodation.
Extraocular muscles were intact bilaterally. Mucous
membranes were dry. Oropharynx was clear. Neck: Her neck
was supple. Her JVP was 7-8J cm at 45 degrees. Chest: With
diminished breath sounds in anterior lower one half of her
lung fields bilaterally with no rales bilaterally. She had
poor aeration overall. Cardiovascular: Irregular regular
rate in 120s with normal S1, S2 with no audible murmur, rubs
or gallop. Abdomen: With diffuse anasarca with pitting
edema in the back and abdomen. Normal bowel sounds
auscultated. Abdomen was nontender, nondistended, no masses
were appreciable. Extremities: Lower extremity ulcers at
shins bilaterally with granulomatous tissue with some
surrounding erythema. No oozing, 2+ pitting edema. Cool,
dry, 1+ radial pulse bilaterally. Neurologic: Oriented to
self and year, not to location or day. She followed some
commands, answers occasional questions. Cranial nerves II to
XII are intact bilaterally. No focal deficits.
RADIOGRAPHIC STUDIES: EKG on [**2136-7-15**] at 4 a.m. showed a
rate of 118 beats per minute, regular, without obvious P
waves, QRS 100 msec, question severe right axis deviation
versus left axis deviation, possible lead reversal. Her
chest x-ray preliminary showed bilateral pleural effusions
consistent with CHF. Her KUB showed anasarca, no bowel gas.
LABORATORY DATA: ABG obtained after multiple attempts,
7.16/49/199/18. Her CK was 18, troponin
0.08. Chem-7, sodium 146, potassium 5.1, chloride 114, BUN
19, chloride 93, creatinine 3.7 and glucose of 124. White
cell count 5.1, hematocrit 35.4, platelets of 38, MCV 111, 91
percent neutrophils, 5 percent lymphocyte, no bands.
ASSESSMENT: A 78-year-old female who was transferred from
outside hospital at 4 a.m. with hypertension, hypoxia,
tachycardia, anasarca in the setting of CLL, anthracycline-
induced cardiomyopathy, recent lower extremity pseudomonal
infection, recent Clostridium difficile infection, acute
renal failure, pulmonary edema, bilateral pleural effusions,
thrombocytopenia, elevated INR of 1.6.
HOSPITAL COURSE: This patient appeared on transfer to be in
shock likely secondary to sepsis in origin though also
possibility of cardiogenic shock as well. In any case, the
patient clearly was in multiorgan system failure despite
pressors and broad spectrum antibiotics, and her prognosis at
the time of transfer appeared grim. Discussion was held
regarding mutuality of a pulmonary artery catheter with
possible intubation that might alter her case; however, it
seemed unlikely that a PA catheter would add information
which would be able to alter the patient's course.
Furthermore given her significant comorbidities, it appeared
the patient would likely not tolerate intubation. The
patient was initially treated with vasopressin and Levophed
as well as the broad spectrum antibiotics started at
[**Hospital1 26200**]. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and [**Name6 (MD) 714**]
the RN in the CCU, spoke at length with the
patient's daughter, son-in-law, and son for greater than an
hour about the patient's grim prognosis. Dr. [**First Name (STitle) **] offered
the family the option of aggressive measures including a
pulmonary artery catheter and possible intubation noting that
they might afford some benefit. Dr. [**First Name (STitle) **] also informed
them of the many significant problems facing the patient and
her overall prognosis. Ultimately, in light of the multiple
problems facing the patient and her grim prognosis, the
family, specifically the patient's son and daughter felt that
the patient would want to be comfort measures only in this
situation. At this point, Dr. [**Last Name (STitle) **], the attending, was
notified and the patient was made comfort measures only. By
11 a.m. on [**2136-7-15**], the patient was pronounced dead.
Telemetry monitor showed asystole and physical exam revealed
pupils, which are fixed and dilated without heart sounds,
respirations on auscultation for greater than 2 minutes. The
patient was pronounced at 10:35 a.m. The family including
the daughter [**Name (NI) **] and the son [**Name (NI) **] were present. The family
declined postmortem examination, and she was also waived by
the medical examiner.
[**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **], M.D. [**MD Number(2) 2139**]
Dictated By:[**Last Name (NamePattern1) 10641**]
MEDQUIST36
D: [**2136-10-25**] 12:04:42
T: [**2136-10-27**] 09:41:54
Job#: [**Job Number **]
ICD9 Codes: 0389, 4280, 5185, 4254 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3788
} | Medical Text: Admission Date: [**2108-12-21**] Discharge Date: [**2109-1-2**]
Date of Birth: [**2062-1-2**] Sex: F
Service: MEDICINE
Allergies:
Tetracycline / Penicillins / Sulfa (Sulfonamide Antibiotics) /
Clindamycin / Cephalosporins / Macrolide Antibiotics
Attending:[**Doctor First Name 2080**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
lumbar puncture
History of Present Illness:
Ms. [**Known lastname 78131**] is a 46 [**Hospital **] transferred from [**Hospital **] [**Hospital 1459**]
Hospital on [**2108-12-20**] with suspected bacterial meningitis. She
initially presented to [**Hospital3 1443**] two mornings ago with
severe HA & N/V of ~12 hours duration. Head CT was negative, she
denied F/C, and she was discharged on medications for headache.
Twelve hours after discharge to home, she was found altered and
agitated at home by her mother, who brought her to [**Name (NI) **]
[**Name (NI) 1459**]. There she had a temp of 102, WBC 27, negative head CT
and CSF c/w bacterial meningitis (Tueb 1 3400 WBC; Tube 4 WBC
7000, 90% poly, gm stain mod WBC, few GPC). She was intubated
for airway protection with etomodate & succinate and was given
vanco 500 mg & chloramphenicol 1 g (given broad allergy mix). A
right IJ was placed.
Upon arrival to the ED here, she had T 100.6, BP 136/81, HR 127,
AC 100%. She was sedated on fentanyl and midazolam. She was
given decadron 10 mg IV as well as vanco 500 mg (for a total of
1 g), ampicillin, ceftriaxone and acyclovir. (The family
explained that her allergy to the [**Name (NI) 621**] was just rash and she
could be challenged on [**Last Name (LF) 621**], [**First Name3 (LF) **] ID.) She was given ~5L between
our ED and OSH.
Past Medical History:
Brain aneurysm s/p coiling (vs. surgery?) at [**Hospital1 112**], 1st surgery
[**2103-4-30**] followed by a 2nd surgery [**2103-9-3**].
Tubal Ligation
DMII/PCOS
Social History:
Drinks "one a night"
Former heavy smoker - quit in [**2103**]. [**2-21**] PPD for 25 years.
Sister and mother involved
Family History:
N/C
Physical Exam:
GENERAL: sedated, intuabed
HEENT: slight scleral edema laterally, [**Last Name (un) **]
LUNGS: CTA anteriorly
CARDIO: RR, no m/r/g
ABD: somewhat obese, non-distended
EXTREMITIES: no edema
SKIN: non-blanching echymotic pacthes on her right MTP joints as
well as dorsal surface of hand (outlined in pen by nurse; new
per mother); also similar marks on dorsal medial right forearm.
No petechiae throughout, no other rashes.
NEURO: sedated, intubated
Pertinent Results:
ADMISSION LABS:
[**2108-12-20**] 11:35PM PT-15.0* PTT-27.7 INR(PT)-1.3*
[**2108-12-20**] 11:35PM PLT COUNT-239
[**2108-12-20**] 11:35PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2108-12-20**] 11:35PM NEUTS-87* BANDS-3 LYMPHS-5* MONOS-4 EOS-0
BASOS-0 ATYPS-0 METAS-1* MYELOS-0
[**2108-12-20**] 11:35PM WBC-22.8* RBC-4.60 HGB-14.1 HCT-39.8 MCV-87
MCH-30.6 MCHC-35.4* RDW-14.7
[**2108-12-20**] 11:35PM GLUCOSE-126* UREA N-14 CREAT-1.1 SODIUM-136
POTASSIUM-4.6 CHLORIDE-98 TOTAL CO2-24 ANION GAP-19
[**2108-12-20**] 11:36PM LACTATE-4.8*
[**2108-12-21**] 12:21AM LACTATE-2.3*
URINE:
[**2108-12-20**] 11:35PM URINE Color-Amber Appear-Cloudy Sp [**Last Name (un) **]-1.028
[**2108-12-20**] 11:35PM URINE Blood-LG Nitrite-NEG Protein-75
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-MOD
[**2108-12-20**] 11:35PM URINE RBC-21-50* WBC->50 Bacteri-MANY
Yeast-NONE Epi-0-2
OTHER PERTINENT LABS:
[**2108-12-21**] 05:34AM BLOOD %HbA1c-6.0*
[**2108-12-22**] 03:38AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
[**2108-12-25**] 04:52AM BLOOD HCG-negative
MICROBIOLOGY:
[**12-20**] BCx: negative
[**12-21**] BCx: negative
[**12-21**] UCx: negative
[**12-21**] Sputum: sparse yeast
[**12-23**] Catheter tip Cx: negative
[**12-23**] [**Last Name (un) **] Legionella: negative
[**12-24**] Sputum: sparse yeast
[**12-25**] Sputum: sparse yeast
[**12-28**] Cdiff: negative
[**12-29**] Stool Cx: negative
[**12-29**] UCx: negative
IMAGING:
CXR [**2108-12-20**]: Probable left lower lobe pneumonia. Pulmonary edema
cleared
CTA [**2108-12-23**]: 1)No pulmonary embolism, aortic dissection or
aneurysm. 2)Small bilateral pleural effusions with overlying
right lower lobe
atelectasis.
TTE [**2108-12-24**]: 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%). Doppler
parameters are indeterminate for left ventricular diastolic
function. Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
The mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The estimated
pulmonary artery systolic pressure is normal. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Normal biventricular cavity sizes with preserved
global and regional biventricular systolic function. No valvular
pathology or pathologic flow identified.
CT Abdoman and pelvis [**2108-12-25**]: 1. No evidence of pelvic abscess
or [**Last Name (un) **]. Small amount of free fluid in the pelvis. 2. 2.8 cm
simple left ovarian cyst. 3. Interval improvement in bibasilar
consolidation with residual basilar airspace opacities
concerning for infection. Stable small bilateral pleural
effusions.
CXR [**2108-12-26**]: 1. Patchy bilateral opacites, greater on the left,
compatible with pneumonia and/or edema. Slight interval
improvement of the left opacifications. 2. Endotracheal tube
terminating 9 cm above the level of the carina.
CT head/CTA head [**2108-12-27**]:
IMPRESSION: 1. CT head shows clipping for MCA and BA aneurysms.
No hemorrhage or hydrocephalus. Mild right mastoid fluid seen.
2. CTA head shows no aneurysms or occlusion.
3. CTV shows no sinus thrombosis.
DISCHARGE LABS:
Brief Hospital Course:
Ms. [**Known lastname 78131**] is a 46 yoF who presented with 24-26 hours of HA,
N/V and found to have evidence of bacterial menigitis on OSH w/u
of agitation and altered MS.
.
#. ALTERED MS/Group B Strep Meningitis: Patient was found to
have pansensitive Group B Strep meningitis from OSH CSF and
urine cultures. She was treated initially with broad spectrum
antibiotics, but was switched to Penicillin G, as per ID. No
primary source of infection was found for the Group B Strep and
all cultures drawn at [**Hospital1 18**] since [**12-21**] have been negative. CT
abdomen/pelvis was negative for abscess.
.
The patient did have persistently elevated WBC's during her
admission, despite IV antibiotics. As the patient had a history
of cerebral aneurysms that were coiled approximately 5 years ago
(titanium clips placed by Dr. [**First Name4 (NamePattern1) 3065**] [**Last Name (NamePattern1) **] at [**Hospital1 112**] Office#:
[**Telephone/Fax (1) 111608**], pager [**Numeric Identifier 44773**]), there was concern that these could
have become secondarily infected leading to persistent
infection. CTA/CTV of the head and orbits was performed as well
as MRI head and all were negative for abscess or dural venous
sinus thrombosis. ECHO was similarly negative for vegetations.
MRI did demonstrate some right-sided mastoid fluid, a known
sequelae of the patient's neurosurgery. ENT was consulted, but
they thought that since patient demonstrated clinical
improvement, no intervention was warranted. The patient's WBC
began trending down and she was discharged with a WBC of 13. She
has completed 12 days of antibiotics and has a plan for q4H IV
Penicillin G therapy for the next 3 weeks. Her mental status at
the time of discharge was at her baseline. She will be followed
by Dr. [**Last Name (STitle) 7443**] in ID with follow-up scheduled for early [**Month (only) 404**].
.
#. RESPIRATORY FAILURE: The patient was initially placed on a
ventilator for "airway protection" with altered MS. It was
difficult to wean her for several days, as the patient was
dysynchronous and required sedation. She had a CTA chest and was
found to have b/l pleural effusions and b/l infiltrate, but no
PE. The patient was extubated on [**12-26**] and did well with frequent
suctioning until her move to the general medicine floor. There
she was quickly weaned off supplemental oxygen and was breathing
room air comfortably until time of discharge.
.
#. PNEUMONIA, Group B Strep: Pt was found to have bilateral
infiltrate on CTA chest and there was concern that this was also
reflective of GBS infection. The patient was treated with
Penicillin G, as above.
.
#. GBS UTI: Patient was found to have GBS in a urine culture
from OSH. Urine cultures obtained at the [**Hospital1 18**] were all
negative. She was treated with Penicillin G, as above.
.
#. ARRHYTHMIA/QTC PROLONGATION ON OSH EKG: Patient had QTc
prolongation on an EKG at an OSH, but had no further prolonged
QTc during this hospitalization.
.
#. DMII/Insulin resistance/PCOS, well controlled no
complications: Patient on low dose Metformin for DMII, HbA1C
6.0, but has lost a significant amount of weight over the last 5
years that has led to improvement in blood sugars. As a result,
the patient was placed on a sliding scale as an inpatient, but
she did not require supplemental insulin.
.
#. Code: Patient remained FULL CODE throughout this
hospitalization.
Medications on Admission:
Metformin
Amitryptyline
Oxycodone
Butalbital
Gabapentin
Ativan
Sertraline
Flonase
Discharge Medications:
1. Outpatient Lab Work
Please draw a CBC, Basic Metabolic Panel, & Liver Function Tests
(including ALT, AST, Alkaline Phosphatase, Total Bilirubin) and
fax results to: Dr. [**Last Name (STitle) 7443**] at [**Telephone/Fax (1) 111609**]
2. Line flush instructions
Flush with 5 to 10ml NS before & after each medication
administration. Flush with 2 to 5ml Heparin Flush after access
unless contraindicated. Flush each lumen daily with 2 to 5ml
Heparin flush when not in use.
3. Penicillin G Pot in Dextrose 2,000,000 unit/50 mL Piggyback
Sig: 4 million units Intravenous every four (4) hours for 22
days: end date [**2108-1-24**].
Disp:*QS QS* Refills:*0*
4. Heparin Flush 10 unit/mL Kit Sig: Ten (10) units Intravenous
see instructions for frequency for 21 days: Flush line before
and after medication infusion with normal saline. Heparanize
infusion line in between infusions and unused lumens.
Disp:*21 days supply* Refills:*0*
5. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain, fever.
6. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for diarrhea.
7. Diphenhydramine HCl 25 mg Tablet Sig: 1-2 Tablets PO every
four (4) hours as needed for allergy symptoms.
8. Metformin Oral
9. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO three times
a day.
10. Ativan Oral
11. Butalbital Compound Oral
12. Flonase 50 mcg/Actuation Spray, Suspension Nasal
Discharge Disposition:
Home With Service
Facility:
Critical Care Infusion Company
Discharge Diagnosis:
Primary: Group B Strep Meningitis
Secondary: Anxiety
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 due to meningitis. In the
hospital,
Medications: The following changes were made to your medication
regimen,
1. Penicillin: Please continue to take this medication until
[**1-24**].
2. Benadryl: You may take 25-50mg of Benadryl as directed to
prevent any allergic reaction the Penicillin, but as this can
may you drowsy, please do not drive while taking.
Followup Instructions:
You will need weekly blood work until you follow-up in the
Infectious Disease Clinic in [**Month (only) 404**]. You can go to any local
lab to have your blood drawn, but please bring your prescription
so that the results can be sent to your doctors.
.
Please follow-up with Dr. [**Last Name (STitle) 7443**] in the Infectious Disease Clinic
on [**2109-1-23**] at 10:30AM. To reschedule, please
call:[**Telephone/Fax (1) 457**]. This will be the physician in charge of
following your care.
ICD9 Codes: 5990, 2930 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3789
} | Medical Text: Admission Date: [**2155-9-29**] Discharge Date: [**2155-10-1**]
Date of Birth: [**2155-9-29**] Sex: F
Service: Neonatology
HISTORY OF PRESENT ILLNESS: The patient is a 35 2/7 weeks
infant born to a 27 year old gravida 2, para 1 woman whose
pregnancy was complicated by chronic hypertension and
gestational diabetes, diet-controlled. Worsening of
pregnancy-induced hypertension prompted delivery on [**9-29**]. Delivery via planned repeat cesarean section. At
delivery infant was vigorous, given blow-by oxygen and
stimulation. Apgars were 8 at one minute and 9 at five
minutes, mild grunting, flaring and retractions prompted
transfer to the Neonatal Intensive Care Unit.
PHYSICAL EXAMINATION: Physical examination on admission
revealed birthweight 2940 gm. On examination, pink, active,
nondysmorphic infant. Well perfused and saturated in blow-by
oxygen and the weaned to room air. Mild tachypnea.
Grunting, flaring and retracting resolved shortly after
admission. Skin without lesions. Normal S1, S2, no murmur.
Abdomen, benign. Genitalia, normal female. Hips stable.
Spine intact. Anus patent. Neurological, nonfocal and age
appropriate.
HOSPITAL COURSE: Respiratory - Infant initially receiving
blow-by oxygen and then went to room air, quickly resolving
respiratory distress during transitional period. Infant has
remained stable in room air with oxygen saturations 98 to
100% and respiratory rate 30 to 60s. The infant has not had
any apnea or bradycardia this hospitalization.
Cardiovascular - The infant has remained cardiovascularly
stable this hospitalization. No murmur. Heartrate 130s.
Mean blood pressures, 48 to 52.
Fluids, electrolytes and nutrition - The infant was initially
nothing by mouth receiving 80 cc/kg/day of D10/W, initial
glucoses were 51 and 87. The infant was started on enteral
feedings on day of delivery and advanced to full volume
feedings by day of life #1. Infant has been receiving
enteral feedings of E20 ad lib p.o. taking 40 to 70 cc q. 4
hours. Glucoses have remained stable off of intravenous
fluids. Most recent weight on day of life #2, 2970, up 30
gm.
Gastrointestinal - The infant has not received phototherapy
this hospitalization.
Hematology - Hematocrit on admission was 51.8%, no
transfusions given.
Infectious disease - Due to initial respiratory distress a
complete blood count and blood culture was drawn.
Antibiotics were not started since respiratory issues
resolved shortly after delivery. The complete blood count
showed a white blood cell count of 10.9, hematocrit 51.8%,
platelets 349,000, 33 polys, 0 bands. Blood cultures
remained negative to date.
Neurology - No issues.
Sensory - Hearing screening is recommended prior to
discharge.
CONDITION ON DISCHARGE: 35 [**3-7**] week premie, now two days
old, stable in room air.
DISCHARGE DISPOSITION: To Newborn Nursery.
PRIMARY CARE PEDIATRICIAN: Unknown at this time.
CARE/RECOMMENDATIONS:
1. Feedings at discharge - E20 ad lib p.o.
2. Medications - None
3. Carseat position screening - Recommended prior to
discharge home.
4. State newborn screen - Due on [**10-1**].
5. Immunizations - The infant has not received any
immunizations, hepatitis B is recommended prior to discharge.
DISCHARGE DIAGNOSIS:
1. Prematurity, former 35 2/7 weeks, female
2. Status post transitional respiratory distress
3. Status post rule out sepsis
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 36142**], M.D. [**MD Number(1) 36143**]
Dictated By:[**Last Name (NamePattern1) 35945**]
MEDQUIST36
D: [**2155-10-1**] 15:45
T: [**2155-10-1**] 18:04
JOB#: [**Job Number 51716**]
ICD9 Codes: 7742, V053, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3790
} | Medical Text: Admission Date: [**2151-9-12**] Discharge Date: [**2151-9-15**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
s/p fall, tx from OSH with C1 and type 2 dens fx
Major Surgical or Invasive Procedure:
none
History of Present Illness:
[**Age over 90 **] year old female who experinced an unwitnessed fall and the
patient was found down on the ground by her daughter who lives
next door. The patient's daughter believes that her mother was
looking for her,was looking out the door,and possibly fell from
her door down 3 steps. EMS came the house on [**9-11**] and picked the
patient off the ground and brought her back into the house and
sat her in a chair. The patient continued to decline over 24
hours and was in bed and began experiencing difficulty with
swallowing pills and neck pain. The patient was brought to [**Hospital 8125**]
Hospital and airlifted to [**Hospital1 18**] for further care.
Past Medical History:
dementia, HTN, MVP, GERD, bilateral cataracts, hyponatremia,
laminectomy, thyroid surgery, umbilical hernia
Social History:
Lives alone. No EtOH, tobacco, drug use.
Family History:
Non-contributory.
Physical Exam:
T:96.8 BP:158/64 HR:88 R:25 O2Sats:99% NRB
NAD/tired/non-cooperative/AAO times 0
R eye 2.5-2 mm, L eye opacified/blind (longstanding per
daughter)
[**Name (NI) 84667**] not participating in exam
hard cervical collar, point tenderness C-[**12-15**]
RRR
coarse bs b/l, decreased bs at bases
SNDNT abdominal exam, + normal bs
multiple skin tears noted on bilateral lower extremities
no e/c/c
Brief Hospital Course:
Pt was admitted on [**2151-9-12**] after transfer from [**Hospital 8125**] Hospital for
further treatment of her C1 and type 2 dens fx. Pt was admitted
to TICU and neurosurgery was consulted. Extensive conversation
took placed between neurosurgery and the patient's daughter
regarding risks and benefits of surgery, after which the patient
declined surgical treatment. Pt's daughter also declined halo
because of risk of aspiration to patient. Plan was made to keep
patient in collar for 2-3 months with plans for follow-up and
reimaging. Pt also had T5 compression fx and plan was made for
TLSO brace. Neurology was consulted because of change in mental
status and discussed with family possibility of sudden paralysis
due to location of her spinal injuries. After extensive
conversation the decision was made by the patient's daughter to
make the pt DNR/DNI. Pt was transferred to floor on [**2151-9-14**]
with plans for transfer back to [**Hospital 8125**] Hospital for further care.
Around 10pm [**2151-9-14**] pt has increased respiration and stated she
was in pain. Pt was given 1 mg of morphine. At 11pm nurse
check on pt and she was more comfortable. At 12:30pm nurse's
assistant went to take pt's vitals and found that pt had passed.
Pt was declared dead at 12:45 am on [**2151-9-15**].
Medications on Admission:
1. Asa 81 mg qd, atenolol 75 qd, diltiazem 180 mg qd, isosorbide
mononitrate 20 mg qd, nitroglycerin .4 mg sublingualq prn
2. Synthroid 112 mcq qd
3. Cipro 500 mg [**Hospital1 **] x 7 days
4. Calcium 500/vitamin D 200 qd
5 Prilosec 40 mg qd
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
pt expired
Discharge Condition:
pt expired
Discharge Instructions:
pt expired
Followup Instructions:
pt expired
ICD9 Codes: 5990, 2761, 4019, 4240, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3791
} | Medical Text: Admission Date: [**2114-10-9**] Discharge Date: [**2114-10-16**]
Date of Birth: [**2048-2-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2114-10-10**] Cardiac catheterization
[**2114-10-11**] Aortic valve replacement ([**First Name8 (NamePattern2) 6158**] [**Male First Name (un) 923**] porcine
aortic) mitral valve repair (28 mm annuloplasty ring) coronary
artery bypass graft x3 (Left internal mammary artery > left
anterior descending, saphenous vein graft > diagonal, saphenous
vein graft > posterior descending artery)
History of Present Illness:
This is a 66 year old male with history of aortic valve disease
followed with serial echocardiograms. Over the past several
months he has noticed worsening of his exertional angina. His
symptoms worsened when he was celebrating his sons engagement by
eating more sodium then normal. He also has developed peripheral
edema and [**1-28**] pillow orthopnea. He denies syncope, presyncope,
palpitations, PND, fevers, chills and rigors. A recent
echocardiogram from [**2114-4-27**] revealed progression of his aortic stenosis. Given that
finding and worsening symptoms, he has been referred for
surgical evaluation. He is admitted today for catherization
tomorrow/IV Heparin bridge with plans for OR on Thurs for
AVR/?MVR/?CABG.
Past Medical History:
Aortic Stenosis and Insufficiency
Mitral Regurgitation
Chronic Atrial Fibrillation, History of unsuccessful
cardioversion [**2108**]
Hypertension
Hypercholesterolemia
Obesity
Anxiety
Varicose veins
s/p Brain surgery age 13 after a fall
s/p Tonsillectomy
s/p Appendectomy
s/p Ventral hernia repair
s/p Cataract surgery
Social History:
Lives with: Wife in [**Location (un) 936**]
Occupation: Musician
Cigarettes: Smoked no [] yes [X] last cigarette [**2091**] Hx: 1ppd x
27 yrs
ETOH: < 1 drink/week [] [**3-5**] drinks/week [X] >8 drinks/week []
Illicit drug use: Denies
Family History:
Father Died of an MI at 32 and father's brother died of MI at
age 40
Physical Exam:
Pulse:66 AF Resp:12 O2 sat: 98% room air
B/P Right: Left:132/75
Height: 5'9" Weight: 195#
General: AAO x 3 in no acute distress
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [] Irregular [x] Murmur [x] grade 4/6 SEM
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x]
Edema: trace LE edema
Varicosities: Significant GSV varicosities noted bilaterally
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 2 Left: 2
DP Right: 1 Left: 1
PT [**Name (NI) 167**]: 1 Left: 1
Radial Right: 2 Left: 2
Carotid Bruit: transmitted murmurs bilaterally
Pertinent Results:
[**2114-10-11**] Intraop TEE
Conclusions
PRE-BYPASS:
-No spontaneous echo contrast or thrombus is seen in the body of
the right atrium or the right atrial appendage.
-The left ventricle is not well seen. There is mild regional
left ventricular systolic dysfunction with inferior wall
hypokinesis.
-There are simple atheroma in the descending thoracic aorta.
-There are three aortic valve leaflets. The aortic valve
leaflets are severely thickened/deformed. There is severe aortic
valve stenosis (valve area 0.8-1.0cm2). Moderate (2+) aortic
regurgitation is seen.
-The mitral valve leaflets are moderately thickened. 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).
Dr. [**Last Name (STitle) **] was immediately notified of the result.
POSTBYPASS
The patient is receiving epinephrine at 0.03 ucg/kg/min
LV systolic function is moderately impaired. The inferior wall
and inferior septum are dyskinetic. LVEF 30-35%
RV systolic functiom is normal. There is a well seated, well
functioning bioprosthesis in the aortic position. No AI is
visualized. There is a ring prosthesis in the mitral position.
The MR is now trace.
The remaining exam is unchanged from prebypass
[**2114-10-16**] 05:25AM BLOOD WBC-7.9 RBC-2.80* Hgb-9.0* Hct-25.7*
MCV-92 MCH-32.2* MCHC-35.1* RDW-14.8 Plt Ct-199
[**2114-10-15**] 06:15AM BLOOD WBC-10.1 RBC-2.87* Hgb-9.6* Hct-26.2*
MCV-91 MCH-33.4* MCHC-36.5* RDW-14.6 Plt Ct-174
[**2114-10-14**] 06:20AM BLOOD WBC-12.1* RBC-2.49* Hgb-8.3* Hct-23.2*
MCV-93 MCH-33.1* MCHC-35.7* RDW-13.7 Plt Ct-128*
[**2114-10-16**] 05:25AM BLOOD PT-21.5* INR(PT)-2.0*
[**2114-10-15**] 06:15AM BLOOD PT-17.6* INR(PT)-1.6*
[**2114-10-14**] 06:20AM BLOOD PT-14.9* INR(PT)-1.3*
[**2114-10-13**] 05:18AM BLOOD PT-13.5* PTT-21.2* INR(PT)-1.2*
[**2114-10-12**] 03:26AM BLOOD PT-14.5* PTT-31.1 INR(PT)-1.2*
[**2114-10-11**] 01:43PM BLOOD PT-16.2* PTT-36.3* INR(PT)-1.4*
[**2114-10-11**] 12:26PM BLOOD PT-17.5* PTT-36.3* INR(PT)-1.6*
[**2114-10-10**] 06:45AM BLOOD PT-13.8* PTT-53.0* INR(PT)-1.2*
[**2114-10-16**] 05:25AM BLOOD UreaN-22* Creat-0.8 Na-134 K-3.8 Cl-96
[**2114-10-15**] 06:15AM BLOOD Glucose-107* UreaN-22* Creat-0.9 Na-132*
K-4.7 Cl-96 HCO3-30 AnGap-11
[**2114-10-14**] 06:20AM BLOOD Glucose-136* UreaN-21* Creat-0.7 Na-129*
K-4.4 Cl-94* HCO3-28 AnGap-11
[**2114-10-13**] 05:18AM BLOOD Glucose-134* UreaN-16 Creat-0.8 Na-132*
K-5.0 Cl-101 HCO3-24 AnGap-12
Brief Hospital Course:
Admitted preoperative for heparin bridge from coumadin for
atrial fibrillation. He underwent preoperative workup that
included cardiac catheterization on [**10-10**] which revealed coronary
artery disease. On [**10-11**] he was brought to the operating room
for aortic valve replacement, mitral valve repair and coronary
artery bypass graft surgery. See operative report for further
details. He was transferred to the intensive care unit for post
operative management.He was extubated later that day and
transferred to the floor on POD #2 to begin increasing his
activity level. Chest tubes and pacing wires removed per
protocol. He was gently diuresed toward his preop weight and
beta blockade was titrated. Coumadin restarted for chronic A
Fib. Continued to make good progress and was cleared for
discharge to home with VNA on POD #5. Target INR 2.0-2.5. First
INR check tomorrow with VNA. All f/u appts were advised. He
does have 2+ edema of the lower extremities, and some serous
drainage from EVH sites. He is advised to cover these with DSD
until it stops.
Medications on Admission:
Warfarin 4 mg Tablet daily Q mon wed fri and 5mg tues thurs sat
sun - Last dose [**2114-10-4**]
Nifedipine 60mg daily
Atenolol 100mg daily
Lisinopril 20mg daily
Crestor 20mg daily
Aspirin 81mg daily
Discharge Medications:
1. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*1*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
4. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/fever.
6. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
7. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
8. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
9. warfarin 1 mg Tablet Sig: Five (5) Tablet PO DAILY (Daily): 5
mg dose today [**10-16**] only;all further dosing by [**Hospital 2287**] [**Hospital 38**]
clinic;target INR 2.0-2.5 for chronic A Fib.
Disp:*40 Tablet(s)* Refills:*1*
10. furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day
for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
11. potassium chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 10 days.
Disp:*20 Packet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Aortic Stenosis and Insufficiency s/p AVR
Mitral Regurgitation s/p MV repair
Chronic Atrial Fibrillation
coronary artery disease s/p cabg
Hypertension
Hypercholesterolemia
Obesity
Anxiety
Varicose veins
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
leg-healing well, no erythema, slight serosanguinous drainage
from EVH sites
Edema- 2+
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication chronic AFib
Goal INR 2.0-2.5
First draw [**2114-10-17**]
Results to: [**Hospital1 **] [**Hospital 38**] [**Hospital 197**] Clinic
FAX [**Telephone/Fax (1) 31021**]
phone [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1557**]/ [**Telephone/Fax (1) 55854**]
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2114-11-14**] 1:15
in the [**Hospital **] medical office building [**Hospital Unit Name **]
Wound check [**Telephone/Fax (1) 170**] Date/Time:Thursday [**10-25**] @ 10:15 AM in
the [**Hospital **] medical office building [**Hospital Unit Name **]
Cardiologist:Dr. [**Last Name (STitle) 19**] (her office will call you with appt in [**3-1**]
weeks)
Please call to schedule appointments with your
Primary Care Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 29117**] [**Telephone/Fax (1) 70698**] in [**5-1**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication chronic AFib
Goal INR 2.0-2.5
First draw [**2114-10-17**]
Results to: [**Hospital1 **] [**Hospital 38**] [**Hospital 197**] Clinic
FAX [**Telephone/Fax (1) 31021**]
phone [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1557**]/ [**Telephone/Fax (1) 55854**]
Completed by:[**2114-10-16**]
ICD9 Codes: 2761, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3792
} | Medical Text: Admission Date: [**2149-11-28**] Discharge Date: [**2150-2-5**]
Date of Birth: [**2149-11-28**] Sex: F
Service: Neonatology
IDENTIFICATION: [**Known lastname **] [**Known lastname **] is a 69 day old former 30+ wk
premature infant with multiple [**Known lastname 68813**] who is being
discharged from the [**Hospital1 18**] NICU.
HISTORY: [**Known lastname **] is a 30-6/7 week baby delivered at 1230 grams
and admitted to the Neonatal Intensive Care Unit for
prematurity, respiratory distress syndrome and sepsis
evaluation. She delivered to a 35 year-old primigravida with
the following antenatal laboratories: Maternal blood type A
positive, antibody negative, hepatitis B surface antigen
negative, rubella immune, RPR nonreactive, and GBS negative.
Maternal history was notable for chronic hypertension, and
pregnancy was complicated by progressive preeclampsia. Mother
was treated with verapamil, aldomet, and nifedipine, and received
a course of betamethasone on [**2149-11-9**] at 27 weeks. Maternal
history was otherwise notable for bipolar disorder, treated with
Seroquel. Due to worsening hypertension and proteinuria, mother
was taken for c-section on [**2149-11-28**]. Infant emerged with good
tone and spontaneous cry, with Apgars [**9-23**], and was brought to
NICU.
PHYSICAL EXAMINATION: Upon admission, weight was noted to be
1230 grams, 10th to 25th percentile, length was 39 cm, 25th
percentile, and Head circumference was 26.5 cm, 10th to 25th
percentile. Infant was in moderate respiratory distress. No
[**Known lastname 68813**] were noted at the time, and infant was
non-dysmorphic. Tone and activity were normal.
HOSPITAL COURSE BY SYSTEMS:
A. Respiratory: Infant was treated for RDS with intubation, one
dose of surfactant, and mechanical ventilation for 2 days. She
was then extubated to RA, and has remained in RA since that time.
She had some mild apnea of prematurity, treated with caffeine for
17 days, with gradual resolution. Last spell occured at
approximately 36 weeks PMA, and by the time of discharge, she has
been without spells for several weeks.
B. Cardiovascular: Infant remained hemodynamically stable
throughout admission without need for cardiovascular support. A
murmur was noted over course of hospitalization, and cardiac
evaluation on [**1-12**] revealed normal chest x-ray, normal
EKG, and normal 4 extremity blood pressures. Murmur persisted,
and cardiology was consulted with ECHO performed on [**2150-2-3**];
ECHO was normal with no structural heart disease noted.
C. FEN/GI: Infant was initially maintained on parenteral
nutrition via a UVC, and then gradually advanced on enteral
feeds. She reached full enteral feeds by day of life 7, and was
subsequently advanced to maximum caloric density of 30 cals/oz.
Progression of oral feedings was slow, most likely secondary to
mechanical and pain issues related to her lip [**Known lastname 68813**] (see
below), but eventually, infant transitioned to all oral feedings.
By the time of discharge, she has been all PO feeding for over 5
days, taking 120-180 cc/kg/day. Her discharge weight is 2955
grams, and she is discharged on similac 28 made with 4 calories
of similac powder and 4 calories of corn oil. Weight gain
overall has been consistent, and caloric density may be able to
be decreased further in the near future.
D. Heme: Maximum bilirubin was 7.5. She received phototherapy
for 6 days and maternal blood type was A positive. Baby's
blood type unknown. She received no transfusions. Her last
hematocrit was drawn on [**1-23**] which showed a hematocrit
of 28 and a reticulocyte count of 2.9. She will be discharged
home on iron. Platelet count on [**1-23**] was normal at 483.
E. Infectious disease: She is status post a 48 hour course of
ampicillin and gentamicin at birth. Blood cultures were
negative. Over the first few weeks of life, a whitish exudate was
noted on the tongue, thought to be thrush. She was treated with
oral nystatin for 14 days and then fluconazole for 7 days with no
improvement or change in the exudate seen. No lesions were noted
on the buccal mucosa or posterior palate, and no lesions were
seen in the perineum. A culture was sent of the tongue on
[**2-2**] which showed no evidence of yeast. Thus, with no
response to therapy, negative gram stain, and no evidence of
yeast infection elsewhere, it was thought that the tongue
findings were unlikely to be a yeast infection. However, a
resistant [**Female First Name (un) 564**] species causing the thrush is possible, and
thus the lesion should be followed. The fluconazole was
discontinued on [**2-4**].
F. Neurologic: Head ultrasound performed on [**12-5**], within
the 1st week of life, was normal as was a head ultrasound
performed on [**1-22**], on day of life 55. Neurologic exam was
appropriate throughout. Of note, a small sacral dimple has been
noted; this was not evaluated by ultrasound by the time of
discharge.
G. Skin: Over the first few weeks of life, the infant was noted
to develop multiple [**Known lastname 68813**], including a large hemangioma on
the lower lip. The lip hemangioma was noted to grow rapidly, and
interfere with attempts at oral feeding. The Vascular Anomalies
Center from [**Hospital3 1810**] was consulted, and the infant
received an intralesional injection of steroid into her lip
hemangioma on [**12-15**]. Subsequently, a portion of the lesion
began to involute, but it subsequently ulcerated causing pain and
discomfort. The lip lesion was treated with topical lidocaine,
antimicrobial ointment, and aquaphor. Due to continued growth of
the remainder of the lip hemangioma, infant was begun on systemic
steroid therapy on [**1-21**], being given Orapred 5 mg per day
(2 mg/kg/day based on weight of 2.5 kg at that time). No further
growth in the lip lesion was seen, with some involution noted and
progressive healing of the ulcerated portion. Oral feedings
began to improve as well, and she was eventually able to be
transitioned to all oral feeds. No significant side-effects of
the steroid therapy related to blood pressure or blood sugar was
noted. She was begun on zantac for GI prophylaxis at the same
time that the steroids were begun. Of note, despite the
improvement in the lip [**Known lastname 68813**], other small [**Known lastname 68813**] were
noted to develop over the rest of her body while on the steroid
therapy. More than 10 [**Known lastname 68813**] are present. Due to the number
of cutaneous [**Known lastname 68813**], a liver ultrasound was performed in
mid-[**Month (only) 1096**] that did not show any visceral [**Known lastname 68813**]. As
mentioned above, head ultrasounds were also normal.
She is followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 40701**] and [**First Name8 (NamePattern2) 62495**] [**Doctor Last Name **] in the
vascular anomaly center at [**Hospital3 1810**]. The number for
the vascular anomaly center is [**Telephone/Fax (1) 68814**], and she will need
follow-up with that center in the first week of [**Month (only) 404**]. Plan at
this time is to continue the current dose of orapred without
adjustment for weight until 1 month of treatment (approximately
[**2-21**]), and then to initiate weaning of the dose. Of note, when
she is hospitalized or is to receive major surgery, she is to
receive stress dose steroids if she remains on this level of
steroids daily.
H. Sensory: A hearing screen was performed with automated
auditory brain-stem responses and she passed on [**2150-2-2**]. Eyes were examined as per protocol without evidence of
retinopathy; they were examined most recently on [**1-12**], revealing mature retinal vessels. A followup exam is
recommended in 8 months.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: Home.
PEDIATRICIAN: Will be Dr. [**Last Name (STitle) 68815**]. The phone number is [**Telephone/Fax (1) 68816**]. They have an appointment on [**2150-2-6**].
CARE AND RECOMMENDATIONS: Feeds at discharge will be Similac
24 plus an additional 4 kilocalories per ounce of corn oil to
make up Similac 28 kilocalories per ounce. Her medications
include iron, Zantac 2 mg per kg per dose 3 times a day which is
5 mg every 8 hours, Orapred 5 mg once in the morning and Aquaphor
to her lip as needed. Orapred dose should be weaned beginning in
early [**Month (only) 404**], and growth and vital signs should be closely
monitored while on the steroid therapy.
IMMUNIZATIONS: She received her 2 month immunizations of
Pediarix, Hib, and PCV on [**2156-2-3**], and Synagis on [**2-4**].
Immunizations recommended: Synagis RSV prophylaxis should be
considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet
any of the following 3 criteria:
1. Born at less than 32 weeks/
2. Born between 32 and 35 weeks with 2 of the following -
day care during RSV season, a smoker in the household,
neuromuscular disease, airway abnormalities or school-age
siblings, or
3. With chronic lung disease.
Influenza immunization is recommended annually in the fall for
all infants once they reach 6 months of age. Before this age and
for the 1st 24 months of the child's life, immunization against
influenza is recommended for household contacts and out-of-home
caregivers.
FOLLOWUP APPOINTMENTS: Include pediatrician on [**2150-2-6**], ophthalmology at 8 to 9 months, and Dr. [**Last Name (STitle) 40701**], [**Telephone/Fax (1) 68817**], within the 1st week of [**Month (only) 404**].
DISCHARGE DIAGNOSES:
1. Prematurity at 30 weeks.
2. Respiratory distress requiring Surfactant.
3. Sepsis evaluation.
4. [**Known lastname **], multiple.
5. Apnea of prematurity.
6. Hyperbilirubinemia.
7. Sacral dimple, not yet evaluated.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**MD Number(2) 56682**]
Dictated By:[**Last Name (NamePattern1) 65868**]
MEDQUIST36
D: [**2150-2-5**] 10:58:00
T: [**2150-2-5**] 12:25:27
Job#: [**Job Number 53474**]
ICD9 Codes: 769, 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3793
} | Medical Text: Admission Date: [**2141-9-11**] Discharge Date: [**2141-9-16**]
Date of Birth: [**2081-4-13**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Exertional chest pain
Major Surgical or Invasive Procedure:
[**2141-9-12**] - Coronary artery bypass grafting to 4 vessels.
History of Present Illness:
This is a 60 year old male with known coronary artery disease
who presents with increasing exertional angina. Recent stress
testing was notable for shortness of breath after walking for
only three minutes of [**Doctor First Name **] protocol with myoview imaging
revealing inferior wall ischemia. Subsequent cardiac
catheterization showed significant three vessel coronary artery
disease. He is now referred for surgical revascularization.
Past Medical History:
Past Medical History:
Coronary Artery Disease - MI at age 38, PCI [**2120**]
Hypertension
Dyslipidemia
Type II Diabetes - c/b Neuropathy
Morbid Obesity
Atrial Fibrillation - s/p DCCV [**2141-1-22**], now in sinus rhythm
Varicose Veins
Chronic Low Back Pain
Past Surgical History:
- Right Leg Vein Stripping
- Left Total Knee Replacement
Social History:
Occupation: On disability
Lives with: Wife and daughter
[**Name (NI) **]: Caucasian
Tobacco: quit [**2118**], 35+pack year history of tobacco
ETOH: rate
Family History:
Father died of MI at age 78. Paternal Uncle died of MI at age
42.
Physical Exam:
Pulse: 64 Resp: 16 O2 sat: 100RA
B/P Right: 137/81 Left: 139/78
General: Obese male in no acute distress
Skin: chronic venous stasis changes on both lower extremities.
fungal skins lesions noted on abdominal pannus.
HEENT: PERRLA [x] EOMI [x], poor dentition
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x]
Edema - trace
Varicosities: right leg stripping/severe varicosities of left
lower extremity/left GSV in thigh did not appear grossly
varicosed but large in size/lesser saphenous without
varicosities
Neuro: Right hand dominant. CN 2-12 grossly intact. [**3-28**]
strength.
No focal deficits.Grossly intact
Pulses:
DP Right: 2 Left: 2
PT [**Name (NI) 167**]: 2 Left: 2
Radial Right: 2 Left: 2
Carotid Bruit Right: none Left: none
Allens Test: left hand with positive allens test. normal
flushing
with radial compression. excellent arterial waveform and oxygen
saturations with radial compression
Pertinent Results:
[**2141-9-11**] 08:10PM PT-14.5* INR(PT)-1.3*
[**2141-9-11**] 08:10PM PLT COUNT-224
[**2141-9-11**] 08:10PM WBC-6.5 RBC-4.25* HGB-12.1* HCT-36.6* MCV-86
MCH-28.4 MCHC-33.0 RDW-14.2
[**2141-9-11**] 08:10PM %HbA1c-6.2*
[**2141-9-11**] 08:10PM ALBUMIN-4.4 MAGNESIUM-1.8
[**2141-9-11**] 08:10PM CK-MB-NotDone cTropnT-<0.01
[**2141-9-11**] 08:10PM LIPASE-66*
[**2141-9-11**] 08:10PM ALT(SGPT)-19 AST(SGOT)-16 CK(CPK)-96 ALK
PHOS-36* AMYLASE-41 TOT BILI-0.3
[**2141-9-11**] 08:10PM GLUCOSE-124* UREA N-17 CREAT-1.1 SODIUM-139
POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-27 ANION GAP-13
[**2141-9-11**] 09:03PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Diastolic Dimension: 5.3 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 3.7 cm
Left Ventricle - Fractional Shortening: 0.30 >= 0.29
Left Ventricle - Ejection Fraction: 55% to 60% >= 55%
Aorta - Sinus Level: *3.9 cm <= 3.6 cm
Aorta - Ascending: 3.3 cm <= 3.4 cm
Aortic Valve - Peak Gradient: 11 mm Hg < 20 mm Hg
Aortic Valve - LVOT diam: 2.4 cm
Findings
LEFT ATRIUM: Normal LA size. No spontaneous echo contrast is
seen in the LAA. Good (>20 cm/s) LAA ejection velocity. No
thrombus in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No spontaneous
echo contrast in the RAA. No thrombus in the RAA. Color-flow
imaging of the interatrial septum raises the suspicion of an
atrial septal defect, but this could not be confirmed on the
basis of this study.
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Normal regional LV systolic function. Overall normal LVEF
(>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Mildly dilated aortic sinus. Simple atheroma in aortic
root. Normal ascending aorta diameter. Normal aortic arch
diameter. Simple atheroma in aortic arch. Normal descending
aorta diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Minimal AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MS.
Trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: Trivial/physiologic pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The patient received antibiotic prophylaxis. The
TEE probe was passed with assistance from the anesthesioology
staff using a laryngoscope. No TEE related complications.
patient.
Conclusions
PREBYPASS:
1. The left atrium is normal in size. No spontaneous echo
contrast is seen in the left atrial appendage. No thrombus is
seen in the left atrial appendage.
2. No thrombus is seen in the right atrial appendage
3. Color-flow imaging of the interatrial septum raises the
suspicion of an atrial septal defect, but this could not be
confirmed on the basis of this study.
4. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is normal (LVEF>55%).
5. Right ventricular chamber size and free wall motion are
normal.
6. The aortic root is mildly dilated at the sinus level. There
are simple atheroma in the aortic root. There are simple
atheroma in the aortic arch. There are simple atheroma in the
descending thoracic aorta.
7. The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. There is a minimally increased gradient
consistent with minimal aortic valve stenosis. No aortic
regurgitation is seen.
8. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen.
9. There is a trivial/physiologic pericardial effusion.
Dr. [**Last Name (STitle) **] was notified in person of the results.
POSTBYPASS: On infusion of phenylephrine, sinus rhythm.
Preserved biventricular systolic function with LVEF now 60%.
Trace MR. Aortic contour is normal post decannulation.
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) **] [**2141-9-12**] 15:55
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2141-9-11**] for surgical
management of his coronary artery disease. He had been off
coumadin for 5 days prior to admission and heparin was started
for antiocagulation. He underwent preoperative testing including
a carotid duplex ultrasound which showed no significant internal
carotid artery disease. Vein mapping showed patent bilateral
lesser saphenous veins. On [**2141-9-12**], Mr. [**Known lastname **] was taken to the
operating room on [**9-12**] where he had coronary artery bypass
grafting x4 with left internal mammary artery graft to left
anterior
descending, free left internal mammary artery segment to the
first diagonal branch, reverse lesser saphenous vein to the
left-sided posterior descending artery and right-sided posterior
descending artery. His bypass time was 164 minutes with a
crossclamp of 126 minutes. Please see operative note for
details. Postoperatively he was taken to the intensive care unit
for recovery. He did well in the immediate post-op period was
weaned from sedation and extubated on the operative day. He
remained hemodynamically stable and was transferred to the step
down unit on POD1.
All tubes lines and drains were removed per cardiac surgery
protocol. The remainder of his hospital course was uneventful.
Over the next several days his activity level was advanced with
the assistance of physical therapy and nursing staff. On POD
four he was discharged home with visiting nurses.
Medications on Admission:
**Warfarin-dtopped [**9-6**]**, Aspirin 325 qd, Metformin 1000 [**Hospital1 **],
Rhythmol 225 [**Hospital1 **], Imdur 120 (2), Fenofibrate 160 qd, Atenolol
100
qd, Triamterene/HCTZ 37.5/25 qd, Lisinopril 10 qd, Gabapentin
100
tid, Simvastatin 80 qd, Omeprazole 40 qd, Oxycodone 15 qid,
Byetta
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. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*0*
4. Propafenone 225 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
5. 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*
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
8. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO once a day for
10 days.
Disp:*20 Tablet(s)* Refills:*2*
9. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
10. Fenofibrate 160 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
11. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*2*
12. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO ONCE (Once)
for 1 doses: take per the office of [**Hospital1 8051**] for afib.
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Coronary artery disease s/p CABG
s/p MI/ PCI [**2120**]
Hypertension
Dyslipidemia
Type II Diabetes - c/b Neuropathy
Morbid Obesity
Atrial Fibrillation - s/p DCCV [**2141-1-22**], now in sinus rhythm
Varicose Veins
Chronic Low Back Pain
Right Leg Vein Stripping
Left Total Knee Replacement
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include redness,
drainage or increased pain. Please report all wound issues to
you surgeon 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) Please shower daily. Wash wound(s) with soap and water. No
lotions creams or powders to incisions for 6 weeks.
5) Report any drainage from sternal drainage
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**]
Please follow-up with Dr. [**Last Name (STitle) **] in [**12-27**] weeks. [**Telephone/Fax (1) 29252**]
Please follow-up with Dr. [**Last Name (STitle) 8051**] in [**12-27**] weeks.
Please call all providers for appointments.
INR should be drawn on [**9-18**] with results sent to the office of
Dr. [**Last Name (STitle) 8051**] at ([**Telephone/Fax (1) 8052**]. Plan relayed to office nurse
on [**2141-9-15**].
Completed by:[**2141-9-16**]
ICD9 Codes: 412, 4019, 2724, 3572 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3794
} | Medical Text: Admission Date: [**2166-9-22**] Discharge Date: [**2166-10-12**]
Date of Birth: [**2166-9-22**] Sex: M
Service: NB
HISTORY OF PRESENT ILLNESS: Baby boy [**Known lastname 56807**] is a 2290
gram product of a 32 and [**12-28**] week gestation born to a 28 year
old gravida 2, para 1, now 2 mother.
Prenatal screens - AB positive, antibody negative, RPR
nonreactive, hepatitis B surface antigen negative, rubella
immune, GBS unknown.
Pregnancy was complicated by gastritis. Mom had preterm labor
and treated with betamethasone the day prior to delivery.
Mother had an appendectomy on the morning of delivery. On
admission, ultrasound which showed biophysical profile of
[**6-29**] with normal amniotic fluid index. He was noted to have
bradycardia and mom was then taken for emergency cesarean
section. She was treated with one dose of cefotaxime 3 hours
prior to delivery. Her membranes were ruptured at delivery.
Mother transferred from [**Hospital6 3872**] because of
suspected appendicitis. Mother is [**Name (NI) 595**] speaking.
Cesarean section for fetal bradycardia. Apgars were 8 at 1
minute and 8 at 5 minutes.
PHYSICAL EXAMINATION: Birth weight 2290 grams (75th
percentile), head circumference 32 cm (90th percentile),
length 47 cm (90th percentile). Anterior fontanel open and
flat, palate intact. Red reflex present bilaterally. Neck
supple. Good air movement bilaterally with intermittent
grunting. Regular rate and rhythm. No murmurs. Femoral
pulses 2+ bilaterally.
ABDOMEN: Soft with active bowel sounds. No masses or
distention. Normal premature male. Testes palpable. Anus
normally placed and patent.
MUSCULOSKELETAL: Hips stable, clavicles intact. Normal tone
for gestational age.
HOSPITAL COURSE BY SYSTEMS: Infant initially received CPAP,
6 cm of water requiring 28 percent and weaned quickly to room
air. Infant remained on CPAP until date of life 2 and
transition to room air without issues. Infant has remained on
room air throughout this hospitalization with respiratory
rate 30's to 60's, oxygen saturations greater than 96
percent. The infant has not had any apnea, bradycardia in
this hospitalization. Infant was not treated with
methylxanthenes this hospitalization.
CARDIOVASCULAR: No murmur. Hemodynamically stable during
this hospitalization.
FLUIDS, ELECTROLYTES AND NUTRITION: The infant was receiving
nothing by mouth initially until day of life 3, until
feedings were started and infant advanced to full volume
feedings by day of life 7. Infant advanced to full feeding
into the 26 calories per ounce by day of life 9. Infant is
currently receiving 140 cc per kg per day of NeoSure 26
calories per ounce po. The infant tolerated feeding advance
without difficulty. The most recent weight is 2525 grams,
head circumference 31.5, length 47 cm.
GASTROINTESTINAL: The infant received single phototherapy
for a total of 3 days. Maximal bilirubin on day of life 2 was
8.3 with direct of 0.2. The most recent bilirubin level on
day of life 6 was 7.4 with direct of 0.3.
HEMATOLOGY: CBC on admission - white blood cell count
10,700, hematocrit 50.6 percent, platelet count 319,000, 47
neutrophils, 0 bands. Infant did not receive any antibiotics
during this hospitalization. His hematocrit prior to discharge
was 38.7 with a reticulocyte count of 0.8.
INFECTIOUS DISEASE: Infant received 48 hours of ampicillin
and gentamycin due to respiratory distress. Antibiotics were
discontinued after 48 hours. Blood cultures were negative to
date. He was noted to have MRSA on routine surveillance cultures
prior to discharge
NEUROLOGY: Normal neuro examination. Infant does not meet
criteria for head ultrasound.
SENSORY: Hearing screen was performed with automated
auditory brain stem responses. The infant passed in both
ears.
OPHTHALMOLOGY: The infant is due to for the first eye
examination at 3 weeks of age.
PSYCHOSOCIAL: Parents involved.
CONDITION ON DISCHARGE: Stable on room air.
DISCHARGE DISPOSITION: Home with parents.
NAME OF PRIMARY PEDIATRICIAN: [**Name6 (MD) **] [**Name8 (MD) 40493**], MD.
FEEDINGS AT DISCHARGE: NeoSure 26 calories per ounce po, 140
cc per kg per day. NeoSure is recommended until 6 to 9
months corrected age.
MEDICATIONS: None.
CAR SEAT POSITION SCREEN: The patient passed the infant car
seat position screen test.
THE STATE NEWBORN SCREEN: This was done on day of 3 and day
of life 4, results are within normal range.
IMMUNIZATIONS RECEIVED: Infant received Hepatitis B vaccine
on [**10-5**].
IMMUNIZATIONS RECOMMENDED:
1. Synagis RSV prophylaxis should be considered from [**Month (only) **]
through [**Month (only) 958**] for infants who meet any of the following
three criteria.
A. Born at less than 32 weeks.
B. Born between 32 and 35 weeks with two of the following:
daycare during the RSV season; a smoker in the household,
neuromuscular disease; airway abnormalities; school age
siblings; or with chronic lung disease.
1. Influenza immunization is recommended annually in the Fall
for all infants once they reach 6 months of age. Before
this age and for the first 24 months of the child's life,
immunization against influenza is recommended for
household contacts and out of home caregivers.
Follow up appointments for infant include:
1. Primary pediatrician.
2. Ophthalmology .
DISCHARGE DIAGNOSES:
1. Prematurity.
2. Status post mild respiratory distress.
3. Status post rule out sepsis. Ruled out.
4. Status post indirect hyperbilirubinemia.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) 55708**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2166-10-12**] 01:15:29
T: [**2166-10-12**] 02:33:22
Job#: [**Job Number 56808**]
ICD9 Codes: 7742, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3795
} | Medical Text: Admission Date: [**2198-9-13**] Discharge Date: [**2198-9-18**]
Date of Birth: [**2124-7-27**] Sex: F
Service:
ADDENDUM: Please change the discharge date to Tuesday,
[**2198-9-18**].
The patient's INR on [**2198-9-18**] was 2.1. She is being
discharged on a Coumadin dose for a goal INR of 3.0. Her
Coumadin dose will range from 2 to 5 mg. She will not be
receiving any heparin. The patient should follow up with Dr.
[**Last Name (STitle) **] in approximately three weeks.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Name8 (MD) 3181**]
MEDQUIST36
D: [**2198-9-18**] 07:36
T: [**2198-9-18**] 08:50
JOB#: [**Job Number 20272**]
ICD9 Codes: 4280, 9971, 4019, 2859, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3796
} | Medical Text: Admission Date: [**2144-1-20**] Discharge Date: [**2144-1-31**]
Date of Birth: [**2084-3-2**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
Esophageal Cancer
Major Surgical or Invasive Procedure:
Minimally invasive esophagectomy, mediastinal
lymph node dissection.
History of Present Illness:
Patient is a 59 year old gentleman who was found to have severe
dysphagia and weight loss and was noted to have a near
obstructing distal esophageal cancer. This was treated with an
esophageal stent placement and then chemotherapy and radiation.
His restaging head CT appeared to show stable if not improved
disease and he presents for minimally invasive esophagectomy.
Past Medical History:
ONCOLOGIC HISTORY (taken from OMR - [**Doctor Last Name **] [**11-12**]): This
59-year-old gentleman initially presented in [**11/2142**] due to
dysphagia and weight loss. At that time, he had a barium
swallow, which showed a pinpoint narrowing of his distal
esophagus. He had endoscopy and underwent dilatation of this
stricture. He did not have much improvement with the dilatation
and in [**Month (only) 116**] of this year underwent a second dilatation once again
with no improvement. He had motility tests, which were most
consistent with achalasia. In [**Month (only) **], he underwent a Botox
injection to the narrowing in order to help to release it. He
had a CT scan after this which showed a 1.5 cm gastrohepatic
lymph node. On [**2143-8-28**] he underwent an upper endoscopy on
which they saw distal esophageal narrowing. They also performed
multiple biopsies of the area of narrowing. Of note, they saw
some ulceration in the GE junction and a thick abnormal fold
concerning for esophageal or gastric cardia cancer. The biopsy
showed moderate to poorly differentiated adenocarcinoma. After
this he underwent endoscopic ultrasound, however, they were
unable to pass the ultrasound probe beyond the stricture. He has
had a port, g-tube, and esophageal stent placed. He started
treatement with 5-FU and Cisplatin on [**2143-10-10**] with concurrent
radiation therapy.
.
PMH:
1. Sinusitis status post 2 surgeries.
2. Hypertension.
Social History:
He originally moved from [**Country 6171**] 17 years ago. Married, 2
children. Teaches french and spanish. He used to smoke a pack a
day, but quit 15 years ago. He used to drink a couple of glasses
of wine with dinner each night, but not since diagnosis.
Family History:
He has a father with pancreatic cancer who died at the age of
70.
Physical Exam:
T: 98.1 HR: 91 BP: 104/58 RR: 20 O2sat: 99% (FM 0.4)
Gen: NAD, normal respiratory effort without stridor or stertor.
Symmetric facial movement.
Lungs: CTA b
Heart: RRR
Abd: Soft, NT, J tube in place
Ext: No CCE
Pertinent Results:
[**2144-1-20**] 09:41AM freeCa-1.07*
[**2144-1-20**] 09:41AM HGB-10.7* calcHCT-32
[**2144-1-20**] 09:41AM GLUCOSE-123* LACTATE-1.1 NA+-137 K+-3.4*
CL--103
[**2144-1-20**] 09:41AM TYPE-ART PO2-253* PCO2-41 PH-7.43 TOTAL
CO2-28 BASE XS-3
[**2144-1-20**] 02:41PM freeCa-1.04*
[**2144-1-20**] 02:41PM HGB-11.9* calcHCT-36
.
DIAGNOSIS:
I. Left peri-esophageal lymph node (A):
1. Anthracosis and hyperplasia.
2. No tumor.
II. Peri-esophageal tissue (B):
Fibroadipose tissue with one small lymph node: No tumor.
III. Esophagogastrectomy (C-AF):
1. Regional lymph nodes and adjacent tissue:
a. Metastatic adenocarcinoma in 4 of 6 perigastric lymph nodes
and separate foci of tumor in the adjacent adipose tissue.
b. No tumor in 10 peri-esophageal lymph nodes.
2. Extensive ulceration and fibrosis of the distal esophagus
with transmural tear, status-post chemoradiation.
3. There is no residual carcinoma in the esophagus.
4. The proximal squamous-lined esophagus and gastric fundic
portion are unremarkable.
Clinical: Esophageal cancer, post-chemoradiation.
.
RADIOLOGY Final Report
UGI SGL CONTRAST W/ KUB [**2144-1-24**] 10:11 AM
Reason: Assess anatomy for leak at anastamosis site. Please use
Thi
IMPRESSION: No evidence of leak at the cervical esophagectomy
anastomosis.
Surgical staples, drain, subclavian line and NG tube in
appropriate position.
.
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2144-1-29**] 5:35 AM
Reason: reasses pneumothoraces
[**Hospital 93**] MEDICAL CONDITION:
59 year old man s/p esophagogastrectomy, s/p R chest tube
removal, stable R PTx on last CXR, now with slight increase SOB
REASON FOR THIS EXAMINATION:
reasses pneumothoraces
REASON FOR EXAMINATION: Followup of a patient after
esophagogastrectomy.
IMPRESSION: Overall stable appearance of post-surgical chest.
Decrease in free intraperitoneal air.
Brief Hospital Course:
Mr. [**Known lastname 73080**] operative course was prolonged as expected, but
uncomplicated. He was routinely observed in the PACU, and
transferred to the ICU for closer monitoring due to the
complexity/acuity of the surgery.
.
ICU [**Date range (1) 68315**]:He tolerated extubation. Both Left & Right CT's
were placed to 20cm of suction. [**1-22**]: hoarseness was noted with
speaking. ENT service was consulted, and patient noted to have
left vocal cord paralysis. Currently, no need for inpatient
intervention as pt stable; should follow-up with Dr. [**Last Name (STitle) **]
as outpt.
.
On [**1-23**], he was transferred to [**Hospital Ward Name 2978**] for routine post-op care.
He continued NPO with NGT to suction, and IV hydration. The
left cervical JP drain to bulb suction was intact with scant
serous output. Left and Right Chest tubes to 20cm of suction
with no evidence of leak; draining serosanguinous fluid. JTUBE
was patent draining green, bilious fluid to gravity bag. Foley
catheter was patent, and draining clear urine. His pain was
managed with IV Dilaudid. He reported adequate pain management,
[**6-13**]. He was assisted to chair.
.
On [**1-24**], Tube feeds were started at 10cc/h. Nutrition Team was
consulted for adequate caloric intake. Tube feed formula and
rate was modified per Nutrition recommendations throughout
admission. He underwent a Barium swallow which revealed NO LEAK.
His NGT was removed. He remained NPO. Social Work was consulted
for support, and Physical Therapy was consulted due to expected
prolonged hospitalization and recovery. He will likely require
REHAB.
.
On [**1-25**], his foley catheter was removed. He was able to urinate
independently. He was advanced to sips of clear liquids, and
tolerated well. He continued with tube feedings via JTUBE.
Medications were transitioned to PO/PJTUBE as tolerated,
including PO oxycodone which relieved pain adequately. CXR
revealed increased bilateral pneumothoraces. Chest tubes were
put back to 20cm of suction. Treated with IV Lasix.
.
On [**1-26**], CXR revealed resolving pneumothoraces. Bilateral chest
tubes were place to water seal. Treated with IV Lasix. He was
advanced to clear liquids, and tolerated well. He continued with
tube feedings via JTUBE. Blood sugars remain controlled, treated
with regular insulin sliding scale. Pain continued to be well
managed.
.
On [**1-27**], Chest xray improved, and Righ Chest Tube was removed.
Treated with IV Lasix. Respiratory status remained stable. His
diet was advanced to regular, dysphagia diet.
.
on [**1-29**], Chest xray stable, and Left Chest Tube removed.
Respiratory status remained stable. He was able to tolerate
adequate PO intake with regular food. Tube feedings were
discontinued. His weight has remained stable.
.
On [**1-30**],he has remained stable, awaiting Rehab placement. His
physical & surgical status has improved daily. He was
re-evaluated per physical therapy, and cleared for discharge
home with VNA & PT. He & his wife agreed with this plan. His
last bowel movement was Tuesday [**2144-1-30**]. He will be discharged
with oxycodone, colace, ativan, and albuterol. He will follow-up
with Dr. [**Last Name (STitle) **] in [**2-5**] weeks, JTUBE will be removed in office
at that time as indicated.
Medications on Admission:
Ativan 0.5 PRN, compazine 10 PRN, Zofran 4 PRN, Protonix 40'
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
2. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain for 2 weeks.
Disp:*35 Tablet(s)* Refills:*0*
3. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for sleep anxiety.
Disp:*30 Tablet(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*1*
5. Pantoprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Albuterol 90 mcg/Actuation Aerosol Sig: [**2-5**] Inhalation every
4-6 hours as needed for shortness of breath or wheezing: Use
with spacer chamber.
Disp:*1 * Refills:*1*
7. Spacer
Aerochamber spacer-to be used with albuterol inhaler as
directed.
Size: Large/Adult
Disp:1 Refill:1
Discharge Disposition:
Home With Service
Facility:
VNA of [**Location (un) 270**]-East & Visiting Nurse Hospice
Discharge Diagnosis:
Primary:
Esophageal cancer
.
Secondary:
sinusitis/sinus polyps, HTN, anxiety
Discharge Condition:
Stable
Tolerating Regular Consistency: Soft (dysphagia); Thin liquids
diet
Adequate pain control with oral medications
Discharge Instructions:
Incision Care:
-Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
.
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomitting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons.
*Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
*Do not drive or operative heavy machinery while taking pain
medication.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to amubulate several times per day.
.
JTUBE care:
*Keep tube securely fastened to skin to avoid pulling.
*If tube falls out, apply dressing & pressure, and head to
closest Emergency Room.
Followup Instructions:
1. Follow up with Dr. [**Last Name (STitle) **] in [**2-5**] weeks. Please call his
office for an appointment ([**Telephone/Fax (1) 1483**].
2. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD Phone:[**0-0-**]
Date/Time:[**2144-2-20**] 11:30
3. Provider: [**Name10 (NameIs) 8111**] [**Name11 (NameIs) 8112**], RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2144-2-20**] 12:30
4. Please follow-up with your primary care provider, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 36206**] [**Telephone/Fax (1) 73081**], in 1 week or as needed.
Completed by:[**2144-1-30**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3797
} | Medical Text: Admission Date: [**2119-6-18**] Discharge Date: [**2119-6-28**]
Date of Birth: [**2119-6-18**] Sex: M
Service:
ADMISSION DIAGNOSES:
1. Newborn ex 37 and [**5-15**] week male infant.
2. Respiratory distress.
3. Rule out sepsis.
DISCHARGE DIAGNOSES:
1. Day of life number 11, ex 34 and [**5-15**] week infant male.
2. Respiratory distress resolved.
3. Sepsis ruled out.
4. Empiric treatment for possible pneumonia now completed.
5. History of hyperbilirubinemia status post phototherapy.
IDENTIFICATION: Baby boy [**Known lastname 10162**] [**Known lastname 48345**] is now day of life
number 11 ex 37 and [**5-15**] week male who was admitted to the
Neonatal Intensive Care Unit at [**Hospital1 188**] secondary to respiratory distress and rule out sepsis.
HISTORY OF PRESENT ILLNESS: Baby boy [**Known lastname 10162**] [**Known lastname 48345**] is now
day of life number 11 ex 37 and [**5-15**] week infant who was
admitted on [**2119-6-18**] secondary to respiratory distress
and rule out sepsis. The baby was delivered via [**Name (NI) 48346**] under
epidural anesthesia to a 28 G1 P0 now 1 mother with a past
medical history, which was notable for glomerulonephropathy
with onset during pregnancy. She had a high degree of
proteinuria during that time. Her prenatal screens were
significant for blood type O positive, antibody screen
negative, HBSAG negative, RPR nonreactive, rubella immune and
GBS unknown. The mother's estimated date of delivery was
[**2119-7-5**] for an estimated gestational age at the time of
delivery at 37 and 4/7 weeks. Mom's pregnancy as noted above
was complicated by nephropathy. Betamethasone was
administered on [**2119-5-15**] in case preterm delivery was necessary
secondary to the maternal glomerulonephropathy. Rupture of
membranes occurred naturally and was 16 hours prior to
delivery yielding a clear amniotic fluid. There was no
history of maternal fever or fetal tachycardia. No
antepartum antibiotics were administered. The infant
proceeded to spontaneous vaginal delivery under epidural
anesthesia. The neonatal Intensive Care Unit was not in
attendance at the time of delivery. The infant received bulb
suctioning and tactile stimulation and then was given blow by
oxygen. Respiratory distress was noted through approximately
30 minutes of age leading to transfer to the Neonatal
Intensive Care Unit for evaluation and then eventual
admission.
PHYSICAL EXAMINATION ON ADMISSION: Birth weight 2485 grams,
saturation 96% on room air. Heart rate 148. Respiratory
rate 70 to 80. Blood pressure not specified. Blood glucose
not specified. HEENT anterior fontanel open, soft and flat.
Nondysmorphic faces. Palette intact. Neck and mouth normal.
Mild nasal flaring. Chest mildly costal retractions. Good
breath sounds bilaterally. No crackles noted.
Cardiovascular regular rate and rhythm. Normal S1 and S2. No
murmur noted. No rubs or gallops. Femoral pulses normal
bilaterally. Abdomen soft, nontender, nondistended. Bowel
sounds active. No organomegaly. Genitourinary normal male
genitalia with testes descended bilaterally. Anus patent.
Central nervous system active, alert, responsive to
stimulation. Tone appropriate. Moving all limbs
symmetrically. Suck, root, gag, grasp reflexes normal.
Extremities normal spine, limbs, clicks and clavicles.
HOSPITAL COURSE: 1. Cardiovascular: Baby boy [**Known lastname 10162**]
[**Known lastname 48345**] was admitted to the Neonatal Intensive Care Unit in
stable condition in terms of his cardiovascular status. He
had no episodes of hypotension nor hypertension. Baby boy
[**Known lastname 10162**] [**Known lastname 48345**] did have several episodes of what appeared
to be apnea with oxygen desaturation noted subsequent to
extubation after being treated for surfactant deficiency.
However, during these events he was not noted to be
bradycardic. Since his respiratory distress has resolved he
has had no episodes of cardiovascular instability and is
discharged to home without any concerns in terms of his
cardiovascular status.
2. Respiratory: Baby boy [**Known lastname 10162**] [**Known lastname 48345**] was admitted in
respiratory distress with grunting, flaring, retracting. His
grunting, flaring, retracting increased such that he was
started on nasal CPAP originally at 5 cm of water with an
FIO2 starting at approximately 40% FIO2. His respiratory
rates were noted to be 60s to 80s during that time. He
remained on mobile CPAP until approximately midnight on the
night of [**6-18**] where upon his respiratory
distress increased and he was intubated and given surfactant
in the early hours of the morning of [**2119-6-19**]. His
initial settings were 20/5 with a rate of 25. He had a good
capillary gas at that time. The settings were weaned and he
was given a second treatment of surfactant on the morning of
[**2119-6-19**]. His vent continued to be weaned and he was in
room air. He was extubated approximately 3:00 p.m. on [**6-19**]
and was placed on nasal cannula oxygen at approximately 400
cc per minute flow. His original FIO2 was about .4, however,
over the course of the next several days his FIO2 increased
to approximately .7 to 1.0 with 1.0 being needed during cares
and feedings. Baby boy [**Known lastname 10162**] [**Known lastname 48345**] remained on nasal
cannula oxygen for an extended period of time meet needing
supplemental oxygen via nasal cannula until approximately the
evening of [**6-25**]. Initially baby boy [**Name (NI) 10162**] [**Name (NI) 48345**]
required continuing 400 cc at near 1.0 FIO2 until
approximately [**6-23**] to [**6-24**] when his flow was weaned to low
flow at approximately 13 to 50 cc per minute at 1.0 and
eventually came off on [**2119-6-25**]. Subsequent to his being
weaned off of his nasal cannula baby boy [**Name (NI) 10162**] [**Name (NI) 48345**] has
been in room air without any difficulties and has had no need
for supplemental oxygen.
Subsequent to extubation baby boy [**Name (NI) 10162**] [**Name (NI) 48345**] had
several episodes of apnea or shallow breathing with oxygen
desaturation, which was not accompanied by bradycardia. At
least one of his episodes occurred while he was being held by
his parents. He did, however, not have any more episodes of
apnea/shallow breathing or oxygen desaturation from the point
of Saturday afternoon [**6-24**] until the time of his discharge,
which constitutes five days without any episodes of oxygen
desaturations or altered breathing pattern. He was not
treated with any methylxanthine for stimulation of his
respiratory center.
3. Fluids, electrolytes and nutrition: Baby boy [**Known lastname 10162**]
[**Known lastname 48345**] was admitted in respiratory distress and was made
NPO. He was started on oral feedings subsequent to
extubation and started feeding on [**6-19**] to [**2119-6-20**]. He did
not feed well, however, po secondary to his degree of
respiratory distress during feeds and thus was fed both po
and pg during the first several days of his enteral feeds.
However, his feeding behavior improved such that by the
weekend of [**2119-6-23**] he was on solely oral feeds without need
for gastric tube feedings and was taking very good volumes of
oral feeds. For example on the day prior to discharge baby
boy [**Name (NI) 10162**] [**Name (NI) 48345**] took 160 cc per kilo per day of breast
milk or Enfamil 20 with iron. During his hospitalization
baby boy [**Name (NI) 10162**] [**Name (NI) 48345**] had no difficulties with
electrolyte instabilities nor with urine output or stooling.
He is thus discharged to home without any concerns regarding
his fluids, electrolytes or nutrition.
4. Hematologic and infections diseases: Upon admission baby
boy [**Name (NI) 10162**] [**Name (NI) 48345**] was started on antibiotics secondary to
his respiratory distress in the setting of a mother whose GBS
status was unknown. He was placed on Ampicillin and
Gentamycin and a blood culture was collected as well as a
CBC. CBC was benign and the blood culture remained no growth
to date after 48 hours and antibiotics were discontinued at
that time. Secondary to his continuing respiratory distress,
however, and the inability to discern whether or not his
original chest x-ray was consistent with surfactant
deficiency or pneumonia baby boy [**Name (NI) 10162**] [**Name (NI) 48345**] was
restarted on antibiotics consisting of ampicillin and
gentamicin for seven days. As his oxygen requirement
gradually reduced to 0 and he reached seven days of therapy
for possible pneumonia, baby boy [**Name (NI) 10162**] [**Known lastname 48347**]
antibiotics were discontinued on [**2119-6-28**].
Baby boy [**Known lastname 10162**] [**Known lastname 48345**] had some difficulty with
hyperbilirubinemia reaching a peak bilirubin of 18 on
[**2119-6-21**]. He was started on phototherapy times two and his
total bilirubin reduced such that by the [**2119-6-26**] he was off
of phototherapy and his post phototherapy total bilirubins
were well within the normal range. The last total bilirubin,
which was measured was 9.3 off of phototherapy. Thus baby
boy [**Name (NI) 10162**] [**Name (NI) 48345**] is discharged to home without any
concerns regarding his hematologic or infectious diseases.
5. Sensory: Hearing screen was performed with automated
auditory brain stem responses and the baby passed this
testing modality.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: To home.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) 17494**] at [**Hospital3 **]
Pediatrics, phone number is [**Telephone/Fax (1) 17663**]. Follow up
appointment is to be made early next week.
FEEDING AT DISCHARGE: Mother's milk or Enfamil 20 with iron
ad lib on demand.
MEDICATIONS: Ferrous sulfate 0.2 cc po q day.
State newborn status pending. Immunizations received is
hepatitis B vaccine.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 37237**], M.D. [**MD Number(1) 37238**]
Dictated By:[**Dictator Info 48348**]
MEDQUIST36
D: [**2119-6-28**] 02:47
T: [**2119-6-28**] 15:01
JOB#: [**Job Number 48349**]
ICD9 Codes: 769, 486, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3798
} | Medical Text: Admission Date: [**2163-3-31**] Discharge Date: [**2163-4-2**]
Service: MEDICINE
Allergies:
Celebrex / Aspirin
Attending:[**First Name3 (LF) 5510**]
Chief Complaint:
melena, syncope
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
[**Age over 90 **] year-old female with CAD admitted with melena and syncope.
Evening preceding admission she woke up with chest pain, similar
to prior episodes. She took SLNTG x2 with relief. Subsequently
had large volume melena followed by syncope while seated on
toilet. Witnessed; no trauma. She did not have abdominal pain,
nausea/vomiting, and has otherwise felt well recently. Sent
from nursing home for further evaluation.
.
In the ED, 98.2 65 93/41 18 96%. Hypotension improved to sBP
100s with hydration. Had large dark bowel movement, followed by
red "jelly" like stool. NG lavage with coffee grounds which
cleared with 200-300cc, no bright red blood. Laboratory data
significant for hematocrit 23 (baseline 30), BUN 49 and
chemistry panel otherwise within normal limits, troponin-T 0.02.
GI was consulted - recommended pRBCs, PPI gtt with plan to
scope this morning. Received 1.5L NS IVF, PPI bolus/gtt, 2
units pRBCs. For access she has 2 18G PIV. On transfer to
MICU, 69 109/79 17 97%RA.
.
In the MICU, she reports fatigue and wishes to rest. She denies
lightheadedness, chest pain, palpitations, abdominal pain,
nausea, vomiting, recent dark or bloody stools (prior to today),
dysuria. She feels that she needs to have a bowel movement now.
Past Medical History:
- CAD: Chronic stable angina.
- Diastolic dysfunction, preserved EF (TTE [**5-7**])
- Hypertension
- Osteoarthritis
- Osteoporosis
- Hyperlipidemia
- Hearing loss
- Pseudogout
- B12 deficiency
- Sick sinus syndrome
- Urinary incontinence
- s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 51105**] to basal cell carcinoma of left eyelid
- s/p oophorectomy
- s/p cystocele & rectocele repair
- s/p left eye cataract surgery
- s/p appendectomy
- s/p tonsillectomy
Social History:
Lives at [**Hospital1 789**] House Senior Living Community.
Well-supported by her daughter. She denies tobacco or alcohol
use.
Family History:
Extensive CAD causing death of both parents in 60's, all 3
brothers ages 50s-80s.
Physical Exam:
ADMISSION EXAM:
Vitals: 73, 118/47, 22, 96%RA
General: Appears pale, fatigued
HEENT: Sclera anicteric, dry mucous membranes
Neck: Prominent jugular venous pulsation
Lungs: Few bibasilar crackles
CV: RRR; normal S1/S2; no murmurs appreciated
Abdomen: Hyperactive bowel sounds; soft, non-tender, not
distended
Ext: Warm, well-perfused; radial pulses 2+ and symmetric
Neuro: A&Ox3, CN II-XII intact, motor and sensory function
grossly intact
.
DISCHARGE EXAM:
Tc: 98.3 Tm: 98.8 BP: 128-150/42-75 RR: 64-66 RR: 18 O2: 96%RA
I: 1350 Out: 1650
GENERAL - pleasant, NAD
HEENT - MMM, clear OP, EOMI, decreased hearing bilaterally,
LUNGS - CTAB on anterior exam, unlabored
HEART - RRR, normal S1, S2, no m/r/g
ABDOMEN - soft/NT/ND, +bowel sounds, no rebound/guarding
EXTREMITIES - WWP, 2+ peripheral pulses, pneumoboots
Neuro - AAOx3, CN II-XII intact, 4+/5 strength upper/lower
extremities
Pertinent Results:
ADMISSION LABS:
[**2163-3-31**] 03:10AM BLOOD WBC-7.1# RBC-2.59*# Hgb-8.3* Hct-23.2*
MCV-90 MCH-32.2* MCHC-35.9* RDW-13.2 Plt Ct-190
[**2163-3-31**] 03:10AM BLOOD Neuts-63.4 Lymphs-30.8 Monos-4.5 Eos-0.8
Baso-0.5
[**2163-3-31**] 03:10AM BLOOD Glucose-164* UreaN-49* Creat-0.9 Na-141
K-4.6 Cl-106 HCO3-27 AnGap-13
[**2163-3-31**] 11:17AM BLOOD Calcium-6.8* Phos-3.3 Mg-1.9
.
PERTINENT LABS:
[**2163-3-31**] 03:10AM BLOOD cTropnT-0.02*
[**2163-3-31**] 11:17AM BLOOD CK-MB-7 cTropnT-0.01
[**2163-3-31**] 11:17AM BLOOD CK(CPK)-122
.
MICROBIOLOGY:
[**2163-3-31**] Urine Cx: URINE CULTURE (Final [**2163-4-2**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
[**2163-3-31**] HELICOBACTER PYLORI ANTIBODY TEST (Final [**2163-4-1**]):
POSITIVE BY EIA.
.
PATHOLOGY:
[**2163-3-31**] Gastric biopsy: PENDING
.
IMAGING:
none
.
DISCHARGE LABS:
[**2163-4-2**] 06:55AM BLOOD WBC-4.7 RBC-3.36* Hgb-10.5* Hct-29.4*
MCV-88 MCH-31.3 MCHC-35.8* RDW-14.4 Plt Ct-118*
[**2163-4-1**] 08:50AM BLOOD Glucose-139* UreaN-34* Creat-0.7 Na-140
K-4.0 Cl-110* HCO3-24 AnGap-10
[**2163-4-1**] 08:50AM BLOOD Calcium-7.8* Phos-2.8 Mg-1.9
Brief Hospital Course:
[**Age over 90 **]F with CAD, HTN, diastolic dysfunction, admitted with syncope
in the context of melena, had EGD with 2 non-bleeding ulcers in
stomach, H. pylori positive also found to have UTI with pan
sensitive E coli.
.
# GI bleed: Given the melena and coffee grounds on NG lavage, an
upper GI bleed was suspected. The patient was started on a
protonix gtt and was transfused 2 units of PRBCs in the ED. She
was admitted to the MICU for further monitoring with Q6h
hematocrits. EGD revealed diffuse gastritis and two clean-based
ulcers in the gastric antrum. A biopsy was taken and serology
was sent for H. pylori, which returned positive. The patient
was transferred to the floor and transfused 1 unit PRBC for a
goal Hct of 30. She was evaluated by physical therapy and
cleared to go home with services. She was discharged with
instructions to start treatment for H pylori.
.
# Syncope: In the context of GI bleed, while on the commode.
Preceded by chest pain for which she took SLNTG x2. Syncope may
be related to hypovolemia from blood loss vs. vasovagal episode
in context of bowel movement/SLNTG. She was volume resuscitated
in the ED with 1.5L NS and 2 units pRBCs. Cardiac enzymes were
negative.
.
# UTI - Patient was having dysuria prior to admission to
hospital. Urine culture grew pan sensitive E coli. Patient
will be taking amoxicillin for H pylori eradication which will
also treat her UTI.
Inactive Issues:
# Diastolic dysfunction: Known LVH, preserved EF per TTE [**5-7**].
.
# CAD: Not currently taking aspirin, Plavix, or beta-blocker.
.
# Hypertension: Initially held home amlodipine and lisinopril in
the setting of GI bleed.
Transitional Issues:
- GI f/u
- Discuss with Cardiology regarding necessity of aspirin - If
patient is to continue on aspirin longer than planned 6 week
course of pantoprazole, she will need to continue pantoprazole
as well
- Platelets follow-up - Patient did have mild thrombocytopenia
on discharge
Medications on Admission:
1. Nitroglycerin patch 0.3mg/hour 12 hours daily
2. Amlodipine 5mg PO daily
3. Vitamin B12 250mcg PO daily
4. ASA 81mg PO daily - patient reports not taking
5. MVI
6. Fosamax once weekly
7. Vitamin D3 1000 units PO daily
8. Lisinopril 2.5mg PO QHS
9. SLNTG prn
Discharge Medications:
1. nitroglycerin 0.3 mg/hr Patch 24 hr Sig: One (1) patch
Transdermal once a day: Please leave on for 12 hours daily.
2. amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day.
3. Vitamin B-12 250 mcg Tablet Sig: One (1) Tablet PO once a
day.
4. aspirin 81 mg Tablet Sig: One (1) Tablet PO qMon, Wed, Fri.
5. multivitamin Tablet Sig: One (1) Tablet PO once a day.
6. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week.
7. Vitamin D-3 1,000 unit Tablet, Chewable Sig: One (1) Tablet,
Chewable PO once a day.
8. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO at bedtime.
9. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual once a day as needed for chest pain.
10. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
11. amoxicillin 500 mg Capsule Sig: Two (2) Capsule PO twice a
day for 7 days.
Disp:*28 Capsule(s)* Refills:*0*
12. clarithromycin 500 mg Tablet Sig: One (1) Tablet PO twice a
day for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary: Peptic ulcer disease
Secondary: Hypertension, coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname 51106**],
It was a pleasure taking care of you during your
hospitalization. You were admitted after you had a bloody bowel
movement and passed out. You were noted to have a low blood
level in the ED. You were transfused with blood and admitted to
the Intensive Care unit. You had an upper endoscopy that showed
inflammation and 2 ulcers in the stomach, however they were not
bleeding. A biopsy from your stomach returned positive for H
pylori, a bacteria known to cause ulcers. We will treat you
with antibiotics and acid suppressing medications to treat this.
You also had a urinary tract infection that will be treated
with the antibiotics you will take for the H. pylori. We checked
your blood levels on the floor and they were stable. You were
seen by our physical therapists who thought you were safe to go
home.
.
We made the following changes to your medications:
STARTED:
Pantoprazole 40mg by mouth twice daily for at least 6 weeks - If
you continue on aspirin, you will need to continue on this
medicine
Amoxicillin 1gm by mouth twice daily for 7 days
Clarithromycin 500gm by mouth twice daily for 7 days
Hold your aspirin until Monday, then you can restart this
medication.
.
Please follow up with your appointments below.
Followup Instructions:
Dr. [**Last Name (STitle) 1266**] should see you at your [**Hospital3 **] home in a
few days.
Department: DIV. OF GASTROENTEROLOGY
When: WEDNESDAY [**2163-4-27**] at 2:00 PM
With: [**Name6 (MD) 21154**] [**Last Name (NamePattern4) 21155**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
.
Department: CARDIAC SERVICES
When: MONDAY [**2163-5-2**] at 8:20 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2385**], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: ORTHOPEDICS
When: MONDAY [**2163-6-6**] at 10:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10486**], MD [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2163-4-3**]
ICD9 Codes: 5990, 2851, 2875, 4589, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3799
} | Medical Text: Admission Date: [**2146-1-12**] Discharge Date: [**2146-1-15**]
Service: MICU
CHIEF COMPLAINT: Cardiac arrest, respiratory arrest.
HISTORY OF PRESENT ILLNESS: The patient is an 81 year-old
man with a history of bipolar disorder who was referred to
the Emergency Department by his psychiatrist with agitation
and mental status change and was admitted to Medicine for a
delirium workup. The family reported that in [**Month (only) 404**] the
patient presented with palpitations and had an
echocardiogram, which revealed mild pulmonary hypertension.
Telemetry revealed two asymptomatic runs of nonsustained
ventricular tachycardia and the patient was started on
Metoprolol. Several weeks later the patient was readmitted
for bright red blood per rectum with a negative
esophagogastroduodenoscopy and barium enema. Over the past
weeks prior to presentation the patient had been agitated,
yelling and cursing with visual hallucinations and paranoia.
The patient was not sleeping well. The patient presented to
the Emergency Department on [**2146-1-12**], minimally responsive
with dramatic Parkinsonism features. Lithium levels 1.3.
The patient also had a sodium of 150, which is a chronic
problem secondary to nephrogenic diabetes insipidus. Head CT
was negative. The patient's psychiatric medications were
held and a lumbar puncture was performed, which was negative.
The patient had received 10 mg of intravenous Ativan for the
lumbar puncture. That evening the patient was found to be
diaphoretic and in respiratory distress. First responders
found a weak pulse, heart rate in the 30s. This degenerates
a PEA. The patient was given epinephrine and atropine and
then developed ventricular tachycardia. The patient was
shocked with 200 jewels and developed a narrow complex
tachycardia. The patient was intubated and sent to the
Intensive Care Unit for further management. the patient
coded for twenty minutes.
PAST MEDICAL HISTORY: 1. Hypertension. 2. Bipolar
depression. 3. History of nonsustained ventricular
tachycardia. 4. History of gastrointestinal bleed. 5.
Hemorrhoids. 6. Increased PSA. 7. Abnormal thyroid
function tests. 8. Pulmonary hypertension.
MEDICATIONS: Ativan 1 to 2 mg intravenous prn. Risperdal
0.25 q.h.s., Metoprolol 25 mg po b.i.d., Lithium 300 mg in
the a.m. and 600 in the p.m. Ketorolac 0.5% ophthalmic one
drop OD t.i.d. Voltaren drops OS t.i.d., CoSopt one drop OU
b.i.d., Ocuflox 0.3% drop OD t.i.d., Prednisone 1% drop OD
t.i.d., Alphagan 0.2% drop b.i.d.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient is a retired chef with 100 pack
year history of smoking quitting in [**2133**]. The patient denies
any alcohol or drug use.
PHYSICAL EXAMINATION: On general examination the patient was
an elderly man lying in bed unresponsive. HEENT examination
revealed pupils that were minimally reactive, 3 mm and
midline. Neck examination revealed a supple neck.
Cardiovascular examination revealed regular tachycardiac with
normal S1 and S2. No murmurs, rubs or gallops. Chest
examination revealed good air movement with coarse bilateral
breath sounds. Abdominal examination revealed soft,
nontender, nondistended belly with normal bowel sounds.
Extremity examination revealed no edema. Neurological
examination the patient was intubated and sedated with no gag
reflex, no over breathing of the vent, inability to withdraw
to pain and no spontaneous movements.
PERTINENT LABORATORY FINDINGS: The patient had a white blood
cell count of 9 with a hematocrit of 36.9 and platelets of
267. The patient had a sodium of 150 with a creatinine of
1.1. The patient had initial CK of 59. Initial urinalysis
revealed nitrite negative, leukocyte negative, no white blood
cells, no red blood cells. Lithium level was 1.3. RPR was
negative. Tox screen was negative. Cerebral spinal fluid
gram stain was negative for organisms and neutrophils.
Cerebral spinal fluid culture was negative at the time of
this dictation. Tube number four of cerebral spinal fluid
had 1 white blood cell and 0 red blood cells. Cerebral
spinal fluid protein was 46 with a glucose of 67.
Chest x-ray revealed infiltrate in the right lower lobe.
There was a right IJ in place. There was no pneumothorax.
ET tube was approximately 4 cm above carinii.
Electrocardiogram sinus at 65 with a left axis deviation, PR
interval of .16, QRS of .16, QTC of .36 and minimal T wave
flattening in V5 and V6, which was new. Head CT revealed no
infarct or bleed. Chest CT revealed no PE and a right lower
lobe infiltrate.
HOSPITAL COURSE: This 81 year-old man presented for
evaluation of delirium and was admitted to the MICU after
respiratory and cardiac arrest.
The patient remained intubated and sedated in the Intensive
Care Unit on supportive mechanical ventilation. He ruled out
for myocardial infarction with three negative creatine
kinases. The patient was given antibiotics consistent of
Levofloxacin and Flagyl for right lower lobe presumed
aspiration pneumonia. Neurology and psychiatry were
consulted and a repeat head CT revealed no changes from the
prior study. On the day after admission to the MICU the
patient had some brain stem function present, but remained in
a coma. Propofol was discontinued and the patient did not
show any increase in mental status. All psychiatric
medications were held. Neurology followed the patient as did
psychiatry. The patient's hypernatremia was treated with D5W
and he required phosphate supplementation for
hypophosphatemia. A family meeting was held with the
patient's relatives and after 24 hours of minimal progress in
the patient's mental status and neurologic examination the
patient elected to make the patient CMO. The patient expired
shortly thereafter.
CONDITION AT DISCHARGE: Expired.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], M.D. [**MD Number(1) 292**]
Dictated By:[**Last Name (NamePattern1) 5246**]
MEDQUIST36
D: [**2146-1-15**] 08:01
T: [**2146-1-18**] 09:23
JOB#: [**Job Number 92904**]
ICD9 Codes: 4271, 4168, 5070, 2760, 4019 |
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