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{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3800
} | Medical Text: Admission Date: [**2112-2-29**] Discharge Date: [**2112-3-4**]
Date of Birth: [**2034-9-14**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Iodine; Iodine Containing / Biaxin / Librium
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
resp failure, tx from OSH
Major Surgical or Invasive Procedure:
Flexible bronchoscopy ([**2112-3-4**])
mechanical ventillation
History of Present Illness:
77 yo f with trach, no vent for COPD, HTN, CHF transferred here
for resp failure at NH. History is from the ED Attn at NWH and
husband. [**Name (NI) **] her husband, she was well yesterday, comminucating
and eating normally. This morning, she had decreased O2 sats and
change in mental status with decreased attetivnss and ability to
obey commands. Normally she is A and O x3. [**Hospital1 **] staff checked
an ABG which was 7.36/93/126 on 35% TM. She was changed to 25%
TM and ABG was 7.35/93/74. There is a note from [**Hospital1 **] that
says she refused the vent there. The patient was slumped over
when EMS arrived and was brought to the NWH ED.
.
In the NWH ED, vitals were BP 132/61, HR 63, RR 16, temp 97.8,
sat 98% on venti mask. CXR was "unchaged from prior", and CE
were reportedly negative, though these were not sent in the
records. She recieved solumedrol 125 IV, ativan 2IV, and
fantanyl 100 iv on route for pain in the ambulance. She was
noted to have a facial ecchymosis, scalp hematoma, and L arm
hematoma that the husband [**Name (NI) 81717**] is new as compared to yesterday.
No imagining of these areas was done.
.
last admission was [**2-10**] for PNA, DM, and severe deconditioning.
She was treated with linezolid for MRSA and p aruginosa PNA.
FInichsed course on [**2-1**].
In the [**Hospital Unit Name 153**], she has the vent in place. She winces to pain.
Otherwise, she does not follow commands
Past Medical History:
1. COPD, on trach mask normally. chronic prednisone. She
recieved a trach after a [**1-6**] admission for which she had a PEA
arrest and was severely hypercarbic. Pulm: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at
NWH
2. ?tracheomalacia + tracheal stenosis - bronch at NWH on [**1-6**]
demonstrated dynamic exp collapse of the trachea extending to
tbe mainstem bronchi and stenosis above the stomal trach
involving the croicoid
3. DMII
4. hypothyroidism
5. HTN
6. OA
7. OSA
8. hypoventaliation syndrome
9. Depression
10. Morbid obesity
11. R hip avulsion fracture
12. chronic leg edema
13. MRSA
14. highly resistant p. aruginosa
15. L frozen shoulder
16. CHF with diastolic dysfunction
17. afib not on anticoagulation
18. large ventral hernia
Social History:
Married lives at [**Hospital1 **] NH for the last year. Hs been in and
out of multiple hospitals the last year. Is able to eat. Cannot
walk. Frequent falls per husband where she tried to get up and
falls to the floor.
Family History:
NC
Physical Exam:
PE: T 98.0 BP 120/108 HR 67 O2Sat 99% RA AC 450/18/5/50%
Gen: arousable elderly female
Heent: large ecchymosis on L face and L forehead. pus around
trach site. PERRLA.
Lungs: transmitted vent sounds
Cardiac: RRR S1/S2 no m/r/g
Abd: soft NT NABS, large ventral hernia
Ext: 2cm x 3cm stage III ulcer in interior aspect of R thigh.
chronic cellilutic changes of Bilateral LE.
Neuro: arousable, not following commands. Moving all 4.
Pertinent Results:
Labs on admission:
[**2112-3-2**] 04:37AM BLOOD WBC-13.8* RBC-3.36* Hgb-9.1* Hct-29.7*
MCV-88 MCH-27.1 MCHC-30.6* RDW-14.5 Plt Ct-379
[**2112-2-29**] 07:39PM BLOOD Neuts-92.7* Lymphs-5.6* Monos-1.4*
Eos-0.1 Baso-0.2
[**2112-3-2**] 04:37AM BLOOD PT-11.4 PTT-36.4* INR(PT)-1.0
[**2112-2-29**] 07:39PM BLOOD Glucose-122* UreaN-40* Creat-1.3* Na-140
K-5.1 Cl-93* HCO3-41* AnGap-11
[**2112-2-29**] 07:39PM BLOOD ALT-16 AST-29 LD(LDH)-282* CK(CPK)-268*
AlkPhos-135* TotBili-0.5
[**2112-2-29**] 07:39PM BLOOD CK-MB-7 cTropnT-0.10*
[**2112-2-29**] 11:46PM BLOOD CK-MB-5 cTropnT-0.09*
[**2112-3-1**] 03:31AM BLOOD CK-MB-4 cTropnT-0.11*
[**2112-2-29**] 11:46PM BLOOD CK(CPK)-346*
[**2112-3-1**] 03:31AM BLOOD LD(LDH)-226 CK(CPK)-313* AlkPhos-110
[**2112-2-29**] 07:39PM BLOOD Albumin-3.2* Calcium-9.3 Phos-2.1* Mg-2.2
CXR: Limited study due to patient rotation, with:
1. No evidence of heart failure or definite pneumonia
2. Small right pleural effusion.
3. Increased bibasilar opacities suggestive of
atelectasis/aspiration.
Elbox Xray:
IMPRESSION: Left elbow joint effusion with malalignment of the
medial humeral condyle is suggestive of underlying fracture. CT
of the elbow is recommended for further characterization.
NOTE ADDED IN ATTENDING REVIEW: Only two views are provided,
both of which are obliquely positioned. Allowing for this, there
is no evidence of joint
effusion, the alignment is normal and there is no fracture. A CT
of the elbow has already been arranged.
CT elbow: Limited study due to patient motion and habitus;
allowing for
this, there appears to be normal alignment without definite
fracture or joint effusion.
CT Head:
There are no comparisons on record. There is no intra- or
extra-
axial hemorrhage, the midline structures are in the midline and
the ventricles and cisterns are normal in size and in contour.
The [**Doctor Last Name 352**]-white matter differentiation is, overall, maintained,
with no focal sulcal effacement or loss of [**Doctor Last Name 352**]-white matter
differentiation to indicate acute vascular territorial
infarction. There are scattered and somewhat ill-defined low-
attenuation foci in both cerebral hemispheres, particularly
evident in the left frontal subcortical, bilateral
subinsular/external capsule and left periatrial regions, likely
representing a combination of chronic microvascular and lacunar
infarction. There is no evidence of significant soft tissue
injury and no underlying skull fracture is seen. The middle ear
cavities and included portions of the paranasal sinuses are
largely clear; the mastoid processes, bilaterally, appear
sclerotic and may be congenitally non- pneumatized.
IMPRESSION:
1. No acute intracranial abnormality.
2. Evidence of chronic microvascular and lacunar infarction, as
described.
CT Spine: No fracture. Marked degenerative changes involving
the cervical
spine notably grade I anterolisthesis of C4 on C5 with focal
angular kyphosis. There is also moderate canal narrowing
secondary to exuberant posterior endplate osteophytes at C5-C6.
EKG:
Sinus rhythm
Atrial premature complex
First degree A-V delay
Left atrial abnormality
Left bundle branch block
No previous tracing available for comparison
Culture data:
[**2112-2-29**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC
BOTTLE-PENDING INPATIENT
[**2112-2-29**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC
BOTTLE-PENDING INPATIENT
[**2112-2-29**] URINE URINE CULTURE-PRELIMINARY {GRAM NEGATIVE ROD
#1, PROTEUS SPECIES} INPATIENT
[**2112-2-29**] 7:26 pm SPUTUM Site: ENDOTRACHEAL
Source: Endotracheal.
GRAM STAIN (Final [**2112-2-29**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Preliminary):
OROPHARYNGEAL FLORA ABSENT.
STAPH AUREUS COAG +. MODERATE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
SENSITIVE TO AMIKACIN (<=2).
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
| PSEUDOMONAS AERUGINOSA
| |
CEFEPIME-------------- 4 S
CEFTAZIDIME----------- 16 I
CIPROFLOXACIN--------- =>4 R
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S =>16 R
IMIPENEM-------------- 8 I
LEVOFLOXACIN---------- =>8 R
MEROPENEM------------- 8 I
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
PIPERACILLIN---------- =>128 R
PIPERACILLIN/TAZO----- 16 S
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TOBRAMYCIN------------ 8 I
VANCOMYCIN------------ <=1 S
[**2112-2-29**] 5:24 pm SWAB Site: TRACHEA Source: trach site.
WOUND CULTURE (Preliminary):
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup is performed appropriate to the isolates recovered
from the
site (including a screen for Pseudomonas aeruginosa,
Staphylococcus
aureus and beta streptococcus).
STAPH AUREUS COAG +. MODERATE GROWTH.
GRAM NEGATIVE ROD(S). SPARSE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
Brief Hospital Course:
A/P: 77 yo f with h/o severe COPD requiring trach, here with
hypercarbic resp failure, altered mental status, h/o of fall per
husband.
.
# Hypercarbic Resp failure: Given her h/o of hypoventilation and
COPD, it is likely that she is normally very hypercarbic and
then began to hypoventilate overnight leading to further
hypercarbia. She will need the vent support overnight. She was
weaned off the vent and was placed on trach mask on [**3-2**]. Passy
Muir valve mask attempted to be fitted but patient with
difficulty, gagging and choking sensation though sats stable.
Flex bronch [**3-4**] with subglottic/ glottic edema, no granulation
tissue. Recommended PPI, in addition to lifting head of bed and
possible decreasing trach size.
***Pt discharged to have PS at night to prevent hypoventilation
with 5/5 in addition to trach mask during the day.***
.
# Hypoventalitation: - Team continued theophylline 300 [**Hospital1 **] for
hypoventiliation.
.
# Bronchitis: Pt had pus coming from trach site and very
pruluent sunction sectretions on admission. Sputum cx sent and
trach wound was cultureded. These showed coag + S aureus and
sparse growth of P. aeruginosa. Since she has a h/o VRE and
highly resistant pseudomans per old DC summaries. Started on
meropenem (on sertraline, concern for seratonin syndrome
precliuded linezolid) and vanc. With sensitivities returning
back P. Aeruginosa (Intermediate to meropenem) and growth of
proteus in urine, pt was switched to cefepime for coverage of
both Proteus UTI and Pseudomonas in sputum. Will need to
complete a 14 day course with last day being on [**2112-3-14**] for
vancomycin and cefepime. PICC line was placed [**3-4**] for Abx
administration.
.
# Fall: Has a h/o falls. Husband say day before admission and
said there were no ecchymosis on face on arm. On presentation,
she had large ecchymosis on face and arm. no imagining was done
at NHW. Therefore, head CT and c-spine clearance was done. Elbow
was deformed therefore XRAY was done. was concerneing for
fracture. CT showed no fracture. Likely only hematoma.
.
# DMII: continued on insulin. NPH
.
# HTN: Disconinuted her atenolol since her PR is so prolonged.
Started
amlodipine [**3-1**] 5 mg daily to uptitrate as per BP. Can uptitrate
as needed and resume BB as PCP sees fit as outpatient.
.
#CHF: Pt volume depleted while in house. Held Bumex with no
evidence of failure on X-ray. As patient begins appropriate PO
intake can restart Bumex.
.
# Stage III decub wound on innter thigh: wound consult saw
patient.
.
# Code: Full
# Communication: Husband [**Name (NI) **] [**Telephone/Fax (1) 93098**]
Medications on Admission:
Imdur 60 [**Hospital1 **]
prednisone 10
theophylline 300 [**Hospital1 **]
colace 100 [**Hospital1 **]
ISS
lidoderm patch to R hip q24
fondaparinux 2.5 mg SC for DVT ppx
ativan 0.5 po q6 prn
tylenol prn
NPH 30 [**Hospital1 **]
levothoryxine 100 mcg
bumex 1 [**Hospital1 **]
atenolol 25 daily
zoloft 150 daily
Kcl 40 meq daily
iron
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Hypercarbic respiratory failure
Tracheobronchitis
Discharge Condition:
good, trach mask on during day, vent on at night
Discharge Instructions:
You were admitted with hypoxia, and found to have a low oxygen
level and high CO2. You were intubated and then extubated. You
were treated with antibiotics for a pneumonia. You are currently
on PS ventilation at 5/5 to be worn nightly to help avoid C02
narcosis and a similar episode.
Followup Instructions:
To follow up with Doctors [**First Name (Titles) **] [**Last Name (Titles) 100**] Rehab and Dr. [**Last Name (STitle) 59771**]
[**Telephone/Fax (1) 59772**]
ICD9 Codes: 4280, 5990, 486, 5849, 4019, 2449, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3801
} | Medical Text: Admission Date: [**2157-3-22**] Discharge Date: [**2157-4-4**]
Date of Birth: [**2096-5-22**] Sex: F
Service: MEDICINE
Allergies:
Meperidine
Attending:[**First Name3 (LF) 30201**]
Chief Complaint:
Fever, cough urinary frequency
Major Surgical or Invasive Procedure:
PICC placement
R nephrostomy replacement
History of Present Illness:
60 yo woman with endometrial/cervical cancer s/p chemo/XRT c/b
severe radiation cystitis/colitis s/p colectomy resulting in
short gut syndrome), enterocutaneous fistula, vesiculopelvic
fistula s/p bilat nephrostomy tubes, chronic rectal bleeding,
here w/ fever and malaise and abdominal pain. Admitted to MICU
for closer monitoring. Most recently admitted for hydronephrosis
and line bacteremia (CN staph), noted at that time to have high
alk phos (3000s) and elevated Bili (as high as 5) thought to be
[**1-14**] TPN induced cholestasis. Completed Vanco [**2157-3-15**].
.
USOH since discharge until 4 days prior to admission. Developed
fever, chills, then developed non-productive cough 2 days prior
to admission. One day prior to admission, noted chest pain
across lower chest, but predomininantly on L under breast, worse
with deep inspiration. Also noted increasing urinary frequency.
Denies nausea, vomiting, increased abdominal pain (has "surface
abdominal pain" chronically - "it's the muscles").
.
In ED, noted to be mildly hypotensive to 80s. Given two liters
of fluid with good response. Received Vancomycin/Zosyn. CXR
revealed no pneumonia, but some degree of atelectasis. She also
spiked temp t o101. KUB revealed dilated loops of bowel, but no
overt evidence of obstruction. CTA chest, abdomen/pelvis was
pending at the time of this note.
Past Medical History:
1. Endometrial/cervical cancer
2. S/p TAH in [**2153**] (due to uterine cancer)
3. Chylous ascites
4. Colectomy, cholecystectomy, and ileostomy ([**11-16**], likely
related to radiation bowel damage.)
5. Small bowel removal and ileostomy ([**6-17**])
6. S/p ventral hernia w/ repair
7. PE s/p IVC filter
8. Anxiety
9. Bronchitis ([**2099**])
10. Pneumonia ([**2109**])
11. Nephrostomy tube replacements, multiple (last [**2-16**] on L)
12. Hyperbilirubinemia and hyper alkaline phosphatemia thought
to be [**1-14**] TPN induced chronic cholestasis.
13. Anemia of chronic disease
14. VRE
Social History:
Lives with her husband and has 2. Denies current alcohol use.
Had been banking executive prior to development of health
issues. Smokes + [**12-14**] PPD for 19 years.
Family History:
Father 83 (deceased, CVA, MI); Mother (deceased, 92, CVA);
Brother (79, esophageal cancer); Sister (60s, colon cancer, lung
mass, afib)
Physical Exam:
VS T 98.1 BP 105/52 (105-116/54-66) HR 112 (112-139) RR25 O298%
GENERAL: NAD, mild diaphoretic, tachypneic
HEENT: Icteric sclerae, EOMI, Dry MM
NECK: JVP ~6cm, supple, no LAD
CARDIOVASCULAR: RRR, tachy, S1, S2, reg, no murmurs
LUNGS: mild tachypenia, CTAB
ABDOMEN: Soft, tender diffusely, no rebound, no guarding,
suprapubic fistula with dressings dry and intact
BACK: Nephrostomy tube and sites intact, no erythema or
tenderness, clear urine.
EXTREMITIES: Warm, 2+ pitting edema in bilat lower extremities
R>L
NEURO: A/OX3.
Pertinent Results:
[**2157-3-22**] 10:30AM BLOOD WBC-4.5 RBC-3.10*# Hgb-10.6*# Hct-32.1*#
MCV-104* MCH-34.2* MCHC-33.0 RDW-19.3* Plt Ct-171
[**2157-3-22**] 10:30AM BLOOD Neuts-71.7* Lymphs-12.5* Monos-14.6*
Eos-0.8 Baso-0.5
[**2157-3-22**] 10:30AM BLOOD Glucose-106* UreaN-33* Creat-0.6 Na-146*
K-3.4 Cl-108 HCO3-32 AnGap-9
[**2157-3-22**] 10:30AM BLOOD ALT-44* AST-58* CK(CPK)-8* AlkPhos-[**2056**]*
Amylase-6 TotBili-5.2* DirBili-3.3* IndBili-1.9
[**2157-3-22**] 10:30AM BLOOD Lipase-7
[**2157-3-27**] 04:45AM BLOOD GGT-312*
[**2157-3-22**] 10:30AM BLOOD TotProt-6.0* Albumin-2.6* Globuln-3.4
Calcium-9.0 Phos-2.0* Mg-2.1
[**2157-3-22**] 03:07PM BLOOD Lactate-2.3*
[**2157-4-1**] 05:22AM BLOOD WBC-6.2 RBC-2.35* Hgb-7.8* Hct-24.3*
MCV-103* MCH-33.3* MCHC-32.2 RDW-18.4* Plt Ct-205
[**2157-4-1**] 05:22AM BLOOD Glucose-124* UreaN-39* Creat-1.0 Na-133
K-5.3* Cl-103 HCO3-26 AnGap-9
[**2157-4-1**] 05:22AM BLOOD ALT-48* AST-52* LD(LDH)-85* AlkPhos-2129*
TotBili-3.6*
[**2157-3-27**] 04:45AM BLOOD GGT-312*
[**2157-4-1**] 05:22AM BLOOD Calcium-9.6 Phos-4.0 Mg-1.9
.
.
CXR [**2157-3-25**]:
The left upper extremity approach PICC line has been removed.
There are stable bilateral pleural effusions, left greater than
right. There is marked stability of the retrocardiac opacity
previously noted consistent with left lower lobe collapse.
IMPRESSION: Aside from the removal of the left upper extremity
PICC line, there is little interval change again demonstrating
left lower lobe collapse and bilateral pleural effusions, left
greater than right.
.
[**3-22**] SINGLE UPRIGHT AP ABDOMINAL RADIOGRAPH: In the right lower
quadrant, there are two loops of dilated small bowel measuring
up to 3.8 cm. No other loops of dilated bowel are seen. There is
evidence of numerous prior procedures including bilateral
nephrostomy tubes, IVC filter, and clips in the pelvis and
scattered throughout the abdomen. No free air is seen under the
hemidiaphragms. Colostomy bag is noted in the right lower
abdomen.
.
[**3-22**] CT chest, abd/pelivs:
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Bilateral pleural effusions with compressive atelectasis,
unchanged.
3. Unchanged appearance of extensive radiation changes in the
pelvis.
4. Bilateral nephrostomy tubes.
5. No intrahepatic biliary dilatation.
6. Generalized soft tissue edema.
7. No evidence of small bowel obstruction.
.
[**3-23**] Fistulogram:
Enterocutaneous fistula with no evidence of abscess.
.
UNILAT LOWER EXT VEINS Study Date of [**2157-3-27**] 11:21 AM
1. No evidence of DVT within the visualized portion of the left
common
femoral, superficial femoral, and popliteal veins.
2. Monophasic waveform within the left common femoral,
superficial femoral, and popliteal veins, indicating limited
transmission of both respiratory variation and change in
pressures from Valsalva. These findings are most consistent
with an occlusion within the left common or external left iliac
vein. There is normal waveform demonstrated within the right
common femoral vein indicating that the lesion is unlikely to be
within the IVC. Review of a prior CT Torso from [**3-22**] shows
compression upon the left external iliac vein by an overlying
fluid filled presumed loop of bowel, This finding may account
for such a monophasic waveform.
.
FOOT AP,LAT & OBL RIGHT Study Date of [**2157-3-28**] 6:01 PM
No evidence of fracture or dislocation.
Brief Hospital Course:
60 YO F h/o endometrial/cervical CA s/p XRT c/b bowel
obstruction leading to colectomy and short gut syndrome on TPN,
who was admitted to the MICU for klebsiella urosepsis, abdominal
wound infection with [**Date Range 8974**].
.
* Fever: Patient continue to spike temperature while on cipro
for UTI and vanco for wound infection. Potential sources of
infection included UTI, wound infection, c.diff.
-PICC was pulled and cultured, but without growth.
-wound culture from abd grew [**Date Range 8974**] and streptococcus
-blood cultures with no growth
-initial urine culture grew Klebsiella. Subsequent urine
culture grew yeast.
-initially on ciprofloxacin and vancomycin, but cipro broadened
to zosyn given persistent fevers. Also started on fluconazole
given persistant fevers with funguria. After afebrile x 48
hours therapy was narrowed on [**3-29**] narrowed therapy to
levofloxacin (to cover Klebsiella, [**Month/Year (2) 8974**]) and fluconazole.
Remained afebrile for subsequent hospitalization. Will complete
2 weeks course of IV levofloxacin and fluconazole.
.
* HYPERBILIRUBINEMIA: Patient has history of hyperbilirubinemia
and elevated alkaline phosphatase felt secondary to cholestasis
in setting of TPN. High GGT and minimally elevated AST and ALT
consistent with this diagnosis.
-Treated w/ ursodiol.
-Abd CT did not demonstrate acute hepatic pathology.
.
* NUTRITION: Short gut syndrome. Clears. Initially held on TPN
while awaited blood culture results and resolution of fever, on
PPN instead.
-PICC line placed [**3-29**] after afebrile x 48 hours
* Tachycardia: HR elevated throughout hospital stay even after
fever defervesed. EKG demonstrated sinus tach w/ ectopy. Given
risk for DVT/PE, U/S lower extremities were obtained and were
negative for DVT. Likely secondary to dehydration, especially
given high ostomy output.
.
* ANEMIA: Likely multifactoral. Macrocytic, although B12 and
folate levels wnl. Iron studies indicate ACD. Was maintained on
epogen; received 1 U PRBCs on day of discharge, and TPN
contained folate.
.
-RENAL/GU: Initially Klebsiella urosepsis. Subsequent urine
cultures from nephrostomy tubes grew yeast. Will continue
antibiotics and antifungal agents as above. R nephrostomy tube
replaced [**4-1**] for poor output and subsequently drained well.
.
*Orthostatic Hypotension: Patient was to be discharged [**4-1**] but
became orthostatic. In conjuction w/ increase in BUN and Cr
over prior days, felt secondary to dehydration. Patient
received additionsl fluid boluses and 1 L PRBCs.
.
*Prophylaxis: Given high risk for DVT, prescribed heparin and
pneumoboots, but patient repeatedly decline these treatments.
.
*Goals of Care: Given Ms. [**Known lastname 103420**] susceptibility to
infections, discussion was initiated in conjunction with [**First Name8 (NamePattern2) 2270**]
[**Last Name (NamePattern1) 1764**] regarding goals of care. These discussions will be
continued as an outpatient. Ms. [**Known lastname 3694**] did confirm that she
is DNR/DNI.
Medications on Admission:
1. Ativan p.r.n.
2. Mirtazapine 15 mg
3. Epogen five times per week
4. TPN
5. Vancomycin (completed [**2157-3-15**])
6. Ursodiol TID
Discharge Medications:
1. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. 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*
3. Levofloxacin 25 mg/mL Solution Sig: Seven [**Age over 90 1230**]y (750)
mg Intravenous once a day for 12 days.
Disp:*QS QS* Refills:*0*
4. TPN Electrolytes Solution Sig: One (1) TPN Solution
Intravenous once a day: 2.2 liters; 300g dextrose; 96g amino
acids; 175 NaCl; 100 NaAcetate; 20 NaPo4; 45 KCl; 5 KAc; 15
MgSO4; 8 CaGluc.
**50 g fats twice weekly ONLY**
Cycle over 12 hours.
Disp:*QS QS* Refills:*2*
5. PICC Sig: line care per protocol once a day.
Disp:*qs * Refills:*2*
6. Fluconazole in Saline(Iso-osm) 200 mg/100 mL Piggyback Sig:
One (1) Intravenous once a day for 12 days.
Disp:*qs qs* Refills:*0*
7. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day).
8. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
9. Octreotide Acetate 100 mcg IV Q8H
10. IV Fluids
Please administer 1 L NS after each TPN order.
Thanks
11. Outpatient Lab Work
Thursday [**2157-4-7**]: Please draw CBC, Chem10, Total Bilirubin,
Alkaline Phosphatase, AST, ALT.
12. Outpatient Lab Work
qMonday blood draws: CBC, Chem10. Please release to nutritionist
for tailoring TPN order.
13. Epoetin Alfa 10,000 unit/mL Solution Sig: [**Numeric Identifier 961**] units
Injection 5 times per week.
Disp:*qs qs* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary diagnosis:
- Klebsiella urosepsis
- Cellulitis
- Candidal pyelonephritis
- Hyperbilirubinemia, elevated alkaline phosphatase (likely
secondary to cholestatis related to chronic TPN)
.
Secondary Diagnoses:
-Endometrial/cervical cancer s/p TAH in [**2153**] (due to uterine
cancer)
-Chylous ascites
-Colectomy, cholecystectomy, and ileostomy ([**11-16**], likely
related to radiation bowel damage.)
-Small bowel removal and ileostomy ([**6-17**])
-PE s/p IVC filter
-Nephrostomy tube replacements, multiple (last [**2-16**] on L)
-Anemia of chronic disease
Discharge Condition:
Stable
Discharge Instructions:
You were hospitalized and treated for a serious infection, and
found to have a urinary tract infection and skin infection. The
urinary tract infection was serious and caused a dangerously low
blood pressure that required admission to the intensive care
unit.
.
You were also found to have elevations in some liver tests; but
imaging of your liver was normal.
Take all medications as directed. You will need to receive
antibiotics by vein for several weeks.
Attend all follow up appointments.
If you develop fever, chills, shortness of breath, chest pain,
worsening or severe abdominal pain, persistant nausea/vomiting,
or any other symptom that concerns, contact your primary doctor
or if unavailable, go to the emergency room.
Followup Instructions:
Please follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**2157-4-11**] at
12:20 PM.
.
You will need to have blood tests to help your doctor follow
your liver function and to help determine your TPN prescription
.
Provider: [**Name10 (NameIs) 454**],TWO [**Name10 (NameIs) 454**] Date/Time:[**2157-6-1**] 7:00
Provider: [**Name10 (NameIs) 6122**] WEST Phone:[**Telephone/Fax (1) 8243**] Date/Time:[**2157-6-1**] 8:30
Completed by:[**2157-4-4**]
ICD9 Codes: 5180, 2768, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3802
} | Medical Text: Admission Date: [**2126-9-6**] Discharge Date: [**2126-9-25**]
Date of Birth: [**2054-11-1**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Codeine / Dalmane
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
fevers, rigors
Major Surgical or Invasive Procedure:
pacemaker extraction
pacemaker extraction via re-do sternotomy
History of Present Illness:
Mr [**Name13 (STitle) **] is a 71yo man who has a pacemaker and bioprosthetic
mitral and aortic valve replacements who presented with rigors
and a fever to 103.2 with mental status changes on [**2126-9-5**]. He
was found to have pacemaker endocarditis and 6/6 bottles of
blood cultures were positive for staph aureus.
.
In the ED, initial vitals were 147/61 103.2 89 18 91%RA 97% on
2L
Labs and imaging significant for WBC of 14.2, drug screen at OSH
was negative, UA was positive only for albumin, ketone, blood.
Creatinine is 1. Bicarb 28. LFTs wnl. PFTs mild obstruction.
Echo-EF 55%.
Patient given rifampin, ceftriaxone, vancomycin, gentamicin and
1L of NS for hypotension, which improved his blood pressures. He
did have his pacer interrogated which revealed underlying SB
50's. PMT noted on device, V paced 98%. Lactic acid 2.6. Trop
2.29. CSF normal. CXR wnl.
Vitals on transfer were BP 88-92/58-67 HR89-112 RR16
.
On arrival to the floor, patient endorsed CP over the pacemaker
site, SOB, abdominal pain, constipation x 3 days, rare
non-productive cough. He also endorses a reecent history of
myalgias, especially in his calves.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-CABG: CABG x4 ([**2124-10-19**] at [**Hospital3 **]) with saphenous vein
graft to OM ramus PLV and LIMA to LAD,
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD: Symptomatic sinus bradycardia--s/p dual chamber
PPM [**2119-12-13**], with pocket revisions in [**2119**] and [**2120**]; Guidant
Insignia PPM
3. OTHER PAST MEDICAL HISTORY:
-aortic valve replacement with a 21 mm [**Doctor Last Name **] pericardial
tissue heart valve, and mitral valve replacement with a [**Street Address(2) 70723**]. [**Male First Name (un) 923**] bioprosthesis.
-Hep C, chronic, no cirrhosis
-History of cocaine use; history of IVDU
-Lung cancer, s/p resection of L upper lobe
-Multiple cysts removed
-Spine surgery, metal rods in place
-Asthma
-stroke
Social History:
The patient lives by himself in an apartment as part of a group
home. He is an ex-smoker- 2ppd x60y, quit seven years ago.
History of IVDU (30 years ago) and cocaine abuse (25years ago).
He no longer drinks alcohol but used to abuse alcohol. Works at
Salvation Army as drug counselor now
Family History:
Mother-deceased of MI at age 65. Grandma deceased of MI.
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T=99.7 BP= 111/70 HR= 95 RR=18 O2 sat= 98% 2L NC
GENERAL: NAD. Oriented x2 (not to date). Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP flat.
CARDIAC: RR, normal S1, S2. systolic murmer II/VI heard best at
apex. No S3 or S4. tender to palpation over pacer pocket on
left anterior chest.
LUNGS: CTAB, no crackles, wheezes or rhonchi. No chest wall
deformities, scoliosis or kyphosis. Resp were unlabored, no
accessory muscle use.
ABDOMEN: Soft, no distension. mild tenderness to palpation. No
HSM or tenderness.
EXTREMITIES: Positive clubbing. No cyanosis, edema.
SKIN: No stasis dermatitis, ulcers, or xanthomas. Large scar
down spine beginning around L2.
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
NEURO: slight pronator drift on left. strength and gait normal.
CNII-XII intact.
DISCHARGE PHYSICAL EXAM:
VS: Tm 99.5 Tc 98.6 134/70 (134-156/73-93) 103 (85-103) 18 99%RA
GENERAL: NAD. Alert.
CARDIAC: RRR, normal S1, S2. systolic murmur III/VI heard best
at apex. No S3 or S4
CHEST: healing incision from clavicle to umbilicus, c/d/i. No
ecchymosis. Right sided pacer pocket with staples in place,
non-erythematous, dry, no discharge.
LUNGS: CTAB
ABDOMEN: normoactive bowel sound, NTND
EXTREMITIES: no peripheral edema, 2+ peripheral pulses.
Pertinent Results:
ADMISSION LABS:
.
[**2126-9-7**] 07:48AM BLOOD WBC-7.6 RBC-3.58* Hgb-10.8* Hct-30.6*
MCV-85 MCH-30.1 MCHC-35.4* RDW-13.6 Plt Ct-68*
[**2126-9-7**] 07:48AM BLOOD Plt Ct-68*
[**2126-9-7**] 07:48AM BLOOD Glucose-159* UreaN-22* Creat-0.8 Na-138
K-3.5 Cl-104 HCO3-23 AnGap-15
[**2126-9-8**] 05:30AM BLOOD CK(CPK)-66
[**2126-9-10**] 04:30AM BLOOD ALT-15 AST-20 LD(LDH)-299* AlkPhos-52
TotBili-0.8
[**2126-9-7**] 07:48AM BLOOD Calcium-8.7 Phos-1.4* Mg-1.9
.
PERTINENT LABS AND STUDIES:
[**2126-9-7**] 07:48AM BLOOD VitB12-545 Folate-10.8
[**2126-9-10**] 04:30AM BLOOD CRP-253.6*
[**2126-9-7**] 07:48AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2126-9-8**] 05:30AM BLOOD CK-MB-3 cTropnT-0.10*
[**2126-9-8**] 01:30PM BLOOD CK-MB-3 cTropnT-0.10*
[**2126-9-11**] 05:40AM BLOOD ESR-100*
[**2126-9-6**] 09:25PM URINE Blood-LG Nitrite-NEG Protein-300
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-SM
[**2126-9-19**] 12:37PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
[**2126-9-19**] 12:37PM URINE Eos-NEGATIVE
[**2126-9-19**] 12:37PM URINE Hours-RANDOM UreaN-211 Creat-49 Na-61
K-29 Cl-67
[**2126-9-19**] 04:45AM BLOOD Calcium-8.6 Phos-3.2 Mg-1.9 Iron-21*
[**2126-9-19**] 04:45AM BLOOD calTIBC-176* Ferritn-290 TRF-135*
[**2126-9-18**] 04:39PM BLOOD Hapto-263*
[**2126-9-7**] 07:48AM BLOOD VitB12-545 Folate-10.8
[**2126-9-19**] 04:45AM BLOOD CRP-107.3*
[**2126-9-14**] 12:40PM BLOOD freeCa-1.14
[**2126-9-18**] 04:39PM BLOOD Albumin-2.8*
[**2126-9-20**] 04:30AM BLOOD ESR-109*
.
Culture data (organism and susceptibilities)
[**2126-9-5**] (at [**Hospital3 **]) STAPHYLOCOCCUS AUREUS
Target Route Dose RX AB Cost M.I.C. IQ
------ ----- ------------------ ------ -- ------ ---------
-----CEFAZOLIN S <=4
CLINDAMYCIN SERUM X S 0.5
ERYTHROMYCIN SERUM X S <=0.25
LEVOFLOXACIN SERUM X S <=0.5
OXACILLIN SERUM X S <=0.25
TETRACYCLINE SERUM X S <=1
TRIM/SULFA SERUM X S <=0.5/9.5
VANCOMYCIN SERUM X S 1
.
All Blood Cultures since [**2126-9-6**] are negative
C. diff cultures negative x4
Urine cultures negative
.
[**2126-9-10**] CTA Coronary Arteries
1. Retained one larger and one small object in the right
subclavian vein as described in detail. Please review the
addition volume rendering images for better localization of this
finding.
2. Status post CABG with patent bypasses.
3. Status post left upper lobectomy.
4. Extensive venous collaterals in the anterior mediastinum with
some of them located right underneath the sternotomy.
5. Small bilateral pleural effusion.
6. Status post aortic and mitral valve replacement. Extensive
mitral annulus calcification.
7. Several pulmonary nodules. Followup of this patient given the
presence of the nodules, several mediastinal lymph nodes and
prior lobectomy should be obtained in three months with
conventional chest CT. Right middle lobe
subpleural opacity most likely represents atelectasis, but
pleural plaque
would be another possibility and can be also reassessed on the
subsequent
study.
.
TEE (Complete) Done [**2126-9-11**]
The left atrium is 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. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is normal (LVEF>55%).
A bioprosthetic aortic valve prosthesis is present. The aortic
valve prosthesis appears well seated, with normal leaflet/disc
motion and transvalvular gradients.
A bioprosthetic mitral valve prosthesis is present. There is a
large vegetation 1.3 cm x 1.3 cm on the posterior annulus of the
mitral bioprosthetis. No mitral regurgitation is seen. There is
no mitral stenosis. The mean mitral gradient is 5mm of Hg.
Moderate to severe [3+] tricuspid regurgitation is seen. IVC is
dilated (2.9cm) with preserved respiratory variation although
small. There is systolic flow reversal at the hepativ veins.
There is no pericardial effusion.
.
[**2126-9-15**] CT Head No Contrast No acute intracranial process. If
clinical concern for stroke is high, MRI is more sensitive.
.
[**2126-9-18**] ECHOCARDIOGRAM
The left atrium is mildly dilated. The left atrium is elongated.
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.
[Intrinsic right ventricular systolic function is likely more
depressed given the severity of tricuspid regurgitation.] A
bioprosthetic aortic valve prosthesis is present. The aortic
valve prosthesis appears well seated, with normal leaflet/disc
motion and transvalvular gradients. Trace aortic regurgitation
is seen. A bioprosthetic mitral valve prosthesis is present. The
gradients are higher than expected for this type of prosthesis.
There is echodense thickening of the posterior annulus of the
mitral bioprosthesis measuring 1.3 cm x 1.1 cm. No mitral
regurgitation is seen. Moderate to severe [3+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. [In the setting of at least moderate to
severe tricuspid regurgitation, the estimated pulmonary artery
systolic pressure may be underestimated due to a very high right
atrial pressure.] There is no pericardial effusion.
IMPRESSION: Preserved left ventricular systolic function with
normally functioning aortic bioprosthesis. There is focal
echodense thickening of the posterior annulus of the mitral
bioprosthesis with gradients higher than expected for this type
of prosthesis. Given the history of mitral bioprosthesis
endocarditis on recent TEE dated [**2126-9-11**], a healed vegetation
cannot be excluded.
.
CXR [**2126-9-15**] FINDINGS: The patient is status post median
sternotomy, aortic valve replacement, as well as left upper lobe
resection. Cardiomediastinal contours are similar to the prior
exam. Interval resolution of congestive heart failure and
associated decrease in size of right pleural effusion with
residual small pleural effusion remaining. Left pleural effusion
is small and similar to the prior study.
IMPRESSION: Resolution of congestive heart failure and improved
right pleural effusion.
CT Thorax [**2126-9-19**] Air and fluid collection with enhancing walls
as discussed in the suprasternal notch. This finding is
suspicious for early abscess formation. No evidence to suggest
osteomyelitis. Communication with the right sternoclavicular
joint is not excluded. Right pleural effusion with adjacent
compressive atelectasis. Interval removal of retained pacemaker
fragment in the right subclavian vein. Extensive vascular
calcification within the common and external iliac
arteries. In combination with the extensive streak artifacts
from the
vertebral column hardware, evaluation of lumen is difficult. If
there is
clinical concern for significant stenosis MRI can help better
evaluate the
vasculature.
.
DISCHARGE LABS:
[**2126-9-25**] 05:40AM BLOOD WBC-9.8 RBC-3.26* Hgb-9.4* Hct-27.9*
MCV-86 MCH-28.9 MCHC-33.8 RDW-14.8 Plt Ct-325
[**2126-9-25**] 05:40AM BLOOD Glucose-123* UreaN-15 Creat-2.0* Na-136
K-3.6 Cl-98 HCO3-26 AnGap-16
[**2126-9-25**] 05:40AM BLOOD Calcium-8.7 Phos-4.1 Mg-2.1
Brief Hospital Course:
71M PMH CAD-CABG and bioprosthetic MVR/AVR, DM, HTN, HLD, lung
cancer s/p resection, Hepatitis C, and dual-chamber PPM
implanted in [**2118**] for symptomatic sinus bradycardia, followed by
pocket revisions in [**2119**] for infection and [**2120**] due to painful
location, who presented to [**Hospital6 1597**] with mental
status changes on [**2126-9-5**], and was found to have fever to 103
with 6/6 bottles with Staph Aureus, and an 8mmx8mm vegetation on
the RV lead seen on TEE, now transferred for further care and
lead extraction, s/p lead extraction, with atrial lead initially
retained. The patient required re-do sternotomy for removal of
the wire, which was done on [**9-11**]. A MV vegetation was seen on
TEE done intraoperatively. The patient will have antibiotics for
6 weeks and then consideration for MVR. Hospital course was
complicated by [**Last Name (un) **].
.
ACTIVE ISSUES
# MSSA Bacterial Endocarditis: The patient initially presented
with sepsis to the OSH, but was hemodynamically stable
throughout his hospitalization at [**Hospital1 18**]. His cultures here were
consistently negative--blood, urine, sputum, the pacemaker
leads-- but grew MSSA at the OSH. The source of the infection
was not clear. He was initially treated with pacemaker removal
with the EP service, but unfortunately, the atrial lead was
friable and broke off and was lodged in the chest. He required
re-do sternotomy by the cardiac surgeons for removal of the
lead. His wounds from the sternotomy and the pacemaker
extraction remained clean, dry and intact with no erythema
throughout his hospitalization. ID was consulted and the patient
was treated with Vancomycin, which was transitioned to
Cefazolin, and Gentamicin and Rifampin for synergy. He did have
nightly fevers in the 2 weeks subsequent to his surgery despite
blood cultures remaining negative and treatment with the
antibiotics. It was thought that his fevers may have been drug
fever but resolved spontaneously. Out of concern for his nightly
fevers, the patient was pan-scanned and a small sub-sternal
fluid collection was visualized. The cardiac surgeons, ID and
orthopedic surgeons all discussed the possibility of incision
and drainage but the fluid collection was thought to be small
and not a source of infection. He also developed a transient
leukocytosis which resolved and he was consistently tachycardic
in the 90-110 range during his hospitalization. The patient did
have some wound-associated discomfort but refused opioid
medication due to his history of heroin abuse. He preferred to
use tramadol throughout the hospitalization. The patient will
need LFTs checked on Rifampin. He may need MVR and replacement
of the pacemaker in the future after he completes the
antibiotics. He will need repeat echo in 1 week.
.
# Diarrhea: the patient developed diarrhea after initiation of
antibiotics. He was treated empirically for c. diff with Flagyl.
This was transition to PO Vanc given that pt had ongoing fevers
without clear source. However, he had four negative c.diff
cultures so treatment was discontinued. Pt continued to have
occasional diarrhea. We opted not to treat with anti-motility
agents given that no clear cause of diarrhea was identified. He
may benefit from pro-biotic treatment.
.
# Acute Kidney Injury: the patient's creatinine was 0.8 at
baseline and trended up as he was initiated on gentamicin. It
peaked at 2.0 which we attributed to gentamycin toxicity in
setting of contrast dye-induced nephropathy. His gentamycin was
stopped, and his lasix, losartan and spironolactone were held.
His creatinine remained stable at 2.0. Lasix, losartan, and
spironolactone should be resumed once his Cr <1.5.
.
# Chest Pain associated with surgery: the patient had some minor
pain associated with his surgical wounds. He was treated with
tramadol, per his preference.
.
.
CHRONIC ISSUES:
# Normocytic Anemia: the patient's hematocrit is in the 27-30
range. Recommend outpatient follow up. Iron studies and
hemolysis labs were obtained. The picture was not consistent
with hemolysis.
.
# Coronary artery disease: the patient is s/p CABG. His EF is
preserved (55%). He was maintained on a BB (switched from home
atenolol to metoprolol). Continued on a statin, his LFTs were
within normal limits. His ASA was continued. His lasix was held
in the setting of [**Last Name (un) **].
.
# Hepatitis C: chronic, no cirrhosis. LFTs within normal limits.
.
# Diabetes: maintained on ISS. His HgbA1c was 6.5.
.
ISSUES OF TRANSITIONS IN CARE:
CODE: full code
EMERGENCY CONTACT:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 96666**], C [**Telephone/Fax (1) 96667**]
[**Doctor Last Name **] C. [**Telephone/Fax (1) 96668**]
# pt will need close follow up with cardiology regarding
possible replacement of pacemaker, mitral valve replacement. He
will need repeat ECHO in 1 week.
# He will need weekly labs to monitor LFTs while on rifampin,
along with CBC.
# His creatinine will need to be closely monitored as well.
Lasix, spironolactone, and losartan should be resumed once
creatinine <1.5.
# Pt found to have normocytic anemia that should be worked up
further as an outpatient.
Medications on Admission:
-metformin,
-tramadol 50mg qhs prn pain,
-Lasix 40mg qam and 20mg qpm
-atenolol 100mg qday
-trazodone 400mg qday,
-aspirin 325 mg qday,
-Neurontin 600mg QID
Discharge Medications:
1. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
2. trazodone 100 mg Tablet Sig: Four (4) Tablet PO at bedtime.
3. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO QID (4
times a day).
4. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*0*
6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
Disp:*60 Tablet(s)* Refills:*0*
7. rifampin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every 8
hours) for 31 days: Course will be complete on [**10-24**].
Disp:*0 Capsule(s)* Refills:*0*
8. cefazolin 10 gram Recon Soln Sig: Two (2) gram Injection Q8H
(every 8 hours) for 31 days: Course will be complete on [**10-24**].
Disp:*0 gram* Refills:*0*
9. Outpatient Lab Work
frequency: weekly
CBC with diff
BMP
LFT's
Fax to Infectious disease R.Ns. at ([**Telephone/Fax (1) 1353**]
10. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
11. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
12. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
primary diagnosis: endocarditis of the pacemaker, coronary
artery disease, bradycardia, diabetes, hypertension
secondary diagnoses: hepatitis C, hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Last Name (Titles) **],
You were admitted to the hospital because you had an infection
in the wires of your pacemaker. You were treated with
antibiotics and you also had your pacemaker removed. You
required a surgery to get the pacemaker out. One of the
antibiotics caused kidney dysfunction but this was stable at the
time of discharge and we expect it to get better quickly.
Please note the changes to your medications:
- START Cefazolin 2g IV q8h for 6 weeks starting
[**Date range (3) 96669**]
- START Rifampin 300mg po q8h for 6 weeks starting
[**Date range (3) 96669**]
- STOP Atenolol
- START Rosuvastatin
- START Losartan
- START Metoprolol
- START Spironolactone
- DECREASE Lasix from 40mg every morning and 20mg every evening
to 20mg in the morning and the evening
- INCREASE tramadol 50mg, you may take this every 4 hours as
needed for pain.
- CONTINUE Gabapentin, Trazadone, Aspirin, Metformin
Please be sure to follow up with your physicians.
Followup Instructions:
Department: CARDIAC SURGERY
When: [**2126-10-1**], 1:15
With: [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 170**], staples will be removed
Building: LM [**Hospital Unit Name **] [**Location (un) 551**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Name:[**Name6 (MD) **] [**Name8 (MD) **], MD
Specialty: Cardiology
Address: [**Hospital3 **] [**Apartment Address(1) 3882**], [**Hospital1 **],[**Numeric Identifier 53049**]
Phone: [**Telephone/Fax (1) 73509**]
When: We put a call into the office but it is closed until
Monday so wewere unable to schedule a follow up. Please call
the above number to schedule a follow up within the next two
weeks.
Completed by:[**2126-9-25**]
ICD9 Codes: 5849, 5119, 4019, 2724, 4439, 4240 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3803
} | Medical Text: Admission Date: [**2150-7-29**] Discharge Date: [**2150-8-12**]
Date of Birth: [**2110-1-11**] Sex: M
Service: MEDICINE
Allergies:
Didanosine / Iodine; Iodine Containing
Attending:[**First Name3 (LF) 8487**]
Chief Complaint:
transfer from floor (west) for hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: 40 yo Indian male with HIV/AIDs (CD4 17), chronic
wasting/malnutrition on TPN, on treatment for cryptosporidium
diarrhea, c. diff, who originally presented to [**Hospital1 **] On [**2150-7-29**]
with worsening pancytopenia and epistaxis (plt 17 on admission).
Hematology saw pt while hospitalized and differential for
thrombocytopenia was drug induced from
flagyl/gancyclovir/bactrim, myelosuppression from HIV, vs ITP.
Bone marrow biopsy was performed and pt was started on IV
steroids for presumed ITP. Additionally, pt has been having
guaiac positive stools and GI saw pt though opted not to scope
as pt likely bleeding in setting of thrombocytopenia. Mr.
[**Known lastname 64553**] was also diagnosed with Norwegian scabies, thrush, and
likely esophageal candidiasis.
.
Last night ~midnight, MICU green called for pt being hypothermic
to 92.9, BP: 58/pal (100s prior), P: 88; RR: 26; O2: 2L with a
new productive cough. He was given cefepime 2 g IV x 1, 4 L NS.
Pt was started on a dopamine gtt for SBP in the 60s and
transferred to [**Hospital Unit Name 153**] via ambulance.
Past Medical History:
PMHx copied per old note:
1) HIV: Diagnosed [**2138**]. Last CD4 17 on [**2150-6-3**] (45 on
[**2150-3-27**]), VL 33,000 on [**2150-3-27**]. Last HAART regimen in [**3-23**]
consisted of Kaletra/Trizivir/Viread; however, this regimen did
not suppress his VL or raise his CD4 count. As his HAART meds
were thought to be worsening his diarrheal symptoms and were
unlikely to be absorbed, they were held at that time.
.
2) Cryptosporidium: Positive [**2150-3-27**] and [**2150-5-4**], negative
[**2150-6-2**]. Started treatment with paromycin and azithromycin on
[**5-27**] for projected 18 week course. Terminal ileum biopsies
taken, which was c/w cryptosporidiosis.
.
3) CMV colitis: One cell suspicious for CMV on [**5-23**] terminal
ileum biopsy, though staining was negative. CMV VL found to be
6830. He was started on ganciclovir 150mg IV bid on [**2150-6-23**] for
2wk induction period, then to qD maintenance dosing.
.
4) C. diff colitis: Started treatment with flagyl 500mg IV tid
on [**2150-7-24**] for 14 day course, holding antimotility agents that
had been previously used.
.
5) Esophageal candidiasis: Dx'ed on [**5-23**] EGD, s/p 14 days
fluconazole. Recently diagnosed with thrush, started on another
course of fluconazole 100mg IV qD x 14 days.
.
6) Malnutrition: Likely [**2-19**] chronic diarrhea and AIDS. Receives
chronic TPN
.
7) Abnormal TFT's: TSH 4, FT4 0.7 in [**2150-6-9**]. Not repleted [**2-19**]
sinus tach and diarrhea. Planned for recheck in 6 weeks.
.
8) h/o pancreatititis [**2-19**] DDI c/b pseudocyst requiring drainage
.
9) h/o scabies tx with permethrin
.
10) Anal condylomata
Social History:
Indian born. Economic professor [**First Name (Titles) **] [**Last Name (Titles) 64552**]. No tobacco, alcohol,
or IVDU.
Family History:
Grandmother with ovarian cancer
Physical Exam:
Physical Exam: 18mcg dopamine, SBP 85
VS: 92.9
I/O [**8-1**] 1550 / BR BM(1600)
Gen: Mild distress,
HEENT: PERRL, EOMI, nonicteric sclera, OP with extensive thrush,
dry mm, JVD flat,
CV: rrr no mrg
Lungs: decrease bs,
Abd: decrease BS, soft nt/nd
Ext: no c/c/e
Skin: hyperkeratotic scales on neck
Neuro: aaox3
Pertinent Results:
Radiology:
[**2150-7-31**] Abdominal ultrasound-
IMPRESSION: Minimal thickened gallbladder wall with intraluminal
sludge and slightly dilated common bile duct. These
constellation of findings are concerning for HIV cholangiopathy.
.
TTE [**2150-7-31**]-The left atrium is normal in size. Left ventricular
wall thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). 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 pericardial effusion. No vegetation
seen (cannot definitively exclude).
.
[**2150-7-30**] CXR PA/LAT- no acute cardiopulm process
[**2150-7-29**] 06:00PM GLUCOSE-84 UREA N-40* CREAT-1.6*# SODIUM-147*
POTASSIUM-3.7 CHLORIDE-110* TOTAL CO2-23 ANION GAP-18
[**2150-7-29**] 06:00PM ALT(SGPT)-29 AST(SGOT)-48* LD(LDH)-261* ALK
PHOS-854* AMYLASE-51 TOT BILI-1.0
[**2150-7-29**] 06:00PM GGT-446*
[**2150-7-29**] 06:00PM CALCIUM-7.1* PHOSPHATE-4.0 MAGNESIUM-1.9
[**2150-7-29**] 06:00PM HAPTOGLOB-166
[**2150-7-29**] 06:00PM WBC-1.0*# RBC-2.46* HGB-7.9* HCT-22.7*
MCV-92# MCH-32.0# MCHC-34.7 RDW-18.1*
[**2150-7-29**] 06:00PM NEUTS-72* BANDS-0 LYMPHS-18 MONOS-10 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2150-7-29**] 06:00PM PLT COUNT-7*#
[**2150-7-29**] 06:00PM PT-12.9 PTT-26.9 INR(PT)-1.1
[**2150-7-29**] 06:00PM GRAN CT-760*
[**2150-7-29**] 06:00PM RET AUT-0.2*
Head CT [**8-8**]: FINDINGS: There is no evidence of acute intra- or
extra-axial hemorrhage. The [**Doctor Last Name 352**]-white matter differentiation
appears grossly preserved. There is slight prominence of the
ventricles and sulci that may be related to volume loss. The
basal cisterns appear patent. Imaged paranasal sinuses appear
clear.
[**8-10**] Portable chest x-ray:
The heart size is normal. There is a persistent area of opacity
in the right lower lobe with associated displacement of the
fissure suggestive of
atelectasis. There is a new area of opacity in the left
retrocardiac region with air bronchograms, concerning for
infectious pneumonia or aspiration. There is a persistent small
right pleural effusion and there is a new small left pleural
effusion.
IMPRESSION:
Persistent right lower lobe opacity, most likely atelectasis.
New left
retrocardiac opacity, concerning for infectious pneumonia or
aspiration.
Brief Hospital Course:
A/P: 40M with HIV/AIDS (CD4 17) with chronic diarrhea [**2-19**]
cryptosporidium, c. diff, and CMV colitis, pancytopenia,
electrolyte abnormalities, transfer from floor for hypotension,
hypothermia, and new O2 requirement.
.
#) Septic shock: Likely due to Pseudomonas in blood +/- ? left
lower lobe infiltrate
He was started on Broad spectrum abx cefepime/levo to double
cover for Pseudomonas. He was started on Levophed and dopamine
was weaned off on [**8-3**] to maintain MAPs>60. He completed a 7 day
course of stress dose steroids. Intravenous fluids and
antibiotics were continued until [**8-11**] when patient was made
comfort measures.
.
#) Pancytopenia : Multifactorial: Likely HIV + medication
.
a. Thrombocytopenia - ITP vs. medication
(bactrim/ganciclovir/flagyl) vs. myelosuppression from HIV/AIDs.
Also possible include infection with PCP, [**Last Name (NamePattern4) **]. s/p BMBx by heme
on [**2150-7-30**].
.
b. Anemia - Hct on admission 22.7. Likely from GIB and HIV.
Peripheral smear did not show evidence of hemolysis and iron
studies in [**5-23**] consistent with anemia of chronic disease. Pt
also has been having guaiac positive stools. On [**8-3**] he was
transfused 1U PRBCs and 2U PRBCs on [**8-4**]
.
c. Neutropenia and lymphopenia - marrow suppression likely [**2-19**]
HIV, infection.
GCSF was continued until blood counts increased and no longer
neutropenic.
.
#) GIB/Coagulopathy: Likely from INR of 2.0 as well as low
platelets. Patient has been putting out bloody watery BMs from
mushroom cath. He was transfused with plts, PRBCs, received
10Sc of Vit K on [**8-3**] and FFP. GI was consulted regarding GI
Bleed - no intervention because of low platelet count.
.
#) Access: Patient had double lumen PICC placed.
.
#) Diarrhea - Etiology multifactorial including crytosporidia
and C.Difficile, but completed a 14 day course of flagyl
treatment. He was started on opium tincture and loperamide.
Patient had over 4L stool production. He had frequent labs
checked to replete electrolytes and aggressive fluid
resuscitation. This was stopped when he was made comfort
measures only.
.
#) AIDS - CD4 of 17 in [**5-23**]. He was restarted on HAART
medications but these were stopped when made comfort measures.
.
#) AIDS cholangiopathy - seen on RUQ u/s and pt with elevated
AP. It is a biliary obstruction from infection associated
strictures of biliary tract, most common being cryptosporidiumm
as well as CMV, microsporidia, cyclospora. Followed LFTs.
.
#) Norwegian scabies-received ivermectin PO x 1 on [**2150-7-30**] and
permethrin cream.
He remained on contact precautions.
.
#) Esophageal candidiasis-originally dxd by EGD in [**5-23**] and he
is s/p 14 day trt with fluconazole. Pt again dxd with thrush at
[**Hospital1 **]. Was on fluconazole IV (started [**2150-7-26**]) but switched
to Voriconazole until antibiotics were stopped.
.
#) Code Status - Patient was a DNR/DNI but initially was willing
to have pressors. As treatments did not seem to be effective,
GI losses remained great, and patient remained with low CD4
count despite HAART therapy a family meeting was held on [**8-10**]
with patient's infectious disease doctor, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] and
the ICU team. The patient expressed his wishes to be comfort
measures only. On [**8-11**] all iv fluids and antibiotics were
stopped. He was transitioned to a morphine drip and passed away
peacefully with his family at his bedside on [**2150-8-12**] at 7:25p.m.
Medications on Admission:
Medications on transfer:
1. RISS
2. Tylenol prn
3. Carmol topical
4. Methylprednisolone 40 mg IV q24
5. Nystatin Oral Suspension 10 ml PO TID
6. Fluconazole 100 mg IV Q24H ([**7-30**]-)
7. Paromomycin *NF* 750 mg Oral tid
8. Glutamine 10 gm PO TID
9. Hydrocerin 1 Appl TP TID
10. Cefepime x 1-7/15/06
.
Outpatient medications:
Azithromycin 500mg PO qD
Flagyl 500mg IV tid (started [**7-24**])
Fluconazole 100mg IV qD (started [**7-26**])
Ganciclovir 150mg IV bid (started [**6-23**])
Bactrim DS 1 tab qD
Paromycin 750mg PO tid
Metoprolol 25mg PO bid
SSI
Glutamine 10gm packet tid c meals
Nystatin 10mL PO tid
Discharge Medications:
Not applicable
Discharge Disposition:
Expired
Discharge Diagnosis:
AIDS/HIV
Pseudomonas sepsis
diarrhea: crytopsoridia, C.Difficile
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
Completed by:[**2150-8-13**]
ICD9 Codes: 5845 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3804
} | Medical Text: Admission Date: [**2136-2-28**] Discharge Date: [**2136-3-7**]
Date of Birth: [**2077-7-1**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Meperidine & Related / Codeine / Propoxyphene
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
Dyspnea and pleuritic chest pain
Major Surgical or Invasive Procedure:
Transfusion of 1unit of pRBCs
History of Present Illness:
History of Present Illness: Ms. [**Known lastname **] is 58 year old female with
history of COPD, Systolic CHF (EF 45-50%), Bipolar disease,
Borderline Personality Disorder, severe pain, depression, RA,
and oxygen use (4L without a clear-cut rationale). She was
admitted today for chest pain and dyspnea.
.
Ms. [**Known lastname **] reports that she had the flu last week and began
experiencing diffuse chest pain (10+/10), a non-productive
cough, fatigue, and pain-associated dyspnea over the weekend
that differed in quality from her normal angina. The pain
intensitifed when she would breath deeply or cough and she had a
reported fever of 102.0, and she denied chills/sweats as well as
any radiating pain to her neck or arms. Ms. [**Known lastname **] did not take
her usual nitroglycerin, but instead called Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 575**], her pulmonologist who directed her to get a CXR at
the ED. Medical records indicate that she described her chest
pain to EMT as left-sided, stabbing, associated with pressure
and dyspnea -- similiar to her normal angina-like symptoms. Ms.
[**Known lastname **], however, disputes this characterization (along with
receiving any pain medications en-route or in the ED.
.
Ms. [**Known lastname **] also reports a worsening of her chronic diarhrea since
[**Last Name (LF) 2974**], [**1-19**]. She also reports that some blood in her
diarrhea since that time, but denies any change in her PO
intake, reporting that she had a proper dinner last night.
.
In the ED, Ms. [**Known lastname 3728**] vitals were BP: 115/63 & 102/53, HR: 107 &
90, RR: 16 & 20, O2 Sat: 100% 5L NC & 94% on 3L NC. She was
also afebrile. In the ED she received ASA (325 mg),
Nitroglycerin, Kcl (40mEq), Percocet (5/325), morphine (2mg IV),
and Levofloxacin (750mg). She denied any abdominal pain and
refused a guaiac exam. On physical exam, no wheezing. A CXR
identified multifocal bilateral airspace opacities and blunting
of the left costophrenic angle -- consistent with multifocal
pneumonia and a small parapneumonic effusion. Her EKG was
reassuring, and her cardiac enzymes (CK: 21) were negative. She
also had no events on telemetry and was reportedly chest pain
free before being transfered to [**Doctor Last Name **].
.
After being transferred to [**Doctor Last Name **], she complained of chest pain
and dyspnea, abdominal pain, and pain in the balls of her feet.
She also refused rectal guiac as well as an ABG. A second CXR
indicated that her cardiac sillihette was stable, that she had
multifocal pneumonia with multifocal hazy opacities in her RUL,
RML, and LLL as well as a blunted left costrophrenic angle.
Past Medical History:
COPD w/ Emphysema on CT scan; Decreased DLCO
Systolic CHF (EF 45%)
RA
Chronic Diarrhea of Unknown Etiology: atonic colon per pt.
per [**1-/2134**] note by her PMD and [**9-/2133**] note by Gastroenterology,
symptoms may be functional
Severe Pain, on Narcotics
Cigarette Smoking
Fibromyalgia
Migraine H/A
Anorexia; History of laxative and diuretic abuse
Oxygen Use (4L), without clear cut rationale per pulmonology
History of Breast Cancer; s/p resection x 4 lumps, No chemo or
radiation; Years ago per pt
History of Seizure disorder; Last in [**2126**]; ETOH Withdrawal
History of CVA: Many years ago
TAHBSO: [**2113**]; For cancer
History of [**Last Name (un) **] syndrome: Requiring inpatient decompression
.
PSYCHIATRIC HISTORY: (Per [**Last Name (un) **])
.
Bipolar Disorder
Borderline Personality Disorder
Attention Deficit Disorder
Depression
Multiple Prior Hospitalizations, Over 20 years ago
History of Suicide Attempt: Via OD; Over 20 Years Ago
Psychiatrist Dr. [**Last Name (STitle) 3704**] [**Telephone/Fax (1) 3715**], last visit unknown
Therapist unknown
FROM [**Telephone/Fax (1) **]:
- Diastolic CHF, EF 50%.
- COPD on 3.5L oxygen at home.
- Psychiatric disease including anorexia nervosa, past laxative
and diuretic abuse. Distant suicide attempt by overdose.
- Fibromyalgia.
- Arthritis.
- Seizure disorder, last seizure [**2126**] in the setting of EtOH
withdrawal.
- Breast CA s/p resection many years ago in Wisconson.
- Past Bell's palsy.
- CVA many years ago.
- Past TAHBSO for cancer in [**2113**].
- Chronic diarrhea.
- History of [**Last Name (un) 3696**] syndrome requiring inpatient
decompression.
- History of migraine headache.
PSYCHIATRIC HISTORY:
per [**Last Name (un) **], diagnosis of AN, borderline personality disorder and
poly substance abuse
- patient reports psychiatrist Dr. [**Last Name (STitle) 3704**] [**Telephone/Fax (1) 3715**], whom
she sees every few months for meds
- prior therpaist was [**Doctor First Name **] Aparcio, who she says stopped
seeing her 6 months ago. She says that " I begged and pleaded"
but that the therpaist let her go. No current therpaist
- reports mutiple prior psychiatric hospitalizations, but
deniesany in the last 20 years
- reports suicide attempt by OD over 20 years ago, nothing
recent per [**Doctor First Name **], certian notes indicate she had multiple SA and
hospitalizations in the past
Social History:
Reports that she is a recovering alcholic and addict, but
adamently denies ETOH and ilicit drug use for several years.
40-pack-year history of smoking, (still smokes occasionally).
Married for 20 years, alhough separated for 15 (per [**Doctor First Name **]).
Husband has multiple medical issues and is currently at a
nursing home.
Family History:
Mother & Sister: [**Name (NI) 3729**]
MOther: CAD, Breast Cancer
Father: Pancreatic [**Name (NI) 3730**], Lung Cancer
Physical Exam:
VS: T: 98.0 BP 91/48 HR: 122 reg RR 28 O2 sat 90% on 6L->98%
NRB->95% on 50% venti-mask
Gen: Anxious, Ill-appearing,
Cardiac: Increased rate, Normal S1 & S2, no m/r/g
Pulm: Diminished breath sounds bilaterally (anterior)
Abd: Refused
Ext: No edema
Neuro: A/O x 3. [**3-22**] motor strength LLE/RLE.
Pertinent Results:
[**2136-2-28**] 07:28PM CK(CPK)-19*
[**2136-2-28**] 07:28PM CK-MB-NotDone cTropnT-<0.01
[**2136-2-28**] 07:28PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG
[**2136-2-28**] 03:28PM URINE bnzodzpn-POS barbitrt-NEG cocaine-NEG
amphetmn-POS mthdone-NEG
[**2136-2-28**] 03:28PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2136-2-28**] 03:15PM LD(LDH)-132 TOT BILI-0.1 DIR BILI-0.1 INDIR
BIL-0.0
[**2136-2-28**] 03:15PM proBNP-8010*
[**2136-2-28**] 03:15PM IRON-9*
[**2136-2-28**] 03:15PM calTIBC-124* VIT B12-GREATER TH FOLATE-15.4
HAPTOGLOB-283* FERRITIN-228* TRF-95*
[**2136-2-28**] 03:15PM HCT-28.5*#
[**2136-2-28**] 12:48PM LACTATE-1.2
[**2136-2-28**] 10:40AM GLUCOSE-61* UREA N-24* CREAT-1.0 SODIUM-133
POTASSIUM-4.4 CHLORIDE-99 TOTAL CO2-25 ANION GAP-13
[**2136-2-28**] 10:40AM CK(CPK)-21*
[**2136-2-28**] 10:40AM cTropnT-<0.01
[**2136-2-28**] 10:40AM WBC-7.9 RBC-2.15* HGB-7.4* HCT-21.5* MCV-100*
MCH-34.4* MCHC-34.4 RDW-12.5
[**2136-2-28**] 10:40AM NEUTS-87.4* LYMPHS-10.1* MONOS-1.4* EOS-1.0
BASOS-0.1
[**2136-2-28**] 10:40AM PLT COUNT-306
[**2136-2-28**] 10:40AM FIBRINOGE-1005*#
[**2136-2-28**] 10:20AM HCT-24.9*
MICRO:
U/A: SpeGr: 1.006; pH: 7.0; Urobil Neg; Bili Neg; Leuk Neg; Bld
Neg; Nitr Neg; Prot Neg; Glu Neg; Ket Neg
IMAGES:
STRESS ECHO ([**1-25**]) Poor functional exercise capacity. No ischemic
ECG changes with 2D echocardiographic evidence of possible prior
myocardial infarction without inducible ischemia at the limited
achieved workload. Estimated pulmonary artery systolic pressures
were normal before and after exercise.
CXR ([**2-28**]; am) FINDINGS: PA and lateral views of the chest were
obtained. The cardiac silhouette is stable in appearance. There
is prominence of the right paratracheal stripe which is new
compared to the prior study and may reflect mediastinal
lymphadenopathy. There are multifocal hazy opacities noted
within the right upper lobe, right middle lobe, and left lower
lobe. There is blunting of the right costophrenic angle
suggestive of a small pleural effusion. The osseous structures
are intact. IMPRESSION: Multifocal bilateral airspace opacities
and blunting of the left costophrenic angle, the appearance of
which is consistent with multifocal pneumonia and a
small parapneumonic effusion. Interval development of prominence
of the right paratracheal stripe which may reflect reactive
mediastinal lymphadenopathy. A follow up CXR is recommended
following treatment.
CXR ([**2-28**];pm) FINDINGS: AP single view of the chest obtained
with patient in semi-upright position demonstrates again the on
next previous examination demonstrated multifocal parenchymal
densities in the pulmonary parenchyma preferentially in the
right upper lobe and left mid lung field and left lung base.
They persist practically unaltered. There is no evidence of
pneumothorax, and the lateral
pleural sinuses are only mildly blunted. Review of the next
preceding chest examination of [**2136-2-8**] showed
remarkable absence of any significant parenchymal densities at
that time. IMPRESSION: Bilateral multifocal extensive pulmonary
infiltrates consistent
with inflammatory processes. In light of patient's previous
diagnosis of COPD, consider also possibility of atypical edema
in particular as patient received large dose of fluid.
Brief Hospital Course:
This is a 58 year old female with history of COPD on 2-4L home
O2, Systolic CHF (EF 45-50%), Bipolar and Borderline Personality
Disorder admitted [**2135-2-27**] for chest pain and dyspnea after 5
days of viral syndrome with multi-focal pneumonia and
respiratory distress.
1) Chest Pain/Dyspnea: Patient has history of systolic CHF and
COPD - although according to pulm notes may not be obstructive
and may not actually need O2. At home on 4L NC at all times.
Reportes that chest pain differs from her usual anginal chest
pain and hurts more with deep breaths and coughing. In
addition, her EKG and cardiac enzyme levels suggested that a
myocardial infarction was not the source of her symptoms.
Likely her symptoms were caused by PNA (bibasilar multifocal
opacities on 2 CXRs) and exacerbated by getting fluids in the ED
(2L NS). Also, may in part, be attributed to anxiety as patient
has extensive psych history. Levo (750mg) was provided in the
ED and scheduled for [**2136-3-1**]. Upon arrival to the floor she
triggered immediately for low o2 sats on 4L NC and tachycardia.
She was put on venti mask and sats came up. It was felt she had
pulm edema given IVF in ED and CXR with possible edema. She
continued with tachycardia and it was thought this was a
combination of the CHF with BNP 8000 (highest in [**Month/Day/Year **] only 800s),
respiratory distress, and anxiety. She may also have taken her
home medications including adderall. Her room was searched and
these were taken from her. Got total of 30mg IV lasix over the
course of the late afternoon/evening as well as ativan and her
home dose of clonipin. HR came down to 120s. Overnight she
continued to have tachypnea with recurrently low O2 sats on 6L
NC so was placed on venti-mask. She continued to be tachycardic
all night with no improvement after ativan and confiscating her
adderall which she had been hiding in her room. An ABG revealed
hypoxia (PO2 61) without CO2 retention. She was given an extra
10mg IV lasix and put out total of 2.3L over the night.
In the am she continued to be tachypnic, hypoxic, and
tachycardic. She was started on IV vanc for empiric coverage of
HAP given recent hospitalizations. A repeat CXR did not show
pulm edema so no further lasix was given. She was started on
BIPAP. Repeat ABG with PO2 50s. She was transferred to the MICU
for respiratory distress and possible intubation. Of note she
did say she would take intubation "as a last resort". Would not
give us the phone numbers of next of [**Doctor First Name **] and in [**Name (NI) **] sister's
number is out of service.
She was transferred to the MICU where she was stabilized after
briefly being on BIPAP. A speech and swallow evaluation
confirmed that she was aspirating. The MICU team discussed with
her placing a PEG tube and she refused. She also pulled out an
NGT placed for feeding two times.
She came back to the floor and was satting 94% on 2L NC which
is her baseline. We attempted to convince her to comply with a
video swallow exam to rule out silent aspiration but the patient
refused. Given that she was high aspiration risk it was felt
that she should not eat, however, the patient threatened to
leave the hospital if she was not given food. Therefore, after
explaining her risk of choking and developing further
pneumonias, a compromise was reached. The patient had a
nectar-thickened diet while in house. She was set up with an
outpatient speech and swallow evaluation (including video
swallow) which she said she would comply with as long as we did
not try to evaluate her in the hospital. She was discharged with
"Thick-aid" to add to her liquids and will see the speech and
swallow team in one week for her evaluation. Her primary care
doctor will discuss these results with her.
2) Anemia: Patient with history of chronic inflammation (RA) as
well as gastritis likely from NSAIDs reports both bright and
dark blood in stool starting on [**Name (NI) 2974**]; attributes blood, in
part, to internal and external hemmorhoids and refused rectal
guiac on mulitple occasions. Normal MCV, low Fe, low TIBC, low
tranferrin and high ferritin suggestive of anemia of chronic
disease which is associated with both chronic inflammatory
processes and heart failure. Patient may be suffering from ACD
along with co-existing iron deficiency, requiring both iron
supplementation as well as addressing her underlying disorder.
Stool guaiacs were negative on the floor. Patient was consented
for blood transfusion but was not transfused given volume
overload and stable hcts while on floor.
In the MICU she was given 1unit pRBCs for a slightly lower hct
than previously. Her hct continued to be stable throughout her
stay. Her naproxen was held throughout her stay and she was
started on iron which she will take as an outpatient. Her
primary care doctor will follow her blood counts as an
outpatient.
3) Diarrhea: Patient has chronic history of diarrhea with a
question of laxative abuse and anorexia; Had some loose stools
on the floor even after medications were comfiscated and with
recent hospitalizations may have an infection. CDiff tests were
negative.
4) Pain Management/Psych issues: Unclear who is following her
for psych as an outpatient. Will likely need psych consult at
some point given medication regimen is likely not correct
regimen and she has off and on been refusing medical care.
Currently does have capacity per the medicine floor team's
assessment but may need formal capacity assessment in the
future. Also has h/o eating disorders and with laxative abuse
may need eating disorder team consult when more acute medical
issues resolved.
Medications on Admission:
ALBUTEROL - 90 mcg Aerosol - 1 to 2 puffs, QID
ALBUTEROL SULFATE - 0.83 mg/mL, QID
ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg - 2 puffs inhaled [**4-22**]
times a day; PRN
AMPHETAMINE-DEXTROAMPHETAMINE - 20 mg Capsule, 1 Cap TID
BUTALBITAL-ACETAMINOPHEN-CAFF [FIORICET] - 50 mg-325 mg-40 mg
Tablet - 1 TAB Q Daily
CLONAZEPAM - 2 MG TABLET 1 TAB QID
FEXOFENADINE - 180 mg Tablet - I TAB Q Daily
FLUOXETINE - 20 mg Tablet - QID
FLUTICASONE - 50 mcg Spray 1 to 2 sprays [**Hospital1 **]
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 500 mcg-50 mcg/Dose
Disk
with Device - 1 Inhalation [**Hospital1 **]
FOLIC ACID - 1 Tab Q Daily
FUROSEMIDE - 20 mg Tablet - 2 Tabs [**Hospital1 **]
HYDROCORTISONE ACETATE [ANUSOL HC-1] - 1 % Ointment - Q Bedtime
LIDOCAINE [LIDODERM] - 5 % (700 mg/patch) Adhesive Patch, 3
Patches on neck or back for 12 hours on/12 hours off
MISOPROSTOL [CYTOTEC] - 100 mcg Tablet - 2 Tabs [**Hospital1 **]
MULTIVITAMINS - SOLUTION - 1 Tab Q Daily
NAPROXEN - 500 mg Tablet - 1 Tab [**Hospital1 **]
NITROGLYCERIN - 0.4 mg Tablet, Sublingual - 1 Tab every 5
minutes/3 doses PRN
OXYCODONE-ACETAMINOPHEN [PERCOCET] - 5 mg-325 mg Tablet - 1 Tab
QID
PANTOPRAZOLE - 40 mg Tablet, 1 Tab Q Daily
PERPHENAZINE - 8 mg Tablet - 1 Tab Q PM
POTASSIUM CHLORIDE - 20 mEq Tab 3 Tab [**Hospital1 **]
RALOXIFENE [EVISTA] - 60 mg Tablet - 1 Tab Q Daily
RISPERIDONE - 2MG Tablet - 1 Tab Q Daily
SULFASALAZINE - 500 mg Tablet - 2 Tab [**Hospital1 **]
TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule,
w/Inhalation Device - 1 Inhalation Q Daily
TRAMADOL - 50 mg Tablet - 4 Tabs Q4-Q6
TRIAMCINOLONE ACETONIDE - 0.1 % Ointment - [**Hospital1 **]
Discharge Medications:
1. Clonazepam 1 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours).
2. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Fluoxetine 20 mg Capsule Sig: Four (4) Capsule PO DAILY
(Daily).
4. Perphenazine 8 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
5. Risperidone 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Misoprostol 200 mcg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. Fexofenadine 180 mg Tablet Sig: One (1) Tablet PO once a day.
8. Hydrocortisone Acetate 1 % Ointment Sig: One (1) Appl Rectal
QPM (once a day (in the evening)).
9. Sulfasalazine 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
10. Triamcinolone Acetonide 0.1 % Cream Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day).
11. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
Three (3) Adhesive Patch, Medicated Topical DAILY (Daily): On
for 12 hours, off for 12hours.
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
13. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) inh Inhalation once a day.
14. Raloxifene 60 mg Tablet Sig: One (1) Tablet PO once a day.
15. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every six
(6) hours.
16. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tab
Sublingual Q 5 mins as needed for chest pain for 3 doses.
17. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
18. Lasix 20 mg Tablet Sig: Two (2) Tablet PO twice a day.
19. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
20. Advair Diskus 500-50 mcg/Dose Disk with Device Sig: One (1)
inh Inhalation twice a day.
21. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
spray Nasal twice a day.
22. Fioricet 50-325-40 mg Tablet Sig: One (1) Tablet PO once a
day.
23. Amphetamine-Dextroamphetamine 20 mg Tablet Sig: One (1)
Tablet PO three times a day.
24. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) puff Inhalation four times a day as needed for shortness
of breath or wheezing.
25. Thick-Aid Liquid Sig: AS DIR Topical three times a day:
Add to liquids to thicken prior to eating.
Disp:*1 months supply* Refills:*2*
26. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: Three (3) Tab Sust.Rel. Particle/Crystal PO twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Aspiration PNA
Discharge Condition:
The patient was febrile, hemodynamically stable, and satting 98%
on 2L NC when she was discharged.
Discharge Instructions:
You were admitted to the hospital with pneumonia. We think you
got pneumonia from having food go down your windpipe when you
swallow. We have recommended that you not eat and have advised
you have a feeding tube instead. You have refused this treatment
and you have stated that you understand that you may get
pneumonia again if you eat.
Medication Changes:
START: Iron 325mg by mouth twice daily
STOP: Naproxen
Diet Changes: You have been advised to have a feeding tube
placed and no longer eat anything by mouth. You have refused the
feeding tube. We have thus advised that you eat only
nectar-thickened liquids. We have given you a prescription for
"Thick-Aid" which you can use to thicken your food.
Please call your doctor or come back to the hospital if you
develop shortness of breath, fevers, chills, chest pain,
confusion, weakness, or any other concerning symptoms.
Followup Instructions:
F/U CXR for mediastinal LAD in 6 weeks.
Please call your primary care doctor, Dr. [**Last Name (STitle) 3707**]
([**Telephone/Fax (1) 2205**]), for a follow up appointment in [**1-20**] weeks. She
will call you with the appointment time. She will listen to your
lungs and help you with setting up your swallowing doctor.
Please follow up with the speech pathologists ([**Telephone/Fax (1) 3731**]) who
will give you exercises for strenghthening your swallowing
muscles and test how you are swallowing. They will see you on
[**3-14**] at 1:00 pm in the [**Location (un) 591**], [**Hospital1 3732**]. [**Location (un) 470**] in the radiology department. Your
primary care doctor will discuss the results with you.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
Completed by:[**2136-3-7**]
ICD9 Codes: 5070, 4280, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3805
} | Medical Text: Admission Date: [**2176-8-9**] Discharge Date: [**2176-8-16**]
Date of Birth: [**2113-1-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
angina, SOB
Major Surgical or Invasive Procedure:
right carotid endarterectomy [**2176-8-9**]
CABG x3 [**2176-8-12**] (LIMA to LAD, SVG to OM, SVG to PDA)
History of Present Illness:
63 yo male with recent admission to OSH for angina. Ruled out
for MI, but had abnormal stress test.Also was anemic and had
guaiac positive stool. Referred for CABG with pre-op eval.
Past Medical History:
prior left CEA
PVD
HTN
anemia with GI bleed/PUD
pancreatitis/ETOH abuse
elev. lipids
COPD
headaches
CVA
bil. carotid disease
prior tonsillectomy
Social History:
tool maker
[**2-6**] ppd x 50 years
2 drinks per week
denies recreational drugs
Family History:
mother with MI ( unsure of age)
Physical Exam:
6'0 155# HR 68 139/58
97.6 98% 2L NC RR 14
NAD, well-developed
EOMI, PERRLA
neck supple, full ROM, no LAD
CTAB anteriorly
RRR no m/r/g with distant heart sounds
soft, NT, ND, + BS, tender RLQ , no palpable mass
warm, well-perfused, no edema or varicosities
alert and oriented x3 , nonfocal
2+ bil. fem/DP/PT/radials
right carotid bruit, none on left
Pertinent Results:
[**2176-8-16**] 07:05AM BLOOD WBC-6.1 RBC-2.97* Hgb-9.1* Hct-27.6*
MCV-93 MCH-30.6 MCHC-33.0 RDW-13.4 Plt Ct-406#
[**2176-8-8**] 01:50PM BLOOD WBC-5.7 RBC-4.34* Hgb-13.6* Hct-40.1
MCV-92 MCH-31.3 MCHC-33.9 RDW-13.5 Plt Ct-433
[**2176-8-16**] 07:05AM BLOOD Plt Ct-406#
[**2176-8-12**] 03:23PM BLOOD PT-12.0 PTT-49.5* INR(PT)-1.0
[**2176-8-11**] 11:40AM BLOOD PT-11.9 PTT-32.1 INR(PT)-1.0
[**2176-8-8**] 01:50PM BLOOD Plt Ct-433
[**2176-8-16**] 07:05AM BLOOD Glucose-131* UreaN-14 Creat-0.8 Na-136
K-4.4 Cl-98 HCO3-32 AnGap-10
[**2176-8-10**] 04:22AM BLOOD Glucose-114* UreaN-8 Creat-0.7 Na-139
K-4.1 Cl-107 HCO3-26 AnGap-10
[**2176-8-13**] 03:15AM BLOOD ALT-12 AST-23 LD(LDH)-206 AlkPhos-60
Amylase-28 TotBili-0.2
[**2176-8-13**] 03:15AM BLOOD Lipase-11
[**2176-8-16**] 07:05AM BLOOD Calcium-9.1 Phos-3.9 Mg-2.2
RADIOLOGY Final Report
CHEST (PA & LAT) [**2176-8-16**] 10:39 AM
CHEST (PA & LAT)
Reason: r/o inf, eff
[**Hospital 93**] MEDICAL CONDITION:
63 year old man s/p cabg
REASON FOR THIS EXAMINATION:
r/o inf, eff
REASON FOR EXAMINATION: Followup of a patient after CABG.
PA and lateral upright chest radiograph was compared to [**8-11**]
and [**2176-8-13**].
The cardiomediastinal post-surgical appearance is stable. The
lungs are hyperinflated with underlying emphysema changes again
noted but there is no new infiltrates, masses or nodules. The
pleural effusions are bilateral and small, stable.
IMPRESSION: Stable small bilateral pleural effusions. Emphysema.
Otherwise, stable appearance of post-surgical chest.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**]
DR. [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1508**]Approved: FRI [**2176-8-16**] 12:15 PM
Cardiology Report ECG Study Date of [**2176-8-12**] 3:23:22 PM
Sinus rhythm. Non-specific low amplitude T waves in the limb
leads. Compared
to tracing on [**2176-8-11**] QRS change in lead V4 could be positional.
T wave changes
are new.
Read by: [**Last Name (LF) 2889**],[**First Name3 (LF) 2890**] K.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
95 110 94 362/414.71 79 85 71
Cardiology Report ECHO Study Date of [**2176-8-12**]
*** Report not finalized ***
PRELIMINARY REPORT
PATIENT/TEST INFORMATION:
Indication: cabg
Status: Inpatient
Date/Time: [**2176-8-12**] at 11:00
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007AW1-:
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name (STitle) **] R. [**Doctor Last Name **]
MEASUREMENTS:
Left Ventricle - Septal Wall Thickness: 1.1 cm (nl 0.6 - 1.1 cm)
Left Ventricle - Inferolateral Thickness: 1.1 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.2 cm (nl <= 5.6 cm)
Left Ventricle - Ejection Fraction: 50% to 55% (nl >=55%)
[**Doctor Last Name **] - Valve Level: 3.5 cm (nl <= 3.6 cm)
[**Doctor Last Name **] - Ascending: *3.5 cm (nl <= 3.4 cm)
[**Doctor Last Name **] - Descending Thoracic: *2.6 cm (nl <= 2.5 cm)
INTERPRETATION:
Findings:
LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.
LV WALL MOTION: Regional LV wall motion abnormalities include:
basal anterior
- normal; mid anterior - normal; basal anteroseptal - normal;
mid anteroseptal
- normal; basal inferoseptal - normal; mid inferoseptal -
normal; basal
inferior - normal; mid inferior - normal; basal inferolateral -
normal; mid
inferolateral - normal; basal anterolateral - normal; mid
anterolateral -
normal; anterior apex - hypo; septal apex - hypo; inferior apex
- hypo;
lateral apex - hypo; apex - hypo;
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
[**Doctor Last Name **]: Normal aortic diameter at the sinus level. Normal
ascending [**Doctor Last Name 5236**]
diameter. Mildly dilated descending [**Doctor Last Name 5236**]. Complex (>4mm)
atheroma in the
descending thoracic [**Doctor Last Name 5236**].
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. No TEE
related
complications. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. The patient was
under general
anesthesia throughout the procedure.
Conclusions:
Pre-CPB: No spontaneous echo contrast is seen in the left atrial
appendage.
Right ventricular chamber size and free wall motion are normal.
Mild systolic
dysfxn of distal and apical segments of LV. The descending
thoracic [**Doctor Last Name 5236**] is
mildly dilated. There are complex (>4mm) atheroma in the
descending thoracic
[**Doctor Last Name 5236**]. The aortic valve leaflets (3) appear structurally normal
with good
leaflet excursion and no aortic regurgitation. The mitral valve
leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen. There
is no
pericardial effusion.
Post procedure (patient had Off-Pump coronary bypasses) :
Preserved
biventricular systolic fxn. No AI. Trace MR. [**First Name (Titles) **] [**Last Name (Titles) 5235**]. Other
parameters as
pre-bypass.
[**Location (un) **] PHYSICIAN:
Brief Hospital Course:
Admitted [**8-9**] for right CEA done by Dr. [**Last Name (STitle) **]. Monitored
over the weekend, and underwent cabg x3 with Dr. [**Last Name (STitle) **] on [**8-12**].
Extubated late that evening, and transferred to the floor on POD
#1 to begin increasing his activity level. Gentle diuresis
started and beta blockade titrated. Chest tubes and pacing wires
removed per protocol. ACE inhibitor also started for tighter BP
management. He continued to progess and was ready for discharge
home POD 4 with services.
Medications on Admission:
plavix 75 mg daily
pravastatin 10 mg daily
ASA 81 mg daily
nexium 40 mg [**Hospital1 **]
metoprolol 50 mg daily
oxycodone 5 mg QID (headaches)
combivent 2 puffs QID
advair one puff [**Hospital1 **]
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
[**Hospital1 **]:*60 Capsule(s)* Refills:*0*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Hospital1 **]:*30 Tablet(s)* Refills:*0*
3. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Hospital1 **]:*30 Tablet(s)* Refills:*0*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
[**Hospital1 **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
[**Hospital1 **]:*40 Tablet(s)* Refills:*0*
6. Chantix 0.5(11)-1(3X14) mg Tablets, Dose Pack Sig: One (1)
Tablets, Dose Pack PO once a day: 0.5 mg ORALLY once daily for
days 1 through 3, then 0.5 mg twice daily for days 4 through 7,
then 1 mg twice daily follow up with PCP .
[**Name Initial (NameIs) **]:*30 Tablets, Dose Pack(s)* Refills:*2*
7. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
[**Name Initial (NameIs) **]:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
8. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Name Initial (NameIs) **]:*30 Tablet(s)* Refills:*0*
9. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
[**Name Initial (NameIs) **]:*60 Tablet(s)* Refills:*0*
10. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours).
[**Name Initial (NameIs) **]:*qs qs* Refills:*2*
11. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
[**Hospital1 **]:*60 Disk with Device(s)* Refills:*2*
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
[**Hospital1 **]:*30 Tablet(s)* Refills:*0*
13. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 5 days.
[**Hospital1 **]:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
s/p CABGx3(LIMA-LAD,SVG-PDA,SVG-OM)[**8-12**]
PMH: CAD,PVD,PUD,HTN,+ ETOH/Tob, Left CEA
Discharge Condition:
good
Discharge Instructions:
Shower daily, no bathing or swimming.
Take all medications as prescribed.
Call surgeon for any fever, redness or drainage from wounds.
[**Telephone/Fax (1) 170**]
No lotions, creams, powders, or ointments on any incision
No driving for one month or while on narcotics.
No lfting greater than 10 pounds for 10 weeks.
Please do not smoke, Quitworks information provided please
follow up with primary care physician
Followup Instructions:
Please call to schedule all appointments
[**Hospital 409**] clinic on [**Hospital Ward Name 121**] 2 in 2 weeks [**Telephone/Fax (1) 170**]
Dr [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
Dr [**First Name4 (NamePattern1) 3613**] [**Last Name (NamePattern1) 23019**] in [**3-9**] weeks [**Telephone/Fax (1) 3183**]
Dr [**Last Name (STitle) 23155**] in 4 weeks [**Telephone/Fax (1) 3121**]
Completed by:[**2176-8-16**]
ICD9 Codes: 496, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3806
} | Medical Text: Admission Date: [**2155-11-17**] Discharge Date: [**2155-11-19**]
Date of Birth: [**2126-3-8**] Sex: M
Service: MEDICINE
Allergies:
Haldol / Penicillins / Toradol
Attending:[**First Name3 (LF) 8487**]
Chief Complaint:
suicide attempt by drug overdose
Major Surgical or Invasive Procedure:
Intubation [**11-17**], extubation [**11-18**] for airway protection
History of Present Illness:
HPI: 29 yo male, h/o BPD, schizoaffective disorder,
polysubstance abuse, s/p prior suicide attempts (with multiple
hospitalizations for suicidality), presenting s/p ingestion of
multiple substances. Per ED notes, pt took an unknown quantity
of Zyprexa/Klonopin as a suicide attempt; he denied ingestion of
other substances. In the ED,pt was somnolent (hemodynamically
stable, saturating adequately). Received 2 mg of Naloxone in ED
with mild improvement but then became more somnolent requiring
intubation for airway protection. NGT was also placed, and he
received 50 gm of activated charcoal. Serum/urine tox screens
were obtained; urine tox came back positive for benzos,
barbiturates, opiates, and cocaine (negative for methadone and
amphetamines).
Past Medical History:
PMH: (obtained via [**Month/Year (2) **] notes)
1. Bipolar Disorder, Schizoaffective disorder, with multiple
prior suicide attempts/hospitalizations for this (most recently
[**10-4**], methadone, klonopin, chloral hydrate). First admission
for suicidality was at age 13 (ASA overdose)
2. Chronic LBP x 9 yrs, s/p injury to 2 lumbar discs
3. Trigeminal neuralgia
4. Migraines
Social History:
SH: polysubstance abuse, including IV heroin, cocaine,
methadone, speedballs, benzos, smokes 1 ppd, longest sobriety
period 1 yr
?Sexual abuse in childhood, left school in 12th grade and was
working in family business, homeless, homosexual
Family History:
FH: Mother with BPD, schizophrenia, EtOH
Father with BPD
Maternal GM with alcoholism
Physical Exam:
VS: on admission: 97.5 96 101/55 18 97% RA
s/p intubation: 92/41 81 21 100% on AC--
AC: 600/12, PEEP=5, RR=20-21
Gen: intubated, sedated, lying in bed
HEENT: PERRL, OP clear, MMM
Neck: no JVD or LAD
Lungs: CTA ant/lat
CV: RRR, nl s1/s2, no m/r/g
Abd: obese, with pannus, decreased BS, no reb/guard, no
tenderness
Extr: no c/c/e, 2+ PT/DP bilat
Neuro: sedated, not responsive to commands
Skin: erythematous macular rash under pannus, groin region.
Pertinent Results:
[**2155-11-19**] 10:24AM BLOOD WBC-5.3 RBC-4.05* Hgb-11.8* Hct-32.9*
MCV-81* MCH-29.1 MCHC-35.8* RDW-13.3 Plt Ct-131*
[**2155-11-18**] 04:50AM BLOOD WBC-5.6 RBC-3.86* Hgb-11.3* Hct-32.0*
MCV-83 MCH-29.4 MCHC-35.4* RDW-14.4 Plt Ct-167
[**2155-11-18**] 04:50AM BLOOD WBC-5.6 RBC-3.86* Hgb-11.3* Hct-32.0*
MCV-83 MCH-29.4 MCHC-35.4* RDW-14.4 Plt Ct-167
[**2155-11-17**] 07:50PM BLOOD WBC-10.8 RBC-4.63 Hgb-13.7* Hct-36.9*
MCV-80* MCH-29.5 MCHC-37.0* RDW-13.1 Plt Ct-207
[**2155-11-19**] 10:24AM BLOOD Plt Ct-131*
[**2155-11-18**] 04:50AM BLOOD Plt Ct-167
[**2155-11-18**] 04:50AM BLOOD PT-13.5* PTT-32.6 INR(PT)-1.2
[**2155-11-17**] 07:50PM BLOOD Plt Ct-207
[**2155-11-17**] 07:50PM BLOOD PT-13.6* PTT-31.3 INR(PT)-1.2
[**2155-11-19**] 10:24AM BLOOD Glucose-116* UreaN-6 Creat-0.7 Na-143
K-3.7 Cl-109* HCO3-24 AnGap-14
[**2155-11-18**] 04:50AM BLOOD Glucose-129* UreaN-12 Creat-0.8 Na-140
K-3.7 Cl-107 HCO3-23 AnGap-14
[**2155-11-17**] 07:50PM BLOOD Glucose-124* UreaN-13 Creat-1.0 Na-136
K-4.5 Cl-98 HCO3-23 AnGap-20
[**2155-11-18**] 04:50AM BLOOD ALT-22 AST-22 AlkPhos-77 TotBili-0.4
[**2155-11-17**] 07:50PM BLOOD ALT-27 AST-31 AlkPhos-93 TotBili-0.6
EKG: NSR=90, nl axis/intervals, ?J-pt elev in I, II, V2-V6;
unchanged from prior, nl QTc
.
CXR: NGT/ETT in place, adequate position, lung fields otherwise
clear
.
CT Head (non-contrast): No acute ICH
Brief Hospital Course:
A/P: 29 yo male, h/o polysubstance abuse,
BPD/schizoaffective/panic disorders, s/p multiple suicide
attempts, presenting s/p overdose with multiple substances.
.
1. Overdose: Multiple substances (cocaine, BZ, barb, narcotics,
zyprexa). s/p activated charcoal and narcan x 1. Neg TCA and QTc
wnl.
- Tox consult: supportive care.
- supportive care for cardiovascular/pulmonary; includes
mechanical ventilation overnight, support of BP, monitoring on
tele
- ?benzo OD; no flumazenil as this can cause withdrawal
seizures, precipitate arrhythmias if concomitant TCA OD
- ?barbits OD--can alkalinize urine, will ck urine/urine pH
- ?cocaine-can become hyperthermic, ?rhabdo, hypertensive; again
supportive measures, alpha/beta blocker
- ?zyprexa--sx can include tachycardia, bp fluctuations, EPS
symptoms
Patient is now 48 hours after admission for overdose and is
stable from a medical standpoint. He is s/p extubation and is
breathing fine on RA without any respiratory compromise. Per
psych recommendations, he has been getting prolexin and ativan
for agitation. Needs inpatient psych admission for further care
and therapy as he is now medically stable.
.
2. Respiratory failure: intubated [**1-22**] somnolence, respiratory
depression, on AC, overbreathing vent
-extubated [**11-18**] without complications, stable respiratory-wise
.
3. Hypotension: Likley secondary to sedation prior to intubation
- now resolved after extubation and off propofol gtt. With
normal BP for over 30 hours.
.
4. Psych: as above, with BPD, schizo, anxiety; will need to
clarify med regimen and consult psych; will likely need Section
12/psych treatment
-psych consult recs prolexin and ativan for agiation as needed
.
5. ?Skin rash: appears c/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], can give topical nystatin
powder, keep area dry
.
6. PPX: OOB and walking, eating
.
7. Code: presumed full
.
8. Communication: need to determine (?parents)
.
9. Access: PIVs
.
10. Dispo: ICU care -> now medically stable, to inpatient
psychiatric facility
Medications on Admission:
Meds on Admission: (as per [**Last Name (LF) **], [**First Name3 (LF) **] notes)
methadone 20 mg po qam
klonopin 1 mg po tid
albuterol
zyprexa 20 mg po qhs
effexor XR 75 mg po bid
fioricet
clorhydrate 500 mg po qhs
Discharge Medications:
1. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
2. Fluphenazine HCl 2.5 mg Tablet Sig: Two (2) Tablet PO Q2-4H
(every 2 to 4 hours) as needed for severe agitation.
3. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
4. Lorazepam 2 mg/mL Syringe Sig: One (1) Injection Q2-4H
(every 2 to 4 hours) as needed for severe agitation.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary - Suicide attempt by drug overdose, bipolar d/o,
schizoaffective d/o, h/o multiple suicide attempts
Secondary - Chronic LBP x 9 yrs, s/p injury to 2 lumbar discs,
trigeminal neuralgia, migraines
Discharge Condition:
Medically stable and cleared for inpatient psychiatric admission
Discharge Instructions:
-please continue with medications and therapy as determined by
Psychiatry facility
-you need to obtain primary medical care here in [**Location (un) 86**] as well
as psychiatric care
Followup Instructions:
As determined by Psychiatric facility
Completed by:[**2155-12-1**]
ICD9 Codes: 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3807
} | Medical Text: Admission Date: [**2116-11-17**] Discharge Date: [**2116-12-1**]
Date of Birth: [**2059-12-18**] Sex: F
Service: NEUROSURGERY
Allergies:
Codeine / Vicodin / Rowasa / Ciprofloxacin / Requip / Depakote /
Nsaids / Duragesic / Pregabalin / Latex
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
Back Pain
Major Surgical or Invasive Procedure:
T6 vertebrectomy and posterior fusion T2-9
TRANSFUSION FOR BLOOD LOSS ANEMIA POST-OP
History of Present Illness:
56yo female with newly diagnosed metastatic cancer of unknown
primary (likely lung) was admitted with back pain likely related
to cord compression and destructive metastatic lesions.
Unfortunately patient does not have any medical records at [**Hospital1 18**]
and is somewhat poor historian herself.
She was reportedly diagnosed with metastatic cancer (no
pathologic diagnosis but thought likely primary lung) over the
last several weeks. She has had chronic back pain, which has
worsened over the last several weeks. She was diagnosed with
multiple vertebral compression fractures and was scheduled for
outpatient kyphoplasty at [**Hospital6 10353**]. She then
presented to [**Hospital6 10353**] on the day prior to admission
with increased back pain. CT T and L spine demonstrated findings
concerning for cord compression at T6. Due to the concern for
cord compression, she was transferred to [**Hospital1 18**] for further
evaluation.
Upon arrival in the ED, temp 97.6, HR 68, BP 132/68, RR 14, and
pulse ox 98% on room air. Exam was notable for marked back pain
and rhonchorous bilateral breath sounds. She received total of
5mg IV dilaudid (2mg, 2mg, and 1mg) and zofran. Neurosurgery was
consulted in the ED who recommended MRI T spine.
Review of systems:
(+) Per HPI. back pain, 3 weeks of night sweats, 20 lb weight
loss over the last 2 months, chronic loose stools related to her
colectomy, occasional shortness of breath, anterior rib pain
diffusely, bilateral hip pain, occasional palpitations, nausea,
muscle aches
(-) Denies fever, chills, headache, sinus tenderness,
rhinorrhea, congestion, cough, vomiting, constipation, abdominal
pain, change in bladder habits, dysuria, arthralgias, or
myalgias, urinary incontinence, fecal incontinence
Past Medical History:
1. Metastatic Cancer, presumed primary lung
2. Hyperlipidemia
3. Depression / Anxiety
4. Seasonal Allergies
5. s/p Total Colectomy for Collagenous Colitis
6. Fibromyalgia
7. h/o Alcoholism
8. Emphysema
9. h/o Prescription Drug Abuse
Social History:
- Home: lives in [**Location 5110**] and rents room in sister's home
- Occupation: has not worked for the last ~15 years, previously
employed as a Mental Health worker at [**Last Name (un) 18355**] State School in
[**Hospital1 **]
- EtOH: history of marked alcohol abuse, drinking several cases
(24 cans) of beer daily but reportedly stopped > 20 years ago;
does still drink ~several times a month at social functions
- Drugs: history of remote marijuana use, history of remote
prescription drug abuse including with valium and percocet
- Tobacco: reportedly quit yesterday, 60-80 PPY history ([**1-24**] PPD
x 40 years)
Family History:
Sister - history of cancer, unsure what kind
Father - died of emphysema in his 70s
Mother - died of unknown causes at age 82
Physical Exam:
T 97.9 / BP 155/99 / HR 80 / RR 28 / Pulse ox 99% RA
Gen: uncomfortable appearing, lying on her right side, no acute
distress, very pleasant, very thin
HEENT: Clear OP, dry mucous membranes
NECK: Supple, No LAD, No JVD
CV: RR, NL rate. NL S1, S2. No murmurs, rubs or gallops
LUNGS: CTA, BS BL, No W/R/C
ABD: Soft, NT, ND. NL BS. No HSM
EXT: No edema. 2+ DP pulses BL
SKIN: No rash
NEURO: A&Ox3. Appropriate. CN 2-12 intact. Preserved sensation
throughout. 5/5 strength in right lower extremity / right upper
extremity / left upper extremity; 5-/5 in left lower extremity
secondary to pain; Normal coordination. Gait assessment
deferred; intact rectal tone on exam in the ED
PSYCH: Listens and responds to questions appropriately, pleasant
Exam upon discharge: motors full, sensation intact, no clonus,
wound cdi with staples
Pertinent Results:
OSH LABS:
[**2116-11-16**]
WBC 21.5 / Hct 44.6 / Plt 426
N 59 / Bands 1 / L 31 / M 7
INR 1.1 / PTT 23.5
Na 139 / K 3.7 / Cl 98 / CO2 30.7 / BUN 10 / Cr 1 / BG 78
Ca [**17**].9 / TP 6.5 / Alb 4.3 / TB .7 / Trop T < .01
AST 11 / ALT 8 / Alk Phos 67
[**2116-11-17**]
WBC 15.3 / hct 37.8 / Plt 325
N 52 / L 31 / M 16 / E 1 / B 1
Na 138 / K 3.2 / Cl 102 / CO2 27.6 / BUN 10 / Cr .9 / BG 68
Ca 9.3
UA - yellow, clear, 1.021, 2+ LE, negative nit, neg prot, neg
gluc, 1+ ket, neg urobili, neg blood, 80-90 WBCs, [**11-5**] RBCs, 3+
muc, 1+ bact, 1+ epi
OSH STUDIES:
CXR - [**2116-11-16**] right lung mass compatible with neoplasm
CT Thoracic and Lumbar Spine - [**2116-11-16**] - Findings are
compatible with right middle lobe primary lung cancer with
metastatic disease to the T2 and T6 vertebral bodies. There is
destruction of the T6 vertebral body with posterior extension of
tumor to cause cord compression. There is what appears to be
metastatic disease to the left adrenal gland.
[**Known lastname **],[**Known firstname 18356**] [**Medical Record Number 18357**] F 56 [**2059-12-18**]
Cytology Report BRONCHIAL BRUSHINGS Procedure Date of [**2116-11-19**]
REPORT APPROVED DATE: [**2116-11-23**]
SPECIMEN RECEIVED: [**2116-11-20**] [**-9/4281**] BRONCHIAL BRUSHINGS
SPECIMEN DESCRIPTION: Received brush in Cytolyt.
Prepared 1 ThinPrep slide.
CLINICAL DATA: 56 y/o female with right lung mass and spinal
mets
suspicious for lung cancer.
PREVIOUS BIOPSIES:
[**2116-11-20**] [**-9/4281**] TBNA-RML MASS
REPORT TO: DR. [**First Name8 (NamePattern2) **] [**Name (STitle) **]
DIAGNOSIS: Bronchial brushing:
POSITIVE FOR MALIGNANT CELLS
consistent with non-small cell carcinoma.
Note:
Please correlate with endobronchial biopsy (S09-[**Numeric Identifier 18358**]).
DIAGNOSED BY:
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **], CT(ASCP)
[**First Name11 (Name Pattern1) 636**] [**Last Name (NamePattern4) 5337**], M.D.
Brief Hospital Course:
56F with a history of asthma, COPD, R lung mass and metastatic
cancer with 8-wk h/o LBP related to cord compression and
metastatic lesions. The patient also suffers from spinal
stenosis. The lung mass was sampled via broncoscopy and shown
to be NSCLC. CT is concerning for metastatic disease to
vertebral bodies and cord compression at T6. There is an
additional met to an adrenal gland.
.
1) Back pain.
Etiology likely r/t metastatic disease to spinal cord in
background of 6-year h/o spinal stenosis. CXR [**11-19**] shows no
evidence of pneumothorax.
?????? Dilaudid PO
?????? Fentanyl patch (100 mcg/hr TP Q72H)
?????? Lidocaine patch (5% 3 daily)
?????? Tizanidine (2 mg PO QHS) for muscle relaxation
- PRN bowel regimen in setting of high dose narcotics (note h/o
colectomy).
?????? Patient allergic to lyrica
.
2) Cord compression. T-spine MRI reveals cord compression at T6
from path comp fracture and circumferential epidural mass.
Advanced DDD including compressive central disc herniation at
C3-4 w/ additional multilevel canal/foraminal narrowing in C/L
spine. Lytic lesion in anterosuperior R iliac crest, L pelvic
side wall. Head CT/MRI show no acute intracranial processes or
masses. Bone scan completed, no other mets.
- Out of bed with brace
- Lower left weakness improving ([**5-26**]), otherwise neurologically
intact. Frequent neuro checks
- Neurosurgery and rad onc recs greatly appreciated
- Continuing dexamethasone 4 mg Q6H (stop prednisone). Please
note: given chronic h/o prednisone use, MUST start PO prednisone
taper after dexamethasone is discontinued.
- Neurosurg took to OR [**2116-11-27**] where under general anesthesia pt
underwent T6 vertebrectomy with cage placement and posterior
fusion T2-9. Due to prolonged prone position, pt was kept
intubated overnight and monitored closely in ICU and was
extubated POD#1. Her motor exam was full. She had JP drain that
was monitored for output. It was removed POD#3. Her incision was
clean and dry. Her diet and activity were advanced. She wears
TLSO when out of bed. She worked with PT/OT and was recommended
for rehab. She prefers oncologic follow up closer to home and
appt was arranged for her and she was informed.
.
3) Metastatic cancer - NSCLC on preliminary brushings
?????? Bone scan ([**11-20**]) - known thoracic spine T3 lytic bony met,
uptake involving right ilium.
?????? Social work consulted for coping
?????? [**First Name8 (NamePattern2) **] [**Doctor Last Name **] (Heme/onc) to follow for chemo eligibility - PT
PREFERS TO HAVE ONCOLOGY TREATMENT CLOSER TO HOME
.
.
4) Leukocytosis - likely reactive/secondary to use of
dexamethasone.
5) Psych: depression, anxiety, current smoking addiction, former
substance abuse, restless leg syndrome
- On trazodone for insomnia
- Continue bupropion
- Social work following
- Continue clonazepam for now
.
5) Respiratory issues:
- Emphysema - stable on RA.
- Seasonal allergies - stable
- Continue albuterol nebs, fexofenadine
.
.
6) GU: pyuria, previous evidence of UTI.
?????? UA and culture were negative
.
.
7) Hyperlipidemia - stable. Continue statin.
.
8) History of chronic steroid use for unclear etiology.
?????? Contact Dr. [**First Name (STitle) 6164**] (GI) @ [**Hospital3 **] ([**Telephone/Fax (1) 4475**]);
waiting to hear from PCP [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 18359**] ([**Telephone/Fax (1) 18360**];
[**Telephone/Fax (1) 18361**])
?????? On PCP [**Name Initial (PRE) 1102**] (Bactrim SS)
.
FEN: regular diet, replete electrolytes PRN, ordered sodium
Polystyrene Sulfonate
PPx: heparin SC, bowel regimen PRN, on PPI
Code: Full code
Comm: patient; sister [**Name (NI) 18362**] [**Name (NI) 4154**], Cell [**Telephone/Fax (1) 18363**]; home
[**Telephone/Fax (1) 18364**]
Medications on Admission:
HOME MEDICATIONS:
1.Morphine 35mg PO qid
2.Clonazepam .25mg PO bid
3.Albuterol nebs q4-6h prn
4.Albuterol inh prn
5.Simvastatin 20mg PO qhs
6.Vitamin B12 1000 mcg PO daily
7.Prednisone 20mg PO daily
8.Fentanyl Patch 75mcg/hour q72h
9.Loratadine 10mg PO daily
10.Trazodone 400mg PO qhs
11.Bupoprion SR 150mg PO daily
Discharge Medications:
1. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for shortness of breath, wheezing.
3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO QAM (once a day (in the morning)).
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily) as needed for On
steroids.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation: hold for loose stool.
9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day).
10. Trazodone 50 mg Tablet Sig: Four (4) Tablet PO HS (at
bedtime) as needed for insomnia.
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation: hold for loose stool.
12. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
13. Tizanidine 2 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
14. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
15. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
Three (3) Adhesive Patch, Medicated Topical DAILY (Daily).
16. NPH Insulin Human Recomb 100 unit/mL Suspension Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED).
17. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day).
18. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily) as needed for PCP [**Name Initial (PRE) **] .
19. Bismuth Subsalicylate 262 mg/15 mL Suspension Sig: 15-30 MLs
PO TID (3 times a day) as needed for constipation.
20. Dexamethasone 2 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8
hours) for 1 days: dose for [**2116-12-1**].
21. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
22. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for fever.
23. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
24. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for diarrhea.
25. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): start [**2116-12-2**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
lung mass with T6 mass
Discharge Condition:
Neurologically stable
Discharge Instructions:
?????? Do not smoke
?????? Keep wound clean / No tub baths or pools until seen in
follow up/ begin daily showers [**2116-12-1**]
?????? No pulling up, lifting> 10 lbs., excessive bending or
twisting for two weeks.
?????? Limit your use of stairs to 2-3 times per day
?????? Have your incision checked daily for signs of infection
?????? You are required to wear back brace whenever out of
bed.
?????? You may shower briefly without the back brace.
?????? Take pain medication as instructed; you may find it
best if taken in the a.m. when you wake for morning stiffness
and before bed for sleeping discomfort
?????? Do not take any anti-inflammatory medications such as
Motrin, Advil, aspirin, Ibuprofen etc. for 3 months.
?????? Increase your intake of fluids and fiber as pain
medicine (narcotics) can cause constipation
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, drainage
?????? Fever greater than or equal to 101?????? F
?????? Any change in your bowel or bladder habits
Followup Instructions:
YOU HAVE APPT WITH ONCOLOGIST [**2116-12-14**] AT 12:30PM
DR [**Last Name (STitle) 18365**] AT
[**Location (un) **] [**Hospital 2287**] Cancer Center
[**Street Address(2) 18366**]
[**Location (un) **], [**Numeric Identifier 18367**]
[**Telephone/Fax (1) 18368**]
PLEASE RETURN TO THE OFFICE IN [**11-4**] DAYS FOR REMOVAL OF YOUR
STAPLES OR HAVE THEM REMOVED AT REHAB OR BY VISITING NURSE BY
[**2116-12-11**]
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.
[**Last Name (STitle) **] TO BE SEEN IN 6 WEEKS.
YOU WILL NEED XRAYS PRIOR TO YOUR APPOINTMENT
YOU SHOULD ALSO CONTACT YOUR PCP [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 18359**] AND SET UP APPT
TO DISCUSS NEED FOR CONTINUED STEROID USE (YOU HAVE BEEN ON
PREDNISONE LONG TERM)
Completed by:[**2116-12-1**]
ICD9 Codes: 2851, 2724, 2767, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3808
} | Medical Text: Admission Date: [**2100-7-14**] Discharge Date: [**2100-7-22**]
Date of Birth: [**2048-1-28**] Sex: F
Service: Medicine, [**Hospital1 **] Firm
CHIEF COMPLAINT: Abdominal distention.
HISTORY OF PRESENT ILLNESS: The patient is a 52-year-old
female with a history of hypertension, hypercholesterolemia,
and alcohol dependence who presents with approximately a
3-month history of increasing abdominal girth which has been
acutely worsening in the last three weeks with dyspnea and
lower extremity edema.
The patient had associated mild pain in the periumbilical
region with possible chills, nausea, and vomiting secondary
to abdominal fullness. The patient also noticed yellowing of
eyes, [**Location (un) 2452**] urine, and tarry stools. The patient denied
fevers, headache, and chest pain. No history of intravenous
drug use, tattoos, hepatitis, or unsafe intercourse. She
drinks four drinks per day and two times this amount on
weekends. The patient was admitted to the Medicine Service
in fair condition.
PAST SURGICAL HISTORY: Breast reduction.
PAST MEDICAL HISTORY: Past medical history as above.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: None.
SOCIAL HISTORY: As noted in the History of Present Illness
plus a 40-pack-year history of smoking.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
on admission revealed temperature was 97.4 degrees
Fahrenheit, heart rate was 125, blood pressure was 131/71,
respiratory rate was 16, and oxygen saturation was 99% on
room air. In general, anxious but in no acute distress. A
distended abdomen. Head, eyes, ears, nose, and throat
examination revealed the neck with lymphadenopathy,
thyromegaly, and was supple. Cardiovascular examination
evaluated tachycardia with a regular rate. Respiratory
examination revealed the lungs were clear to auscultation
bilaterally. Gastrointestinal examination revealed bowel
sounds were present. The abdomen was taut. Periumbilical
tenderness in the right and left lower quadrant.
Genitourinary examination revealed no costovertebral angle
tenderness. Musculoskeletal examination revealed no aches.
Good range of motion. Neurologic examination revealed alert
and oriented times three. No asterixis. Extremity
examination revealed 2 to 3+ bilateral lower extremity edema.
Dermatologic examination revealed positive spider angiomata,
plus palmar erythema.
PERTINENT LABORATORY VALUES ON PRESENTATION: Hepatitis
serologies indicated past exposure to hepatitis A but was
negative for hepatitis B or hepatitis C. Anti-smooth muscle
antibody titer was 1:80; which was nonspecific. Antinuclear
antibody was negative. Alpha-fetoprotein was within normal
limits.
RADIOLOGY/IMAGING FINDINGS: Abdominal ultrasound
echocardiogram revealed ascites plus gallbladder wall
thickening; consistent with ascites. The liver had an
increased echogenic texture. No intrahepatic ductal
dilatation. Positive flow in portal vein. Positive flow in
the common hepatic artery.
A computed tomography of the abdomen showed "heterogenously
decreased attenuation of the liver with reflux of contrast
material into the hepatic veins with associated large amount
of ascites. Fatty replacement/tumor infiltration/other
chronic liver disease are differential possibilities.
Congestive hepatopathy was thought less likely."
A chest x-ray was negative.
HOSPITAL COURSE BY ISSUE/SYSTEM:
1. ASCITES ISSUES: In the Emergency Department, at the time
of presentation on [**2100-7-14**], a paracentesis of one liter
was done with Gram stain and culture negative for organisms,
white blood cell count was 210 (with 7 polys) and consistent
with spontaneous bacterial peritonitis. Serum-ascites
albumin gradient was greater than 1.1; indicating portal
hypertension. [**Last Name (un) 26460**] discriminant factor was less than 32;
so treatment was not started for possible alcoholic hepatitis
given AST of 159 and ALT of 19; which is greater than a 2:1
ratio. Amylase and lipase were within normal limits.
A transjugular liver biopsy with Hepatology consultation was
done in the Intensive Care Unit on [**2100-7-15**] which found
changes consistent with toxic metabolic injury plus fibrosis
of the portal and sinusoidal portions. Stenosis was also
noted in the inferior vena cava close to this junction with
the hepatic vein. The pathology was felt to be sufficient to
explain the ascites. Therefore, a stent procedure was
considered but ultimately deferred at this time.
Upon discussion with Hepatology consultation, medical
management through aggressive diuresis was constituted. A
regimen of Lasix 80 mg, spironolactone 200 mg by mouth once
per day, and pentoxifylline 400 mg three times per day
resulted in fluid loss and decreased body weight. The
patient also denied any new onset of shortness of breath.
2. LEUKOCYTOSIS ISSUES: On admission, white blood cell
count was 25.3 was noted. The differential possibilities
included possible cholangitis; alkaline phosphatase was 998
and GGT was 1003. Prophylaxis was started with
metronidazole, levofloxacin, and ampicillin.
Possibility number two was possible spontaneous bacterial
peritonitis. All paracentesis done on [**2014-7-14**], and 20
were negative for spontaneous bacterial peritonitis with a
white count of 210, 173, and 46; respectively. Ascites
protein was 3.1; making spontaneous bacterial peritonitis
unlikely. However, concern over a possible gastrointestinal
bleed made prophylaxis against spontaneous bacterial
peritonitis with levofloxacin 500 mg a necessity. This was
discontinued on [**2100-7-20**].
Possibility number three; urine cultures. Peritoneal
cultures and blood cultures were all negative; ruling out
likely bacteremia.
Possibility number four; pneumonia. A chest x-ray was
negative. No signs on review of systems or examination.
3. ALCOHOL ABUSE WITHDRAWAL CONSIDERATION ISSUES: The
patient showed no signs of delirium tremens. Lorazepam given
q.6h. as needed to alleviate anxiety possibly related to
alcohol withdrawal.
The patient's stay was complicated by a possible
gastrointestinal bleed/fall in hematocrit. On [**2100-7-15**]
the patient had a hematocrit drop of 25.5 to 14.1 and was
transferred to the Intensive Care Unit for workup of possible
variceal bleed. Esophagogastroduodenoscopy and colonoscopy
performed in the Intensive Care Unit were negative for
gastrointestinal bleed, and no source of bleeding was
identified. 4500 cc of clear straw-colored fluid was removed
by paracentesis.
The patient received a transfusion of 4 units of packed red
blood cells, one unit of fresh frozen plasma, and 10 mg of
vitamin K. The patient returned to the floor on [**2100-7-18**].
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE STATUS: Discharge status was to home.
DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was to follow
up in both the Liver Clinic with Dr. [**Last Name (STitle) 497**] as well as with
new primary care physician [**Last Name (NamePattern4) **]. [**First Name (STitle) **] in the resident clinic.
MEDICATIONS ON DISCHARGE:
1. Folic acid 1 mg by mouth once per day.
2. Thiamine 100 mg by mouth once per day.
3. Pantoprazole 40 mg by mouth q.12h.
4. Pentoxifylline 400 mg by mouth three times per day.
5. Furosemide 80 mg by mouth once per day.
6. Spironolactone 200 mg by mouth once per day.
[**Name6 (MD) 2415**] [**Last Name (NamePattern4) 3474**], M.D. [**MD Number(1) 3475**]
Dictated By:[**Last Name (NamePattern1) 21646**]
MEDQUIST36
D: [**2100-7-24**] 11:25
T: [**2100-8-4**] 10:19
JOB#: [**Job Number 26461**]
ICD9 Codes: 5789, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3809
} | Medical Text: Admission Date: [**2200-2-1**] Discharge Date: [**2200-3-20**]
Date of Birth: [**2200-2-1**] Sex: F
Service: Neonatology
HISTORY: Baby Girl [**Known lastname **] is a former 30-5/7 week female
admitted to the Newborn Intensive Care Unit for management of
prematurity. She was born to a 37-year-old G5P1 A positive,
antibody negative, GBS unknown, hepatitis B surface antigen
negative, RPR nonreactive woman.
OB HISTORY: Remarkable for delivery of a term infant 15
months prior to this child and a LEEP procedure four months
prior to this pregnancy. Antepartum remarkable for initial
prenatal care in [**Country 10181**]. Normal amnio reported. Vaginal
bleeding developed three days ago and worsened during flight
from [**State 4565**]. Admitted to [**Hospital6 2561**] with
preterm labor. Transferred to the [**Hospital1 190**] with preterm labor being treated with
magnesium sulfate.
Preterm premature rupture of membranes occurred at [**Hospital1 **] soonafter transfer 13 hours prior to
delivery. Received one dose of betamethasone 18 hours prior
to delivery. No maternal fever, foul smelling lochia noted.
Has received several days of antepartum ampicillin,
progressive cervical dilatation with normal spontaneous
vaginal delivery with Apgars of eight at one minute and eight
at five minutes.
PHYSICAL EXAMINATION ON ADMISSION: Remarkable for pink,
generally well appearing preterm infant with vital signs as
noted. Normal facies. Intact palate. Soft anterior
fontanel. No grunting, flaring, or retracting. Clear breath
sounds. No murmur present. Femoral pulses flat. Nontender
abdomen without hepatosplenomegaly. Normal external
genitalia. Stable hips. Normal tone and activity and normal
perfusion.
REVIEW OF HOSPITAL COURSE BY SYSTEMS:
Respiratory: Baby remained stable in room air with no
respiratory distress. She did exhibit some apnea and
bradycardia of prematurity, and was started on caffeine
citrate on day of life five. She continued to receive her
caffeine until day of life 21 when it was discontinued. At
the time of discharge she has been free of apnea and
bradycardia for greater than five days.
Cardiovascular: Baby initially required one normal saline
bolus for marginally low blood pressure and perfusion. She
did not require pressor support. Her baseline heart rate is
140s-150s. She has had a soft intermittent murmur thought to
be a benign flow murmur or PPS. Stable blood pressures with
systolics in the 60s-70s, diastolics in the 30s-40s and means
in the 40s-50s, pulses are 2+ and equal.
Fluids, electrolytes, and nutrition: Baby initially had
peripheral IV and received maintenance IV fluids. Enteral
feedings were introduced on day of life one. She advanced to
full enteral feeds of Premature Enfamil (PE) or breast milk
150 cc/kg/day. Caloric density was increased to PE or breast
milk 28 with ProMod.
Currently, she is ad lib feeding with Enfamil 24 calories with
iron all po. She is receiving supplemental iron 0.2 cc po q
day which equals 2 mg/kg/day. She is voiding and stooling
without issue.
Admission weight 1465, 50th-75th percentile, length 41 cm,
50th percentile, head circumference 27 cm, 50th percentile.
Discharge weight 2555 grams. Discharge head circumference 32
cm, greater than 25th percentile. Discharge length 46 cm
25th-50th percentile.
Gastrointestinal: Baby did demonstrate some physiologic
jaundice. She had a peak bilirubin on day of life three of
9.9/0.4, 9.5. She responded to double phototherapy. She had
a rebound bilirubin on day of life nine of 6.0/0.4, 5.6.
She has had no further issues.
Hematology: Baby did not require any blood products during
this admission.
Infectious Disease: Baby initially had a 48 hour course of
ampicillin and gentamicin because of presentation of
foul-smelling lochia in premature rupture of membranes. The
baby's white count was 17.6, 44 polys, 0 bands, platelets of
285,000, hematocrit of 53.8. At 48 hours, the baby was
clinically well. Antibiotics were discontinued at that time.
On day of life seven, she had increase in apnea and
bradycardia, and described as being lethargic. As a result she
had another sepsis evaluation, which had a white count of
16.9, 63 polys, 0 bands, platelet count of 327,000,
hematocrit of 54. She was started on a 48 hour course of
Vancomycin and gentamicin. At 48 hours, baby was clinically
well, and antibiotics were discontinued.
On day of life 11, the baby spiked a temperature of 101.3.
Because of the history of persistent concerns, she had a
repeat complete blood count sent with a white count of 21.8,
67 polys, 0 bands, platelet count of 418,000, hematocrit of
48.4. She also had a lumbar puncture done that had 3 white
cells, 5 red blood cells, 0 polys, and 93 lymphocytes,
protein of 134 and a glucose of 151. The urine was a bagged
urine, which ultimately was positive for Staph-coag negative
thought to be a contaminant. Baby had a 48 hour course of
Vancomycin and gentamicin. Cultures remained negative. Baby
was clinically well, had no further fevers, and the
antibiotics were discontinued.
On day of life 18 because of the previous positive bagged
urine, urine catheter was performed for urine culture. This
remained negative with no growth.
Baby has an umbilical cord which has not fallen off. On
[**3-11**], day of life 37, Immunology consult was requested from
the [**Hospital3 1810**]. Their assessment was that with her
normal peripheral white blood cells (that were between 13.6
and 21.8), and absence of leukocytosis or cutaneous
infections, the likelihood of a leukocytic adhesion
deficiency is very low. If she were to develop either of
these symptoms, they would be happy to see her outpatient.
She was seen by Dr. [**Last Name (STitle) 47149**] at the [**Hospital3 1810**],
beeper #[**Pager number **]. Attending was Dr. [**Last Name (STitle) 12507**]. The cord currently
is still on, although less adhered requiring cleansing with
some alcohol wipes as it is a little weepy when she lies on
it, but no purulent drainage and no signs of infection.
Parents have been instructed on how to care for the cord and
would like to keep the cord once it falls off.
Neurology: Baby has had serial head ultrasounds, the last
one being on [**3-7**] which was within normal limits. No
evidence of interventricular hemorrhage, no evidence of
periventricular leukomalacia. Baby acts appropriately for
gestational age.
Sensory: Audiology screening has been passed.
Ophthalmology: Eye examination on [**2-26**]. She was immature
zone three. Follow-up evaluation on [**3-19**] revealed mature
retinas, follow-up recommended in [**9-9**] months with Dr.
[**Name (NI) **] at [**Hospital3 1810**].
Psychosocial: Parents have been visiting. Are appropriately
anxious regarding discharge and transition home.
CONDITION ON DISCHARGE: Home with family. Stable.
PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 44797**], [**Hospital1 8**],
[**State 350**], [**Telephone/Fax (1) 47150**], fax [**Telephone/Fax (1) 47151**].
CARE RECOMMENDATIONS: Continue ad lib feeding with E24 with
iron, and supplemental iron as above.
MEDICATIONS: Fer-In-[**Male First Name (un) **] 0.2 cc po q day.
CAR SEAT POSITION SCREENING: Passed.
STATE NEWBORN SCREEN: Serial state screens have been sent,
last one being on [**2200-2-25**] which was within normal range.
IMMUNIZATIONS RECEIVED:
1. Hepatitis B vaccine [**3-3**].
2. Synagis [**3-8**].
IMMUNIZATIONS RECOMMENDED: 1. Synagis RSV prophylaxis should
be considered from [**Month (only) 359**] through [**Month (only) 547**] for infants who meet
any of the following three criteria: 1) Born at less than 32
weeks, 2) born between 32 and 35 weeks with plans for daycare
during RSV season, with a smoker in the household, or with
preschool siblings, or 3) with chronic lung disease.
2. 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:
1. Dr. [**Last Name (STitle) 44797**], appointment made for [**2200-3-24**] by family.
2. Visiting nurse, Care Group VNA [**Telephone/Fax (1) 37503**], fax
[**Telephone/Fax (1) 38333**].
3. Early Intervention Program [**Hospital1 8**] [**Hospital1 3494**] referral
activated by nursing staff.
4. Dr. [**Name (NI) **], ophthalmalogy, [**Hospital3 1810**]
(number to be given to family).
DISCHARGE DIAGNOSES:
1. Former 30-5/7 week premature female.
2. Intermittent cardiac murmur.
3. Status post apnea and bradycardia of prematurity.
4. Status post hyperbilirubinemia.
5. Status post rule out sepsis.
6. Status post feeding discoordination/immature feeding
skills.
7. Delayed cord separation.
[**First Name8 (NamePattern2) 36400**] [**Name8 (MD) **], M.D. [**MD Number(1) 37201**]
Dictated By:[**Last Name (NamePattern1) 36146**]
MEDQUIST36
D: [**2200-3-19**] 01:54
T: [**2200-3-19**] 05:24
JOB#: [**Job Number 47152**]
ICD9 Codes: 7742, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3810
} | Medical Text: Admission Date: [**2201-1-17**] Discharge Date: [**2201-2-5**]
Date of Birth: [**2122-12-28**] Sex: F
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: The patient is a 78 year old
woman, transferred from [**Hospital 8641**] Hospital, after developing the
worst headache of her life while drying her hair. She had
positive nausea and vomiting. Head CT at an outside hospital
showed spontaneous subarachnoid hemorrhage. The patient was
started on Nipride drip and transferred to [**Hospital1 346**] for further management.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Ulcer.
3. Bronchitis.
4. Depression.
5. Hypercholesterolemia.
MEDICATIONS:
1. Hydrochlorothiazide.
2. Effexor.
3. Lipitor.
4. Accupril.
HOSPITAL COURSE: The patient was transferred to [**Hospital1 346**] and admitted to the neurologic
Intensive Care Unit for close neurologic observation. She was
taken to angiography and found to have an A-COM aneurysm. She
underwent coil embolization of the aneurysm without complication.
Post procedure, she was awake, alert and oriented times
three; moving all extremities with good strength, with no
pronator drift. Speech fluent. Neurologically stable. She
remained in the neurologic Intensive Care Unit for
approximately 14 days post aneurysm coiling for close
observation and treatment of potential vasospasm. The
patient never developed vasospasm. She did have repeat
angiograms on two separate occasions which showed no evidence
of vasospasm. She remained neurologically stable throughout
her Intensive Care Unit stay with intermittent episodes of
atrial fibrillation with some electrocardiogram changes. Also
some problems with hyponatremia requiring 3% saline on and
off for about a week and a half and intermittent episodes of
congestive heart failure due to the high volume of
intravenous fluid that she was receiving for prevention of
vasospasm. She remained in the Intensive Care Unit until
[**2201-2-3**] when she was transferred to the regular floor. She
was seen by physical therapy and occupational therapy and
found to require a short rehabilitation stay prior to
discharge to home.
DISCHARGE MEDICATIONS:
1. Midodrine 10 mg p.o. three times a day; hold for systolic
blood pressure of less than 170.
2. Amiodarone 400 mg p.o. q. day.
3. Amlodipine 30 mg p.o. q. 4 hours for 21 days post
hemorrhage; to be discontinued on [**2201-2-7**].
4. Diltiazem 90 mg p.o. four times a day; hold for heart
rate less than 60.
5. Metoprolol 75 mg p.o. three times a day; hold for
systolic blood pressure less than 100; heart rate less than
50.
6. Sodium chloride two grams p.o. three times a day to be
weaned off as tolerated to keep sodium level above 135.
7. Percocet one to two tablets p.o. every four hours prn.
8. Pantoprazole 40 mg p.o. q. 24 hours.
9. Insulin sliding scale.
10. Heparin 5000 units subcutaneous q. 12 hours.
11. Colace 100 mg p.o. twice a day.
12. Venlafaxine XR 225 mg p.o. q. day.
13. Estrogen .625 mg p.o. q. day.
14. Miconazole powder 2% topically prn.
The patient's condition was stable at the time of discharge.
She will follow-up with Dr. [**Last Name (STitle) 1132**] in two weeks time. Her
condition was stable.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2201-2-4**] 02:21
T: [**2201-2-4**] 14:31
JOB#: [**Job Number 52895**]
ICD9 Codes: 9971, 2761, 4280, 4019, 2720, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3811
} | Medical Text: Admission Date: [**2200-1-14**] Discharge Date: [**2200-1-24**]
Date of Birth: [**2120-4-7**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3283**]
Chief Complaint:
hypoglycemia, hypertensive urgency
Major Surgical or Invasive Procedure:
None
History of Present Illness:
79 y/o F with PMHx of type II DM, CRI & HTN who presented to
clinic today for follow up of elevated creatinine and was found
to be profoundly hypoglycemic with BS of 20 that did not improve
with po trial. Per family, pt has not been taking much po for
the last few days and has been complaining of fatigue. She has a
long history of poor med compliance and has been living with her
daugter for the last 2 months who has been managing her
medications. Pt was seen in clinic on [**2200-1-2**] and was noted to
be increasingly hypertensive, for which Lisinopril was increased
to 40mg daily. Follow up labs were notable for a progressive
rise in creatinine from 1.5 to 2.9. During this time, Lisinopril
was stopped and Glipizide was increased to 15mg [**Hospital1 **]. Pt denies
having low BS at home and reports decreased appetite and dark
urine. Per family, there were no significant changes in MS prior
to presenting to clinic today. Pt received some juice prior to
transfer to the ED.
.
VS on arrival to ED: T 97.8 BP 194/90 HR 56 RR 18 Sat 100% on
RA. BS on arrival was noted to be 35, she received a total of
2.5 amps of dextrose, Glucagon, Octreotide 50mcg, 1L of NS and
started on D5 1/2 NS for BS that would transiently come up above
100 and then fall back to 40s. EKGs were essentially unchanged
and CXR was clear. Pt was given Hydralazine 50mg X 1 po for sbp
in 200s, followed by Hydralazine 10mg IV. SBPs came down to 170s
prior to transfer.
.
On arrival to the ICU, pt was responding slowly but denying any
chest pain, shortness of breath, abdominal pain, nausea,
headache, fevers, chills and feels generally improved since
arrival to the ED.
.
Review of sytems:
+ recent wt loss of 15 lbs, decreased appetite and dark yellow
urine
.
Denies fever, chills, headache, sinus tenderness, rhinorrhea or
congestion, shortness of breath, chest pain, nausea, vomiting,
diarrhea, constipation or abdominal pain. No recent change in
bowel or bladder habits. No dysuria.
Past Medical History:
DM II
HTN
Thyroid Nodule
Anemia
Bilateral Cataracts
s/p TAH
Social History:
The patient currently lives with her daughter [**Name (NI) **] in [**Name (NI) 2268**].
The patient is reported at baseline to be completely independent
in all ADL, she currently works a 40 hour work week in the [**Hospital1 18**]
lab cleaning glassware, etc.
Tobacco: None
ETOH: None
Illicits: None
Family History:
NC
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T:99.6 BP:178/69 P:95 R:14 O2:100% on RA
General: responsive but sleepy, oriented to day and "shakiro"
only
HEENT: Sclera anicteric, pupils enlarged bilaterally s/p
cataract surgery, oropharynx clear, MM dry, no precervical LN
Neck: supple, JVP not elevated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: RRR, harsh gr 3 SEM loudest over LUSB, radiates through
precordium and to left carotid, S2 preserved, no rubs or gallops
Abdomen: soft, non-tender, mildly distended, bowel sounds
present, no rebound tenderness or guarding, no HSM
Ext: Warm, well perfused, 2+ distal pulses, no edema
Neuro: CN 2-12 grossly intact, strength 5/5 in all four
extremities, finger to nose very slow, not following directions
easily and mildly disoriented, gait not assessed.
Pertinent Results:
Admission Labs:
[**2200-1-14**] 05:00PM BLOOD WBC-7.0 RBC-4.57 Hgb-12.8 Hct-37.8 MCV-83
MCH-28.0 MCHC-34.0 RDW-14.2 Plt Ct-249
[**2200-1-15**] 03:06AM BLOOD PT-14.3* PTT-39.1* INR(PT)-1.2*
[**2200-1-14**] 05:00PM BLOOD Glucose-102 UreaN-64* Creat-3.0* Na-138
K-4.1 Cl-96 HCO3-30 AnGap-16
[**2200-1-15**] 03:06AM BLOOD ALT-13 AST-27 CK(CPK)-65 AlkPhos-160*
TotBili-0.6
[**2200-1-15**] 03:06AM BLOOD TotProt-6.4 Albumin-3.1* Globuln-3.3
Calcium-12.5* Phos-3.9 Mg-2.2
[**2200-1-14**] 05:03PM BLOOD Lactate-2.2*
[**2200-1-17**] 01:00AM BLOOD WBC-4.2 RBC-3.44* Hgb-9.9* Hct-28.3*
MCV-82 MCH-28.9 MCHC-35.1* RDW-14.1 Plt Ct-190
[**2200-1-17**] 01:00AM BLOOD Glucose-129* UreaN-47* Creat-2.7* Na-135
K-3.4 Cl-103 HCO3-25 AnGap-10
[**2200-1-15**] 03:06AM BLOOD ALT-13 AST-27 CK(CPK)-65 AlkPhos-160*
TotBili-0.6
[**2200-1-14**] 05:00PM BLOOD CK-MB-4 cTropnT-0.13*
[**2200-1-15**] 03:06AM BLOOD CK-MB-NotDone cTropnT-0.14*
[**2200-1-15**] 03:06AM BLOOD TotProt-6.4 Albumin-3.1* Globuln-3.3
Calcium-12.5* Phos-3.9 Mg-2.2
[**2200-1-15**] 04:00PM BLOOD Calcium-12.7* Phos-4.0 Mg-2.0
[**2200-1-17**] 08:40AM BLOOD Calcium-11.0* Phos-3.5 Mg-1.8
[**2200-1-17**] 01:00AM BLOOD Albumin-2.8* Calcium-11.5* Phos-3.7
Mg-1.9
[**2200-1-16**] 06:15AM BLOOD calTIBC-259* Ferritn-248* TRF-199*
[**2200-1-16**] 03:58PM BLOOD PTH-12*
[**2200-1-17**] 01:40AM BLOOD freeCa-1.51*
[**1-15**] TTE
The left atrium is moderately dilated. The estimated right
atrial pressure is 10-20mmHg. There is moderate symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Regional left ventricular wall motion is normal. Overall
left ventricular systolic function is normal (LVEF>55%).
Transmitral Doppler and tissue velocity imaging are consistent
with Grade I (mild) LV diastolic dysfunction. Right ventricular
chamber size and free wall motion are normal. The right
ventricular free wall is hypertrophied. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild to moderate ([**12-20**]+) mitral regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
Compared with the report of the prior study (images unavailable
for review) of [**2193-1-18**], the left ventricle is more
hypertrophied with increased severity of mitral regurgitation.
[**1-15**] Head CT
No evidence of acute intracranial hemorrhage, edema or mass.
[**1-15**] Renal US with dopplers
IMPRESSION: Limited examination. Bilateral brisk systolic
upstrokes in the
main renal arteries at the hilum are present and therefore no
evidence of renal artery stenosis is present. Blunted systolic
upstrokes of intrarenal waveforms could reflect parenchymal
abnormality but cannot be reliably assessed due to limitations
of the examination. If further evaluation is required then non-
gadolinium- enhanced MRA may be attempted.
.
[**2200-1-18**] CHEST CT W/O CONTRAST
IMPRESSION:
1. No evidence of pulmonary nodule or mass.
2. Cardiomegaly, with coronary artery calcification, as
described above.
3. Heterogeneous, enlarged thyroid, with calcifications as
described above. The patient has not had a thyroid ultrasound at
this institution since [**2191**], and if there has not been a recent
evaluation, repeat assessment is recommended.
.
[**2200-1-20**] THYROID U/S
THYROID ULTRASOUND: Evaluation is somewhat limited due to
patient
positioning. The right lobe measures 7.2 x 4.8 x 3.2 cm. The
left lobe
measures 4.8 x 3.22 x 2.9 cm. Both lobes are heterogeneous with
multiple
nodules. Again, nodules range from hyper to hypoechoic and some
nodules
contains cystic areas. The largest nodule is again located in
the lower pole of the right lobe, a solid nodule measuring 4.1 x
2.4 x 3.9 cm. On the left, the largest (spongy) nodule measures
1.8 x 2.1 x 1 cm. In the isthmus, a mixed cystic and solid
nodule measures 1.2 x 0.9 x 1.2 cm.
IMPRESSION: Multinodular goiter. The gland and nodules have
enlarged since
the prior study of [**2191**], although technical differences make
direct comparison difficult. The overall appearance is generally
unchanged with no new dominant nodules or masses.
.
[**2200-1-20**] RENAL U/S
RENAL ULTRASOUND: Both kidneys are slightly increased in
echogenicity
diffusely. The right kidney measures 9.2 cm and the left kidney
measures 10.5 cm. There is no hydronephrosis, stones or masses
of either kidney. Simple cysts are again noted of both kidneys.
The largest is located on the left, measuring up to 1.4 cm. The
urinary bladder is collapsed around a Foley catheter and
balloon.
IMPRESSION: Slightly increase in diffuse echogenicity of both
kidneys,
otherwise no change since renal ultrasound of [**2200-1-15**]. This can
be seen in
chronic renal disease.
.
[**2200-1-21**] BONE SCAN
Whole body images of the skeleton were obtained in anterior and
posterior
projections and demonstrate several areas of increased uptake in
the knees, and ankles, consistent with degenerative changes.
There is also intense increased uptake in the region of L5 and a
smaller region laterally in L4. These are most likely due to
degenerative changes, however plain xray or CT imaging of the
lower lumbar spine may be of assistance for further evaluation,
if clinically indicated. The remainder of the bony skeleton
appears normal. The kidneys and urinary bladder are visualized,
the normal route of tracer excretion.
No prior studies available.
IMPRESSION: Probable degenerative changes as discussed above. If
hyperparathyroid adenoma is considered as a cause of
hypercalcemia, suggest nuclear medicine parathyroid scanning.
.
Brief Hospital Course:
#Hypoglycemia - Thought to be due to sulfonylurea therapy in the
setting of acute on chronic renal insufficiency. Oral
hypoglycemics were held. Corrected with dextrose, glucagon, and
octeotide in the MICU. Patient tolerated the eventual
reintroduction of basal and sliding scale insulin therapy.
.
#Hypertensive Urgency - Remained asymptomatic. Lisinopril had
been discontinued one week prior in the setting of acute on
chronic renal insufficiency. Initially treated with a
betablocker, norvasc, and hydralazine but the former was
subsequently held due to bradycardia. HCTZ was held in the
setting of hypercalcemia. The home dose of hydralazine was
increased to 75 mg QID and imdur was started at a dose of 30 mg
daily with subsequent improvement in blood pressure control.
Renal ultrasound did not reveal evidence of renal artery
stenosis, consistent with the results of an MRA in [**2195-4-18**].
.
# Hypercalcemia: [**Year (4 digits) 32883**] calcium peaked at 12.7 with a peak
ionized calcium of 1.51. The level improved modestly with
aggressive IVF. [**Name (NI) 32883**] PTH was low. Workup for an underlying
cause was unremarkable, including [**Name (NI) **] cortisol, SPEP/UPEP,
chest x-ray, non-contrast CT of the chest/abdomen/pelvis, and
bone scan. [**Name (NI) 32883**] vitamin D and PTHrP are pending at the time of
discharge. She will continue receiving saline infusions at rehab
to ensure adequate hydration. The importance of adequate oral
hydration was nonetheless reinforced with the patient and her
family. She will follow up with endocrinology clinic as an
outpatient.
.
#Acute on Chronic Renal Failure - Creatinine improved from 3.0
to 1.9 with volume repletion. A new baseline was attributed to
the progression of nephropathy as evidenced by diffuse
echogenicity in both kidneys on ultrasound.
.
#Acute uncomplicated cystitis - Treated with ciprofloxacin for 7
days.
.
#DMII - Oral hypoglycemic agents were held initially in the
setting of hypoglycemia and were not restarted due to renal
insufficiency. She was started on basal and sliding scale
insulin, as above.
.
#Thyroid nodule - Chest CT incidentally discovered a
heterogeneous enlarged thyroid with asymmetric enlargement of
the right lobe and coarse calcifications in both lobes. Thyroid
ultrasound revealed multinodular goiter with the largest nodule
in the lower pole of the right lobe measuring 4.1 x 2.4 x 3.9
cm. The patient may benefit from outpatient FNA.
Medications on Admission:
AMLODIPINE 10 mg daily
GLIPIZIDE 15 mg Tablet [**Hospital1 **]
HYDRALAZINE 50mg q6hrs
PRAVASTATIN 40 mg daily
TRIAMTERENE-HYDROCHLOROTHIAZIDE 37.5 mg-25 mg daily
Discharge Medications:
1. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO at bedtime:
hold for sbp<100.
2. Pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
3. Hydralazine 50 mg Tablet Sig: 1.5 Tablets PO every six (6)
hours: hold for sbp<100.
4. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily):
hold for sbp<100.
5. Insulin Glargine 100 unit/mL Solution Sig: Six (6) units
Subcutaneous at bedtime.
6. Polyethylene Glycol 3350 17 gram (100 %) Powder in Packet
Sig: One (1) packet PO once a day as needed for constipation.
7. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO twice a
day.
8. Senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day.
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
10. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 3 days: Through [**2200-1-27**].
11. Humalog 100 unit/mL Solution Sig: ASDIR inj Subcutaneous
QACHS: Goal blood sugar
150-200 mg/dL;
For BREAKFAST:
<76 units: give 1 amp D50
76-100: give 0 units
101-150: 2 units
151-200: 4 units
201-250: 6 units
251-300: 8 units
301-350: 10 units
351-400: 12 units
>400 Notify MD
For LUNCH AND DINNER:
<76 units: give 1 amp D50
76-100: give 0 units
101-150: 1 units
151-200: 2 units
201-250: 4 units
251-300: 6 units
301-350: 8 units
351-400: 10 units
>400 Notify MD
For BEDTIME:
<76 units: give 1 amp D50
76-100: give 0 units
101-150: 0 units
151-200: 0 units
201-250: 2 units
251-300: 4 units
301-350: 6 units
351-400: 8 units
>400 Notify MD.
12. Lactulose 10 gram/15 mL Solution Sig: 15-30 ml PO twice a
day: please give if no BM in 2 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
Primary
1. Hypoglycemia
2. Hypertensive urgency
3. Hypercalcemia
4. Acute on chronic renal insufficiency
5. Acute uncomplicated cystitis
6. Diabetes mellitus type II
Secondary
1. Thyroid nodule
2. Anemia of chronic disease
Discharge Condition:
Asymptomatic with stable vital signs.
Discharge Instructions:
You were admitted to the hospital with very low blood sugar,
possibly because your kidneys weren't properly clearing your
diabetes medication from the blood. We have therefore
discontinued GLIPIZIDE. In its place, we recommend that you
begin taking insulin shots to help control your diabetes.
You were also found to have high levels of calcium in the blood.
The cause of this problem remains unclear despite many tests.
Please stop taking TRIAMTERENE-HYDROCHLOROTHIAZIDE because it
can raise calcium levels. It is imperative that you stay
well-hydrated by drinking plenty of fluids to help keep the
calcium level down.
You had a urinary tract infection which was partially treated
with the antibiotic ciprofloxacin. Please continue taking this
medication through Monday [**1-27**].
The following changes to your blood pressure medications were
recommended:
1) Start taking ISOSORBIDE MONONITRATE (IMDUR) 30 mg daily.
2) Increase HYDRALAZINE to 75 every 6 hours.
3) Discontinue TRIAMTERENE-HYDROCHLOROTHIAZIDE.
Please have repeat blood work done on Monday, [**1-27**].
Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2450**] on [**2-12**] at 8:10
AM.
Please attend your follow up appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of [**Hospital 18**] [**Hospital 6091**] Clinic on [**2200-2-19**] at
4:00 PM. The phone number is [**Telephone/Fax (1) 1803**] if you would like to
reschedule.
Please call your physician or return to the Emergency Department
if you experience fever, chills, sweats, dizziness,
lightheadedness, confusion, chest pain, cough, shortness of
breath, abdominal pain, vomiting, diarrhea, or bloody or dark
stools.
Followup Instructions:
Please have repeat blood work done on Monday, [**1-27**].
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8145**], M.D. Date/Time:[**2200-2-12**] 8:10
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2164**], MD Phone:[**Telephone/Fax (1) 1803**]
Date/Time:[**2200-2-19**] 4:00
Completed by:[**2200-1-24**]
ICD9 Codes: 5849, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3812
} | Medical Text: Admission Date: [**2132-1-26**] Discharge Date: [**2132-1-31**]
Date of Birth: [**2114-1-4**] Sex: F
Service: TRA
HISTORY OF PRESENT ILLNESS: The patient is an 18 year old
female who was transferred from an outside hospital status
post motor vehicle accident in which the front end of her car
impacted with a truck. She did not sustain any head trauma
or loss of consciousness, but she did hit her abdomen against
the steering wheel. When she presented to the outside
hospital, she was complaining of abdominal pain. Her CT scan
of her abdomen at the outside hospital showed a liver and
splenic laceration, and her hematocrit at that time was 35.0.
She was given one unit of packed red blood cells at the
outside hospital and then transferred to [**Hospital1 346**] Emergency Department.
PHYSICAL EXAMINATION: Initial physical examination at [**Hospital1 1444**] Emergency Department showed
vital signs with temperature 98.5, heart rate between 103 and
112, blood pressure 112/60, respiratory rate 12, oxygen
saturation 100 percent. The patient was in no acute distress
with moist mucous membranes. The pupils are equal, round and
reactive to light and accommodation. Extraocular movements
are intact. Tympanic membranes clear bilaterally. No neck
tenderness. Lungs clear to auscultation bilaterally, no
crepitus. Heart tachycardic, normal S1 and S2, no murmurs
heard. Abdomen soft, nondistended, tender to palpation
throughout. Positive voluntary guarding. Rectal tone
normal, guaiac negative. Back - no pain to palpation.
Neurologically, moving all four extremities, 5/5 strength
throughout and normal sensation.
PAST MEDICAL HISTORY: No past medical history.
PAST SURGICAL HISTORY: No past surgical history
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: No home medications.
SOCIAL HISTORY: The patient denies alcohol or tobacco use.
LABORATORY DATA: When the patient presented to [**Hospital1 346**], her pertinent laboratories include
white blood cell count 27.3, hemoglobin 10.5, hematocrit 30.6
down from 35.0 at the outside hospital, platelet count
351,000. Urinalysis negative. Blood urea nitrogen 14,
creatinine 0.5. Initial liver function tests showed ALT 543,
AST 504, alkaline phosphatase 36.3, amylase 30, total
bilirubin 0.4, lipase 14. Toxicology screen negative.
Chemistries showed glucose 155, sodium 141, potassium 3.8,
chloride 106, bicarbonate 29, lactate 1.4.
The patient had an initial CT of her spine which was negative
and abdominal CT which showed a grade II splenic laceration
and a grade III liver laceration and a small left
pneumothorax. She had a negative chest x-ray and a negative
pelvis x-ray.
HOSPITAL COURSE: The patient was admitted on [**2132-1-25**], to
the trauma service and was given a bed in the trauma surgical
Intensive Care Unit. The patient remained stable in the
Intensive Care Unit with unchanged abdominal examination and
stable hematocrit, and she was transferred to the surgical
floor on [**2132-1-27**]. On [**2132-1-29**], the patient spiked a
fever to 101.0. Chest x-ray at that time showed a right
lower lobe consolidation, and she was started on Levaquin.
The patient's hematocrit remained stable. Her abdominal
examination improved and her liver function tests steadily
decreased. During the hospital stay, the patient did have
consistent tachycardia usually ranging between 100 and 110
but occasionally going up to the 120 to 140 range. The
patient had electrocardiograms done which showed sinus
tachycardia but unchanged from the baseline electrocardiogram
on admission. On [**2132-1-31**], a cardiology consultation was
obtained. The cardiologist felt the tachycardia was
consistent with the patient's activity and given the setting
of the liver and splenic lacerations with a pneumonia, the
sinus tachycardia was consistent with an increased adrenergic
state post injury. A TSH was checked and the patient was
continued on antibiotics. She was discharged on [**2132-1-31**],
to home in stable condition.
DISCHARGE DIAGNOSES: Grade II splenic laceration.
Grade III liver laceration.
Small left pneumothorax.
Pneumonia.
MEDICATIONS ON DISCHARGE: Levaquin 500 mg p.o. daily times
seven days.
FOLLOW UP: The patient will follow-up in the Trauma Surgery
Clinic in two weeks. She will follow-up again in the Trauma
Surgery Clinic in two months for a repeat abdominal CT.
[**First Name11 (Name Pattern1) 518**] [**Last Name (NamePattern4) **], [**MD Number(1) 17554**]
Dictated By:[**Last Name (NamePattern4) 6394**]
MEDQUIST36
D: [**2132-1-31**] 13:38:58
T: [**2132-2-1**] 15:17:08
Job#: [**Job Number 58238**]
ICD9 Codes: 486, 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3813
} | Medical Text: Admission Date: [**2146-1-3**] Discharge Date: [**2146-1-13**]
Date of Birth: [**2067-12-24**] Sex: M
Service: Cardiothoracic Surgery Service
CHIEF COMPLAINT: Cardiac catheterization.
HISTORY OF PRESENT ILLNESS: The patient is a 78-year-old
gentleman with a history of coronary artery disease,
hypertension, hypercholesterolemia, thrombocytopenia, and
acute tubular necrosis who presented to [**Hospital **] Hospital on
[**2145-12-25**] after a 2-day episode of intermittent chest
pain.
The patient described the chest pain as being [**5-16**] with no
radiation and having chest pressure at rest. The pain was
relieved with sublingual nitroglycerin for the first episode.
The second episode occurred while the patient was lying in
bed.
The patient was brought to the Emergency Department. The
patient's troponin at the outside hospital came back at 0.43.
The patient was transferred to the [**Hospital1 190**] on [**1-4**].
The patient underwent a cardiac catheterization, and the
following was demonstrated: (1) a right-dominant system with
severe 3-vessel coronary artery disease; the left main
coronary artery had a distal 50% stenosis; the left anterior
descending artery had diffuse disease after dual high
diagonal with a maximal stenosis of 80%; the left circumflex
had 70% restenosis in the previously placed mid left
circumflex stent; the right coronary artery had diffuse
disease with a 30% ostial lesion and a 90% mid right coronary
artery lesion and serial 80% and 90% lesions in the distal
vessel and (2) the left ventriculography revealed mild
systolic dysfunction with an ejection fraction of 47%.
Following the cardiac catheterization, the patient was
referred to the Cardiothoracic Surgery Service.
PAST MEDICAL HISTORY:
1. Status post non-Q-wave myocardial infarction with left
circumflex stent in [**2137**].
2. Hypertension.
3. Hypercholesterolemia.
4. Gout.
5. Acute tubular necrosis.
6. Thrombocytopenia.
7. Acute inflammatory response.
8. Pneumonia.
9. Status post appendectomy.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Aspirin 325 mg by mouth once per day.
2. Atenolol 25 mg by mouth once per day.
3. Lipitor 10 mg by mouth once per day.
4. Plavix 75 mg by mouth once per day.
PHYSICAL EXAMINATION ON PRESENTATION: On physical
examination, the patient was alert and oriented and in no
apparent distress. Vital signs revealed the patient was
afebrile, his heart rate was 55, his blood pressure was
177/61. Head, eyes, ears, nose, and throat examination
revealed the pupils were equal, round, and reactive to light.
The extraocular movements were intact. The neck was supple.
No jugular venous distention. No bruits. There were 2+
carotid pulses. Chest examination revealed the lungs were
clear to auscultation bilaterally. Cardiovascular
examination revealed a regular rate and rhythm. The
abdominal examination revealed there were positive bowel
sounds. The abdomen was soft, nontender, and nondistended.
On neurologic examination, the patient was alert and oriented
times three. Cranial nerves II through XII were grossly
intact.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories on
admission with a complete blood count which revealed the
patient's white blood cell count was 6.2, his hematocrit was
31.3, and his platelets were 186. The patient's sodium was
136, potassium was 3.7, chloride was 104, bicarbonate was 22,
blood urea nitrogen was 24, and creatinine was 1.1. His
prothrombin time was 13.3, his partial thromboplastin time
was 37.5, and his INR was 1.2. His alanine-aminotransferase
was 13, his albumin was 3.4, his aspartate aminotransferase
was 16, his alkaline phosphatase was 62, and his total
bilirubin was 0.5.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: The
patient was initially admitted to the Cardiac Medicine
Service.
Preoperatively, the patient was placed on intravenous heparin
and intravenous nitroglycerin. The patient was found to be
in atrial fibrillation but remained asymptomatic.
On [**2146-1-7**] the patient underwent a coronary artery
bypass grafting times three. For complete details, please
see the Operative Report dictated on that same day. The
patient has a left internal mammary artery to the left
anterior descending artery, saphenous vein graft to the
obtuse marginal, and a saphenous vein graft to the posterior
descending artery. The procedure was performed by Dr. [**First Name (STitle) **]
[**Last Name (Prefixes) **] and assisted by Dr. [**Last Name (STitle) 8419**] and Dr. [**Last Name (STitle) 8420**].
The patient tolerated the procedure well, and there were no
complications during the surgery. Following the surgery, the
patient was admitted to the Cardiothoracic Surgery Recovery
Unit intubated and on a Nipride and nitroglycerin drip.
On postoperative day one, the patient was extubated and
placed on a 50% face tent. This allowed his oxygen
saturations to remain greater than 95%. The patient was
started on an insulin drip. The patient continued to be
hypertensive and required an increase in his nitroglycerin.
In addition, the patient was on Isordil. Later in the
evening of the same day, the patient was out of bed. The
patient was placed on intravenous morphine and Percocet for
pain control.
On postoperative day two, the patient continued to do well.
The patient's respiratory status improved, and he was able to
be weaned down to 2 liters nasal cannula and maintained his
oxygen saturations at greater than 98%. The patient
demonstrated a strong cough and was able to expectorate thick
tan sputum.
From a cardiovascular standpoint, the patient remained
hypertensive with systolic blood pressures of 140s to 180.
His Isordil was continued at 20 mg by mouth q.8h. His
captopril was increased to 25 mg three times per day, and
Lopressor was added at 25 mg twice per day. The patient was
continued on his twice per day Lasix. The patient was weaned
off his insulin drip and placed only on an insulin
sliding-scale. The patient's major issue during the day was
pain control. The patient was taken off Percocet and
switched to by mouth Dilaudid along with intravenous morphine
which made the patient considerably more comfortable.
On postoperative day three, the patient was transferred out
of the Cardiothoracic Surgery Recovery Unit down to the
floor. The patient was evaluated by Physical Therapy at this
time, and it was determined that after a few sessions the
patient would be able to go home.
On the floor, the patient's course was only complicated by a
fair amount of serosanguineous fluid drainage from his
incision. As a result, the patient was given twice per day
dressing changes along with Betadine to the sternal incision.
The patient was also placed on by mouth Keflex 500 mg four
times per day.
On postoperative day four, the patient had his wires removed.
The procedure was done without any difficulties and without
any complications. The patient continued to be weaned off
his 2 liters nasal cannula. By the end on postoperative day
four, the patient was on room air and able to maintain his
oxygen saturations at greater than 92%.
Cardiovascularly, the patient continued to be slightly
hypertensive and his captopril was increased from 37.5 mg by
mouth three times per day to 50 mg by mouth three times per
day. The drainage from the patient's surgical incision
decreased a great deal over the next day. The patient still
remained hypertensive, and the patient's metoprolol was
increased from 12.5 mg by mouth twice per day to 25 mg by
mouth twice per day.
By postoperative day five, the drainage from the sternal
incision had completely stopped and the wound was clean, dry,
and intact. The patient's blood pressure was under better
control with a maximum systolic blood pressure of 150. The
patient was cleared by Physical Therapy to go home.
DISCHARGE DISPOSITION: The patient was to be discharged to
home.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was instructed to follow up with his primary
care physician in one to two weeks.
2. The patient was instructed to follow up with his
cardiologist (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 8421**]) in two to three weeks.
3. The patient was instructed to follow up with his
cardiothoracic surgeon (Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **]) in four weeks.
4. The patient was instructed to call to schedule these
appointments.
CONDITION AT DISCHARGE: The patient's condition on discharge
was good. The patient was afebrile, ambulating
independently, pain well controlled on oral medications,
tolerating his diet, and moving his bowels.
MEDICATIONS ON DISCHARGE: (The patient was discharged on the
following medications)
1. Lasix 20 mg by mouth twice per day (times seven days).
2. Potassium chloride 20 mEq by mouth twice per day (times
seven days).
3. Colace 100 mg by mouth twice per day as needed (for
constipation).
4. Enteric-coated aspirin 325 mg by mouth every day.
5. Plavix 75 mg by mouth once per day.
6. Imdur 30 mg by mouth once per day.
7. Benadryl 25 mg by mouth at hour of sleep as needed.
8. Amiodarone 400 mg by mouth twice per day.
9. Dilaudid 2 mg to 4 mg by mouth q.4-6h. as needed (for
pain).
10. Captopril 50 mg by mouth three times per day.
11. Atorvastatin 10 mg by mouth once per day.
12. Ranitidine 150 mg by mouth twice per day.
13. Cephalexin 500 mg by mouth four times per day (times 10
days).
14. Metoprolol 25 mg by mouth twice per day.
DISCHARGE DIAGNOSES:
1. Status post coronary artery bypass grafting times three.
2. Status post cardiac catheterization.
3. Non-Q-wave myocardial infarction with left circumflex
artery stent in [**2137**].
4. Hypertension.
5. Hypercholesterolemia.
6. Gout.
7. Acute tubular necrosis.
8. Thrombocytopenia.
9. Acute inflammatory response.
10. Pneumonia.
11. Status post appendectomy.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Name8 (MD) 846**]
MEDQUIST36
D: [**2146-1-13**] 14:55
T: [**2146-1-13**] 16:58
JOB#: [**Job Number 8422**]
cc:[**Last Name (NamePattern1) 8423**]
ICD9 Codes: 4111, 2875, 2720, 4019, 2749, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3814
} | Medical Text: Admission Date: [**2136-10-4**] Discharge Date: [**2136-10-8**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2840**]
Chief Complaint:
foley change
Major Surgical or Invasive Procedure:
G tube replacement
Right SC line placement
History of Present Illness:
85M w/PMHx sx for C5/C6 subluxation s/p fixation, HTN, dementia
(vascular vs. Alzheimer's), h/o CVA, and prostate cancer who
initially admitted [**2136-10-4**] for a Foley change. At [**Hospital 100**] rehab,
he was being treated with vanco/flagyl for suspected aspiration
pneumonia. He maintained sbps >1001/3 bottles (+) for GPC in
chains and pairs for which he was started on linezolid (given
concern for VRE). He was transufsed 1u PRBC for HCT 22At rehab
on day of admit, his chronic foley was removed for scheduled
changed and could not be replaced (although reportedly pus was
expressed). He was sent to ED, where frank blood was noted at
his urethral meatus. Urology placed a foley with 300 cc pink UOP
and then irrigated the bladder. He was noted to have fever of
102 with tachypnea (RR high 20s). ABG 7.27/38/56 on RA with
lactate 4.6 and HCO3 15. He became hypotensive with sbp 80s. CXR
showed RLL opacity. A central line was placed and he was covered
with vanco/flagyl/cipro and amditted to the [**Hospital Unit Name 153**]. Following
fluid resuscitation, his blood pressure stabilized. His bcx grew
GPC in pairs and chains and linezolid was added given concern
for VRE. He is now being transferred to the floor for further
management
Past Medical History:
1) HTN
2) hyperchol
3) Dementia: vascular vs Alzheimer's
4) s/p CEA b/l [**2118**]/[**2125**]
5) R stroke [**3-19**] with residual left hand weakness
6) h/o prostate CA s/p prostatectomy
7) UGIB
8) C spine subdural hematoma
9) pseudoaneurysm aortic arch
10) Mass in hepatic flexure of colon: Noted on [**4-19**] Abd CT,
concerning for colonic adenocarcinoma. Has not had additional
work-up since that time.
11) Right SFV thrombosis s/p placement of IVC filter.
12) C5/C6 neck fracture s/p reduction anterior/posterior fusion
13) s/p G-tube placement
14) Type II DM
15) Hypothyroidism
16) CRI: baseline Cr 1.4-1.6
Social History:
[**Hospital 100**] rehab resident. No tobacco, alcohol, or other drug use.
Son very involved
Family History:
Noncontributory
Physical Exam:
Tc 97.6, pc 77, bpc 110/60, resp 20, 97% RA
Gen: elderly male, lying in bed, alert but not following
commands or vocalizing. NAD
HEENT: anicteric, pale conjunctiva, OMM slightly dry, OP clear,
neck supple, no JVD, LAD, or thyromegaly noted
Cardiac: RRR, II/VI SM at apex
Pulm: Crackles at bases bilaterally with occasionally ronchi.
Abd: NABS, soft, mildly distended, non-tender, G tube in place
Ext: [**12-18**]+ LE and UE edema, lower extremities warm with good cap
refill.
Neuro: moves all extremities in response to noxious stimuli, 1+
DTR throughout, toes mute bilaterally.
GU: Foley draining grossly bloody urine, small clots with
flushing.
Skin: 7 X 6 cm sacral ulcer with central necrotic area. Mild
skin breakdown at heels bilaterally.
Pertinent Results:
[**2136-10-4**]
PT-14.0 PTT-31.2 INR(PT)-1.3
GLUCOSE-126 UREA N-53 CREAT-0.9 SODIUM-142 POTASSIUM-4.3
CHLORIDE-118 TOTAL CO2-14
CALCIUM-7.9 PHOSPHATE-2.6 MAGNESIUM-1.6 IRON-16
WBC-8.6 RBC-2.42 HGB-6.8 HCT-22.4 MCV-92 MCH-28.1 MCHC-30.5
RDW-17.1
PLT COUNT-357
LACTATE-2.6*
EKG [**10-4**]: ST at 113 bpm, RBBB, no [**Month/Year (2) 65**] change from prior
.
Radiology:
[**10-5**] CXR: increased patchy opacities in left middle and lower
lung fields and right abses
Brief Hospital Course:
85 year old male w/ h/o dementia/CVA presents with sepsis, found
to have VRE bacteremia, multifocal pneumonia, C. diff colitis.
.
P:
1) Sepsis: The patient was initially admitted to the intensive
care unit for fluid resuscitation. He was covered broadly with
antibiotics to treat presumed pneumonia (multifocal opacities on
CXR) and urinary tract infection with
vancomycin/ciprofloxacin/metronidazole and pan-cultured.
Following volume resucitation, he became hemodynamically stable.
Blood cultures from [**10-4**] grew [**1-22**] VRE, which presumably came
from a urinary source, although urine culture only grew ~1000
GNR. He was also found on [**2136-10-5**] to be C. diff (+). His
antibiotics were changed to linezolid/levofloxacin/metronidazole
to treat C. difficile colitis, VRE bactremia, and multifocal
aspiration pneumonia. He will complete 14 day courses of
linezolid (to complete [**2136-10-18**]) and levofloxacin (to complete
[**2136-10-17**]). He will continue metronidazole until 14 days after the
completion of his other antibiotics (to complete [**2136-11-1**]).
Echocardiogram was obtained, which is pending at time of
discharge.
2) Sacral decubitus ulcer: Wound care and plastic consults were
obtained for assistance with wound care.
3) Hematuria: The patient's gross hematuria on admission was
likely secondary to traumatic foley insertion. Urology was
consulted, who recommended monitoring and flushes as needed to
remove clots. By the time of discharge, the patient's urine had
cleared. His urine output will need to be monitored as an
outpatient and the foley flushed as needed.
4) NAG acidosis: During his admission, the patient was noted to
have a non-AG acidosis, most likely secondary to a combination
of diarrhea and aggressive saline resusication. However, RTA is
also possible, given baseline HCO3 has been in the high 10s for
the last year. Hopefully, his diarrhea will gradually improve
with treatment of C. diff. He will continue sodium bicarbonate
at his home dose.
5) Anemia: The patient received a total of 2 units of PRBC (last
[**2136-10-6**]) given drop in HCT 24 to from 31.3 on admit (baseline
30-35). His anemia likely represents hemodilution in the setting
of chronic fluid resuscitation superimposed on ACD (based on
iron studies). His vit B12 and folate were normal. He will
continue on darbopoietin as an outpatient. His hematocrit at
discharge was 27.9.
6) HTN: Given hypotension on admission, his metoprolol initially
held and then gradually titrated up. At time of discharge, he
was tolerating metoprolol 50 mg PO TID, which can be titrate up
as tolerated as an outpatient to his prior dose of 75 mg PO TID.
7) Type II DM: The patient was continued on his home NPH/RISS
regimen with adequate glucose control.
8) FEN: His G-tube became occluded on [**2136-10-7**] and required
revision by interventional radiology on [**2136-10-8**].
9) Code -- DNR/DNI
Medications on Admission:
Na bicarb [**2080**] TID
Zn sulfate 220 mg [**Hospital1 **]
Metoprolol 75 mg TID
Vancomycin 1000 mg
Lactobacillus 2 tabs G tube QID
Levothyroxine 25 mcg daily
Flagyl 500 mg TID
Ipratropium neb
Fluconazole 50 mg daily
NPH
Insulin 6 U QAM, 4U QPM
Cholestyramine 1 scoop tube [**Hospital1 **]
Nexium 40 [**Hospital1 **]
Darebpoietin 100 mcg SC Wed
Docusate 100 [**Hospital1 **]
MOM
Discharge Medications:
1. Sodium Bicarbonate 650 mg Tablet [**Hospital1 **]: Two (2) Tablet PO TID
(3 times a day).
2. Zinc Sulfate 220 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
3. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID
(3 times a day).
4. Lactobacillus Acidophilus Tablet [**Hospital1 **]: Two (2) Tablet PO
once a day.
5. Levothyroxine Sodium 25 mcg Tablet [**Hospital1 **]: One (1) Tablet PO
DAILY (Daily).
6. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
7. Fluconazole 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q24H (every
24 hours).
8. Insulin NPH Human Recomb 100 unit/mL Suspension [**Hospital1 **]: Six (6)
units Subcutaneous qAM: and 4 units qPM.
9. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
10. Cholestyramine (Bulk) Powder [**Last Name (STitle) **]: One (1) packet
Miscell. twice a day: Please dose separate from other
medications.
11. Darbepoetin Alfa-Albumin 100 mcg/mL Solution [**Last Name (STitle) **]: One
Hundred (100) mcg Injection once a week.
12. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
13. Ascorbic Acid 500 mg/5 mL Syrup [**Last Name (STitle) **]: Five Hundred (500) mg
PO DAILY (Daily).
14. Insulin Regular Human 100 unit/mL Solution [**Last Name (STitle) **]: sliding
scale Injection qAC and qHS: If FS <150 give 0 units, if
151-200 give 2 units, if 201-250 give 4 units, if 251-300 give 6
units, if 301-350 give 8 units, if 351-400 give 10 units, if
>400 [**Name8 (MD) 138**] MD.
15. Linezolid 600 mg Tablet [**Name8 (MD) **]: One (1) Tablet PO Q12H (every
12 hours) for 10 days: to complete [**2136-10-18**].
16. Levofloxacin 500 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO Q24H
(every 24 hours) for 9 days: to complete [**2136-10-17**].
17. Metronidazole 500 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO TID (3
times a day) for 24 days: to complete [**2136-11-1**] (14 days after
completion of linezolid/levofloxacin course).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **] CENTER
Discharge Diagnosis:
Primary: sepsis
Secondary: Aspiration pneumonia, VRE bacteremia, C. diff
colitis, dementia, hypertension, hyperlipidemia
Discharge Condition:
Good. The patient is at his baseline in terms of mental status.
Discharge Instructions:
Please follow-up or come to the emergency room if you develop
shortness of breath, persistent/worsening diarrhea, nausea,
vomiting.
Followup Instructions:
Please follow-up with primary care physician [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 140**] [**Last Name (NamePattern1) 141**]
([**Telephone/Fax (1) 142**]) within 2 weeks following discharge
Completed by:[**2136-10-22**]
ICD9 Codes: 0389, 5070, 5990, 2762, 5859, 5849, 2767, 4589, 4019, 2859, 2724, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3815
} | Medical Text: Admission Date: [**2183-4-16**] Discharge Date: [**2183-4-18**]
Date of Birth: [**2129-5-24**] Sex: F
Service: NEUROSURGERY
Allergies:
Latex
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
Transfer with subdural hematoma
Major Surgical or Invasive Procedure:
None
History of Present Illness:
53 year-old left-handed woman with past
history of stroke 27 years ago with residual left-sided weakness
who presents for evaluation after transfer from [**Hospital3 **] for
SDH.
She reports a fall about 10 days, when she slipped on some wet
tile in her bathroom. She awoke on the floor. She is not sure
how long she lost consciousness for. She is not sure she even
hit her head.
She felt somewhat tired and malaised all week. Then, this
morning, she noted gradual onset of numbness, described as a
pens
and needles sensation in her left hand. The whole hand was
affected. Over the course of the next several hours, numbness
and paresthesias spread over her left arm and to her left face.
Left leg not affected. Her arm and face were more weak than her
baseline.
No blurred or double vision, speech or language disturbance, new
focal weakness.
Past Medical History:
1. Stroke, post-partum, 27 years ago with residual left-sided
weakness.
2. Hypertension.
3. Hypercholesterolemia.
4. Status post hysterectomy
Social History:
Married, lives with husband. Does not work
outside the home. Smokes 1 ppd for 20 years. Drinks several
glasses of wine daily. No drug use.
Family History:
Non contributory
Physical Exam:
Blood pressure 142/76, heart rate 70s, respiratory rate 16,
oxygen 98%/RA.
Gen: WD/WN, comfortable, NAD.
HEENT: NC/AT. Anicteric. MMM.
Neck: Supple.
Lungs: CTA bilaterally. No R/R/W.
Cardiac: RRR. S1/S2. No M/R/G.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect. Oriented to person, place, and date. Able to recite [**Doctor Last Name 1841**]
forwards and backwards. Registration intact. Recalled [**1-27**]
objects at 5 minutes. Speech fluent with good comprehension and
repetition. Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to 3 mm
bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength symmetric. Decreased sensation to V1-V3
to light touch, pain.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Decreased bulk in left hand intrinsics, thenar eminence.
Increased left-sided tone. No abnormal movements, tremors. Mild
left upward drift. Mild left hemiparesis with delt [**3-31**]/, tricep
5-/5, IO 5-/5. Left IP pain limited [**3-1**], left hamstrings [**3-1**].
Sensation: Decreased to light touch and pain over left arm and
leg, torso spared.
Reflexes: Brisk, slightly increased on left but no spread or
clonus. Toes are downgoing.
Coordination: No dysmetria or clumsiness on finger-nose-finger,
rapid alternating movements but more deliberate on left. Gait
deferred.
Pertinent Results:
[**2183-4-18**] 05:45AM BLOOD WBC-7.3 RBC-3.39* Hgb-11.3* Hct-33.2*
MCV-98 MCH-33.2* MCHC-33.9 RDW-13.5 Plt Ct-703*
[**2183-4-18**] 05:45AM BLOOD Plt Ct-703*
[**2183-4-18**] 05:45AM BLOOD Glucose-103 UreaN-8 Creat-0.6 Na-138
K-4.8 Cl-102 HCO3-27 AnGap-14
[**2183-4-18**] 05:45AM BLOOD Calcium-9.3 Phos-4.7* Mg-1.8
[**2183-4-18**] 05:45AM BLOOD Phenyto-18.6
[**2183-4-16**] 06:53PM BLOOD GreenHd-HOLD
Brief Hospital Course:
Ms [**Known lastname 32662**] was admitted overnight to the surgical ICU where she
monitored closely for with Q1 neurocheck keep BP<140. She was
started on Dilantin for seizure prophylaxis. She had a follow up
CT on hospital day which showed decrease blood and she was
transferred to the surgical floor. On HD#3 her CT continued to
show decrease blood, her left arm numbness and tingling seemed
to be resolving. Her Dilantin level on discharge was 18. The
patient was called after discharge and told to hold the next two
doses and follow up with her primary care in a week to check a
level.On discharge her strength was full throughout. She was
cleared by PT for discharge.
Medications on Admission:
PCN, Verapamil, Pravstatin and Ezetimibe
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for headache: Do not take with Percocet.
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): Use while on Percocet.
Disp:*40 Capsule(s)* Refills:*0*
4. Penicillin V Potassium 500 mg Tablet Sig: One (1) Tablet PO
Q12H (every 12 hours).
5. Verapamil 120 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
6. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
Disp:*90 Capsule(s)* Refills:*1*
9. Outpatient Occupational Therapy
Treat and eval left hand weakness
Discharge Disposition:
Home
Discharge Diagnosis:
Subdural Hematoma
Discharge Condition:
Neurologically stable
Discharge Instructions:
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? New onset of tremors or seizures
?????? Any confusion or change in mental status
?????? Any numbness, tingling, weakness in your extremities
?????? Pain or headache that is continually increasing or not
relieved by pain medication
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
?????? Fever greater than or equal to 101?????? F
Followup Instructions:
Follow up in 1 month with a head CT call [**Telephone/Fax (1) 1669**] for an
appointment with Dr [**Last Name (STitle) 739**]
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2183-4-18**]
ICD9 Codes: 4019, 2720, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3816
} | Medical Text: Admission Date: [**2117-3-10**] Discharge Date: [**2117-3-14**]
Date of Birth: [**2030-2-17**] Sex: M
Service: MEDICINE
Allergies:
Omeprazole / Sulfa (Sulfonamide Antibiotics) / Tetracycline /
ibuprofen
Attending:[**First Name3 (LF) 2782**]
Chief Complaint:
Hypotension/ dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
87M history of cardiomyopathy with both systolic/diastolic CHF
(LVEF 50-55%), mitral and aortic valve insufficiency, atrial
fibrillation on coumadin, CKD Stage IV (baseline Cr 2.4-3),
myeloproliferative disease, PVD, Ileostomy secondary to total
colectomy from C. diff colitis in [**2111**] that presented to the
emergency department complaining of shortness of breath over the
last several days which is getting worse.
He states that for the shortness of breath that this has
resulted in difficulty walking from the bed to the bathroom. His
normal level of activity includes being able to walk on a
treadmill. He denies PND and states that he has slept on 2
pillows for quite sometimes. He denies dietary indiscretion. He
also feels like he is having a little more fluid on legs.
He does endorse associated central chest discomfort during
exertion. He denies a history of angina, and this is the first
time he has experienced chest discomfort with activity. He
denies chest discomfort at rest, at night, or with meals. He
notes this with activity like going up the stairs.
He also endorses feeling dizzy characterized by dysequilibrium
and lightheadedness. He denies any falls or trauma.
He also endorses that his heat works at home.
He denies any medication changes except starting thyroid
medication for a TSH ~ 9 recently.
In the ED inital vitals were, 15:02 Pain 0 HR 54 BP 87/42 RR 20
pOx 100% (oxygen therapy not given).
Initial ECG showed atrial fibrillation at 40 bpm with T-wave
flattening laterally consistent with previous non-stemi.
Bedside ultrasound reveals no pericardial effusion but apparent
hypokinesis.
Temperature was noted to be 89.6 (rectal) with improvement to 90
(rectal) with [**Last Name (un) **] Hugger.
Labs showing WBC 4.3, Hgb 12.3, Plt 418 Diff 88% N. [**Name (NI) 2591**] PTT
53.2, INR 3.4 (H).
Chemistry panel Na 134, K 6.2 (H), Cl 104, HCO3 12 (H), BUN 184,
Cr 5.9 with anion gap.
ALT 69 (H), AST 65 (H), CPK 184, Tbili 1.
CK-MB 48 (H), MB Indx 26.1 (H), cTropnT 0.06, proBNP 7492.
TG 88
Osm 327
TSH 7.4, T4 7.5
Recent cortisol was 15.3 ([**2117-3-2**])
Digoxin was 0.8.
Serum tox was negative.
Recent SPEP/UPEP was negative.
In the ER, his BP ran 80/40-90/50, HR 40-50. He was given
bicarbonate, insulin, dextrose, sodium polystyrene. He also
received 1121 mL of fluid including NS and D5W with 3 amps
bicarb. Pressures appeared to be responsive to IVF. Of note,
baseline SBP 90-100 per Atrius records.
Renal was consulted and recommended bicarbonate infusion.
Patient has avoided dialysis in the past. Further plans will be
discussed in AM.
Patient was admitted to the ICU for bradycardia, hypotension,
hypothermia, lethargy.
I requested that blood cultures be drawn and that broad spectrum
antimicrobials be started (vancomycin/zosyn) given ? hypothermic
sepsis.
Patient's vital signs were T 90, HR 46, RR 12, BP 89/40, pOx
100, 10L neb mask.
On arrival to the ICU, patient was cool to touch. He was AAOx3.
He related the above history.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough or wheezing. Denies palpitations or
weakness. Denies nausea, vomiting, diarrhea, constipation,
abdominal pain, or changes in bowel habits. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
- Cardiomyopathy with systolic/diastolic CHF (LVEF 50-55%)
- Mitral and Aortic Valve Insufficiency
- Atrial Fibrillation on coumadin
- CKD (stage IV) - baseline Cr 2.4- 3.0
- Myeloproliferative Disease - thrombocytosis
- GERD
- PVD
- Onychomycosis
- Osteoarthritis (knee)
- Ileostomy [**3-4**] total colectomy [**3-4**] c-diff in [**2111**]
- Glaucoma left eye
Social History:
Patient is married 60 years.
Has 6 children, used to work as letter carrier and a basist
(mucsician).
Also was in Navy worked as radio operator.
Smoked 1 yr while in Navy.
Has not had etoh in [**8-8**] yrs.
No other drugs.
Lives independently with wife at home.
He denies any occupational exposure, such as asbestos.
Family History:
Mother died at 93 secondary to unknown cause.
Father died at 83 with heart disease and emphysema.
Sister died in 40s in cardiac surgery for valves.
Physical Exam:
Admission:
General Appearance: No acute distress, cool to touch
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: Cervical WNL
Cardiovascular: heart sounds distant
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Crackles : bibasilar)
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right lower extremity edema: Trace, Left lower
extremity edema: Trace
Skin: Warm
Neurologic: Attentive, Responds to: Not assessed, Movement: Not
assessed, Tone: Not assessed, AAOx3
Discharge:
Pertinent Results:
Admission:
[**2117-3-10**] 04:10PM BLOOD WBC-4.3 RBC-3.80* Hgb-12.3* Hct-37.3*
MCV-98 MCH-32.2* MCHC-32.9 RDW-20.0* Plt Ct-418
[**2117-3-10**] 04:10PM BLOOD Neuts-88* Bands-0 Lymphs-6* Monos-6 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-3*
[**2117-3-10**] 04:10PM BLOOD Hypochr-NORMAL Anisocy-2+ Poiklo-2+
Macrocy-2+ Microcy-NORMAL Polychr-NORMAL Ovalocy-1+
Burr-OCCASIONAL Tear Dr[**Last Name (STitle) **]1+ Ellipto-OCCASIONAL
[**2117-3-10**] 04:10PM BLOOD PT-35.2* PTT-53.2* INR(PT)-3.4*
[**2117-3-11**] 12:41AM BLOOD Fibrino-188
[**2117-3-10**] 04:10PM BLOOD Glucose-90 UreaN-184* Creat-5.9*# Na-134
K-6.2* Cl-104 HCO3-12* AnGap-24*
[**2117-3-10**] 04:10PM BLOOD ALT-69* AST-65* CK(CPK)-184 AlkPhos-126
TotBili-1.0
[**2117-3-10**] 04:10PM BLOOD CK-MB-48* MB Indx-26.1* cTropnT-0.06*
proBNP-7492*
[**2117-3-10**] 04:10PM BLOOD Albumin-4.1
[**2117-3-11**] 12:41AM BLOOD Calcium-6.7* Phos-7.7*# Mg-1.7
[**2117-3-11**] 12:41AM BLOOD Triglyc-122
[**2117-3-10**] 04:10PM BLOOD TSH-7.4*
[**2117-3-10**] 04:10PM BLOOD T4-7.5
[**2117-3-12**] 06:15AM BLOOD Vanco-10.7
[**2117-3-10**] 04:10PM BLOOD Digoxin-0.8*
[**2117-3-10**] 04:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2117-3-11**] 01:20AM BLOOD Type-[**Last Name (un) **] Temp-34.6 pO2-64* pCO2-32*
pH-7.45 calTCO2-23 Base XS-0
[**2117-3-10**] 05:03PM BLOOD Lactate-1.9 K-5.9*
[**2117-3-11**] 02:28PM BLOOD freeCa-0.88*
[**2117-3-10**] 06:10PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.009
[**2117-3-10**] 06:10PM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2117-3-10**] 06:10PM URINE RBC-<1 WBC-1 Bacteri-FEW Yeast-NONE
Epi-<1
[**2117-3-10**] 06:10PM URINE CastHy-11*
[**2117-3-12**] 03:13AM URINE Eos-POSITIVE
[**2117-3-10**] 06:10PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
Blood cultures pending x2
Urine culture pending
CHEST (PORTABLE AP) Study Date of [**2117-3-10**] 4:35 PM
FINDINGS: There is evidence of emphysema, although no focal
consolidation is seen. There is no evidence of pulmonary edema.
Mild-to-moderate cardiomegaly is not significantly changed.
There are no pleural effusions. No pneumothorax is seen. Aortic
calcifications are noted.
IMPRESSION:
1. No acute cardiopulmonary process.
2. Mild-to-moderate cardiomegaly, not significantly changed.
ECG Study Date of [**2117-3-10**] 3:30:56 PM
Atrial fibrillation with a slow ventricular response and a
ventricular
premature beat. Non-specific intraventricular conduction delay.
Poor R wave progression. Cannot exclude a prior anterior
myocardial infarction. Compared to the previous tracing of
[**2117-2-28**] no significant change.
Brief Hospital Course:
87M history of cardiomyopathy with both systolic/diastolic CHF
(LVEF 50-55%), CKD Stage IV (baseline Cr 2.4-3) among other
issues that presented to the emergency department complaining of
shortness of breath with no overt evidence of heart failure
exacerbation in addition to hypothermia, acute on chronic renal
failure with toxic-metabolic derangements, and hypotension in
setting of hypovolemia.
#Hypotension/ Hypothermia, initially concerning for sepsis, but
he was found to have no infectious source.
Patient states normal temperature is around T 96. He has
underlying hypothyroidism and likely disturbance in
thermoregulation given elderly and underlying kidney
dysfunction. Recent cortisol within normal limits. Hypothermia
also concerning for sepsis, but patient has no obvious source of
infection. Patient's temperature has risen from 89 rectal to 95
rectal with passive re-warming and currently above 96 since [**3-12**]
orally. Patient was initially warmed passively with a Beir
hugger, which was then discontinued as patient stated that he
was too hot. Patient was treated emperically with zosyn and
vancomycin (1000mg given [**3-10**] 1900 and 1250mg given [**2117-3-12**] am)
and his antibiotics were stopped on [**3-13**] as he had no signs of
infection and a negative infectious workup including negative
blood and urine cultures a CXR with evidence of pneumonia. We
continued home thyroid medications.
# Acute on chronic renal failure: Patinet presented with a
creatinine of 5.9 up from 3.2 on discharge 7 days ago. He also
had metabolic acidosis and hyperkalemia on admission. His
metabolic disturbances improved after he was initially fluid
resucitated and given IV bicab and started on calcium acetate.
On Discharge his creatinine was 4.3, with a BUN of 113, and a
bicarb of 19. The patient was quite clear that he was not
interested in pursuing HD. Renal followed the patient here and
the patient has an outpatient nephrologist. Renal also
recommended sarna lotion for uremic itching.
# Chronic diastolic and systolic heart failure per prior notes,
though an echo from [**2117-1-31**] showed an EF 50-55% with [**Hospital1 **]-atrial
ennlargement, RV enlargement and severe TR. He had an ntBNP of
7000 similar to prior values. Diuretics were held during this
admission given ARF. He can resume torsemide on Monday [**3-15**]
with close attention to his electrolytes and volume status.
# Atrial fibrillation/bradycardia
Initially, patient likely with bradycardia secondary to
hypothermia. Rhythm is slow atrial fibrillation.
Metoprolol/digoxin were both held because of bradycardia.
Coumadin was held on admission as he had an INR of 3.4, and
coumadin 2mg was resumed on [**3-13**] when his INR was 2.3.
**Both digoxin and metoprol held at discharge given concerns of
bradycardia and hypotension with metoprolol, flucuating renal
function in respect to digoxin (level 0.8 on admit)
[]Digoxin can be resumed per his PCP
# Hypothyroidism continued on levothyroxine
# Myeloproliferative Disease His hydroxyurea was held in setting
of ARF and was resumed on discharge. Pharmacist confirmed that
his prior dose is OK even with his creatinine clearance of
[**11-15**]. He has been on this dose for a while # Glaucoma
continued latanoprost
#Goals of Care: Patient and family intersted in having more
services provided at home. He is already established with VNA,
but given daughter's concern to have daily help with his ostomy,
our CM referred her to [**Hospital 18639**] home health aides.
We discussed code status, but the patient seemed to want his
doctors to give [**Name5 (PTitle) **] a shot at CPR, even despite explaining how
the majority of patients do not survive a cardiac arrest and
with his illnesses it would be less likely and that cardiac
resuscitation can be just as invasive or more than dialysis and
if he survived he would need dialysis. The patient is not ready
for dialysis because his approach would be to return to the
hospital if he got sick again.
The patient can be referred to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], who is a
palliative care provider with [**Name9 (PRE) 2287**] and discuss his chaning
health with her and his PCP.
Medications on Admission:
Verified from last discharge summary and Atrius records
1. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*15 Tablet(s)* Refills:*2*
2. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. digoxin 125 mcg Tablet Sig: One (1) Tablet PO 3X/WEEK
(MO,WE,FR).
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. esomeprazole magnesium 20 mg Capsule, Delayed Release(E.C.)
Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day.
6. torsemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
7. hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO 5X/WEEK
(MO,TU,WE,TH,FR).
8. econazole 1 % Cream Sig: One (1) application Topical twice a
day as needed for rash.
9. warfarin 2 mg Tablet Sig: One (1) Tablet PO 5X/WEEK
([**Doctor First Name **],MO,TU,TH,FR).
10. warfarin 1 mg Tablet Sig: One (1) Tablet PO 2X/WEEK (WE,SA).
11. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO QID (4 times a day).
12. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
13. baking soda
[**2-1**] teaspoon, by mouth, three times a week
14. Levothyroxine 100 mcg Oral Tablet
Discharge Medications:
1. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a
day.
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. esomeprazole magnesium 20 mg Capsule, Delayed Release(E.C.)
Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day.
4. torsemide 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
5. hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO 5 days a
week (not on sat, [**Last Name (un) **]).
6. econazole 1 % Cream Sig: One (1) Topical once a day.
7. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day: TAKE
2 TABS ON SUNDAY, MONDAY, TUESDAY, THURSDAY, FRIDAY AND TAKE 1
TAB ON WED, SATURDAY.
Disp:*90 Tablet(s)* Refills:*0*
8. calcium acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Capsule(s)* Refills:*0*
9. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
10. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. BAKING SODA Sig: [**2-1**] TEASPOON THREE TIMES A WEEK.
12. hospital bed
please call Clincial 1 Home Medical at [**Telephone/Fax (1) 90308**] to ask about
insurance coverage
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Hypotension
Hypothermia
ESRD, not on HD
Congestive heart failure, diastolic, chronic
atrial fibrillatin
ileostomy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - WALKER.
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Your discharge weight was 144.5
You were hospitalized for low blood pressure and low body
temperature that have both improved. You continue to require
close attention to any symptoms of congestive heart failure
including shortness of breath, leg swelling, difficulty
breathing at night and kidney failure with less urination.
MEDICATION CHANGES:
[]TORSEMIDE WAS HELD THIS ADMISSION AND CAN BE RESUMED ON MONDAY
[**3-15**]
[]HYDROXYUREA DOSE HELD DURING ADMISSION, RESUMED ON DISCHARGE,
(we confirmed with pharmacist that this is an OK dose for your
creatinine clearance)
[]CALCIUM ACETATE STARTED
[]METOPROLOL STOPPED DURING THIS ADMISSION DUE TO BRADYCARDIA
[]DIGOXIN WAS NOT CONTINUED DURING HOSPITALIZATION, BUT CAN BE
RESUMED ON DISCHARGE PER YOUR PCP
TRANSITIONAL ISSUES
[]REFERRAL TO PALLIATIVE CARE TO DISCUSS GOALS OF CARE, CODE
STATUS AND POTENTIAL FOR HOSPICE IN THE FUTURE IF HE HAS
PROGRESSIVE ILLNESS
[]DECISIONS ABOUT METOPROLOL, DIGOXIN
[]MONITOR RENAL FUNCTION, INR,
[]discharge weight was:
Followup Instructions:
Please call your PCP on [**Name9 (PRE) 766**] to arrange an appointment for
this week:
Name: [**Name9 (PRE) 36023**],[**Name9 (PRE) **]
Location: [**Location (un) 2274**]-[**Location (un) **]
Address: 111 [**Doctor Last Name **] DR, [**Location (un) **],[**Numeric Identifier 17464**]
Phone: [**Telephone/Fax (1) 36024**]
Please discuss with Dr. [**Last Name (STitle) **] if he can make a referral to a
palliative care specialist at [**Location (un) 2274**]: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Please see your nephrologist as [**Last Name (NamePattern1) 1988**] Dr. [**Last Name (STitle) **] (confirm
appointments)
Please confirm appointments with your cardiologist.
ICD9 Codes: 5849, 4254, 2762, 4589, 4280, 2449, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3817
} | Medical Text: Admission Date: [**2127-10-8**] Discharge Date: [**2127-10-21**]
Date of Birth: [**2046-10-11**] Sex: M
Service: SURGERY
Allergies:
Percocet
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
Ruptured abdominal aortic aneurysm
Major Surgical or Invasive Procedure:
[**2127-10-8**]: Endovascular aortic aneurysm repair.
[**2127-10-16**]: Abdominal aortogram. Balloon angioplasty of proximal
extension cuff of endograft(aorta) and left CIA and EIA.
History of Present Illness:
HPI: Pt is 80 y/o M with h/o CAD, PVD, bilateral carotid
endarterectomies within past year who presents with ~10cm,
leaking infrarenal AAA. Pt had an acute onset of abdominal pain
radiating to the back today and presented to OSH where
subsequent
CT scan revealed the AAA. No fevers or chills. Currently, no
chest pain, shortness of breath, lightheadedness or dizziness.
Past Medical History:
PMH: CABG in [**2-/2117**] with an LIMA to LAD and vein graft to the
first diagonal, obtuse marginal, and right coronary arteries
Carotid stenosis s/p bilateral carotid endarterectomies
COPD
hyperlipidemia
hypertension
mild congestive heart failure
anxiety
rotator cuff tear
sleep apnea
Social History:
FH: non-contributory
Family History:
SH: No ETOH or smoking. He is a remote smoker.
Physical Exam:
PE: T 97 P 56 BP 132/74 R 18 SaO2 95%
Gen: nad
Heent: an-icteric
Lungs: clear
Heart: RRR
Abd: mild periumbilical abd pain, soft, nondistended, nonrigid
Extrem: palpable femoral/popliteal/DP/PT pulses bilaterally
Pertinent Results:
[**2127-10-21**] 06:30AM BLOO
WBC-10.1 RBC-3.59* Hgb-10.7* Hct-32.8* MCV-91 MCH-29.9 MCHC-32.7
RDW-14.5 Plt Ct-529*
[**2127-10-21**] 06:30AM BLOOD
PT-13.8* PTT-32.0 INR(PT)-1.2*
[**2127-10-21**] 06:30AM BLOOD
Glucose-113* UreaN-14 Creat-1.3* Na-140 K-3.9 Cl-101 HCO3-28
AnGap-15
[**2127-10-21**] 06:30AM BLOOD
Calcium-8.4 Phos-2.6* Mg-1.8
CT ANGIOGRAM:
The patient is status post placement of endovascular stent.
There is no sign of migration of the stent compared to prior
study, with its proximal margin just at the origin of the SMA
and extending distally with the longer limb
extending into the left common/external iliac artery junction
while the
shorter right limb terminates at the right common iliac artery.
Again seen the endoleak in the aneurysmatic sac, in similar
amount as in prior study. In the late venous phase, there is
phasing out of the contrast
enhancement. On today's study, the impression is that the
endoleak originates from the area of overlapping stent- grafts
(endoleak type 3).
Both renal arteries arise at or just below the top of the
endovascular stent, with a very stenotic origin of right renal
artery. The left common iliac artery aneurysm is unchanged in
size (13 mm), with the endovascular limb feeding the left
external iliac artery and the excluded enhancing portion is
feeding the left internal iliac artery. Again seen thedifference
in enhancement between the right internal iliac artery and the
left internal iliac artery (which is fed by the excluded portion
of the left common iliac artery).
IMPRESSION:
Compared to prior study performed in [**2127-10-14**], again
seen is the
endoleak in the aneurysmatic sac. On today's examination, the
impression is of a Type 3 endoleak.
All the other previously described findings are unchanged
compared to prior study, as follows:
1. Left iliac artery aneurysm. Difference in contrast
enhancement of left and
right internal iliac arteries.
2. Hypodensities seen in spleen that could represent infarct; an
ultrasound
examination is recommended for further evaluation.
3. Simple cyst in left hepatic lobe.
4. Bilateral pleural effusion with adjacent atelectasis.
5. Incidental left lower lobe lung nodule. A dedicated chest CT
scan is
recommended for further evaluation of other nodules.
6. Atrophic right kidney with delayed nephrogram and no
excretory phase could
be secondary to a significant stenosi at the origin of the right
renal artery.
Brief Hospital Course:
[**10-8**]: Ruptured abdominal aortic aneurysm.
Pt urgently taked to the OR for EVAR.
PROCEDURE: Endovascular aortic aneurysm repair.
Introduction of catheter into the aorta.
Bilateral femoral artery exposure M-50
Zenith bifurcated modular graft placed
Right limb graft placed with extension.
Left femoral graft placed with extension.
He tolerated the procedure well. No complications. Intubated.
Precautions taken for hx of renal failure, Bicarb drip.
Transfered to the CVICU in stable condition post operative
[**10-9**]: CVIU intubated and sedated. Making good urine. Had bump in
creat to 1.6.
Lines remain in.
[**10-10**]: CVICU. Extubated. PO pain meds. Drop in HCT to 26. Making
good urine. Creat bump to 2.2. kept NPO. HCT followed.
Transfused 2 units PRBC.
[**10-11**]: Transfered to the VICU. Nitro for HTN. Creat improved to
1.9. Diet advanced. PT consult. HCT stable after PRBC. Making
good urine. OOB.
[**10-12**] - [**10-13**]: stable / ambulating / delined. Foley DC making
urine. IS support.
[**10-14**]: Creat stable at 1.5. Mucomyst PO and IV bicarb given in
preperation for CTA. recieves CTA. Endoleak seen. HCT stable.
EKG DC'd. Nitro weaned with PO HTN medications. Made floor
status.
[**10-15**] - [**10-16**]: Creat normalizes. HCT stable. Preperation for
Angiogram: Again given Mucmyst and bicarb protocol. Making good
urnine.
[**10-16**]: goes for angio under general:
OPERATION PERFORMED:
1. Exposure of left common femoral artery and primary repair
2. Introduction of catheter into aorta.
3. Abdominal aortogram.
4. Balloon angioplasty of proximal extension cuff of
endograft(aorta) and left CIA and EIA
Extubated in the OR. Sent to the PACU for recovery. IOnce
recovered from the PACU sent back to the VICU for recovery.
[**10-17**]: Delined. heplocked. Making good urine. Creat stable at
1.6. OOB to chair. foley left in. Diet advanced. Drop in HCT to
23 post op Transfused 2 units PRBC. Needs nitro for HTN:
Cardiology consult for persistant HTN; PO medications adjsted.
HTN adjusts.
[**10-18**] - [**10-20**]: Foley DC'd. Making good urine. Creat remains
stable. Normotensive with adjustment of pain meds. Ambulating
with PT. Had to be given lasix for fluid overlaod secondary to
CHF Systolic chronic stable. Creat stable at 1.5. Mucomyst PO
and IV bicarb given in preperation for CTA. recieves CTA.
Endoleak seen, much improved.
[**10-21**]: recieves PMIBI for future open AAA repair. Pt deciding
wether or not to have an open procedure. He is being DC'd today
understanding the risk of rupture. His creatinine is stable.
Normotensive on PO medications. Making good urine. HCT stable.
VNA to check HCT and BP at home.
Medications on Admission:
Meds: Aspirin 81',Zocor 80',Plavix 75',albuterol inhaler,Spiriva
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
9. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff
Inhalation Q6H (every 6 hours).
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
11. Simethicone 80 mg Tablet, Chewable Sig: 0.50 - 1.0 Tablet,
Chewable PO three times a day as needed.
12. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*30 qs* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
Abdominal aortic aneurysm; persistent type I endoleak
I had a long talk with patient and family. he is pending
completion operative repair. he knows going home even for a few
days subjects him to potential risk of rupture and death. he
accepts those risks
Discharge Condition:
Improved
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please 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.
* Continue to ambulate several times per day.
* No heavy ([**11-5**] lbs) until your follow up appointment.
Followup Instructions:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 11767**] Date/Time:[**2128-2-2**] 10:40
Call Dr [**Last Name (STitle) 8888**] [**Name (STitle) 42274**] at [**Telephone/Fax (1) 1241**]. To discuss further
surgery.
Completed by:[**2127-10-21**]
ICD9 Codes: 2851, 5119, 5180, 496, 5859, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3818
} | Medical Text: Admission Date: [**2156-10-8**] Discharge Date: [**2156-10-13**]
Date of Birth: [**2107-3-3**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a 49-year-old male who
presented with chest pain and palpitations to an outside
hospital. He had a positive stress test at that time, and
was transferred to [**Hospital1 69**] for
catheterization. Catheterization showed left main disease
and preserved left ventricular function.
PAST MEDICAL HISTORY: Significant for anxiety, hypertension,
obesity.
MEDICATIONS ON ADMISSION: Atenolol 25 mg by mouth once
daily, aspirin 325 mg by mouth once daily, vitamin E, vitamin
C.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: He was afebrile. His vital signs were
stable. His neck was supple, with no bruits. His lungs were
clear to auscultation bilaterally. His heart was regular
rate and rhythm, with no murmurs, gallops or rubs. His
abdomen was soft, nontender, nondistended, bowel sounds
present. Extremities were warm and well perfused, with no
cyanosis, clubbing or edema.
LABORATORY DATA: White count 6.5, hematocrit 40, platelet
count 213. Sodium 138, potassium 4.1, chloride 105,
bicarbonate 26, BUN 11, creatinine 0.9, glucose 106. PT
12.8, PTT 22.7, INR 1.1.
HOSPITAL COURSE: The patient was planned to have a coronary
artery bypass graft. Due to his left main disease, the
patient was taken to the operating room on [**2156-10-9**], where a
coronary artery bypass graft x 2 was performed. The patient
was transferred to the CSRU postoperatively, and did well.
He was extubated and continued to improve. The patient was
started on beta blockers and lasix, and his chest tubes were
removed. He continued to improve. His Foley was removed,
and the patient was transferred to the floor.
Physical Therapy was consulted at that time for ambulation
and for evaluation of his cardiac rehabilitation potential.
They felt that he would do quite well and, do to his age,
could function well. It was suggested at that time and
decided that the patient would be able to be discharged home.
The patient did well, and was transferred to the floor on
[**2156-10-11**], and continued to improve. His wires were removed on
[**2156-10-12**], and his Lopressor was increased. On [**2156-10-12**], he was
also cleared by Physical Therapy.
The patient was discharged on [**2156-10-13**] in stable condition.
DISCHARGE MEDICATIONS:
1. Motrin 600 mg by mouth every six hours as needed
2. Xanax 0.5 by mouth three times a day as needed
3. Lopressor 50 mg by mouth twice a day
4. Percocet one to two tablets by mouth every four hours as
needed
5. Aspirin 325 mg by mouth once daily
6. Colace 100 mg by mouth twice a day
7. Zantac 150 mg by mouth twice a day
8 Potassium chloride 20 mEq by mouth twice a day
9. Lasix 20 mg by mouth twice a day
DISCHARGE DIAGNOSIS:
1. Anxiety
2. Hypertension
3. Coronary artery disease status post coronary artery
bypass graft x 2
4. Obesity
DI[**Last Name (STitle) 408**]E INSTRUCTIONS: He is instructed to follow up with
Dr. [**Last Name (Prefixes) **] in four weeks and with his primary care
physician in one to two weeks, and with his cardiologist in
two to four weeks.
The patient is discharged home in stable condition.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern4) 10459**]
MEDQUIST36
D: [**2156-10-12**] 23:32
T: [**2156-10-13**] 00:53
JOB#: [**Job Number 45145**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3819
} | Medical Text: Admission Date: [**2111-1-17**] Discharge Date: [**2111-1-22**]
Date of Birth: [**2111-1-17**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: [**Known lastname **] [**Known lastname **] is a former 1.08
kg product of a 26 and 2/7 weeks gestation pregnancy, born to
a 44 year old, Gravida V, Para 0 woman.
PRENATAL SCREENS: Blood type 0 negative; antibody Anti-D
positive; Rubella immune; RPR nonreactive; hepatitis B
surface antigen negative; Group Beta strep status unknown.
Pregnancy was notable for cervical shortening with a cerclage
placed on [**2110-10-22**]. A placenta previa was noted at 18 weeks
which resolved. She presented on [**2111-1-13**] with vaginal
bleeding. There was a large clot seen on ultrasound. The
biophysical profile on the fetus was eight out of eight. She
received a complete course of Betamethasone on the day of
delivery. The mother spiked a fever to 103 degrees F and had
increased breathing. She was taken to cesarean section for
concern for chorioamnionitis and a septic hematoma. The
infant emerged apneic with some tone. He required bagged
mask ventilation. He was intubated at 10 minutes of life.
Apgars were four at one minute and eight at five minutes.
Postoperatively, the mother's cerclage was removed and a
septic hematoma was revealed. The infant was admitted to the
Neonatal Intensive Care Unit for treatment of prematurity.
PHYSICAL EXAMINATION: Upon admission to the Neonatal
Intensive Care Unit, weight was 1.08 kg; length 38 cm; head
circumference 26 cm (all 75th percentile for gestational
age). General: Nondysmorphic preterm infant, consistent
with a 26 to 27 week gestational age. HEAD, EYES, EARS, NOSE
AND THROAT: Anterior fontanel soft and flat; non dysmorphic
facies; palate intact; neck and mouth normal. Chest:
Moderate retractions with spontaneous breaths; fair excursion
with ventilator breaths; good breath sounds bilaterally; few
scattered coarse crackles. Cardiovascular: Well perfused;
regular rate and rhythm; femoral pulses normal; normal S1 and
S2; no murmur. Abdomen: Three vessel umbilical cord.
Abdomen soft, nondistended. Liver 2 cm below the right
costal margin. No splenomegaly, no masses. Bowel sounds
active. Anus patent. Genitourinary: Normal preterm male
genitalia. Testes undescended bilaterally. Central nervous
system: Active, responsive to stimuli; tone reduced
symmetrically; moving all extremities symmetrically; gag
intact; no suck; grasp symmetric. Skin: Normal, intact.
Color pink. Musculoskeletal: Normal spine, hips and
clavicle.
HOSPITAL COURSE: History by system, including pertinent
laboratory data: 1.) Respiratory: [**Known lastname **] received two
doses of Surfactant. His initial ventilatory settings with a
peak inspiratory pressure of 20 over a positive end
expiratory pressure of 6 and intermittent mandatory
ventilatory rate of 25. He weaned to room air. On day of
life #4, he was changed to continuous positive airway
pressure in room air. He was treated with caffeine
prophylactically for apnea of prematurity. When his bowel
perforation was diagnosed on [**2111-1-22**], he was electively
reintubated and placed on settings of a peak inspiratory
pressure of 15/5; a positive end expiratory pressure;
intermittent mandatory ventilatory rate of 25. A blood gas
on those settings in room air had a pH of 7.32, PC02 of 41;
P02 of 65.
2.) Cardiovascular: A murmur was noted on day of life #2,
consistent with patent ductus arteriosus. He received three
doses of Indomethacin. The murmur resolved by day of life
four.
On the day of birth, mean arterial pressure was noted to be
24. He received two normal saline boluses and was started on
a Dopamine drip. His maximum Dopamine dosage was 10 mcg per
kg per minute. He weaned off Dopamine by 36 hours of life.
3.) Fluids, electrolytes and nutrition: [**Known lastname **] was
initially n.p.o. and maintained on intravenous fluids. A
percutaneously inserted central catheter was placed on day of
life three, with the tip in a non central location. He was
started on total parenteral nutrition on day of life one.
Enteral feeds were started on day of life #4 at 10 cc per kg
but he was made n.p.o. on the evening of [**2111-1-22**]. Serum
electrolytes were checked daily and peak serum sodium was 146
meq per liter. Recent electrolytes had a sodium of 135;
potassium of 4.8; chloride 102 and PC02 of 21.
At the time of transfer, his weight was 955 grams. Total
fluids were 140 cc per kg per day of PN 7% glucose; 3.1%
amino acids.
4.) Infectious disease: Due to the presumed chorioamnionitis
and prematurity, [**Known lastname **] was evaluated for sepsis. His
initial white blood cell count was 5,000 with a differential
of 36% polys, 0% bands, 44% lymphs. A blood culture was
obtained prior to starting IV Ampicillin and Gentamycin. The
plan was to administer a week of antibiotics. Cultures of
the mother's hematoma grew Enterococcus species, sensitive to
Ampicillin. On [**2111-1-22**] with the diagnosis of the intestinal
perforation. Clindamycin was added. The blood culture from
birth was no growth at 48 hours.
A lumbar puncture was performed on day of life #3 and had
404,000 red cells; 150 white cells; 18% polys; glucose of
115; protein of 572.
5.) Gastrointestinal: [**Known lastname **] was treated for unconjugated
hyperbilirubinemia with phototherapy. His peak serum
bilirubin was on day of life #2 with a total of 4.6 over 0.3
direct mg per dl. He remained on single phototherapy through
[**2111-1-22**]. On the evening of [**2111-1-22**], his belly, on
examination, was noted to be distended, slightly tender with a
bluish hue in the periumbilical area. The feedings were held.
A flat belly abdominal x-ray was obtained which showed air
around the liver and air in the portal venous system. A
repeat left lateral decubitus film showed a large amount of
air, consistent with an intestinal perforation. Pediatric
surgery from [**Hospital3 1810**] was notified and transfer was
arranged for an exploratory laparotomy.
Repeat CBC, blood culture and electrolytes were obtained
prior to transfer.
6.) Hematology: Hematocrit at birth was 43.8%. Repeat
hematocrit at the time of transfer was 31%. [**Known lastname **] was
blood type 0 positive, Coombs negative. He has not received
any transfusions of blood products prior to transfer from a
clot for type and screen was obtained prior to transfer.
7.) Neurology: Head ultrasound was performed on [**2111-1-21**] and
was within normal limits. [**Known lastname **] maintained a neurologic
examination consistent with his gestational age.
8.) Sensory: Hearing screening not yet performed.
Ophthalmology: He was not examined for retinopathy of
prematurity. His first examination will be due at five weeks
of age.
9.) Psychosocial: [**Hospital1 69**]
Social Work was involved with the family. The social worker
was [**Name (NI) 36130**] [**Name (NI) 36527**]. She can be reached at [**Telephone/Fax (1) **].
CONDITION AT DISCHARGE: Guarded.
DISCHARGE DISPOSITION: Transfer to [**Hospital3 1810**] for
an exploratory laparotomy.
PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) **] at [**Hospital **] Medical
Associates, [**Location (un) **], MA.
CARE AND RECOMMENDATIONS:
1. N.P.O. on TPN and lipids via a percutaneously inserted
central catheter.
2. Medications:
Ampicillin 150 mg intravenous q. 12 hours.
Gentamycin 3.5 mg intravenous q. 24 hours.
Clindamycin 5.5 mg intravenous q. 12 hours.
3. Car seat position screening not performed.
4. State newborn screen was sent on day of life #3, with a
repeat sent on [**2111-1-22**]. There has been no notification
of abnormal results to date.
5. No immunizations administered.
6. Immunizations recommended:
Synagis-RSV prophylaxis should be considered from [**Month (only) 359**]
through [**Month (only) 547**] for infants who meet any of the following
three criteria:
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.
DISCHARGE DIAGNOSES:
1. Prematurity at 26 and 2/7 weeks gestation.
2. Respiratory distress syndrome.
3. Suspicion for sepsis.
4. Unconjugated hyperbilirubinemia.
5. Apnea of prematurity.
6. Intestinal perforation.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 36142**], M.D. [**MD Number(1) 36143**]
Dictated By:[**Last Name (Titles) 37548**]
MEDQUIST36
D: [**2111-1-22**] 12:24
T: [**2111-1-23**] 05:31
JOB#: [**Job Number 53205**]
ICD9 Codes: 769, 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3820
} | Medical Text: Admission Date: [**2130-8-28**] Discharge Date: [**2130-9-4**]
Date of Birth: [**2072-10-27**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
Defibrillation for torsade de pointes
History of Present Illness:
57 y/o male with stage [**Doctor First Name 690**] esophageal adenocarcinoma (last
chemoRx on [**2130-8-18**]), hepatitis C related to prior IVDU p/w
syncopal episode in the ED. Since [**2130-8-25**], patient has been
having "black out spells" (one on Friday, one Saturday, one
Sunday, two today). Today, he presented to [**Hospital3 **] OSH where
it was thought he was having a seizure. He was loaded with
dilantin (1g IV) for suspected seizure (but billed as a cardiac
arrest?). He was transferred here for neurologic evaluation.
During evaluation, it was noted that patient's telemetry
resembled non-perfusing pulseless VT. He received 10 seconds of
CPR and shocked x 1. Loaded with 300 mg amiodarone IV and
started on gtt, given 4g IV magnesium, next rhythm check sinus
rhythm, given 40 mEQ IV potassium. Upon reviewing the old
telemetry strip, it was felt that his rhythm strip was most c/w
torsades. His QTc was estimated to be 456 (or greater).
Initial vitals in ED: T98.4, 124/58, 76, 18, 99% 2L NC. Labs
were pertinent for Mg level 1.3. K+ 2.7 at OSH, prior to
transfer to [**Hospital1 18**] ED.
.
On transfer, VS: AF, BP 100/59, HR 71, RR 16, 100% 4L.
.
On review of systems, pt mentions mild dysphagia for solid
foods, nausea, decreased PO, and syncopal spells. S/he denies
any prior history of stroke, TIA, deep venous thrombosis,
pulmonary embolism, bleeding at the time of surgery, cough,
hemoptysis, black stools or red stools. S/he denies recent
fevers, chills or rigors. He denies exertional buttock or calf
pain. All of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations.
Past Medical History:
1. CARDIAC RISK FACTORS: (-)Diabetes, (-)Hypertension
2. CARDIAC HISTORY:
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
-hepatitis C related to prior IVDU, dx 10 years ago.
-distal esophageal adenocarcinoma that is stage [**Doctor First Name **] by
endoscopic
ultrasound (on cisplatin, 5FU with last cycle [**2130-8-18**]).
- status post car accident with some mild head trauma in [**2101**].
There is no residual deficits.
Social History:
-Tobacco history: Per OMR, he is a one-pack per day smoker and
has a total 47-pack-year exposure history. Today, he says he
smokes 1 pack in 3 days.
-ETOH: currently does not drink alcohol. It seems that
throughout his teenage years he had some exposure to alcohol;
however, he has not had significant exposure since his early
30s.
-Illicit drugs: prior heroin addict. He has been on a methadone
program for over 10 years and has now relapsed. He denies
recent drug use.
- The patient previously worked in heavy construction. He is
currently disabled. The patient is very active. The patient
lives in [**Location (un) 5503**], which is approximately one hour from
[**Location (un) 86**].
-patient's pharmacy is [**Company 25795**] in [**Location (un) 5503**]; he gets his
methadone from [**Hospital3 19386**] ([**Location (un) 5503**]).
Family History:
The patient's mother had diagnosis of cervical cancer and also
of a brain malignancy. She died from these malignancies. There
is also a history of type 2 diabetes in both the patient's
maternal and paternal side. The patient's father had a
myocardial infarction and at time of all autopsy, was found
to have also a small lung cancer. There is no other history of
cancer in the family.
Physical Exam:
VS: T99.1, BP 115/62, HR 63, RR 13, 100% 4L.
GENERAL: thin, pleasant, cooperative male in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 5 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: Coarse BS, with occasional rales b/l
ABDOMEN: Soft, NT, ND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: Chronic venous stasis changes.
PULSES:
Right: 2+ DP 2+ PT 2+
Left: 2+ DP 2+ PT 2+
Pertinent Results:
EKG [**2130-8-28**]: polymorphic ventricular tachycardia with long QTc
consistent with torsades.
.
TTE [**2130-8-29**]: The left atrium is normal in size. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%). Right ventricular chamber size
and free wall motion are normal. The aortic arch is mildly
dilated. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
The mitral valve appears structurally normal with trivial mitral
regurgitation. The pulmonary artery systolic pressure could not
be determined. There is no pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function.
.
Head and facial bone CT (OSH [**Hospital3 15402**]): no intracranial injury,
no definitive facial bone fx, there is deformity of the right
orbital floor (probably related to old trauma), several small
radio-opaque foreign bodies projecting superficial to the
zygomatic arch of uncertain age. Paranasal sinus disease.
.
CXR (OSH [**Hospital3 **]): R Subclavian CVL with tip in the SVC. No
acute cardiopulm abnormality.
.
On discharge: potassium level 4.3, magnesium levl 1.6
[**2130-9-2**] 06:05AM BLOOD WBC-1.3*# RBC-2.74* Hgb-9.8* Hct-27.1*
MCV-99* MCH-35.7* MCHC-36.1* RDW-19.8* Plt Ct-41*
[**2130-9-4**] 11:47AM BLOOD Hct-31.7*
[**2130-9-2**] 06:05AM BLOOD Plt Ct-41*
[**2130-9-4**] 11:47AM BLOOD Glucose-97 UreaN-17 Creat-0.9 Na-133
K-3.5 Cl-102 HCO3-23 AnGap-12
[**2130-8-30**] 06:37AM BLOOD ALT-35 AST-52* LD(LDH)-210 AlkPhos-70
TotBili-1.4
[**2130-9-4**] 11:47AM BLOOD Mg-1.6
[**2130-8-28**] 06:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Brief Hospital Course:
57 y/o male with stage [**Doctor First Name 690**] esophageal adenocarcinoma and
hepatitis C related to prior IVDU, presented with syncopal
episode, initially questioned as seizure, but then found to be
in non-sustained polymorphic VT/torsades with prolonged QTc,
then shocked into sinus rhythm. He has been stable on Mexelitine
PO and methadone has been changed to MS contin, wean in
progress.
.
# torsade de pointes - patient had episode of seizure-like
episode, found to be in non-sustained polymophic ventricular
tachycardia with prolonged QTc, on telemetry in [**Hospital1 18**] ED.
Etiology felt to be related to medication-induced prolonged QTc
(i.e. methadone, compazine) in the setting of electrolyte
derangements (hypokalemia and hypomagnesemia) from nausea s/p
recent chemoRx. Quickly shocked into normal sinus rhythm.
Patient was treated with IV magnesium and mexiletine 150 mg po
tid for methadone-induced prolonged QTc. Echo was performed
which was normal, and did not show any structural cause for
prolonged QTc. Patient was monitored on telemetry without any
further events or arrhythmias. His potassium was kept above 4
and his magnesium was kept above 2. Patient is not to take
methadone again, as it can precipitate torsades on repeat use.
To maintain potassium, patient was discharged on spironolactone.
Magnesium Oxide was given PO. Pt should have his labs checked on
Thursday [**9-7**] with results to Dr. [**Last Name (STitle) 36924**].
.
# stage [**Doctor First Name 690**] esophageal adenocarcinoma - staged by EUS, has been
on initial regimen of cisplatin, 5FU, and XRT. Severe anorexia
and mild dysphagia have improved. Pt has his next Appt with Dr.
[**Last Name (STitle) **] (oncology) on [**2130-9-19**]. Plan is for surgery in the future,
anticipate pt will need large narcotics doses for pain control.
.
# pancytopenia (leukopenia/neutropenia/anemia/pancytopenia) -
likely related to recent chemoRx for esophageal adenocarcinoma.
Patient was placed on neutropenic precautions and CBC was
monitored while admitted. Received 2 units PRBC and hct on
discharge 31.
.
# chronic methadone use/abuse - prior heroin addict. He has
been on a methadone program for over 10 years. Patient is not
to take methadone again, as it can precipitate torsades on
repeat use. Addiction team was consulted, and patient was
placed on MS Contin as a substitute (to be tapered). Pt was
waiting for a bed at [**Hospital1 882**] inpatient addiction program but
has refused placement and will go home on 2 days of low dose MS
Contin only. Clonidine patch has been uptitrated for potential
withdrawal symptoms but pt has been remarkably free of
withdrawal symptoms. His addiction clinic has been notified that
he is never to get methadone and has been updated on new
medicines and taper schedule of morphine. Message left for
counselor, [**First Name4 (NamePattern1) 401**] [**Last Name (NamePattern1) 14323**] as well
.
# hypoalbuminemia - Likely [**2-27**] PO's in setting of nausea and
chemotherapy. Clinically monitored and to be addressed as an
outpatient. Pt has 1+ edema in LE, likely related. At discharge,
pt is eating meals and drinking Ensure for increased protein.
.
# syncope - likely related to arrhythmia noted above. Head CT
at OSH negative for ICH.
.
# Left Arm Phlebitis: Noted after IV discontinued, no known
infiltration. No evidence for systemic infection. Given pt is
neutropenic, 24 hours of IV Kefzol was given and changed to PO
Cephalexin and doxycycline on [**9-1**] to cover gram positive
bacteria and potential MRSA. Today, swelling is gone, there is
no redness and tenderness at the old IV site.
.
# constiptation: R/T [**Month (only) **] PO's and narcotics. No abdominal pain,
abdomen is soft and non-tender to palpation. Resolved after
aggressive bowel regimen.
.
# hepatitis C related to prior IVDU - untreated and stable.
.
# Dispo: Pt was waiting for a bed at an acute addiction program
at [**Hospital 882**] Hospital. This morning, he has decided he wants to
go home and agrees to a 2 day taper of his morphine. He states
he can stay with his brother and sister in law. He knows that if
he has signs of withdrawal, he will contact his addiction
clinic. His methadone clinic was contact[**Name (NI) **] and updated on plan.
Pt was advised that although the CCU teams feels that he should
go to the [**Hospital1 882**] program for close monitoring during his
morphine wean, he is competant to make his own decisions
regarding follow up care.
Medications on Admission:
-nexium 40 mg Capsule, Delayed Release(E.C.)once a day
-methadone 10 mg tab, 10 tablets once daily
-emend 1 capsule once daily
-compazine 10 mg tab (1 tab q6-8 hrs)
-oxycodone 20 mg tab (1 tab q4-6 hrs)
-megace oral 400 mg/10 mL (40 mg/mL): 1 suspension once daily
Discharge Medications:
1. Mexiletine 150 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
Disp:*90 Capsule(s)* Refills:*2*
2. Polyethylene Glycol 3350 17 gram (100 %) Powder in Packet
Sig: One (1) packet PO once a day.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO three
times a day.
4. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
6. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours) for 2 days.
Disp:*4 Capsule(s)* Refills:*0*
7. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) for 2 days.
Disp:*6 Capsule(s)* Refills:*0*
8. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*90 Tablet(s)* Refills:*2*
9. Outpatient Lab Work
Pleaes check chem-7 on Wednesday [**9-7**]
Goal K> 4.0, goal Mag > 2.0. Please call results to Dr.
[**Last Name (STitle) **],[**First Name3 (LF) **] R. [**Telephone/Fax (1) 18050**]
10. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO twice a day for 2 days: Take 2 tablets on
[**2130-9-4**] evening. Take one tablet twice daily on [**2130-9-5**] and
[**2130-9-6**], then stop.
Disp:*6 Tablet Sustained Release(s)* Refills:*0*
11. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch
Weekly Transdermal QSAT (every Saturday) for 4 weeks.
Disp:*4 Patch Weekly(s)* Refills:*0*
12. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. Torsades de pointes
.
Secondary:
1. Chronic methadone use
2. Hepatitis C, untreated
3. Stage [**Doctor First Name 690**] esophageal cancer
Discharge Condition:
stable, without chest pain, palpitations, or shortness of breath
Discharge Instructions:
.
You were admitted to the hospital with an irregular and
dangerous heart rhythm, likely due to your methadone use. You
were shocked out of this heart rhythm and treated with
intravenous magnesium. You were monitored on telemetry while
you were admitted, without further arrhythmias. Your
electrolytes were repleted and you will be discharged on a
medication called spironolactone to increase your potassium
levels. In addition, you are not to take methadone again, as it
may cause this dangerous heart rhythm. You will be discharged
on morphine (MS Contin) as a substitute for the methadone for a
few days. If you have any symptoms of withdrawal, please call
your outpatient addiction clinic.
.
In addition, you were placed on an antibiotic for your left hand
phlebitis. Please take this antibioitic as prescribed below.
.
NEW MEDICATIONS:
-Spironolactone: to keep your potassium level up
-MS Contin: to substitute for the methadone. This will be
tapered off
-Cephalexin and Doxycycline: to treat the phlebitis on your left
arm. Total of 7 day course.
- Magnesium Oxide: to keep your magnesium levels up
- Clonidine: to prevent symptoms of narcotics withdrawal
.
Please seek medical attention for chest pain, palpitations,
fainting, shortness of breath, fevers, chills, abdominal pain,
or any other concerns.
Followup Instructions:
Primary Care:
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 36924**] Phone: [**Telephone/Fax (1) 18050**] Date/time: Please make
an appt to be seen at the end of the week.
Oncology:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD Phone:[**0-0-**]
Date/Time:[**2130-9-19**] 9:30
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 831**], MD Phone:[**0-0-**] Date/Time:[**2130-9-19**]
10:00
Cardiology:
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone: [**Telephone/Fax (1) 62**] Date/Time: Monday
[**2130-10-9**] 11:00am. [**Hospital Ward Name 23**] Clinical Center, [**Location (un) 436**], [**Hospital Ward Name 5074**], [**Location (un) **], [**Location (un) 86**].
Completed by:[**2130-9-5**]
ICD9 Codes: 4271, 2768 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3821
} | Medical Text: Admission Date: [**2187-2-26**] Discharge Date: [**2187-2-28**]
Date of Birth: [**2148-4-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
nausea/vomiting
Major Surgical or Invasive Procedure:
PICC line placement and removal
History of Present Illness:
38 y/o man, well known to dept. Medicine, with DMI and severe
gastroparesis and hypertension, [**Name6 (MD) 2091**] on RRT (o/p HD tiw)
frequently admitted for abdominal pain crises with n/v,
resulting in uncontrolled HTN given fact that cannot take po
meds during these episodes. Has had innumerate admissions for
the same here. He presents overnight with 1 day of nausea and
several epsiodes of vomitting. Sxs are typical of prior
episodes. Denies CP/SOB/diarrhea/f/c/URIsx.
.
In the ED he was found to be afebrile, hr 70-80s, hypertensive
to 160s systolic, and sating 99% on RA. EKG was significant for
worsening ST elevations in V1-V4, pseudonormalization of TW in
v2, v3 and new TWI in v6. Per ED report Interventional cards
attending was consulted who felt that this was possibly
developing LV aneurysm and declined to bring him to cath.
.
Of note, during admission from [**Date range (1) 92864**], cardiology was
consulted for ST elevations that were seen on his EKG s/p a
recent STEMI in [**2186-12-14**] elevations were
persistent (possibly due to evolving aneurysm) and that no
further work up would be necessary unless there are further
changes on future EKGS. They also reviewed his recent
echocardiograms which showed akinetic segments of his LV.
However, it was decided to defer anticoagulation since his EF
was relatively preserved.
.
In the ED, labs were significant for a potassium of 6.7, repeat
of 6.4. He received calcium gluc, kayexalate, labetalol 20mg,
ativan 2mg IV x 2, dilaudid 2mg IV x 2 and 4U Reg Insulin. Renal
was consulted and he went to HD.
.
He was evaluated by Merit at HD. There his BP was slightly low
during dialysis and he was very lethargic. It was difficult to
get a full story due to drowsiness.
Past Medical History:
#. DMI uncontrolled with complications
#. CAD s/p STEMI [**12-21**] in setting of cocaine use, s/p cath with
bare metal stent to LAD
#. Recurrent flash pulmonary edema since STEMI [**12-21**]
chronic systolic heart failure
#. [**Month/Year (2) 2091**] stage V on HD since [**2-/2184**] (T/Th/Sat), followed by Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1366**]
#. Recurrent line sepsis, coag negative staph, klebsiella,
enterobacter
#. History of esophageal erosion, [**Doctor First Name **]-[**Doctor Last Name **] tear
#. History of AV fistula clot
Social History:
Patient has a prior history of tobacco and marijauna use, but he
does not currently smoke. He has a prior history of alcohol
abuse and has been sober for 9 years. He has a past history of
cocaine use. He currently denies illicit drugs.
Family History:
Father deceased of ESRD and DM. Mother aged 50's with
hypertension. 2 sisters, one with diabetes. 6 brother, one with
diabetes. There is no family history of premature coronary
artery disease or sudden death.
Physical Exam:
V: Post HD 97.3, BP 167/114, P78, R16, 99%RA
Gen: Drowsy but arousable, middle-aged AA man
HEENT: PERRL, OP clear, MMM
CV: RRR no m/r/g, HD cath in place with no erythema, warmth or
tenderness surrounding
Pulm: CTAB
Abd: decreased BS, NTND
Ext: no edema
Pertinent Results:
[**2187-2-26**]
WBC-8.5# HGB-10.3* HCT-34.6* MCV-82 RDW-18.1* PLT COUNT-343
NEUTS-64.6 LYMPHS-21.3 MONOS-7.0 EOS-6.4* BASOS-0.7
GLUCOSE-292* UREA N-60* CREAT-8.8* SODIUM-137 POTASSIUM-6.3*
CHLORIDE-95*
TOTAL CO2-24 ANION GAP-24*
CALCIUM-10.4* PHOSPHATE-7.5* MAGNESIUM-2.1
CK(CPK)-165 CK-MB-7
cTropnT-0.38* -> 0.37 -> 0.40 -> 0.33
.
CXR: no acute process
.
ECG: Sinus rhythm, ST elevations V1-V4 not significantly changed
from previous. TWIs laterally, not significantly changed from
previous.
Brief Hospital Course:
A/P: 38 year old male with DMI, ESRD on HD, gastroparesis, CAD
s/p STEMI 2 months ago, presenting with nausea, vomiting similar
to prior gastroparesis flares.
.
# Nausea/Vomiting - Likely secondary to gastroparesis, as with
prior admissions. His usual regimen if IV reglan, dilaudid, and
ativan was started. This resulted in significant improvement
and he was able to tolerate POs by the following morning. He
stated he was feeling improved and expressed his intentions to
leave on [**2187-2-28**] AM. At this time he denied abdominal pain and
was tolerated PO intake well.
.
# HTN - Hypertensive prior to HD with some hypotension during
it. Was also labile on the floors, intermittently with elevated
BP but then falling into 100's systolic range. Still able to
tolerate HD. Med compliance as an outpatient is complicated by
N/V and inability to hold down PO meds. Got IV meds (metoprolol,
captopril) overnight, but then able to take in PO meds.
Clonidine patch had come off also; that was replaced. No
evidence of sepsis or cardiac changes.
.
# Hyperkalemia - With ESRD. Had HD on the day of admission and
then again the following day to keep with schedule. K improved
following HD.
.
# CAD - Recent STEMI s/p stent. He was ruled out for MI here
(stable unchanging troponin elevations). EKG with persistent ST
changes as above, ? possible evolving aneurysm per past
cardiology evaluation. Last echo [**2-3**] still without evidence of
aneurysm. Cardiology has previously been involved during
admissions; have felt no further workup needed unless acute
changes in EKG or symptoms. Case was discussed with cards in the
ED. He was scheduled with cardiology as an outpatient. Aspirin,
[**Month/Year (2) **], beta blocker and ACE inhibitor were continued.
.
# DM type I - Given NPH (patient using at home) and regular SS
coverage.
.
# ESRD on HD: Has HD on day of admit and then again the
following day to keep him on schedule and to get him to dry
weight. Lanthanum was continued. Attempted to obtain urine tox
given transplant candidate status, but patient unable to give
urine sample (though does void).
.
# Full code
Medications on Admission:
#. Aspirin 325 mg DAILY
#. Clopidogrel 75 mg DAILY
#. Atorvastatin 80 mg DAILY
#. Clonidine 0.2 mg/24 hr Patch Weekly (every Tuesday)
#. Clonidine 0.1 mg PO BID
#. Lisinopril 40 mg DAILY
#. Labetalol 300 mg [**Hospital1 **]
#. Prochlorperazine Maleate 10 mg Q6PRN
#. Insulin 5U NPH [**Hospital1 **] and RISS for FS>150.
#. Metoclopramide 10 mg QIDACHS
#. Lorazepam 1 mg Q4H PRN nausea
#. Omeprazole 40 mg Daily
#. Lanthanum 500 mg 2 tabs TID QAC
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
4. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QMON (every Monday).
6. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
7. Labetalol 300 mg Tablet Sig: One (1) Tablet PO twice a day.
8. Compazine 10 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for nausea.
9. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO four times
a day: with meals and at bedtime.
10. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for nausea.
11. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
12. Lanthanum 1,000 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO three times a day: with meals.
13. Insulin
Insulin as you have been doing at home: NPH 5 units in the
morning and evening. Regular insulin for fingerstick sugar
above 150 as you have been doing at home.
Discharge Disposition:
Home
Discharge Diagnosis:
Nausea/vomiting
Gastroparesis
Hypertensive urgency
Diabetes mellitus
End stage renal disease
Discharge Condition:
Stable
Discharge Instructions:
You were admitted with nausea, vomiting, abdominal pain, and
inability to hold down food or liquids. This was likely due to
gastroparesis from diabetes as before. We treated you with pain
and nausea medications and you have improved. We have offered
to have you stay to ensure that your symptoms do not return, but
you have indicated that you would like to leave the hospital at
this time.
.
Please call your doctor or return to the hospital if you have
worsening abdominal pain, nausea, vomiting, inability to hold
down liquids, chest pain, dizziness, or any new symptoms that
you are concerned about.
.
Please keep all of your appointments with your doctors and take
[**Name5 (PTitle) **] of your medications as prescribed. We have not made any
changes to you medications since you were admitted.
Followup Instructions:
You have several upcoming appointments at [**Hospital1 18**]:
.
1. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9546**], MD (Neurology) Phone:[**Telephone/Fax (1) 1047**]
Date/Time:[**2187-3-13**] 10:00
2. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RN, CS (Internal Medicine) Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2187-3-27**] 12:00
3. [**Company 191**] CLINICAL PHARMACIST Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2187-3-27**]
1:00
4. Transplant team (Dr. [**Last Name (STitle) **] and [**First Name4 (NamePattern1) 10801**] [**Last Name (NamePattern1) **]); [**2187-4-9**]
starting at 2:00 pm.
5. Dr. [**Last Name (STitle) **] (heart specialist); [**2187-4-9**] at 4:00 pm.
.
You should continue dialysis as usual on Tuesdays, Thursdays,
and Saturdays.
.
You will also need followup with your primary care physician,
[**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 250**]) in the future. In the
meantime, you have an appointment with one of the clinic's nurse
practitioners ([**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) 3817**]) as above.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
ICD9 Codes: 5856, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3822
} | Medical Text: Admission Date: [**2164-11-12**] Discharge Date: [**2164-11-15**]
Date of Birth: [**2111-12-29**] Sex: M
Service: MEDICINE
Allergies:
Lipitor
Attending:[**First Name3 (LF) 134**]
Chief Complaint:
Chief Complaint: Perforated OM during cardiac catheterization
Major Surgical or Invasive Procedure:
Chief Complaint: Perforated OM during cardiac catheterization
History of Present Illness:
EVENTS / HISTORY OF PRESENTING ILLNESS:
Mr [**Known lastname 76050**] is a 52-y/o gentleman with PMHx sig for HTN, HL, CAD
(s/p CABGx4 in [**5-/2164**]), recently admitted to the floor with
unstable angina, now transferred to CCU after SVG-OM perforation
during cardiac cath.
.
Pt has been in his USOH since the CABG in [**5-/2164**] (active,
independent, chest pain free) until ~3 weeks ago, when he began
experiencing intermittent non-radiating chest
tightness/discomfort and shortness of breath on exertion,
similar to the sxs he had before CABG. Pt began to experience CP
with less and less exertion--previously able to walk [**1-18**] mile,
progressing to 1 block pta--at which point, pt presented to PCP
who referred him to the ED ([**11-12**]).Pt had no PND, orthopnea,
pedal edema at that time.
EKG showed no new ischemic changes, troponins were negative and
pt was admitted to the floor with unstable angina, intermediate
risk, TIMI score 3. Pt was started on Heparin and underwent
cardiac catheterization on [**11-13**]. A 95% occlusion was noted in
the SVG-OM graft, but the graft was perforated during stent
placement. Integrillin and Heparin were stopped (Protamine was
given) and hemostasis was achieved after transient balloon
occlusion and placement of 2 covered stents. A small posterior
pericardial effusion was noted on echo and pt c/o CP and HA
following vessel perforation/hemostasis but pt remained
hemodynamically stable throughout the procedure.
On arrival to the CCU, pt's vitals were stable and pt reported
cp resolved, though mild HA persisted.
Past Medical History:
HTN,
Hyperlipidimia
ventral hernia
colon polyps s/p R colectomy
Social History:
Married, 7 children, unemployed
Moved from D.R. one year ago.
Family History:
No tobacco
Social ETOH
Physical Exam:
VS - 99.4, 110/75, 91, 18, 100% on RA
Gen: WD, WN, NAD. A+Ox3
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. MMM
Neck: JVP not appreciated with pt lying flat.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
Chest: CTAB, slighlty decreased air entry at bases, no w/r/r.
Abd: Soft, obese, NTND. No HSM or tenderness. Surgical scars
healed.
Ext: 2+DPs, PTs bilaterally. No c/c. 1+ pedal edema b/l. R
inguinal dressing C,D,I, no hematoma or femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
EKG: sinus rhythm with PACs. Q waves and 1mm ST elevations in
leads seen V1-V3 in previous EKG.
.
Cath: 1. Three vessel coronary artery disease.
2. Patent LIMA-LAD.
3. 95% stenosis in the distal SVG-OM.
4. Non-obstructive disease in the SVG-RPDA, SVG-D1.
.
LABORATORY DATA:
12>13.8/40<208 mcv 81
135/4.1/101/25/9/1.1<93
abg 7.39/44/74/28 on 2L NC
Lipids TC 205, TG 251, HDL 43, LDL 112
Trop .01-->.14-->.09
.
Prelim head CT: No evidence of hemorrhage
.
CXR ([**2164-11-12**]): no acute process, bibasilar atelactesis
unchanged
Brief Hospital Course:
52-y/o M w HTN, HL, CAD (s/p CABGx4 in [**5-/2164**]), recently
admitted for UA now s/p OM perforation during cardiac cath.
.
PERFORATION DURING CATHETERIZATION: Pt arrived in CCU with
stable vitals and Swan numbers. An echo on [**11-14**] showed no
tamponade. Hematocrit was stable. No significant events were
seen on telemetry and EKGs were unchanged. The swan catheter
was pulled and pt ws transferred to floor.
.
CORONARY ARTERY DISEASE: His troponin was initially positive at
.14, attributed intra-procedure placement of stents and
hemostasis. Troponin had trended down to .09 by the following
day. Pt never complained of chest pain or dyspnea or had any
new EKG changes. He was continued on ASA 325mg PO daily,
clopidogrel, pravastatin, metoprolol.
.
FEN: cardiac diet, replete electrolytes PRN
.
Access: PIV, Femoral line.
.
PPx: SQ heparin. Compression boots.
.
Code: FULL
Medications on Admission:
Aspirin EC 325mg PO daily
Clopidogrel 75mg PO daily
Metoprolol succinate 50mg PO daily
Pravastatin 80mg PO QHS
Colace 100mg PO BID
Acetaminophen 1000mg po prn
SLTNG PRN (has not been taking it since CABG)
Astelin (as per [**Month/Year (2) **])
Flonase (as per [**Month/Year (2) **])
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO once a day:
Do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**].
Disp:*30 Tablet(s)* Refills:*11*
3. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*4*
4. Pravastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*4*
5. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
Disp:*1 bottle* Refills:*4*
6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*4*
7. Astelin 137 mcg Aerosol, Spray Sig: Two (2) puffs Nasal twice
a day.
Disp:*1 bottle* Refills:*4*
8. Colace 100 mg Capsule Sig: One (1) Capsule PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
S/P Coronary Artery Bypass Graft
Hyperlipidemia
Hypertension
Non ST Elevation Myocardial Infarction
Discharge Condition:
stable
Discharge Instructions:
You had symptoms that were caused by a blockage in one of your
bypass grafts. This graft was opened in the catheterization lab
and a drug eluting stent was placed. This will help to keep the
artery open but you will need to take aspirin and Clopodigrel
every day for at least one year. Do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] or the
stent can clot off and cause another heart attack. It is very
important that your cholesterol numbers are very well
controlled. Information about a heart healthy diet was discussed
with you.
.
Please take all of your medicines as ordered. Please call Dr.
[**Last Name (STitle) **] if you have any chest pain, nausea, trouble breathing,
unusual swelling, or a new cough.
.
You need to weigh yourself every day and call Dr. [**Last Name (STitle) **] if
you have a weight gain of more than 3 pounds in 1 day of 6
pounds in 3 days.
.
Congratulation on quitting smoking. Information was given to you
on admission regarding smoking cessation. This is the single
most important thing you can do for your health.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 9394**] (ST-3) GI ROOMS Date/Time:[**2164-12-20**] 1:00
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2164-12-20**]
1:00
Provider: [**Name10 (NameIs) **] FELLOW ([**Doctor Last Name 12049**]) Phone:[**Telephone/Fax (1) 41**]
Date/Time:[**2165-1-31**] 1:00
Cardiology:
Provider: [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) 3302**], MD Phone: [**Telephone/Fax (1) 62**] Date/Time:
[**2164-11-23**] at 4:40pm. [**Hospital Ward Name 23**] Clinical Center, [**Location (un) **].
Completed by:[**2164-11-23**]
ICD9 Codes: 2724, 4019, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3823
} | Medical Text: Admission Date: [**2130-8-1**] Discharge Date: [**2130-8-11**]
Date of Birth: [**2065-12-19**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
"Left charcot foot"
Major Surgical or Invasive Procedure:
s/p left lower extremity charcot reconstruction
History of Present Illness:
64 y/o female patient with significant PMH for DM and atrial
fibrilation admitted to Podiatric Surgery service s/p L. LE
charcot reconstruction [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]. Patient states long-standing
history for left foot charcot deformity. Patient states her
surgery was detained [**1-26**] psoriasis on her foot in the surgical
site. Patient denies any recent changes in her PMH/[**Last Name (un) 1724**] of
recent. Patient currently denies any fevers, chills, nausea,
night-sweats or vomiting.
Past Medical History:
Afib - failed cardioversion
-HTN
-IDDM (II)
-Mitral Valve Prolapse
-Hypothyroidism
-Psoriasis
-Hypercholsterolemia
-Obesity
-Hx of Uterine CA
Social History:
Pt is retired. Lives in [**Location **], MA with her husband. 3
children all live nearby. NO smoking, ETOH or drugs illicit drug
use.
Family History:
Father lung cancer, mother 91 stroke.
Physical Exam:
Vitals: T 100.2, BP 119/82, HR 90-110, RR 20-30, 95% on 2l nc
Gen: awake, talkative, singing at times
HEENT: perrla, eomi, sclerae anicteric, op-clear, mmm
Neck: L IJ in place
CV: distant heart sounds, RRR, s1-s2 normal, no murmurs
appreciated.
Resp: Clear anteriorly.
Abd: + bs, obese, soft, non-tender
Ext: LLE under dressing from procedure, trace RLE edema, trace
DP pulse
Skin: scaling erythematous patches over palmar surfaces and
lateral aspect of R foot
Neuro: aao x 3, did not vote for [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2450**], CN 3-12 grossly
intact, decreased sensation in RLE (uncahged from her baseline)
Pertinent Results:
[**2130-8-1**] 01:58PM GLUCOSE-288* UREA N-18 CREAT-1.0 SODIUM-140
POTASSIUM-4.6 CHLORIDE-103 TOTAL CO2-23 ANION GAP-19
[**2130-8-1**] 01:58PM CALCIUM-8.8 PHOSPHATE-4.6* MAGNESIUM-1.8
[**2130-8-1**] 01:58PM WBC-13.3*# RBC-4.28 HGB-12.3 HCT-35.6* MCV-83
MCH-28.7 MCHC-34.6 RDW-15.0
[**2130-8-1**] 01:58PM PLT COUNT-184
[**2130-8-1**] 12:40PM TYPE-ART PO2-336* PCO2-39 PH-7.40 TOTAL
CO2-25 BASE XS-0 INTUBATED-INTUBATED VENT-CONTROLLED
[**2130-8-1**] 12:40PM GLUCOSE-241* LACTATE-4.5* NA+-136 K+-5.1
CL--104 TCO2-24
[**2130-8-1**] 12:40PM HGB-12.9 calcHCT-39
[**2130-8-1**] 12:40PM freeCa-1.14
[**2130-8-1**] 01:58PM BLOOD WBC-13.3*# RBC-4.28 Hgb-12.3 Hct-35.6*
MCV-83 MCH-28.7 MCHC-34.6 RDW-15.0 Plt Ct-184
[**2130-8-6**] 06:09AM BLOOD WBC-8.3 RBC-3.46* Hgb-10.0* Hct-29.1*
MCV-84 MCH-28.9 MCHC-34.3 RDW-15.2 Plt Ct-192
Brief Hospital Course:
Left Lower Extremity Charcot Reconstruction: Patient was
admitted to Podiatric Surgery service post-operatively. Patient
tolerated the procedure well. (Please see operative note for
details.) Patient was continued on Kefzol 1g q8h as prophylaxis
against any post-operative infection.
.
In summary, this is a 64 yo female with Hx of Afib,
hypothyroidism, HTN, obesity, and DM Type II - now PO D# 5 from
a triple arthrodesis of left foot via podiatry. While on the
podiatry service POD #1, patient developed hypotension down to
the 80/42. Her BP came back up with no intervention. This
episode prompted a transfer from podiatry to medicine. While on
the medicine service patient developed hypoxemia 89% on 5 L NC
(had been satting 96% on 3L NC immediately post-op)- sats went
up to 95% on NRB. Given increasing o2 requirement, history of
Afib on anticoagulation - stopped prior to surgery - there was a
concern for PE. Patient was sent for a CTA and lost her
peripheral access, so study could not performed at that time.
Patient required placement of a central line for access. When
ICU team arrived to place line, patient was very agitated with
sats around 90-91% on NRB, tachycardic and febrile. An emergent
femoral line was placed on the floor and patient was sent to
MICU.
.
Heparin gtt was started on arrival to unit given concern for PE.
While in unit patient remained hypoxic and ultimately required
intubation x 24 hours. CTA was performed which demonstrated
focal areas of consildation - most consistent with an aspiration
event - but no PE. LENIs were negative. ECHo on [**8-3**] concerning
for R heart strain. Patient remained hypotensive and required
levophed but patient was weaned off of in ~ 12 hours. She was
started on broad spectrum abx - vancomycin, levofloxacin, and
cefepime - for presumed sepsis. Blood cultures from [**8-3**]
returned positive for gram positive cocci in one bottle,
speciation revealed coag negative and was presumed to be
contaminant. On [**8-5**], levofloxacin was DCed - vanco/cefepime
continued. Although PE was not confirmed, patient was maintained
on the heparin gtt for anti-coagulation in the setting of known
a fib. Patient was also on an insulin gtt, however, has been
transitioned off to glargine w/ RISS. Mental status was back to
baseline when left the unit on HD#5. Blood Cultures from [**8-6**]
grew out coagulase negative staph and surveillance blood
cultures/central line catheter tip cultures were sent on day of
discharge. As patient remained afebrile and w/o signs of
systemic infection, it was determined that these culture results
could be followed up after she leaves the hospital and her
Antibiotics adjusted as needed.
.
Upon returning to the floor patient's mental status continued to
be stable. Her respiratory status remained stable. She
continued to require oxygen via nasal cannula, but was
progressively weaned down and on HD# 9 she was 95% on 2L. Her
Abx were changed on HD #5 to levaquin and flagyl for presumed
aspiration pneumonia. Pt did well and she will continue to
complete a 14 day course of antibiotics.
.
Upon returning to the floor, patient c/o new onset right foot
weakness/numbness. She was examined and found to have a drop
foot picture on the right. Neurology was consulted and CT of
Abd/Pelvis r/o compressive mass/bleed to lumbar plexus. EMG
recommended as outpatient and patient started on Neurontin and
should be increased to 1200mg TID. The most likely cause of her
paralysis is compressive neuropathy to peroneal nerve around the
fibular head from OR/ICU positioning. She is to continue PT and
F/U with neurology as outpatient.
.
Dibetes Mellitus: Patient usually takes 90U of Lantus qhs at
home. Patient was placed on 75U of Lantus qhs while an in-house
patient. Patient was also continued on HISS. Patient also
takes Glipizide 10 [**Hospital1 **], Metformin 500 [**Hospital1 **] as an additive oral
control for her blood sugars.
.
Atrial Fibrilation: Pt was started on Heparin drip in the unit
for presumed PE. She was continued on Heparin and bridged to
therapeutic on her Coumadin. Pt was in and out of afib with a
stable ventricular rate throughout her floor stay. On HD#6 her
telemetry was D/C and her vitals remained stable for the rest of
her hospital course. On HD#7 INR was 2.0 and Heparin Drip was
D/C. On discharge her INR was 2.4
.
She was D/C to acute rehab to participate in PT/OT. Her family
will likely make decisions regarding her future rehabiltation
status as they are actively involved. Pt is to follow-up with
her PCP [**Last Name (NamePattern4) **] [**12-26**] weeks. Pt should also have blood culture and
catheter tip culture from [**8-11**] followed up via the staff
physicians at her acute rehabilitation facility.
Medications on Admission:
ASA 81 qd
Glipizide 10 [**Hospital1 **]
Metformin 500 [**Hospital1 **]
Lisinopril 20 qd
Synthroid 100 qd
Digoxin .25 qd
Coumadin 5mg qd
Lipitor 20 qd
Metoprolol 50 [**Hospital1 **]
Magnesium Oxide 400 mg PO BID
Amitriptyline 10 qhs
Lantus 90U
Novalog
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet 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. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 6 days: Please give separately from
Magnesium.
Disp:*6 Tablet(s)* Refills:*0*
11. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 6 days.
Disp:*18 Tablet(s)* Refills:*0*
12. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS):
Please give separately from Levaquin and synthroid.
13. Lantus 100 unit/mL Cartridge Sig: Seventy (70) units
Subcutaneous at bedtime.
14. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*0*
15. Warfarin 2 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime): You should have your INR level checked with PCP/[**Hospital1 1501**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Left Lower extremity Charcot deformity
Pneumonia
Discharge Condition:
Good
Discharge Instructions:
You should know that Blood Cultures from [**2130-8-6**] grew Coagulase
negative Staphylococcus. We have sent repeat blood cultures and
a culture of the catheter tip from your central line. You
should make sure that the physicians and staff at your
rehabilitation facility follow-up the results of these studies
with [**Hospital1 **]. We will attempt to call and alert
them to any pertinent results.
Please keep all your doctors [**Name5 (PTitle) 4314**]. Please make sure you
follow-up with Dr. [**Last Name (STitle) **] in the [**Hospital **] Clinic. Please
continue to take all your medications that you were taking prior
to your hopitalization. You have been prescribed pain
medication. Please take this as needed.
Please seek medical attention if you experience any fevers,
chills, vomiting, nausea, shortness of breath, coughing up blood
or night sweats. Also if you notice any wound redness, swelling
or foul-smelling drainage/discharge.
Followup Instructions:
Please call [**Telephone/Fax (1) **] to schedule a follow-up appointment
with Dr. [**Last Name (STitle) **] in [**Hospital **] Clinic 7-10 days from hospital
discharge.
Please follow-up with your primary care doctor in [**12-26**] weeks.
Please call and schedule an appointment.
Please have the staff physician at your rehabilitation facility
follow-up the results of your blood and catheter tip cultures
from [**2130-8-11**] done here at [**Hospital1 69**].
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
Completed by:[**2130-8-11**]
ICD9 Codes: 0389, 5070, 4240, 2449, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3824
} | Medical Text: Admission Date: [**2103-7-11**] Discharge Date: [**2103-7-19**]
Date of Birth: [**2032-12-26**] Sex: F
Service: MEDICINE
Allergies:
Naprosyn
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
GI Bleed
Major Surgical or Invasive Procedure:
1. Mesenteric Angiography.
2. Enteroscopy w/ Cautery and Tattoo.
History of Present Illness:
This a 71 year old female with multiple medical problems
including recurrent GI bleed, coronary artery disease,
hypertension, diabetes mellitus type 2, gastritis,
hypercholesterolemia, chronic renal insufficiency and depression
who presents to the ED after finding her blood pressure to be
84/54 at home on the day of admission. Patient reports having
worsening dyspnea on exertion, dark stools, dizziness with
standing and chest pressure with walking x 3-4 days. Patient
has a history of upper GI bleed secondary to gastritis ([**4-27**])
and a negative workup for a duodenal neuro-endocrine tumor.
Most recent hospitalization for bleeding was secondary to small
bowel AVMs found on EGD. Denies changes in diet, fever/chills,
abdominal pain, recent alcohol consumption, nausea/vomitting or
recent trauma. Patient has been taking a baby ASA daily and iron
pills three times daily.
.
In the emergency room, the patient was found to have a Hct of
15.6 and HR or 61. She received intravenous fluids and 40 mg of
intravenous protonix. A nasogastric lavage was performed which
did not reveal an active bleed but also failed to produce bile.
Patient was tranfused two units of PRBCs and her Hct
subsequently rose to 23. GI was consulted and the patient was
admitted to medicine for further observation.
Past Medical History:
1. Gastritis
2. History of upper gastrointestinal bleed
3. Duodenal neural endocrine tumor, negative workup;
4. Coronary artery disease, status post percutaneous
transluminal coronary angioplasty in [**2095**]
5. Hypertension
6. Hypercholesterolemia
7. Type 2 diabetes
8. Chronic renal insufficiency, baseline 1.5 to 1.7
9. osteoarthritis
10. History of sarcoid, untreated
11. History of migraines
12. Status post appendectomy
13. Total abdominal hysterectomy/bilateral salpingo-oophorectomy
14. Status post parathyroid adenoma resection
15. Status post left wrist fusion
16. Status post small bowel resection in [**2077**]
17. History of small bowel bleed, s/p electrocauterization of
AVMs `04
18. History of hospitalization for intermittent small bowel
obstruction
Social History:
Former smoker, quit greater than 30 years
ago. Alcohol use, occasionally.
Family History:
Non-contributory
Physical Exam:
Vital signs on admission
afebrile, heart rate 68, pressure 155/64, breathing at 15, % on
room air. General: Alert and oriented, pleasant, no dyspnea and
no acute distress.
Head, eyes, ears, nose and throat, moist mucous
membranes,oropharynx clear. Lungs clear to auscultation
bilaterally.
Cardiovascular, regular rate with a II/VI systolic ejection
murmur at base radiating to carotids. No carotid bruits
auscultated. No jugulovenous pressure.
Abdominal examination, soft, nontender,nondistended. Hypoactive
bowel sounds.
Extremities, no cyanosis, clubbing or edema. Alert and oriented
times three.
No cranial nerve deficits.
Pertinent Results:
[**2103-7-11**] 02:30AM BLOOD WBC-4.3 RBC-1.58*# Hgb-4.6*# Hct-15.6*#
MCV-99*# MCH-29.4# MCHC-29.7* RDW-21.3* Plt Ct-208
[**2103-7-11**] 02:30AM BLOOD Neuts-76.5* Bands-0 Lymphs-17.1*
Monos-5.9 Eos-0.4 Baso-0.2
[**2103-7-11**] 02:30AM BLOOD Hypochr-3+ Anisocy-2+ Poiklo-1+
Macrocy-3+ Microcy-NORMAL Polychr-1+ Schisto-1+ Stipple-1+ Tear
Dr[**Last Name (STitle) **]1+
[**2103-7-11**] 02:30AM BLOOD PT-12.6 PTT-24.3 INR(PT)-1.0
[**2103-7-11**] 02:30AM BLOOD Glucose-192* UreaN-91* Creat-2.5* Na-138
K-4.1 Cl-103 HCO3-24 AnGap-15
[**2103-7-11**] 02:30AM BLOOD ALT-12 AST-42* LD(LDH)-414* CK(CPK)-51
AlkPhos-53 Amylase-121* TotBili-0.3
[**2103-7-11**] 02:30AM BLOOD Lipase-171*
[**2103-7-11**] 02:30AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2103-7-11**] 02:30AM BLOOD Albumin-3.5 Calcium-9.5 Phos-3.2 Mg-2.2
Cholest-113
[**2103-7-11**] 02:30AM BLOOD VitB12-204* Folate-18.8
[**2103-7-11**] 02:30AM BLOOD Triglyc-191* HDL-28 CHOL/HD-4.0
LDLcalc-47
[**2103-7-11**] 02:30AM BLOOD TSH-2.1
[**2103-7-11**] 03:55AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.009
[**2103-7-11**] 03:55AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
.
EKG [**2103-7-11**]
Sinus rhythm, without diagnostic abnormality. Compared to the
previous tracing of [**2103-1-18**] T wave inversions are no longer
present.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
68 176 102 428/444.85 66 -1 95
.
C1894 INT.SHTH NOT/GUID,EP,NONLASER [**2103-7-16**] 7:12 AM
Reason: embolize site of ooze in proximal jejenum.
IMPRESSION: Selective arteriography of the superior mesenteric
artery and jejunal branches demonstrated no evidence of
arteriovenous malformation or active hemorrhage.
.
ECHO [**2103-7-17**]
The left atrium is mildly dilated. There is severe 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. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. The left
ventricular inflow pattern suggests impaired relaxation. There
is moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
Brief Hospital Course:
A/P: 71 year old female with multiple medical problems who
presented with GI bleed.
1. GIB: A push enteroscopy was performed that revealed melena in
the duodenum and fresh blood in the proximal jejunum 80-90 cm
from teeth. Copious irrigation and epinephrine injection failed
to halt the bleeding. On the floor her Hct dropped to 16 from 23
and the pt became tachycardic, so she was transferred to the
MICU.
.
In the MICU, patient received 4U and went from Hct of ~15 to low
30s. She received 1 more unit given cardiac status to bring
Hct>30. Upon transfer to MICU IR consulted for embolization,
however pt was unstable with MI. Cardiology saw patient on [**7-14**]
felt CEs were trending downward and recommended IR embolization
to stop bleed in proximal jejunum. Patient was subsequently
transferred to the medicine floor.
IR was unable to embolize the source of bleed and so patient
underwent repeat endoscopy with successful cauterization of the
site of bleed. The site was also tattooed. Patient received an
additional unit of PRBCs on the floor and her hematocrit
remained stable and she also was continued on protonix [**Hospital1 **].
.
2. NSTEMI- She developed chest pain and EKG showed ST depression
in V4-V6. Cardiac troponin peaked at 2.5. NSTEMI was likely
secdonary to demand ischemia with tachycardia in setting of her
GI bleed. She was started on BB. Plaxix and asapirin were held
given history of GI bleed. Cardiology saw patient on [**7-14**] felt
CEs were trending downward and recommended IR embolization to
stop bleed in proximal jejunum. A repeat ECHO on [**2103-7-17**] was
mainly unchanged aside from increased left ventricular
hypertrophy. Patient had remained chest pain free from the time
of tranfer from the MICU to the day of discharge.
.
3.HTN- On the floor, blood pressure was not as well controlled
off nitro drip and beta blocker. Patient was transitioned from
PO nitrates and hydralazine to beta blocker and [**Last Name (un) **].
.
4. Acute on CRI- Cr 2.5 on admission from baseline Cr 1.6-1.9.
Creaine was within baseline at 1.7 at time of discharge.
.
5. Hypernatremia- Was thought to be likely secondary to normal
saline boluses and free water loss. PO intake was encouraged
was resolved by time of discharge.
.
6. Anemia- patient was found to have iron deficiency anemia and
vitamin B12 deficient. Patient was started on vitamin B12
1000mcg oral supplementation QD.
6.PPX-pneumoboots, PPI [**Hospital1 **]
.
7.Code- full
Medications on Admission:
1) apirin 81mg QD
2) lipitor 10mg QD
3) [**Doctor First Name 130**] 60mg [**Hospital1 **]
4) celexa 40mg QD
5) clonidine 200mcg [**Hospital1 **]
6) cozaar 50mg QD
7) FeSO4 300mg TID
8) Flonase 50mcg one spray each nostril [**Hospital1 **]
9) Lasix 40mg QAM
10) Glipizide 5mg TID
11) Hydralazine 50mg 1.5 tabs QID
12) Lasix 20mg QHS
13) Nitrostat 0.3mg as needed
14) Norvasc 10mg QD
15) Protonix 40mg [**Hospital1 **]
Discharge Medications:
1. Losartan Potassium 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*120 Tablet, Chewable(s)* Refills:*2*
3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO once a day.
Disp:*120 Tablet(s)* Refills:*2*
4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Lipitor 10 mg Tablet Sig: One (1) Tablet PO once a day.
6. Glipizide 10 mg Tab, Sust Release Osmotic Push Sig: One (1)
Tab, Sust Release Osmotic Push PO once a day.
Disp:*30 Tab, Sust Release Osmotic Push(s)* Refills:*2*
7. Atenolol 25 mg Tablet Sig: Three (3) Tablet PO once a day.
Disp:*120 Tablet(s)* Refills:*2*
8. Fe-Tabs 325 (65) mg Tablet Sig: One (1) Tablet PO once a day.
9. Citalopram Hydrobromide 40 mg Tablet Sig: One (1) Tablet PO
once a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Principal:
1. Gastrointestinal bleed.
2. Non-ST elevation myocardial infarcation.
3. Acute Renal Failure.
4. Blood Loss Anemia.
5. Left Lower Lobe Pneumonia.
6. Vitamin B12 Deficiency.
Secondary:
1. Chronic Renal Insufficiency.
2. Hypertension.
3. Sarcoidosis.
4. Hypercholesterolemia.
5. Osteoarthritis.
6. Migraines.
7. Upper GI Bleed.
8. Duodenal Neuroendocrine Tumor.
9. CAD - Angioplasty Lcx [**10/2096**].
10. Diabetes Mellitus Type II.
11. Iron Deficiency Anemia.
13. s/p Parathryoid Adenoma Resection.
14. s/p Appendectomy.
15. s/p Small bowel resection.
16. s/p TAH-BSO.
Discharge Condition:
Good
Discharge Instructions:
Please take the medications listed below until you follow-up
with your primary care physician. [**Name10 (NameIs) 357**] do not resume your
outpatient medications unless they are listed below:
*1) Celexa (Citalopram Hydrobromide) 40 mg One Tablet by mouth
DAILY
2) Losartan Potassium (Cozaar) 50 mg One Tablet by mouth DAILY
*3) Calcium Carbonate 500 mg Chewable One (1) Tablet Chewable
three times daily W/MEALS
*4) Cholecalciferol (Vitamin D3) 400 unit Two Tablets by motuh
daily
*5) Pantoprazole Sodium (Protonix) 40 mg Delayed Release One (1)
Tablet by mouth daily
6) Lipitor 10 mg One (1) Tablet by mouth daily
*7) Glipizide 10 mg, Sust Release Osmotic Push One (1) Tab by
mouth daily
*8) Atenolol 25 mg Three (3) Tablet all together by mouth daily
9) Fe-Tabs (Iron) 325 (65) mg One (1) Tablet by mouth daily
*signify new doses for medications and prescriptions attached to
this discharge summary
[] Please call your PCP or return to the emergency room if you
experience chest pain, nausea or vomitting, shortness of breath
or any othter worrying symptoms.
Followup Instructions:
[] Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 14839**], MD Where: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:Tues [**2103-7-24**]
9:00am
[] Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD GASTROENTEROLOGIST Where: [**Hospital Unit Name **] [**Location (un) **] SUITE 8E Phone:[**Pager number **]=[**Telephone/Fax (1) **] Date/Time: [**2103-8-1**]
1:15pm
[] Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD CARDIOLOGY Where: [**Hospital 273**] CARDIOLOGY Phone:[**Telephone/Fax (1) 62**] Date/Time: [**2103-8-21**] 10:30am
Completed by:[**2103-9-1**]
ICD9 Codes: 5789, 2851, 486, 5849, 2760, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3825
} | Medical Text: Admission Date: [**2201-2-23**] Discharge Date: [**2201-3-5**]
Date of Birth: Sex: M
Service: SURGICAL
HISTORY OF PRESENT ILLNESS: This 73 year old gentleman is
admitted with a sigmoid carcinoma. The patient had a
colectomy in [**2200-5-23**], for a splenic flexure carcinoma.
At that time, he required a stay in the Intensive Care Unit
for what was thought to be perhaps alcohol withdrawal. At
that time, he had a small polyp in his sigmoid which had not
been resected. On follow-up colonoscopy, this area had
degenerated into a carcinoma which was not amenable to
endoscopic resection. He now presents for resection.
PAST MEDICAL HISTORY:
1. Diabetes mellitus.
2. Hypertension.
3. Above mentioned history of alcohol use.
PAST SURGICAL HISTORY:
1. The above-mentioned left colectomy.
2. Tonsillectomy.
3. Repair of umbilical hernia.
REVIEW OF SYSTEMS: Otherwise negative.
PHYSICAL EXAMINATION: Physical examination, this is a well
developed, quite overweight gentleman. Head, Eyes, Ears,
Nose & Throat were normal. The neck was notable for poor
extension. Chest was clear with distant breath sounds. The
abdomen was obese, with a midline scar with at least two
areas of herniation. There were no masses. The extremities
were without cyanosis, clubbing or edema. He was
neurologically intact.
LABORATORY: Admission labs were hematocrit 40.
HOSPITAL COURSE: The patient admitted with the diagnosis of
colon carcinoma, for sigmoid colectomy following a prior
resection. On the date of admission, he underwent a sigmoid
colectomy. Operation was somewhat difficult due to
adhesions, but was otherwise uncomplicated. Postoperatively,
the patient initially did quite well. He was closely
monitored with the CIWA Scale on the floor. Hematocrit was
32.3 and electrolytes were normal.
He initially seemed to be quite comfortable and was afebrile.
He was seen to be comfortable and talkative. He, however,
had a few episodes of agitation. However, on [**2201-2-26**], he
was noted to be more agitated with initial hypertension. He
had increasing doses of Lopressor as well as Clonidine and
Ativan in addition to some anxiolytics. He appeared to be
diaphoretic and tachycardic. He also was showing signs of
some volume depletion.
The patient was then transferred to Surgical Intensive Care
Unit where he had respiratory distress and was given
intravenous resuscitation. He required intubation and a
Foley catheter was placed with some trauma. Creatinine level
noted to be somewhat elevated. The working diagnosis at this
time was that the patient had alcohol withdrawal originally,
but then decompensated. He was begun on vasopressors due to
decompensation of his hemodynamics. After some
resuscitation, the patient underwent a CT scan which showed
no evidence of extravasation of contrast. Changes seen in
the abdomen were consistent with his postoperative state.
The patient was seen in consultation by the Vascular Surgery
Service because of intense mottling of the periphery which
was presumed secondary to high doses of vasopressors,
however, he continued to have significant mottling of his
legs. He underwent an exploration of the right lower
extremity and right femoral embolectomy and fasciotomy to the
lower leg due to a poor blood flow. This was done on
[**2201-2-28**]. He then developed increasing oliguria with a
rising BUN and creatinine associated with a very elevated CPK
of 28,000, which improved after his fasciotomies. He then
seemed to stabilize to some degree with his acute renal
failure as well as question of septic picture. He was
continued on antibiotics.
A Quinton catheter was placed and the patient was dialyzed
after some period of a bit more stability. The patient
developed increasing amounts of instability and was unable to
be dialyzed. He was thought perhaps to have Clostridium
difficile and was continued on Flagyl as well as other
antibiotics. He then became more unstable and a CT scan was
performed, which showed a pelvic abscess consistent with an
anastomotic leak. This was drained radiologically when the
patient was quite unstable and had an elevated coagulation
profile. This was despite aggressive attempts at repleting
coagulation parameters.
This drainage was attempted because the patient was in florid
sepsis and it seemed to be the only alternative to the
potential of saving his life. After the intervention,
originally some bloody pus type fluid was removed, however,
then he began to have increasing amounts of bleeding from the
area. He became even more hemodynamically unstable. Because
of persistent septic picture and the inability to keep his
blood pressure up despite maximum resuscitation, the patient
was made comfort measures and allowed to expire.
The presumptive scenario was that the patient developed some
alcohol withdrawal and decompensation leading to a low-flow
state, which required vasopressors. This caused the
difficulties with his legs and elevated CPKs and thrombosis
as well as a low flow state to the bowel which then
progressed to a delayed anastomotic dehiscence with sepsis.
FINAL DIAGNOSIS:
1. Carcinoma of the colon.
2. Sepsis.
3. Delayed anastomotic dehiscence secondary to low flow.
4. Diabetes mellitus.
5. Hypertension.
PROCEDURE: Surgical procedures were:
1. Sigmoid colectomy [**2201-2-23**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 6066**]
Dictated By:[**Last Name (NamePattern4) 9706**]
MEDQUIST36
D: [**2201-4-20**] 11:38
T: [**2201-4-21**] 10:50
JOB#: [**Job Number 33622**]
ICD9 Codes: 0389, 5849, 2762 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3826
} | Medical Text: Admission Date: [**2172-5-29**] Discharge Date: [**2172-6-4**]
Service: CARDIAC CARE
HISTORY OF PRESENT ILLNESS: The patient is an 80 year-old
male who began to have a tired feeling in his chest on the
night before admission. It began around midnight and was
accompanied by belching. When EMS arrived the patient was
alert and oriented times three and in no acute distress.
They assessed the patient as hypertensive and his blood
oxygenation levels were 96% on room air, electrocardiogram
changes showed ST elevations in leads 2, 3 and AVF. On the
way to the hospital the patient became unresponsive, went
into ventricular tachycardia, which subsequently went into
ventricular fibrillation. The ambulance was stopped and the
patient was shocked at 200 jewels. The patient subsequently
went into asystole and then spontaneously converted into
sinus rhythm with occasional runs of ventricular tachycardia.
The patient regained consciousness. The patient was brought
to [**Hospital3 3583**]. There was a question of a possible
seizure at [**Hospital3 3583**]. Treatment with Dilantin was
begun. The patient was intubated. Lidocaine and nitro was
given. The patient arrived at [**Hospital1 188**] via helicopter, intubated, normotensive and acidotic.
In the catheterization laboratory the patient had a mid left
anterior descending coronary artery 90% stenosis. After
stenting the lesion dropped to 0% occlusion. The proximal
left anterior descending coronary artery was 80% stenosed.
After stenting the lesion dropped to 0% stenosed. The origin
of the left anterior descending coronary artery was found to
be 40% stenosed and that was left alone. TIMI three flow was
achieved. In addition, the left circumflex artery had a 60%
large obtuse marginal stenoses. The ramus had large mild
irregularities. The right coronary artery had a 70% proximal
right stenosis right after the conus. Two stents were placed
in the left anterior descending coronary artery. His right
heart catheterization data, his right atrium had pressures of
21/18, right ventricle had pressures of 45/14. His pulmonary
artery had pressures of 46/26 and his wedge pressure was 26.
PHYSICAL EXAMINATION: On physical examination on admission
the patient's blood pressure was 139/74, heart rate 87,
respirations 19. The patient was sating 96% on the
ventilation. The pulmonary arterial pressures at that time
were 39/18 with a mean of 23. His cardiac output was 5.9 and
his index was 2.94. In general, the patient was lying in bed
sedated on propofol and intubated. His pupils were equal,
round and reactive to light. His neck had no JVD. There was
on lymphadenopathy. Cardiac examination demonstrated a
normal S1 and S2 and a 2 out of 6 holosystolic murmur that
radiated to the axilla. His chest examination showed some
rales at the bases. Abdominal examination demonstrated
obesity, nontender and bowel sounds were hypoactive. His
extremities were warm. There was no edema and his dorsalis
pedis pulses were 2+.
LABORATORY: White blood cell count of 20, creatinine 1.4,
CPK 1383, troponin of 9.4 and an MB index of 21.5.
His chest x-ray demonstrated enlarged and elongated thoracic
aorta, diffuse pulmonary edema in a mid to apical portions of
the lung. His echocardiogram demonstrated a normal left
atrium, normal right atrium, mild symmetric left ventricular
hypertrophy, left ventricular systolic function was mildly
decreased. Ejection fractions estimated to be 35%. The
mitral valve was found to have 1+ regurgitation. The aortic
valve had mild regurgitation. The anterior septal wall was
found to be hypokinetic. The anterior free wall was also
hypokinetic. The apex was found to be akinetic.
HOSPITAL COURSE: On hospital day two the patient experienced
worsening of his electrocardiogram changes and went back to
the catheterization laboratory and had an 80% lesion in the
proximal left anterior descending coronary artery stented.
Immediately following the procedure the patient was placed on
an intraaortic balloon pump. The patient came back to the
Coronary Care Unit floor intubated. On hospital day three
the patient spiked a temperature to 101.8. Flagyl and
Levaquin was started for a presumed aspiration pneumonia. By
hospital day four the patient was extubated. Aortic balloon
pump was removed and he was transferred to the regular floor.
By hospital day five the day of discharge the patient had an
occasional low grade fever. The medications that he was
being treated with included Plavix, Fluvastatin, aspirin,
Metoprolol, Lisinopril and prn doses of Lasix.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DIAGNOSIS:
Acute myocardial infarction.
MEDICATIONS ON DISCHARGE:
1. Plavix 75 mg po q.d.
2. Fluvastatin 80 mg po q.d.
3. Flagyl 500 mg po q 8 hours times two more days.
4. Levofloxacin 500 mg po q 24 hours times two more days.
5. Aspirin 325 mg po q.d.
6. Metoprolol 75 mg po t.i.d.
7. Haldol 2 mg po t.i.d.
8. Famotidine 20 mg po t.i.d.
9. Furosemide 40 mg po q.d.
10. Lisinopril 40 mg po b.i.d.
FOLLOW UP PLANS: The patient is to follow up with his
primary care physician within one week. The name of the
rehab facility that the patient is being transferred to is
[**Hospital1 **].
DR.[**Last Name (STitle) **],[**First Name3 (LF) 610**] 12-[**Doctor First Name **]
Dictated By:[**Last Name (NamePattern1) 51191**]
MEDQUIST36
D: [**2172-6-4**] 12:21
T: [**2172-6-4**] 12:37
JOB#: [**Job Number 51192**]
ICD9 Codes: 4271, 4280, 2762, 5070 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3827
} | Medical Text: Admission Date: [**2139-7-9**] Discharge Date: [**2139-7-29**]
Date of Birth: [**2057-3-18**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
FEVERS, WEAKNESS
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
82M with history of HTN, HL, BPH and prior stroke, who initially
presented to an OSH on [**2139-7-3**] with 2-3 day history of fevers to
101, chills, and malaise. Patient reports that over the several
days preceding his admission, he felt increasingly fatigued and
weak. Had poor appetite and became so weak he had difficulty
walking. Presented to [**Hospital 1562**] Hospital for evaluation. At OSH,
he was admitted with presumed sepsis of unclear etiology,
pan-cultured and empirically started on ceftriaxone. Was noted
to have a mild transaminitis and underwent RUQ ultrasound, which
showed fatty infiltration of the liver. CXR in ED did not show
PNA, and there was no evidence of a UTI. He continued to have
fevers to 101.9, and antibiotics were broadened to vanc/zosyn.
Given L knee pain and swelling, Ortho consulted and patient
underwent MRI of L knee and arthrocentesis on [**7-7**]. Synovial
fluid w/4182 WBCs, 6000 RBCs, no crystals. Felt unlikely to be
septic joint. ID was consulted, and given concern for tick-borne
illness, patient started on azithro/atovaquone and doxycycline.
Zosyn d/c'd, vanco continued. On [**7-9**],
azithro/atovaquone/doxy/vanc d/c'd and patient started on
ertapenem. Testing for Lyme, Babesia, and anaplasma had all
returned negative, and blood cultures remained negative. The
patient had no focal symptoms, including no CP, SOB, cough,
abdominal pain, vomiting, diarrhea, or dysuria. He remained
hemodynamically stable.
However, he did develop hypoxia, which was attributed to acute
on chronic dCHF in setting of iatrogenic volume overload. Noted
to have bilateral pleural effusions. He was started on lasix 20
mg IV BID, with decrease in O2 requirement.
He underwent a CT torso on [**7-8**], to evaluate for possible
abscess or malignancy given unclear source of fever. No abscess
or pathologic lymphadenopathy noted. Given question of possible
cholecystitis on imaging, General Surgery was consulted. Urology
was consulted given findings of non-obstructing nephrolithiasis
and ureterolithiasis. Also of note, patient's WBC rose
throughout his hospital course, from 13 on admission to as high
as 40.5 on [**7-8**]. Heme/Onc consulted, but as patient's family was
requesting transfer to a tertiary care center, the consultation
was put on hold. Plan was to stop antibiotics and pursue further
work-up for non-infectious causes of fever at [**Hospital1 18**]. Of note,
[**Doctor First Name **] came back positive at 1:80.
On arrival to [**Hospital1 18**], he reports ongoing fatigue but is otherwise
without complaints. He recently returned to the area from
[**State 108**], but has otherwise not traveled recently. No sick
contacts. [**Name (NI) **] insect or tick bites. Had had mild nausea which has
since resolved, and he did not have any vomiting. Also reports
several episodes of loose stools, non-bloody.
REVIEW OF SYSTEMS:
Denies night sweats, weight loss, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, vomiting, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria, or myalgias. No
arthralgias other than left knee pain as above. No rash.
Past Medical History:
HTN
HL
BPH
Prior stroke, minimal right sided weakness
Osteoarthritis
s/p cataract surgery
s/p hernia repair
s/p kidney surgery for nephrolithiasis
Social History:
Married, lives with wife. Non-[**Name2 (NI) 1818**]. No alcohol or illicit drug
use. Retired, previously worked in public relations.
Family History:
No CAD, DM, or cancer. No family history of autoimmune disease
or rheumatologic diseases.
Physical Exam:
Admission physical exam:
VS: 98.2 113/60 82 20 95% 3L
GENERAL: elderly male, fatigued appearing but alert, oriented
x3, NAD
HEENT: NC/AT, right pupil slightly larger than left, both
reactive to light, EOMI, sclerae anicteric, dry mucous
membranes, OP clear
NECK: supple, JVD to earlobe
LYMPH: no cervical LAD, subcentimenter non-tender lymph node in
left supraclavicular area, no axillary adenopathy, no inguinal
adenopathy
LUNGS: faint bibasilar rales, no wheezing or rhonchi, good air
movement, respirations unlabored, no accessory muscle use
HEART: RRR, normal S1-S2, II/VI systolic murmur heard throughout
precordium, loudest at LLSB, radiating to carotids
ABDOMEN: normoactive bowel sounds, soft, slightly distended,
non-tender, no organomegaly, no guarding or rebound tenderness
EXTREMITIES: warm, well-perfused, L ankle more edematous
compared to R, [**11-17**]+ edema of lower legs bilaterally, 2+
peripheral pulses
MSK: left knee with mild soft tissue edema compared to right, no
appreciable joint effusion, no overlying warmth or erythema,
mild tenderness to palpation over medial joint line
SKIN: venous stasis changes, no jaundice, no petechiae
NEURO: CNs II-XII grossly intact, muscle strength 4+/5 upper
extremities, 3+/5 lower extremities, slight tremor of hands
bilaterally
Discharge Physical Exam:
GENERAL: elderly male, fatigued appearing, AAOx3, NAD
HEENT: NC/AT, right pupil slightly larger than left, both
reactive to light, EOMI, sclerae anicteric, dryMM, OP clear
NECK: supple, JVD elevated to angle of the jaw
LYMPH: no cervical LAD
LUNGS: faint bibasilar crackles, decreased breath sounds at the
bases, no wheezing or rhonchi, good air movement, respirations
unlabored
HEART: RRR, normal S1-S2, II/IV diastolic murmur, loudest at
LLSB, nonradiating
ABDOMEN: normoactive bowel sounds, soft, slightly distended,
non-tender, no organomegaly, no guarding or rebound tenderness,
flex-seal in place draining melanotic stool
EXTREMITIES: warm, well-perfused, bilateral LE edema to the
thigh, bilateral UE edema in the hands, 2+ peripheral pulses
SKIN: venous stasis changes, no jaundice, no petechiae,
hemorrhagic appearing pressure ulcer on right heel intact skin
overlying
NEURO: CNs II-XII grossly intact, muscle strength 4+/5 upper
extremities, 4+/5 lower extremities
Pertinent Results:
ADMISSION:
[**2139-7-10**] 12:27AM BLOOD WBC-37.9* RBC-3.13* Hgb-8.9* Hct-27.5*
MCV-88 MCH-28.5 MCHC-32.4 RDW-14.2 Plt Ct-219
[**2139-7-10**] 12:27AM BLOOD Neuts-93.5* Lymphs-5.2* Monos-1.2* Eos-0
Baso-0.1
[**2139-7-10**] 12:27AM BLOOD PT-14.0* PTT-32.8 INR(PT)-1.3*
[**2139-7-10**] 06:30AM BLOOD ESR-135*
[**2139-7-10**] 12:27AM BLOOD Glucose-112* UreaN-38* Creat-1.2 Na-150*
K-3.9 Cl-116* HCO3-21* AnGap-17
[**2139-7-10**] 12:27AM BLOOD ALT-30 AST-19 LD(LDH)-277* AlkPhos-170*
TotBili-1.1
[**2139-7-10**] 12:27AM BLOOD Calcium-8.6 Phos-2.5* Mg-2.3
[**2139-7-10**] 06:30AM BLOOD Albumin-3.0* Iron-22*
[**2139-7-10**] 06:30AM BLOOD calTIBC-185* VitB12-909* Ferritn-561*
TRF-142*
[**2139-7-10**] 06:30AM BLOOD CRP-219.7*
[**2139-7-10**] 07:58AM BLOOD Lactate-2.4*
[**2139-7-10**] 02:43PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.013
[**2139-7-10**] 02:43PM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2139-7-10**] 02:43PM URINE RBC-39* WBC-1 Bacteri-FEW Yeast-NONE
Epi-0
[**2139-7-10**] 02:43PM URINE Mucous-OCC
Discharge labs:
[**2139-7-29**] 05:50AM BLOOD WBC-9.7 RBC-3.13* Hgb-9.5* Hct-28.7*
MCV-91 MCH-30.4 MCHC-33.3 RDW-19.3* Plt Ct-239
[**2139-7-29**] 05:50AM BLOOD PT-12.4 PTT-34.0 INR(PT)-1.1
[**2139-7-29**] 05:50AM BLOOD Glucose-118* UreaN-13 Creat-0.7 Na-134
K-3.6 Cl-98 HCO3-29 AnGap-11
[**2139-7-29**] 05:50AM BLOOD Calcium-7.2* Phos-2.4* Mg-1.9
Other relavent labs:
[**2139-7-10**] 07:58AM BLOOD Lactate-2.4*
[**2139-7-10**] 06:30AM BLOOD b2micro-4.1*
[**2139-7-10**] 06:30AM BLOOD CRP-219.7*
[**2139-7-10**] 06:30AM BLOOD calTIBC-185* VitB12-909* Ferritn-561*
TRF-142*
[**2139-7-10**] 06:30AM BLOOD ESR-135*
[**2139-7-14**] 04:15PM BLOOD CK-MB-1 cTropnT-<0.01
[**2139-7-16**] 06:30AM BLOOD Hapto-311*
[**2139-7-16**] 06:30AM BLOOD Ret Aut-3.1
[**2139-7-16**] 06:30AM BLOOD PEP-NO SPECIFI b2micro-4.0* IgG-759
IgA-345 IgM-62
[**2139-7-17**] 06:15AM BLOOD PSA-6.9*
[**2139-7-18**] 06:45AM BLOOD Ret Aut-2.9
[**2139-7-18**] 06:45AM BLOOD HIV Ab-NEGATIVE
[**2139-7-19**] 07:05AM BLOOD ESR-105*
[**2139-7-21**] 04:40AM BLOOD freeCa-1.00*
Studies:
[**2139-7-27**] LUE U/S: IMPRESSION: No left upper extremity DVT.
[**2139-7-20**] EGD: Ulcer in the stomach body on greater curve
(endoclip) Blood in the fundus. There was a copious amount of
old blood in the stomach so other bleeding sites could of been
hidden under the blood which could not be completely cleaned.
Otherwise normal EGD to third part of the duodenum.
[**7-17**]: B/l LENI: no DVT
[**7-17**]: b/l upper extremity US:
1. No evidence of deep vein thrombosis either right or left
upper extremity.
2. Clot in the medial right cephalic vein, a superficial vein,
consistent with a superficial thrombophlebitis.
[**7-16**] CXR: As compared to the previous radiograph, there is a
minimal improvement of the atelectatic changes at the left lung
base. Moreover, the plate-like atelectasis at the left lung base
is slightly improved. No newly occurred parenchymal opacities
or mediastinal or hilar abnormalities. The size of the heart
continues to be at the upper range of normal. No pulmonary
edema is seen.
[**7-15**] CXR post thoracentesis: (wet read) no pneumothorax. left
basilar linear atelectasis, unchanged.
[**7-14**] CXR: Stable chest findings, moderate cardiac enlargement,
bilateral small amount of pleural effusions, stable appearance
of previously described parenchymal infiltrates. Stable
appearance during the four days' examination interval raises the
possibility of chronic scar formations.
[**7-14**] KUB: Unremarkable bowel gas pattern with no evidence of
obstruction or Preliminary Reporttoxic megacolon.
[**7-14**] CT torso:
1. Since [**2139-7-8**], small bilateral pleural effusions are larger
with adjacent enhancing atelectasis. Supervening infection
cannot be entirely excluded. The aerated lungs are clear.
2. Small ascites, diffuse body wall edema and small pericardial
effusion and pleural effusions are all increased and may be
related to volume overload.
3. No evidence of infection in the abdomen or pelvis.
4. Coronary artery and aortic valve calcifications of unknown
hemodynamic significance.
5. Pulmonary artery enlargement suggests underlying pulmonary
arterial hypertension.
[**2139-7-10**] TTE: IMPRESSION: Suboptimal image quality. No
vegetations seen.
[**2139-7-10**] CXR: Multifocal pneumonia with foci in the left lung
base and the right mid and lower zones.
[**2139-7-9**] ECG: Sinus rhythm. Short P-R interval. Borderline low
precordial lead voltage. No previous tracing available for
comparison.
Pathology:
Thoracentesis path:
[**2139-7-15**] Pleural fluid:
- Gram stain: 3+ PMNs (concentrated smear), transudative
- PLEURAL ANALYSIS: 101 WBC; 153 RBC; 64 Polys; 22 Lymphs; 2
Monos; 12 Meso
- PLEURAL CHEMISTRY: 1.2 TotProt; 161 Glucose; 0.9 Creat; 68
LD(LDH); LESS THAN asssay Albumin; 11 Cholest; 6 Triglyc;
- Cytology: DIAGNOSIS: NEGATIVE FOR MALIGNANT CELLS. Reactive
mesothelial cells and histiocytes.
Brief Hospital Course:
82M with history of HTN, HL, BPH and prior stroke, transferred
from OSH with ongoing fevers and malaise with rising
leukocytosis found to be C. diff positive. Hospital course was
complicated by acute anemia from a bleeding gastric ulcer which
was clipped by GI with hemostasis.
# C. diff infection: Patient presented from outside hospital
with persistent fever and leukocytosis despite an extensive and
appropriate infectious workup in consultation with ID at OSH.
CXR, U/A were reportedly negative. Ortho was consulted and did
left knee arthrocentesis on [**7-7**]-> WBC 4182, RBC 6000, no
crystals. Infectious Diseases started empiric Azithromycin,
Atovaquone, and Doxycycline. Due to persistent fevers, his
antibiotics were broadened from Ceftriaxone to Vancomycin and
Pip-Tazo. On [**2139-7-9**], his above abx were stopped, and he was
started on Ertapenem when serologies for Lyme, Babesia, and
Anaplasma reported negative. He has has no positive blood
cultures. CT torso on [**2139-7-8**] was unremarkable, except for
non-obstructing kidney stones. While as OSH, he had no new
symptoms and WBC increased to 40.5. [**Doctor First Name **] was found to be positive
at 1:80. Course at OSH was otherwise uncomplicated. Transferred
to [**Hospital1 18**] for further management on [**2139-7-10**].
He was found to be C. diff positive on transfer to [**Hospital1 18**] and was
started on PO vancomycin on [**7-10**]. He had a CXR on [**2139-7-10**] that
suggested multifocal PNA, so he was started empirically on
Levofloxacin, which was discontinued after 3 days when
subsequent imaging revealed no pneumonia. A transthoracic ECHO
was done on [**2139-7-10**], which was negative for vegetations
(suboptimal study). A CT chest/abd/pelvis on [**2139-7-14**] showed
bilateral pleural effusions and small ascites, but no evidence
of abscess, GB wall thickening, colitis, toxic megacolon,
consolidations, or significant lymphadenopathy. Despite
reassuring imaging, he continued to spike fevers up to 102.8
with stable leukocytosis in 30s, so he was ultimately broadened
to vancomycin, cefepime, and IV metronidazole on [**2139-7-14**] without
improvement. A thoracentesis of the pleural effusions on [**2139-7-15**]
revealed an unremarkable transudate with no malignant cells
identified. Given his knee pain and swelling, persistent fevers,
and [**Doctor First Name **] of 1:80, rheumatology was called and a repeat knee
arthrocentesis was performed which was unremarkable. After
several days on broad antibiotics, his fevers resolved and
leukocytosis began trending down. His antibiotics were scaled
back to PO vanco and IV flagyl. IV flagyl was discontinued after
14 days and he remained on PO vanco to complete a 21 day total
course to end on [**2139-8-1**].
# Bleeding gastric ulcer: Patient presented The patient
developed a low hematocrit that was not responsive to pRBC
transfusion. He then developed tachycardia to the 120s and
subsequent drop in his systolic BPs to 90. NG tube was
suctioned and showed 200cc of blood, prompting admission to the
ICU for urgent EGD intervention. He was started on a
pantoprazole drip and aspirin was held. His INR of 1.5 was
reversed with vitamin K IV. EGD showed a 20mm ulcer with a
visible vessel that was clipped x3. Follow-up hematocrits were
stable. Prior to sending back to the medicine floor, H. pylori
antibody was sent to elucidate etiology of the peptic ulcer and
returned negative. PPI drip was continued for 72 hours, then
transitioned to pantoprazole 40 mg PO BID and should continue
until resolution of ulcer is seen on endoscopy. He will follow
up as an outpatient with Dr. [**Last Name (STitle) **] [**Name (STitle) 12332**] of GI and will need a
repeat endoscopy in sevral weeks, which will be scheduled.
Aspirin 81 mg daily was restarted several days prior to
discharge and should be continued at rehab.
# Hypoxia: Patient presented with hypoxia to 95% on 3 L NC. This
was initially thought to be due to pneumonia given his fever,
leukocytosis, and possible infiltrates on CXR and was treated
emperically with levofloxacin for 3 days until subsequent
imaging ruled out a pneumonia. CHF was also a consideration
given long-standing history of HTN, bilateral pleural effusions,
iatrogenic volume overload, but TTE was normal, making this
unlikely. It is possible that he has diastolic dysfunction as
his hypoxia improved with lasix. Atalectasis is also possible.
He remained asymptomatic without complaints of cough or dyspnea
and was not in any respiratory distress.
# Pleural effusions: Patient with pleural effusions on CXR.
Thoracentesis by IP on [**7-15**] revealed 360cc straw colored
transudative fluid. Etiology is unclear, but the cytology was
negative for malignant cells. EF was 75% on [**7-10**]. It is possible
that he has diastolic dysfunction, as as his hypoxia was
improved with IV lasix and was clinically fluid overloaded with
upper and lower extremity edema. Hypoalbuminemia is likely
contributing to low oncotic pressure intravascularly (albumin
2.2 during hospitalization). He was initially provided with
supplemental oxygen as needed, but this requirement was weaned
and was started on tube feeds (below) for malnutritioin and poor
PO intake (below).
# Tachycardia: Patient presented with tachycardia to 110s-120s
in the setting of volume depletion from diarrhea and acute blood
loss (above). This resolved somewhat as his hematocrit
stabilized and his diarrhea decreased. He remains tachycardic in
the 90s-110s range on discharge. This is possibly related to his
persistent, albeit stable anemia or possible intravascular
volume depletion from a combination of decreased PO intake and
hypoalbuminemia. As his nutrition status continues to improve
and his anemia resolves with time, we would expect his
tachycardia to resolve as well.
# Hypernatremia: Na 150 on admission. Likely secondary to poor
PO intake/free water intake. His free water deficit was
corrected and his hyponatremia resolved. He later became mildly
hyponatremic in his hospital course.
# HTN: Initially hypotensive in the setting of severe diarrhea
from C. diff and bleeding from gastric ulcer so his blood
pressure medications were held on admission. Following
hemostasis of bleeding gastric ulcer (above) and resolution of
diarrhea, his BP normalized and became hypertensive as is his
baseline. His BP meds were titrated back individually and
eventually all restarted. He was discharged on his home regimen
of lisinopril, hydrochlorothiazide and amlodipine with BPs
ranging from 120s-160s/70s-80s.
# HL: Stable. Continued on home pravastatin.
# BPH: Stable. Continued on home finasteride.
# History of stroke: Patient is on aspirin for stroke
prevention. This was held when bleeding ulcer was discovered
(above) and was restarted several days prior to discharge after
hemostasis was achieved. He should continue taking aspirin 81
mg daily upon discharge.
# Osteoarthritis: Stable. Acetaminophen was geven prn for pain.
# FEN: Patient had reduced appetite on admission and labs
concerning for chronic malnutrition including albumin of 3.0 on
admission (trended down to 2.2 prior to discharge) and elevated
INR of 1.5. He continued to have a minimal appetite throughout
his hospitalization. Nutrition was consulted and provided
recommendations for ensure supplementation, but patient
continued to have decreased appetite. He was ultimately started
on tube feeds through Dobhoff with Fibersource HN at 55cc/hr
which he tolerated well and should be continued as he is
discharged to rehab. He should also be encouraged to eat in
addition to getting tube feeds.
# Pressure ulcer: Patient with pressure ulcer on right heel that
is hemorrhagic appearing with intact overlying skin. This will
require regular wound care on discharge to rehab.
# PPX: Pantoprazole 40 mg PO BID, pneumoboots
# CODE: Full (confirmed)
# CONTACT: [**Name (NI) **], wife [**Name (NI) **] [**Telephone/Fax (1) 83103**]; [**Name2 (NI) **]er [**Name (NI) **]:
[**Telephone/Fax (1) 83104**] or work [**Telephone/Fax (1) 83105**]
# Transitional issues:
- Will need outpatient colonoscopy when acute illness has
resolved
- Will need continued agressive nutrition supplementation with
tube feeds if he is not taking enough PO
- Dr. [**Last Name (STitle) **] [**Name (STitle) 12332**] of GI at [**Hospital1 18**] will schedule follow up
- He will need a repeat EGD to monitor for resolution of gastric
ulcer
- He should continue on pantoprazole 40 mg PO until resolution
of ulcer seen on endoscopy
- He was restarted on aspirin 81 mg daily and should continue
this going forward
- Patient should continue tube feeds through Dobhoff with
Fibersource HN at 55cc/hr
- His PSA was found to be mildly elevated at 6.9, and this
should be followed up as an outpatient
- He will need his HCT followed. Please check HCT on [**2139-7-31**] to
monitor for stable HCT.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Lisinopril 10 mg PO DAILY
2. Hydrochlorothiazide 12.5 mg PO DAILY
3. Pravastatin 20 mg PO HS
4. Amlodipine 5 mg PO DAILY
5. Finasteride 5 mg PO DAILY
6. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Finasteride 5 mg PO DAILY
4. Hydrochlorothiazide 12.5 mg PO DAILY
5. Lisinopril 10 mg PO DAILY
6. Pravastatin 20 mg PO HS
7. Pantoprazole 40 mg PO Q12H
8. Vancomycin Oral Liquid 125 mg PO Q6H
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital for Continuing Medical Care - [**Hospital1 8**]
Discharge Diagnosis:
Primary diagnosis:
- C. difficile infection
- Bleeding gastric ulcer s/p endoclip placement
- L knee swelling s/p arthrocentesis
Secondary diagnosis:
- Hypertension
- Hyperlipidemia
- Prior stroke
Discharge Condition:
Mental Status: Confused - sometimes. Alert and oriented x 3 at
discharge.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Known lastname **],
You were admitted to the hospital for lethargy, fevers, diarrhea
and an elevated white blood cell count at the outside hospital.
On admission, you were found to have an infection of your GI
tract called C. difficile. We treated you with antibiotics and
your infection eventually resolved. You should continue taking
antibiotics (oral vancomycin) for the C. difficile infection
through [**2139-8-1**].
During your hospitalization, you were also found to have low red
blood cell counts (anemia) and had bleeding from your GI tract.
We consulted our GI colleagues who put a scope in your stomach
(EGD) and found a bleeding ulcer, which was clipped. Your blood
counts stabilized and the bloody stools resolved.
You should follow up with GI as an outpatient to have a
colonoscopy and another endoscopy when you are discharged from
rehab.
Followup Instructions:
Please schedule an appointment with your PCP when you are
discharged from rehab.
Please call Dr. [**First Name8 (NamePattern2) 2092**] [**Last Name (NamePattern1) 12332**] of [**Hospital1 18**] Gastroenterology to
schedule follow up for repeat endoscopy in several weeks to
evaluate for resolution of ulcer and for colonoscopy when your
current illness resolves: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 463**]
Completed by:[**2139-7-29**]
ICD9 Codes: 2851, 2760, 2762, 4280, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3828
} | Medical Text: Admission Date: [**2200-6-28**] Discharge Date: [**2200-7-6**]
Date of Birth: [**2144-5-29**] Sex: F
Service: MEDICINE
Allergies:
Tetracycline
Attending:[**First Name3 (LF) 530**]
Chief Complaint:
syncopal event
Major Surgical or Invasive Procedure:
hemodialysis via left arm A-V graft
History of Present Illness:
This is a 56 yo F with HTN, h/o atypical thrombotic
microangiopathy with secondary focal sclerosis off [**First Name3 (LF) **] for
the last year, hepatitis B and C, hypothyroidism here with
syncopal event and acute renal failure, now with hypotension of
unclear etiology. Patient is a poor historian, but states that
she fell on tuesday because she tripped over a wire and hit her
bottom and her head. [**First Name3 (LF) 2974**], she had another fall with unclear
circumstances because she can't remember what happened per ED.
She denied cp, sob, palpatations, etc prior to this event. She
complains of left leg pain. She has erythema and serous blisters
over L hip with hematoma. Labs done in the ED reveal a
creatinine of 8.8 which is up from a baseline of [**3-9**].5 with some
values [**6-10**]. Her BUN is also elevated at 65. Pt reports some
decreased po intake for unclear reasons and decreased urination.
She denies using nsaids, vomiting, diarrhea. She is on
diuretics. Pt denies metallic taste in her mouth, pruritis,
frothy urine, nausea or vomiting. She is not confused.
In the ED, initial vs were T 98.6, HR 92, BP 126/71, R 18, O2
sat 99% RA. Head CT negative. CXR negative. EKG non-ischemic and
unchanged from prior. Labs notable for creatinine 8.8 with bun
65.
On the floor, patient slept comfortably and ate well. She denies
LOC.
Past Medical History:
Acute on Chronic Renal Failure, [**2198-8-4**], thought [**3-8**]
Vancomycin
Atypical Thrombotic Microangiopathy since [**2187**]
CKD, baseline Cr 2.0-recent ARF with increaced Cr to 5.0
Steroid induced osteoporosis
Obesity
HTN
Hep B and C (past IV drug use)
h/o heart murmur
L radius fracture, ([**7-11**])
Cataract surgery, L eye 2 mo ago, R eye 2 yrs ago
Migraines
Social History:
Divorced, lives alone. Has two sisters and aunt for social
support. Unemployed since [**2187**]. Has one daugher in [**Hospital1 1474**].
Smoking-40yr smoking hx-currently <1ppd, but formerly more.
Prior IVDA, last used heroin 10 years ago. Currently on
Methadone maintenance.
Family History:
Father died from unkown malignancy at age 78
Mother had uterine ca-died at age 81
Siblings in good health
No FH of kidney or blood dz, no hx of heart disease
Physical Exam:
Vitals T 98 P 89 BP 130/62 R 18 O2 sat 96% RA
General comfortable, nad
HEENT NCAT, anicteric, no injections, PERRLA, OP clear, MM very
dry
Neck supple, no LAD
Heart RRR, s1s2, loud 3/6 sem RUSB, no friction rub
Lungs CTA
Abd +bs, soft, nt, nd
Ext no cce, chronic venous stasis changes bl
Neuro A/C x 3, neuro exam nonfocal, no asterixis
Pertinent Results:
[**2200-6-28**] 08:30PM WBC-8.7 RBC-4.39 HGB-11.8* HCT-37.9 MCV-86
MCH-26.8* MCHC-31.1 RDW-19.6*
[**2200-6-28**] 08:30PM NEUTS-66.1 LYMPHS-22.4 MONOS-4.8 EOS-6.1*
BASOS-0.6
[**2200-6-28**] 08:30PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL
[**2200-6-28**] 08:30PM PLT COUNT-291
[**2200-6-28**] 08:30PM PT-37.9* PTT-40.3* INR(PT)-4.1*
[**2200-6-28**] 08:30PM GLUCOSE-86 UREA N-65* CREAT-8.8*# SODIUM-134
POTASSIUM-4.9 CHLORIDE-104 TOTAL CO2-15* ANION GAP-20
[**2200-6-28**] 08:30PM CALCIUM-7.3* PHOSPHATE-7.7*# MAGNESIUM-2.0
[**2200-6-28**] 08:30PM C3-139 C4-42*
[**2200-6-28**] 08:30PM CK(CPK)-4028*
[**2200-7-2**] 07:25AM BLOOD Hapto-193
[**2200-7-5**] 09:00AM BLOOD WBC-7.5 RBC-4.05* Hgb-10.6* Hct-35.6*
MCV-88 MCH-26.2* MCHC-29.7* RDW-18.9* Plt Ct-339
[**2200-7-5**] 07:12AM BLOOD PT-24.0* PTT-35.6* INR(PT)-2.3*
[**2200-7-5**] 09:00AM BLOOD Glucose-79 UreaN-35* Creat-7.5* Na-139
K-4.2 Cl-108 HCO3-19* AnGap-16
[**2200-7-5**] 09:00AM BLOOD Albumin-3.2* Calcium-7.9* Phos-6.1*
AP CHEST RADIOGRAPH: No consolidation, pneumothorax or pleural
effusion. Cardiomegaly and central pulmonary vascular congestion
are present, although without evidence of overt edema. The
mediastinum and hila are within normal limits. Tandem vascular
stents are seen within the right subclavian and brachiocephalic
veins and proximal SVC.
AP PELVIS AND FIVE VIEWS OF THE LEFT FEMUR.
There is no fracture or dislocation. Calcific density is seen
adjacent to the greater tuberosity on a single projection which
likely represents calcific gluteal tendinopathy. Vascular
calcifications are present. Limited views of the knee show
tricompartmental osteoarthritis
EKG:
Sinus rhythm. Delayed precordial R wave transition. Compared to
the previous tracing of [**2200-6-28**] no diagnostic interim change.
The rate has slowed.
Transthoracic Echocardiogram:
The left atrium is mildly dilated. The left atrial volume is
markedly increased (>32ml/m2). The right atrium is moderately
dilated. The estimated right atrial pressure is 10-15mmHg. There
is moderate symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is normal (LVEF>55%). The estimated cardiac index is
normal (>=2.5L/min/m2). Transmitral Doppler and tissue velocity
imaging are consistent with Grade II (moderate) LV diastolic
dysfunction. There is no left ventricular outflow obstruction at
rest or with Valsalva. The right ventricular cavity is mildly
dilated with normal free wall contractility. The aortic arch is
mildly dilated. The aortic valve leaflets (3) are mildly
thickened. No masses or vegetations are seen on the aortic
valve. There is no valvular aortic stenosis. The increased
transaortic velocity is likely related to high cardiac output.
Trace aortic regurgitation is seen. The mitral valve leaflets
are mildly thickened. There is no mitral valve prolapse. No mass
or vegetation is seen on the mitral valve. Mild (1+) mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is a trivial/physiologic
pericardial effusion.
Compared with the prior study (images reviewed) of [**2198-9-27**],
the left ventricle is more hypertrophied and the estimated
pulmonary artery systolic pressure has increased. No vegetation
is seen.
Brief Hospital Course:
A/P: A/P: Pt is a 56 yo female with pmhx thrombotic
microangiopathy, CKD, HTN here with several syncopal episodes
and acute on chronic renal failure
.
# Transient Hypotension: On arrival to floor from ED, patient's
blood pressure was low, responded to reducing dose of methadone
from 20 to 10, gentle hydration with isotonic bicarbonate, and
holding BP meds x24 hrs. Stable since on home amlodipine and
metoprolol.
# systolic murmur: Patient also has a harsh murmur, which raises
suspicion for endocarditis, but is afebrile and aside from
hypotension, does not manifest signs of infection. TTE was
normal, with no veg or hemodynamically significant LV outflow
obstruction or AS; suspect aortic sclerosis.
# Acute on chronic renal failure: UOP low initially but pt now
making 500-600cc/day. Baseline Cr 2-3.5 secondary to TTP, peaked
at 10.4 and hemodialysis re-initiated. Suspect [**3-8**]
rhabdomyolysis given elevated CPK on admission. Blood
bank/[**Month/Day (2) **] team did not find any indications for [**Month/Day (2) **],
which was considered given patient's history of atypical
microangiopathy. Continued niferex, epogen, calcitriol at outpt
doses.
Pt will need HD on a Tues/Thurs/Sat schedule with ongoing
re-evaluation of need for hemodialysis.
# Fall, ? Syncope: Pt denies LOC and insists fall was
mechanical. CT head without acute bleed. She did have 14 beats
of VT on telemetry in ICU, asymptomatic (see below), no known
structural heart disease, but with murmur. Also could be renal
failure causing increased circulating levels of methadone.
- ECHO to evaluate for structural heart disease in setting of
murmur was normal
- TSH slightly high, T4 slightly low; increased levothyroxine to
75 mcg daily
# HTN- restarting norvasc and metoprolol
# hypothyroidism- increased levothyroxine to 75 mcg daily for
high tsh/low t4
# H/O IVDA- continue methadone, but at lower dose. No additional
narcotics. Hold for sedation.
# FEN/GI - cardiac, renal diet, IVF as above, replete lytes prn
# PPx - protonix, restarting coumadin at half dose today given
INR of 3.0, bowel regimen
# Code - full
# Dispo: to acute rehab for HD; after 1-2 weeks, will be better
able to determine need for ongoing hemodialysis vs improvement
in renal function.
Medications on Admission:
ALLOPURINOL 100 mg--2 tablet(s) by mouth every day
BUMEX 2 mg--1 tablet(s) by mouth once a day
CALCITRIOL 0.25 mcg--one capsule(s) by mouth every other day
EPOGEN 10,000 unit/mL--1 ml subcutaneously twice a week
FOSAMAX 70 mg--1 tablet(s) by mouth once a week
LEVOXYL 50 mcg--1 tablet(s) by mouth once a day
METOPROLOL TARTRATE 25 mg--1 tablet(s) by mouth twice a day
Methadone 5 mg/5 mL--20 mg by mouth daily
NIFEREX 60 mg--1 capsule(s) by mouth once a day
NORVASC 5 mg--one tablet(s) by mouth once a day
OXAZEPAM 30 mg--two capsule(s) by mouth at bedtime
PHENERGAN 25 mg--one tablet(s) by mouth every 4-6hrs as needed
PLAVIX 75 mg--one tablet(s) by mouth one a day
PRILOSEC OTC 20 mg--1 tablet(s) by mouth daily
Syringe (Disposable) --3 ml syringe, 25 g, [**6-12**] inch needle
twice a week to use for procrit injection
WARFARIN 2 mg----- tablet(s) by mouth daily take up to 3 tablets
daily, as directed by coumadin clinic [**Telephone/Fax (1) 10844**]
Discharge Medications:
1. Epoetin Alfa 4,000 unit/mL Solution Sig: 8000 (8000) units
Injection QMOWEFR (Monday -Wednesday-[**Telephone/Fax (1) 2974**]): during dialsysis.
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. Promethazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Methadone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
note: outpatient methadone maintenance dose was 20, decreased
[**3-8**] somnolence.
8. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day).
11. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Oxazepam 15 mg Capsule Sig: Four (4) Capsule PO HS (at
bedtime) as needed.
13. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
14. Outpatient [**Month/Day (2) **] Work
Check INR regularly and restart warfarin when appropriate for
INR target [**3-9**]
15. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
acute renal failure due to rhabdomyolysis, acute tubular
necrosis (possibly)
history of atypical thrombotic microangiopathy c/b secondary
focal sclerosis; has not required plasmapheresis since [**2198**]
Discharge Condition:
good
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
.
You were admitted to the hospital and then the intensive care
unit because you had some times in which you fell, and then your
blood pressure was low. You may have been sedated because of a
combination of methadone and possibly other medicines; it's
important that you stay on a steady dose of methadone to make
sure you don't become overly sedated. You had damage to your
muscles which had the effect of damaging your kidneys; you also
may have had other reasons that your kidneys were damaged. For
now you will need dialysis and close follow-up with the kidney
doctors [**Name5 (PTitle) 1028**] your [**Name5 (PTitle) 4006**] function improves. You had a urinary
tract infection as well while you were in the hospital, for
which you received antibiotics.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**], M.D. Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2200-7-16**] 10:30
Provider: [**First Name11 (Name Pattern1) 2482**] [**Last Name (NamePattern4) 10466**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 250**]
Date/Time:[**2200-7-25**] 9:00
PCP:
ICD9 Codes: 5849, 2762, 5990, 4280, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3829
} | Medical Text: Admission Date: [**2177-7-1**] Discharge Date: [**2177-7-3**]
Date of Birth: [**2146-7-21**] Sex: F
Service: MEDICINE
Allergies:
Dilaudid / Iodine-Iodine Containing
Attending:[**First Name3 (LF) 5810**]
Chief Complaint:
tachypnea, hypoxia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
30 YO F w ESRD [**12-31**] DM1 on HD M/W/F s/p recent admission for
contrast allergy who presented with SOB after missing her HD
session yest. Went to HD today but was found to be tachypneic to
the 30s w bibasilar rales. EMS gave 15L NRB 97%. Upon arrival,
the patient was 88% on RA. Exam was notable for bibasilar
crackles. She was started on BiPap and given 80IV lasix and
nitro paste, Ca gluconate for peaked T-waves, 20u regular
insulin. Renal was contact[**Name (NI) **] and plan to do HD when she arrives
to the MICU.
.
Upon arrival to the MICU, the patient reports improved SOB with
the Bipap mask. She was noted by nursing to have an episode of
rigors without fever.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough. Denied chest pain or tightness,
palpitations. Denied nausea, vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denied arthralgias or myalgias.
Past Medical History:
- ESRD since [**2174-8-29**] HD through L IJ Tunnelled line
- Peritonitis [**8-7**]
- Type I DM complicated by neuropathy and nephropathy
- Bilateral cataract surgeries
- Ventral Hernia, repaired [**4-/2177**]
Social History:
The patient lives with her mother. Lives with her mother, +
tobacco history, social ETOH, marijuana use noted in history.
Family History:
DM type II.
Physical Exam:
While transfer to floor from MICU [**7-3**] : Vitals: T: 97.1 BP:
120/70 P:47 R:16 18 O2:97%
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: no pus currently seen around HD line. With no fluctuance,
draining fluid, or erythema
.
Pertinent Results:
Admission Labs:
[**2177-7-1**] 01:36PM BLOOD WBC-10.1# RBC-4.20 Hgb-12.8 Hct-38.5
MCV-92 MCH-30.4 MCHC-33.1 RDW-15.8* Plt Ct-203
[**2177-7-1**] 01:36PM BLOOD Neuts-77.9* Lymphs-14.4* Monos-3.3
Eos-3.5 Baso-1.0
[**2177-7-1**] 01:36PM BLOOD Glucose-568* UreaN-78* Creat-11.6*#
Na-129* K-5.6* Cl-90* HCO3-17* AnGap-28*
[**2177-7-1**] 04:43PM BLOOD Calcium-9.2 Phos-4.1 Mg-3.0*
[**2177-7-2**] 09:05AM BLOOD Vanco-32.2*
[**2177-7-1**] 01:43PM BLOOD Glucose-490* Lactate-2.1* Na-132* K-5.4*
Cl-92* calHCO3-24
.
.
Imaging:
CXR [**2177-7-1**]:
1. Increase in interstitial prominence and new development of
small bilateral pleural effusions consistent with moderate
pulmonary edema. Patchy opacities are most likely related to
confluent edema, though infection is not excluded. Repeat
radiography after diuresis is recommended.
2. Stable appearance of hemodialysis catheter.
.
Micro: No growth to date at wound culture preliminary -no growth
to date
Blood and urine cultures- No growth to date
.
Reports: EKG [**7-1**]
Sinus rhythm. Possible left atrial abnormality. Poor R wave
progression.
Consider prior anteroseptal myocardial infarction. Hyperacute T
waves in the
anterior leads raise concern for hyperkalemia or acute
myocardial ischemia.
Clinical correlation is suggested. Compared to the previous
tracing of [**2177-5-15**]
the rate has decreased. Poor R wave progression and hyperacute T
waves are seen
on the current tracing.
TRACING #1
Read by: [**Last Name (LF) **],[**First Name3 (LF) **] D.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
87 170 78 [**Telephone/Fax (2) 5811**] 73
.
CXR [**7-1**]
[**Hospital 93**] MEDICAL CONDITION:
30 year old woman missed dialysis yesterday with crackles and
hypoxia/
REASON FOR THIS EXAMINATION:
assess for pulmonary edema
Final Report
PATIENT HISTORY: 30-year-old female who missed dialysis
yesterday.
TECHNIQUE AND FINDINGS: Portable AP chest radiograph
demonstrates a left
subclavian hemodialysis catheter with its tip at cavoatrial
junction.
Compared with [**2177-6-20**], there is increase in perihilar and
bibasilar
interstitial markings and small bilateral pleural effusions
consistent with
moderate pulmonary edema. The cardiomediastinal silhouette is
unchanged in
appearance. Patchy opacities are superimposed on parasagittal
interstitial
pattern bilaterally.
IMPRESSION:
1. Increase in interstitial prominence and new development of
small bilateral
pleural effusions consistent with moderate pulmonary edema.
Patchy opacities
are most likely related to confluent edema, though infection is
not excluded.
Repeat radiography after diuresis is recommended.
2. Stable appearance of hemodialysis catheter.
The study and the report were reviewed by the staff radiologist.
.
EKG [**7-3**]
Sinus rhythm. Consider left ventricular hypertrophy although may
be
non-diagnostic given patient's age. Delayed R wave progression
may be due to
left ventricular hypertrophy, normal variant or possible prior
anterior wall
myocardial infarction although is non-diagnostic. Inferolateral
lead ST-T wave
changes are non-specific but clinical correlation is suggested.
Since the
previous tracing of [**2177-7-2**] lateral limb lead ST-T wave changes
appear slightly
more prominent.
.
Discharge Labs
.
[**2177-7-3**] 06:55AM BLOOD WBC-6.1 RBC-3.88* Hgb-11.6* Hct-34.7*
MCV-89 MCH-29.9 MCHC-33.5 RDW-15.8* Plt Ct-149*
[**2177-7-2**] 05:29AM BLOOD WBC-6.9 RBC-4.15* Hgb-12.2 Hct-36.9
MCV-89 MCH-29.5 MCHC-33.2 RDW-15.9* Plt Ct-165
[**2177-7-2**] 05:29AM BLOOD Neuts-67.3 Lymphs-23.8 Monos-4.0 Eos-4.2*
Baso-0.7
[**2177-7-1**] 04:43PM BLOOD Neuts-80.3* Lymphs-13.4* Monos-2.7
Eos-3.0 Baso-0.6
[**2177-7-3**] 06:55AM BLOOD Plt Ct-149*
[**2177-7-2**] 05:29AM BLOOD Plt Ct-165
[**2177-7-2**] 05:29AM BLOOD PT-13.3 PTT-27.9 INR(PT)-1.1
[**2177-7-1**] 04:43PM BLOOD Plt Ct-195
[**2177-7-3**] 06:55AM BLOOD Glucose-415* UreaN-33* Creat-6.5* Na-135
K-4.1 Cl-92* HCO3-32 AnGap-15
[**2177-7-2**] 05:29AM BLOOD Glucose-212* UreaN-33* Creat-7.4* Na-135
K-3.9 Cl-91* HCO3-32 AnGap-16
[**2177-7-1**] 09:29PM BLOOD Glucose-46* UreaN-32* Creat-6.7*# Na-136
K-3.6 Cl-90* HCO3-35* AnGap-15
[**2177-7-1**] 04:43PM BLOOD Glucose-343* UreaN-78* Creat-12.0* Na-133
K-4.5 Cl-93* HCO3-25 AnGap-20
[**2177-7-3**] 06:55AM BLOOD Calcium-8.6 Phos-4.7* Mg-2.5
[**2177-7-2**] 05:29AM BLOOD Calcium-8.8 Phos-4.4# Mg-2.3
[**2177-7-1**] 09:29PM BLOOD Calcium-9.2 Phos-2.8 Mg-2.4
[**2177-7-2**] 09:05AM BLOOD Vanco-32.2*
[**2177-7-1**] 04:43PM BLOOD ASA-NEG Ethanol-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
[**2177-7-1**] 11:52PM BLOOD HoldBLu-HOLD
[**2177-7-1**] 01:43PM BLOOD Type-[**Last Name (un) **] pH-7.33* Comment-GREEN TOP
[**2177-7-2**] 05:56AM BLOOD Lactate-1.1
[**2177-7-1**] 05:06PM BLOOD Lactate-2.2*
[**2177-7-1**] 01:43PM BLOOD Glucose-490* Lactate-2.1* Na-132* K-5.4*
Cl-92* calHCO3-24
[**2177-7-1**] 01:43PM BLOOD Hgb-13.4 calcHCT-40 O2 Sat-95 COHgb-2
MetHgb-0
[**2177-7-1**] 01:43PM BLOOD freeCa-1.03*
Brief Hospital Course:
BRIEF MICU COURSE:
MICU Ms. [**Known lastname **] was admitted to the ICU with pulmonary edema
after missing HD. She underwent HD and UF the day of admission
and had another session of UF on [**2177-7-2**]. She was hypertensive
overnight and received both IV and PO Labetolol. After her UF
session on [**2177-7-2**] her blood pressure was 110s-130s systolic.
She was put on her Lisinopril 10mg daily, Lasix 60mg daily and
Carvediolol 25mg [**Hospital1 **] per renal recommendations. She was noted
to have pus coming from her HD line and was given Vancomycin per
HD protocol. She was cultured from her HD line. Her
hyperkalemia resolved after UF.
.
FLOOR : 30 YO F w ESRD [**12-31**] DM1 now with tachypnea, hypoxia and
hyperkalemia in the setting of missing HD. Was admitted to the
MICU intially where she was dialyzed and her fluid
status/tachypnea improved and was transferred to the floor.
.
#Tachypnea, hypoxia. Likely related to missing HD although
initially a underlying respiratory infection cannot be
excluded. On transfer to the floor she complained of no
tachypnea and seemed comfortable with no complaints. Patient
tolerated room air well and complains of no shortness of breath.
UF recieved yesterday ([**7-1**]) with improvement in tachypnea.
Repeat CXR post-UF to eval for clearance on patchy infiltrates
on CXR- showed bilateral parenchymal opacities have decreased in
extent and severity with only a ground-glass like pattern of
opacities seen diffusely throughout the middle and lower lung
zones. Urine/blood /HD entry site cultures-no growth to date.
.
# Hyperkalemia. Likely related to lack of HD. HD with UF as
above . Repeat post-HD-potassium levels were normal Repeat EKG-
no curent EKG peaked T waves which were present on [**7-1**] EKG's.
F/u [**7-3**] EKG - no more peak T waves seen, offical results are
pending.
.
# Hyperglyemia. No gap.
- insulin sliding scale with home regimen- Blood sugars were
initially above 350 however were then controlled under 200-250.
.
# Pus around HD line.-no pus was seen around HD line on the
floors. With no fluctuance, draining fluid, or erythema.
Vancomycin 1.5g with hD per renal fellow- discontinued per
renal. F/u cultures- no growth to date. Bacitracin admin. only
with dialysis to HD entry site recommended.
.
# ESRD.
- continued home meds.Ordered Folic acid home dose. Contnued
Sevelemer 800mg TID per renal.
.
# HTN. Continued home meds including home dose lisinopril
daily in addition to already ordered home dose carvedilol, and
lasix (60mg daily)
Medications on Admission:
. Aspirin 81 mg Tablet, PO DAILY
2. Carvedilol 12.5 mg Two (2) Tablets PO BID
3. Cinacalcet 30 mg PO DAILY
4. Docusate Sodium 100 mg Capsule PO BID
5. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) INJ qweek
6. Insulin Aspart Subcutaneous
7. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) Units
qday
8. Latanoprost 0.005 % Drops Ophthalmic HS (at bedtime).
9. Sevelamer HCl 400 mg 2 tabs TID W/MEALS
10. B Complex-Vitamin C-Folic Acid 1 mg PO DAILY
11. Lisinopril 10 mg Tablet PO once a day.
Discharge Medications:
1. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) units
Subcutaneous once a day: Please admin AM.
2. Novolog 100 unit/mL Solution Sig: One (1) unit Subcutaneous
four times a day: Please follow prior home sliding scale
attatched. .
3. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
6. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
7. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
8. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl
Topical QID (4 times a day) as needed for drainage: Please
admin. to hemodialysis entry site only with dialysis .
Disp:*0 * Refills:*0*
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
13. Travatan 0.004 % Drops Sig: One (1) drop Ophthalmic at
bedtime.
14. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) injection
Injection once a week.
Discharge Disposition:
Home
Discharge Diagnosis:
Acute Pulmonary Edema
Hyperkalemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure to care for you as your doctor.
.
You were brought to the hospital because of diffuculty
breathing,a high potassium level and having excess fluid in your
system. We felt like this was caused by being fluid overloaded
due to missing a dialysis appointment. You were admitted to the
intensive care unit where you had fluid taken off with dialysis
and were given support for your breathing. After these measures
your breathing and potassium levels improved and you were
transferred to the general floors. We observed you and you were
medically stable to be discharged.
.
We made the following changes to your home medication list:
We added Bacitracin which is a topical antibiotic which should
be administered to your hemodialysis entry site before dialysis.
We added Lasix 60mg daily. This will help keep your body fluid
level appropiate.
.
Please take your other home medications as prescribed before
coming to the hospital.
.
Please follow your dialysis schedule as you were before coming
to the hospital.
.
Please weigh yourself daily and if you gain more than 3 pounds
in one day contact your primary care physician.
.
Please follow up with the following outpatient appointments
below:
Followup Instructions:
Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) 1022**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Date: [**8-4**] 10:40AM
Location: [**Hospital3 249**] [**Hospital1 **]
Address: [**Location (un) **], [**Hospital Ward Name **] 1, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 250**]
Fax: [**Telephone/Fax (1) 4004**]
.
Provider:[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1557**] RN
Date:Teusday [**7-8**], 3PM
Location :[**Last Name (NamePattern1) 5812**]
Service: [**Hospital 982**] Clinic
Phone Number:: [**Telephone/Fax (1) 2378**]
.
Department: HEMODIALYSIS
When: FRIDAY [**2177-7-4**] at 7:30 AM
.
Department: [**Hospital **] HEALTH CENTER
When: FRIDAY [**2177-7-4**] at 10:40 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 5808**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: PODIATRY
When: TUESDAY [**2177-7-8**] at 9:20 AM
With: [**First Name11 (Name Pattern1) 3210**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], DPM [**Telephone/Fax (1) 543**]
Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
ICD9 Codes: 5856, 3572, 2767, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3830
} | Medical Text: Admission Date: [**2191-3-4**] Discharge Date: [**2191-3-4**]
Date of Birth: [**2153-3-6**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
ethanol intoxication, suicidal ideation
Major Surgical or Invasive Procedure:
none
History of Present Illness:
38yoM h/o EtoH and heroin abuse, h/o SI attempt in [**2186**], BIBEMS
after verbal acclimation of pending suicide attempt, found to be
intoxicated with concern for withdrawal, admitted to [**Hospital Unit Name 153**] for
withdrawal monitoring.
Patient was brought to ED after he told his uncle that he was
going to jump off the BU bridge. Uncle found [**Name2 (NI) **] on patient.
In [**Hospital1 18**] ED, afebrile, hr 107 to 140, sbp 160/59, 97%ra, rr 17,
Patient walking and asking for ativan with ethanol level of 486.
Given 10mg po diazapem, then with increased tachycardia and htn,
so given 10mg iv, angry when denied ativan. Patient section 12
due to suicidal attempt; pt evasive/circumferential when asked
direct questions. Initially admitted to heroin abuse, then
denied. Admitted to [**Hospital Unit Name 153**] for monitoring given multiple triggers
on CIWA scale.
Past Medical History:
1. ADHD
2. learning disorder (dyslexia)
3. major depression
4. bipolar affective disorder
5. antisocial personality disorder
6. hx head trauma [**1-31**] a beating during court-mandated vocational
program in TX
7. ethanol abuse - szs [**1-31**] ethanol withdrawal/DTs, per pt
8. ?heroin use
.
Psych hx: Bridgwater x2, "21" psych hospitalizations in [**State 2690**],
>50 detoxes, last 2yrs ago. Suicide attempt [**2186**] - hanging.
Social History:
Etoh: + since [**94**], reportedly up to 2pints of vodka/d 2-3 days/wk
Tobacco: 3ppd, smoking since age 13
Illicit Drug Use: cocaine/heroin, both IV. Last used cocaine
[**3-2**], heroin [**2-28**]. Pt reports multiple detox programs. Marijuana
once weekly, methamphetamine once weekly.
Denied sexual activity. Lives in [**Location **], lost job as
cook/prep employee of 17 years. Stated he is a registered sex
offender from an incident several years ago when intoxicated.
Mother lives in [**State 2690**], father disabled.
Family History:
NC
Physical Exam:
T=98 BP=161/99 HR=101 RR=14 98%ra
PHYSICAL EXAM
GENERAL: cooperative, NAD
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear. R submandibular
lymph node palpated, non tender, no thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**].
LUNGS: decreased effort, CTAB, good air movement biaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM, [**Doctor Last Name 7282**] sign (-), 3
spiders angiomas on upper torso.
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
SKIN: upper ext scratches
NEURO: A&Ox3. Appropriate, odd affect. CN 2-12 grossly intact.
No asterixis.
Pertinent Results:
[**2191-3-4**] 02:45AM BLOOD WBC-6.9 RBC-4.84 Hgb-15.7 Hct-44.8 MCV-92
MCH-32.4* MCHC-35.1* RDW-13.8 Plt Ct-253
[**2191-3-4**] 02:45AM BLOOD Neuts-75.0* Lymphs-18.0 Monos-3.7 Eos-1.5
Baso-1.8
[**2191-3-4**] 02:45AM BLOOD Plt Ct-253
[**2191-3-4**] 02:45AM BLOOD Glucose-114* UreaN-12 Creat-0.8 Na-139
K-4.1 Cl-94* HCO3-20* AnGap-29*
[**2191-3-4**] 02:45AM BLOOD ALT-41* AST-107* LD(LDH)-297*
CK(CPK)-381* AlkPhos-70 TotBili-0.3
[**2191-3-4**] 02:45AM BLOOD Albumin-4.7
[**2191-3-4**] 02:45AM BLOOD Osmolal-415*
[**2191-3-4**] 02:45AM BLOOD TSH-PND
[**2191-3-4**] 02:45AM BLOOD ASA-NEG Ethanol-486* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2191-3-4**] 08:00AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.007
[**2191-3-4**] 08:00AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-15 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2191-3-4**] 08:00AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
Brief Hospital Course:
38 year old man with a history of alcohol and heroin abuse, h/o
SI attempt in [**2186**], brought in by EMS after calling uncle to
report his pending suicide attempt, found to be intoxicated with
concern for withdrawal, admitted to [**Hospital Unit Name 153**] for withdrawal
monitoring.
.
# Ethanol intoxication/cocaine use: The pt reported a
polysubstance abuse hx, significant ethanol hx, with report of
withdrawal/DTs in past. Cocaine screen (-), last reported use 2
days prior. Patient was monitored on an alcohol withdrawal
scale, was given po diazepam for tachycardia and hypertension,
but did not show other signs of withdrawal. Patient was given
thiamine, folate, multivitamins, and ivf. Labs showed a
transaminitis, likely [**1-31**] to ethanol use, but should be
rechecked in future. Patient was advised to quit drinking
ethanol.
.
# Suicide attempt: Likely triggered by recent firing from job at
a [**Location (un) 6002**] shop where the pt had been employed for 17 years. The
pt reported being followed by psych, and reported a history of
suicidal ideation in past. The pt was initially section 12,
cannot leave AMA, as per psych recs in ED. He was transferred
to [**Hospital Unit Name 153**] with sitter. The psychiatry team then determined that
the pt did not qualify for section 12, and the pt willingly
accepted admission to an inpatient psychiatric treatment
facility. TSH was normal on this admission.
.
# Anion-gap acidosis: On admission the pt's AG was 25, likely
secondary to ethanol. Osmolar gap suggested other unaccounted
anion, but on repeat electrolyte check the anion gap had
resolved.
.
Medications on Admission:
none
Discharge Medications:
1. Diazepam 5 mg Tablet Sig: Two (2) Tablet PO Q1H (every hour)
for 10 doses: Please give every hour for symptoms of withdrawal
(tachycardia, tremor) and hold for symptoms of sedation,
intoxication (slurred speech, ataxic gait).
2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Discharge Diagnosis:
1. ethanol intoxication
Secondary:
Suicidal ideation, suicide attempt, alcohol withdrawal
Discharge Condition:
patient discharged to detox center, ambulating, tolerating PO
feeds
Discharge Instructions:
Mr [**Known lastname **]: You were admitted for alcohol intoxication, concern for
suicidal ideations, and you were evaluated by psychiatry. You
were given fluids and was medication for alcohol withdrawal.
You were discharged in stable condition.
.
Please seek medical attention if you develop chest pain,
shortness of breath, nausea, vomiting, or any other concern that
is out of the ordinary.
Followup Instructions:
Please arrange follow up for the pt with his primary care doctor
(Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 17826**]) when he leaves inpatient
psychiatric treatment.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
ICD9 Codes: 2762 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3831
} | Medical Text: Admission Date: [**2122-6-22**] Discharge Date: [**2122-7-1**]
Date of Birth: [**2052-2-14**] Sex: F
Service: CME
[**Hospital Unit Name 105427**] SUMMARY--TRANSFERRED TO [**Hospital Ward Name **] INTENSIVE CARE
UNIT
CHIEF COMPLAINT: Dyspnea and weight gain.
HISTORY OF PRESENT ILLNESS: The patient is a 70-year-old
lady, with multiple medical problems including CHF with
severe diastolic dysfunction (EF 55 percent), with multiple
admissions for heart failure exacerbations, who presents with
weight gain and dyspnea. Her last admission was [**5-28**]
through [**2122-6-12**] for similar symptoms. During her last
admission, the patient was treated with low dose dopa at 3
mcg and a Lasix drip at 3-5 mg/h, acetazolamide with good
diuresis and was transitioned to po Bumex prior to DC. She
was then discharged to the [**Hospital3 2558**] for rehab. Her
course was complicated by acute renal failure, a UTI, mild
hypotension with her diuresis. The patient has been in touch
with Dr.[**Name (NI) 13610**] office since discharge and has been
complaining of weight gain ever since her discharge. She
reports a 20 pound weight gain over the last week. The
office of Dr. [**First Name (STitle) 2031**] recommended IV Lasix, but [**Hospital3 2558**]
could not administer this. Thus, she had been treated with
po Bumex. "I have never seen my legs this large before."
The patient uses 2 liters nasal cannula at home for the last
6 months. She reports no increase in requirement, but feels
that her rate is elevated. She has been more immobile over
the last month and is mostly wheelchair bound at this point.
She reports no changes in her medications recently with 100
percent compliance at the [**Hospital3 2558**]. She has been
served kosher food with high sodium content at [**Hospital3 7511**], so the patient believes this may be a culprit. Her 2-
pillow orthopnea is unchanged. She has no PND. She wears
CPAP at night for OSA.
PAST MEDICAL HISTORY: CHF with severe diastolic dysfunction;
her dry weight is approximately 194 pounds. Last ejection
fraction 55 percent. 1 plus TR. 1 plus MR. [**Name13 (STitle) **] wall motion
abnormalities. This is from an echo performed on [**2122-6-1**]. The patient has multiple admissions for failure
requiring IV dopamine and Lasix drips.
Chronic anemia on Epogen.
Coronary artery disease, status post non-ST elevation MI in
[**2121**].
Mild to moderate pulmonary hypertension with pressures
ranging 30-32.
Obstructive sleep apnea, wears CPAP 15/0 q hs.
Hyperlipidemia.
Atrial fibrillation, status post multiple cardioversions.
History of BOOP.
COPD on home O2.
Diabetes mellitus with neuropathy, insulin dependent.
Chronic renal insufficiency with baseline creatinine 1.1 to
1.4.
Status post cholecystectomy.
Hypothyroidism, status post thyroidectomy for thyroid
carcinoma.
History of PE.
History of MRSA and VRE, on contact precautions.
MEDICATIONS UPON ADMISSION:
1. Celexa 60 mg po qd.
2. Amiodarone 200 mg po qd.
3. Neurontin 300 mg po tid.
4. Toprol XL 100 mg po qd.
5. Lipitor 10 mg po qd.
6. Bumex 1 mg po bid.
7. Protonix 40 mg po qd.
8. Lisinopril 2.5 mg po qd.
9. Levothyroxine 100 mcg po qd.
10.Insulin NPH 48 U q am, 10 U q pm.
11.Theophylline 100 mg po bid.
12.Percocet prn.
13.Pyridoxine (B6) 50 mg qd.
14.Calcium carbonate 500 mg po bid.
15.Folate and multivitamin.
16.Mirtazapine 15 mg po qd.
17.Olanzapine 5 mg po q hs.
18.Fentanyl patch 25 mcg q 72 h.
19.Coumadin 5 mg po q hs.
20.Aspirin 81 mg po qd.
21.Bowel regimen.
SOCIAL HISTORY: The patient was discharged to [**Hospital3 2558**]
on [**6-12**], but previously lived alone. She [**Month (only) **] tobacco use
(has remote use). [**Month (only) 4273**] alcohol or IV drug use. She has a
daughter who is a lawyer in the area who she is not close to.
She also has a son who she feels more close to. The patient
is a full code, as discussed with her upon admission.
ALLERGIES: Penicillin which is a very mild allergy as a
child. The patient has been treated with cephalosporins
without incident.
Tegretol.
Pork and beef insulin, not human insulin.
Zaroxolyn.
PHYSICAL EXAM UPON ADMISSION: Temperature 98.5, blood
pressure 91/47, pulse 82, respirations 20, 99 percent on 2
liters of oxygen. In general, the patient was a comfortable
elderly female in no acute distress. Her nasal cannula was
in place. Her mucous membranes were semidry. Her JVP was at
her ear. Her neck was supple with no bruits. Her chest had
bibasilar crackles. Upper fields were clear. There was
expiratory wheezing and chest tightness with poor effort.
Abdomen was distended with normoactive bowel sounds. No
hepatosplenomegaly. She was obese. Extremities - 3 plus
pitting edema up to the knees bilaterally. Venous stasis
changes. The patient had malodorous superficial weeping
ulcers on her anterior left extremity, right greater than
left. No pus, bleeding, but tender.
LABS UPON ADMISSION: White count 6, hematocrit 30.3,
platelets 243, INR 2.2, creatinine 1.5, BUN 38, bicarbonate
38, CK 81, troponin less than 0.01. Urinalysis showed small
blood and was otherwise negative. A chest x-ray showed
bilateral pleural effusions. Echo on [**2122-6-1**] showed
EF of 55 percent. No wall motion abnormalities. 1 plus TR.
PA pressure 30-32 with no changes since [**2121-3-8**] echo.
The patient had a recent colonoscopy in [**2119-10-7**] which
was negative, and an EGD in [**2119-10-7**] which was
negative.
HOSPITAL COURSE BY PROBLEM:
1. DIASTOLIC DYSFUNCTION: The patient reports a 20 pound
weight gain over the week prior to admission. Her dry
weight is approximately 194 pounds. Upon admission, the
patient was 230 pounds. The patient was immediately
started on a Lasix drip, as well as dopamine. Her Lasix
was at 3 mg/h and her dopamine was at 3 mcg/kg/min. The
patient had immediate response to this regimen. She was
slowly titrated up with her Lasix at 4 and dopamine to 5
within several days. She continued to diurese very well
with greater than 1.3 liters negative daily. Her weight
did trend down. On day of this dictation, her current
weight is 95.2 kg. The patient's daily weights were taken
carefully, as well as careful I's and O's with a Foley
catheter in place, given the Lasix drip. The patient was
continued on her Toprol, ACE inhibitor. She has a history
of poor response to nesiritide with hypotension. Thus,
this was not used. The patient's exacerbation is likely
due to her poor diet control. She ruled out for a
myocardial infarction within 24 hours of admission. She
was fluid restricted to 1 liter qd but had a difficult
time with this, so she was switched to 1.5 liters qd and
tolerated this well.
The patient continued to diurese very well until [**6-30**], when
the patient suffered an acute drop in her blood pressure.
Please see below for full details of this hypotension.
However, at this time the patient's Lasix drip was stopped,
and her dopamine was titrated up to 6 mcg/kg/min. The
patient continued to diurese on her own without the help of
Lasix and was approximately 300 cc negative despite cessation
of Lasix. The patient's ACE inhibitor and Toprol were also
held due to her hypotension. At the time of this dictation,
the patient is still above her dry weight, and her aggressive
diuresis has stopped.
1. CORONARY ARTERY DISEASE: The patient had no evidence of
acute MI upon admission. Her enzymes were cycled upon
admission, and she ruled out for a myocardial infarction.
She was continued on her cardiac regimen of beta blocker,
ACE inhibitor, Lipitor, aspirin. Her medications were
held for hypotension, as described below.
1. ATRIAL FIBRILLATION: The patient was rate controlled and
in chronic atrial fibrillation. She was on Coumadin upon
admission with a therapeutic INR. Her INR remained
therapeutic during this admission. She is also on
amiodarone qd. During her [**Hospital Unit Name 196**] course, the patient was
cardioverted by EP with initial success. She remained in
normal sinus rhythm for 2-3 days; however, she did revert
to atrial fibrillation once again. At the time of this
dictation, the patient's rate is slight tachycardic to
high 90's-low 100's. It is thought that this is because
her beta blocker has been decreased due to her
hypotension. She was followed by her outpatient EP
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 73**], during the initial days of this
admission. The patient is also occasionally in atrial
flutter per telemetry tracings.
1. HYPOTENSION: On [**6-30**], I was called to patient's bedside
for decreased mental status. The patient was mentating
but was very lethargic and sluggish. Her blood pressure
at that time was 50's/40's. I laid the patient supine and
in reverse Trendelenburg. I also shut-off her Lasix drip
and increased her dopamine to 6 mcg/kg/min. The patient
had rapid return of her blood pressure to systolic
70's/40's and then a few minutes later, her systolic blood
pressure returned to 90's/40's. It was initially thought
that the patient was hypotensive due to overdiuresis. She
had been diuresing greater than 1 liter daily for
approximately 6 days, and it was thought that the patient
may be having a poor response to this. The patient's
Lasix was held indefinitely, and her dopamine remained at
6 mcg/kg/min for several hours, but we were able to wean
her down to 5 mcg on day of transfer to the [**Hospital Unit Name 153**]. The
patient was also pancultured, as she had been complaining
of dysuria and Foley catheter discomfort. Given her
hypotension and dysuria, the patient was started
empirically on Levaquin at renal dosing. She received one
dose and her urinalysis came back as extremely dirty with
greater than 300 white blood cells, moderate leuk esterase
and hematuria. The patient has a history of E. coli
resistant UTI's that are sensitive to cephalosporin.
Thus, I immediately changed the patient's antibiotics to
IV ceftriaxone 1 gm q 24 h. The patient also had a chest
x-ray at that time, as well as blood cultures. Please see
below for further infectious disease information. The
patient's blood pressure stabilized overnight. Her urine
output remained good, and she put out approximately 1,600
cc of urine over 24 hours. The patient was not mentating
well, however, and is still unclear to me at the time of
this dictation exactly what is causing the patient's
hypotension. I believe the most likely scenario is
sepsis. At the time of this dictation, the patient's
blood pressure is stable in the high 90's/50's. She is
currently on 5 mcg of dopamine peripherally through her
PICC line.
1. DECREASED MENTAL STATUS: The patient initially presented
with decreased mental status on [**2122-6-30**]. This is
when her blood pressure was at its lowest point. The
patient's change in mental status is most likely due to
sepsis and delirium. A STAT head CT was obtained on [**7-1**] for worsening mental status. The preliminary read of
this is negative for bleed. The patient had a witnessed
aspiration and vomiting on [**6-30**] and [**7-1**], and thus the
patient should be made NPO, in fear of further aspiration.
A neurology consult was obtained on day of transfer to the
[**Hospital Ward Name 12573**] ICU; however, this was deferred because of the
patient's inability to cooperate with exam. This consult
was initially obtained for patient's persistent spasticity
that had been going on for several days prior to this
decrease in mental status. Neurology should be
reconsulted in the future if her spasticity continues.
1. INFECTIOUS DISEASE ISSUES: The patient was complaining of
urine discomfort and Foley discomfort on [**2122-6-30**]. A
UA was extremely dirty and she was started on ceftriaxone,
as described above. She also had a witnessed aspiration
with a new right lower lobe infiltrate on her chest x-ray.
Thus, on [**2122-7-1**], prior to her transfer to the
[**Hospital Ward Name 12573**] ICU, she was given a dose of IV Flagyl 500 mg x 1.
The patient has also had a history of UTI's with
Enterococcus, both vancomycin sensitive and vancomycin
resistant. I have given her 1 dose of 1 gm IV vancomycin
prior to her transfer to the [**Hospital Ward Name 12573**] ICU. If patient
persistently declines, VRE should be in the differential.
I am worried this patient is septic. Her lactate level is
1.5; however, her hypotension, decreased mental status,
and continued emesis are worrisome. She has also had a
creatinine elevation on day of transfer to the [**Hospital Ward Name 12573**] ICU
to 2.4. Her white blood cell count is 11 and the manual
differential that was added is still pending at the time
of this dictation. The patient's cultures are pending,
and there is no growth to date.
1. CHRONIC RENAL INSUFFICIENCY: The patient's creatinine
remained at baseline during most of her [**Hospital Unit Name 196**] course.
However, on [**7-1**] she had an acute rise to 2.4. This is
likely ATN, as patient suffered hypotensive episode prior
to this rise. She also may be septic. She is still
making good urine and has a Foley catheter in place. Note
that this Foley catheter was changed when patient was
complaining of her dysuria.
1. DIABETES MELLITUS: The patient's NPH dosing has been
played with during her admission for initially
hypoglycemia. Her evening and morning NPH have both been
decreased. Her sugars are currently normoglycemic with
mild hyperglycemia. Her last 24 hours of sugars are 111
through 171.
1. COPD: The patient was continued on nebulizer treatments.
She has wheezing on exam constantly. She is on home O2
and never needed further oxygen requirements during her
admission at the CCU.
1. ACUTE RESPIRATORY ACIDOSIS: On [**7-1**], with patient's
decreased mental status, a blood gas was obtained that was
on 2 liter nasal cannula. Her pH was 7.29, PCO2 58, PO2
80, lactate 1.6, oxygen saturation 96. It was thought
that the patient may benefit from BIPAP therapy. She
remains a full code. A repeat blood gas 1 hour later
showed pH 7.3, PCO2 53 and PO2 104. Please note, there
were no interventions between these ABG's.
1. HYPOTHYROIDISM: The patient's TSH was mildly elevated
upon admission, but her free-T4 was normal. Her T3 was
decreased; however, and her Synthroid was increased during
her [**Hospital Unit Name 196**] course to 112 mcg qd.
1. OBSTRUCTIVE SLEEP APNEA: The patient was continued on her
CPAP of 15/0 q hs.
1. CHRONIC ANEMIA: The patient has had a GI work-up that has
been negative. Her hematocrit remained greater than 30
during her [**Hospital Unit Name 196**] course, and she never required
transfusion. She was continued on her [**Hospital1 **]-weekly Epogen
shots.
1. LOWER EXTREMITY PAIN: The patient has chronic lower
extremity pain and is maintained on fentanyl patch 25 mcg
and Percocet prn. These were discontinued, given
patient's decreased mental status on day prior to transfer
to [**Hospital Ward Name 12573**] ICU.
DISPOSITION: The patient will be transferred to the [**Hospital Unit Name 153**]
today for further management and care. Please see addendum
to this discharge summary for full details of the rest of the
hospital course. Please note that Narcan 0.4 mg was given to
patient x 1 prior to her transfer to assess for any narcotic
involvement in her decreased mental status. The patient had
no response to this, and her mental status remains very poor.
I attempted to contact the patient's daughter and son prior
to her transfer but was unable to get through. I left a
message with the daughter to call the floor for more
information.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**MD Number(2) 13600**]
Dictated By:[**Last Name (NamePattern1) 13506**]
MEDQUIST36
D: [**2122-7-1**] 13:15:24
T: [**2122-7-1**] 14:41:44
Job#: [**Job Number 105428**]
ICD9 Codes: 4280, 5990, 5070, 496, 2762 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3832
} | Medical Text: Admission Date: [**2100-8-8**] Discharge Date: [**2100-8-12**]
Date of Birth: [**2015-2-6**] Sex: M
Service: [**Year (4 digits) 662**]
Allergies:
Procainamide
Attending:[**First Name3 (LF) 3853**]
Chief Complaint:
Altered mental status, hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
85 yo M w/ PMH of bladder ca, CAD, HTN who is transferred from
OSH for concern for urosepsis. Pt presented to OSH day prior to
admission here with shaking chills and altered mental status. Pt
reports he has had urinary incontinece over the past few days
which is abnormal for him, denies any dysuria. He reports
awaking in the middle of the night with shaking chills and does
not recall what else happed but that his girlfriend must have
taken him to the [**Name (NI) **]. ON arrival to the OSH he was febrile to
103.3 and given 1 dose of tylenol. UA at the OSH was positive
for UTI. His BP dropped to 86/46 and he was given 3-4L of fluids
with improvement in BP to 101/48. They did a head CT for
concern of his altered mental status in the setting of
anticoagulation which was per report negative. He was
transferred here for further care given that this is where he
has all of his providers.
On arrival to the [**Hospital1 18**] ED he was febrile at 102.5 rectally and
was given 650mg of tylenol. He was initially hemodyanmially
stable, however his BP did drop down transiently into the 70s
and he was given 2L bolus of fluid with good response in his BP
and was stable in the 110s prior to transfer to the floor.
Repeat blood and urine cultures were performed and he was
admitted for possible urosepsis.
On arrival to the MICU the patient is sleepy and complains of
some chronic left sided pain. He denies any recent suprapubic
pain, nausea, vomiting, flank pain. He has not had a UTI since
[**2091**] and he denies any hematuria, or changes in his urine color.
10 point ros is negative except per above
Past Medical History:
-Recurrent bladder tumors- followed by Dr. [**Last Name (STitle) 3854**] recent urine
cytology from cystoscopy on [**3-/2100**] showed clusters of highly
atypical urothelial cells,suspicious for urothelial carcinoma.
-history of prostatitis dx at [**Hospital1 2025**]
-ATRIAL FIBRILLATION - amiodarone /warfarin
-CARPAL TUNNEL SYNDROME
-CHOLELITHIASIS
-CORONARY ARTERY DISEASE
CABG in [**2070**]: SVG to LAD, SVG to OM, SVG to PDA, cath in
[**2086**], severe native disease, occluded SVG to RCA and OM, patent
SVG to LAD, redo CABG
-HYPERTENSION
-INGUINAL HERNIA
-RENAL INSUFFICIENCY
Social History:
Social History: lives alone in an apartment and has a service
that he pays for were people can come help him if needed. Has a
son and is in a long term relationship. 40pack year former
smoker, quit years ago. Denies alcohol. Sings in acapella at
[**Hospital **] rehab
Family History:
Noncontributory
Physical Exam:
Admission Physical Exam:
Vitals: 97.8, 115/64, 52, 100% 2L
General: Alert, oriented, no acute distress , sleepy in bed
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Bradycardic, diastolic murmur at the LUSB not radiating,
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Protuberant, soft, non-tender, non-distended, bowel
sounds present, no organomegaly, no rebound or guarding
GU: yellow urine in foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
.
Discharge PE
VSS
CV: systolic murmur [**12-28**], brisk carotid upstroke
Lungs: CTAB, no wrr
Abdomen/Back: NTND, active BS, no CVA tenderness
-otherwise unchanged
Pertinent Results:
Admission Labs:
[**2100-8-8**] 07:24AM URINE RBC-155* WBC->182* BACTERIA-MANY
YEAST-NONE EPI-<1 TRANS EPI-1
[**2100-8-8**] 07:24AM URINE BLOOD-LG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-LG
[**2100-8-8**] 07:24AM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.017
[**2100-8-8**] 07:24AM PLT COUNT-324
[**2100-8-8**] 07:24AM NEUTS-81.8* LYMPHS-10.7* MONOS-6.5 EOS-0.5
BASOS-0.6
[**2100-8-8**] 07:24AM WBC-16.6*# RBC-3.72* HGB-11.4* HCT-34.4*
MCV-93 MCH-30.7 MCHC-33.2 RDW-14.4
[**2100-8-8**] 07:24AM GLUCOSE-115* UREA N-23* CREAT-1.4* SODIUM-144
POTASSIUM-4.4 CHLORIDE-110* TOTAL CO2-25 ANION GAP-13
[**2100-8-8**] 07:33AM LACTATE-1.2
[**2100-8-8**] 12:48PM PT-17.0* PTT-31.6 INR(PT)-1.6*
.
[**2100-8-10**]
IMPRESSION:
1. No evidence of pyelonephritis or perinephric focal fluid
collections. Note
that ultrasound has a relatively low sensitivity for detection
of
pyelonephritis (in the absence of significant phlegmon or
abscess).
2. 0.7 x 0.7 x 0.8 cm anechoic structure, likely representing a
small renal
cyst within the lower pole of the left kidney.
3. Enlarged prostate.
.
[**2100-8-8**] 7:24 am URINE
**FINAL REPORT [**2100-8-10**]**
URINE CULTURE (Final [**2100-8-10**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 8 S
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 32 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
BC pending from [**8-9**] and [**8-10**]
.
Brief Hospital Course:
85 yo M w/ PMHx of bladder tumors, prior episode of bacterial
prostatitis, CAD s/p CABG X2, AF, CKD, HTN who was transferred
from OSH with urosepsis and found to have GNR bacteremia who was
stabilized in the MICU with fluid resucitation and antibiotics
and continued to do well on floor after switching to oral
antibiotics
.
#Urosepsis likely secondary to prostatitis with altered mental
status
Patient has known bladder tumors and noted increased urinary
urgency and incontinence in the few days prior to admission. He
met sepsis criteria at the OSH with fever, tachypnea,
leukocytosis and positive UA which ultimately grew out EColi and
GNR bacteremia. He was started on zosyn at the OSH and this was
switched to cefepime initially in the MICU. His cultures at the
[**Hospital3 1280**] ([**First Name4 (NamePattern1) 3075**] [**Last Name (NamePattern1) 3549**] Hospital) were pending at the time of
discharge and despite multiple calls (including after discharge
on [**2100-8-14**])they were never faxed to [**Hospital1 18**]. I will send a note
to the patients PCP alerting her of the situation. At [**Hospital1 18**] the
patient grew out pan sensitive e. coli in his urine.
Surveillance blood cultures were no growth to date, his WBC
normalized and he was afebrile. His mental status was back to
baseline on the medical floors. In addition, his PSA was
checked which was elevated. After conversations with Dr. [**Last Name (STitle) 79**]
(the patients Urologist) and negative renal US, bacterial
prostatitis was thought to be the ultimate source of the
patients infection. The patient will be sent home on 3 weeks of
cipro for this. An interaction with Coumadin was noted, but
this was thought to be the best drug that concentrates in the
prostate and covers the patients e. coli.
.
# left leg pain
The patient describes about a 1 month history of left leg pain
in a radicular pattern radiating from his back down his leg.
His pain is improved with unloading of the spine (bending
forward) and is somewhat consistent with spinal stenosis. We
also considered sciatic nerve pain as a possibility. PT worked
with the patient and they indicated he was safe to go home with
a wheeled walker, a home safety evaluation and consideration of
home vs. outpatient PT. The patient was sent home with low dose
oxycodone (tolerated this in house with good relief) and a bowel
regimen. He was advised to consider follow up with a
Orthopedist for consideration of further management with
injection vs. surgery.
.
#Afib:
Patient is rhythm controlled with amiodarone. This was continued
while he was inpatient and his Coumadin was increased to 3 mg
QD. Further titration as an outpatient will likely be necessary
given that he will be on cipro for 3 weeks. His PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3855**]
will follow his INR and he was given a prescription to have this
re-checked in the next several days.
.
# Transitional Issues:
-please follow up with the patient blood cultures from [**Hospital 3856**]/[**First Name4 (NamePattern1) 3075**] [**Last Name (NamePattern1) 3549**] in [**Location (un) 47**] which were not yet speciated
but grew GNR
-please also note that the patient has pending blood cultures
from [**Hospital1 18**] on [**8-9**] and [**8-10**] which are pending that the time of
the discharge summary and they need follow up
-Follow up with PCP [**Last Name (NamePattern4) **] [**11-23**] weeks and have INR checked prior to
visit
.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Amiodarone 200 mg PO DAILY
2. Amlodipine 5 mg PO DAILY
hold for sbp<100 or hr<55
3. Losartan Potassium 100 mg PO DAILY
hold for sbp<100 or hr<60
4. Finasteride 5 mg PO DAILY
5. fish oil-dha-epa *NF* (om-3-dha-epa-fish oil-vit D3)
1,200-144-216 mg Oral daily
6. Aspirin 81 mg PO DAILY
7. Warfarin 2 mg PO EVERY OTHER DAY
8. Warfarin 3 mg PO EVERY OTHER DAY
9. Oxazepam 15 mg PO HS:PRN anxiety
10. Cetirizine *NF* 10 mg Oral qday prn allergies
11. Vitamin D 1000 UNIT PO DAILY
12. Multivitamins 1 TAB PO DAILY
13. Metamucil *NF* (psyllium;<br>psyllium husk;<br>psyllium husk
(with sugar);<br>psyllium seed (sugar)) 0.52 gram Oral qday
14. Ranitidine 150 mg PO BID:PRN reflux
15. Cialis *NF* (tadalafil) 20 mg Oral prn
16. Terbinafine 1% Cream 1 Appl TP [**Hospital1 **]
Discharge Medications:
1. Amiodarone 200 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Finasteride 5 mg PO DAILY
4. Losartan Potassium 100 mg PO DAILY
hold for sbp<100 or hr<60
5. Multivitamins 1 TAB PO DAILY
6. Terbinafine 1% Cream 1 Appl TP [**Hospital1 **]
7. Vitamin D 1000 UNIT PO DAILY
8. Ciprofloxacin HCl 500 mg PO Q12H Duration: 21 Days
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*42 Tablet Refills:*0
9. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN severe
pain
RX *oxycodone 5 mg one half to one tablet(s) by mouth every six
(6) hours Disp #*20 Tablet Refills:*0
10. Amlodipine 5 mg PO DAILY
hold for sbp<100 or hr<55
11. Cetirizine *NF* 10 mg Oral qday prn allergies
12. Cialis *NF* (tadalafil) 20 mg Oral prn
13. fish oil-dha-epa *NF* (om-3-dha-epa-fish oil-vit D3)
1,200-144-216 mg Oral daily
14. Metamucil *NF* (psyllium;<br>psyllium husk;<br>psyllium husk
(with sugar);<br>psyllium seed (sugar)) 0.52 gram Oral qday
15. Oxazepam 15 mg PO HS:PRN anxiety
16. Ranitidine 150 mg PO BID:PRN reflux
17. Warfarin 3 mg PO DAILY16
18. Outpatient Lab Work
please draw an inr on [**2100-8-13**] and fax to the office of the
patient pcp, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 3857**] [**Last Name (NamePattern1) 3855**] Phone: [**Telephone/Fax (1) 3858**]
Fax: [**Telephone/Fax (1) 3859**] atrial fibrillation (427.31)
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
acute bacterial prostatitis
e. coli bacteremia with sepsis and hypotension
coronary artery disease
hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You came to [**Hospital1 18**] from an outside hospital because you had low
blood pressure and bacteria in your blood. You were in the ICU
here and on antibiotics and your condition improved. The
bacteria from your blood likely came from an infected prostate.
Please take your antibitoics for a total of 3 additional weeks.
You will also be sent home with home PT. Please follow up with
your doctors as below.
.
Medication changes
1) cipro 500 mg Q12H for 3 weeks, last dose is [**2100-9-2**]-***please do not take cipro within 2 hours of taking milk,
iron or calcium***
2) coumadin 3 mg QD
3) tylenol 650 Q6H prn for mild to moderate pain (over the
counter)
4) oxycodone 2.5-5 mg Q6H prn for severe pain
5) docusate 100 [**Hospital1 **], for constipation while on narcotics (over
the counter)
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] T.
Location: [**Hospital1 **] [**First Name (Titles) 3860**] [**Last Name (Titles) 662**] CENTER
Address: [**Street Address(2) 3861**], [**Location (un) **],[**Numeric Identifier 3862**]
Phone: [**Telephone/Fax (1) 3858**]
Appointment: Thursday [**2100-8-19**] 12:00pm
Department: RADIOLOGY
When: TUESDAY [**2100-9-7**] at 10:35 AM
With: RADIOLOGY MRI [**Telephone/Fax (1) 590**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 861**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: SURGICAL SPECIALTIES
When: TUESDAY [**2100-9-7**] at 1 PM
With: [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 276**], M.D. [**Telephone/Fax (1) 277**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 5990, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3833
} | Medical Text: Admission Date: [**2109-4-1**] Discharge Date: [**2109-4-13**]
Date of Birth: [**2045-4-2**] Sex: F
Service: MEDICINE
Allergies:
Lisinopril / Kefzol / Sulfa (Sulfonamide Antibiotics) /
Shellfish Derived
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Temporary HD line placement
Arterial Line Placement
CVVH
Hemodialysis
Subclavean Central Line Placement
History of Present Illness:
63 y/o F with hx of severe diastolic CHF, pulm HTN, afib,
ulcerative colitis, and recent lower GI bleed who is transferred
from [**Hospital1 1774**] with acute dyspnea and hypoxia. Per her daughter,
she has been more dypsneic on exertion for the past week with
episodes somewhat relieved with albuterol. The pt reports that
she awoke at 3:15 AM with acute shortness of breath and
wheezing. She denies chest pain, palpitations, fevers, chills,
night sweats. She denies cough. An albuterol inhaler did not
help, so she went to the [**Hospital1 1774**] ED.
.
In the [**Hospital1 1774**] ED, she placed on bipap with O2sat 100%. Her BP
was initially 104/67, HR 55, RR13. CXR showed R pleural
effusion. BNP was 1500, cardiac enzymes negative. HCT was
noted to be 24.9 (baseline 24-27). At 6am her blood pressures
dropped to 83/44 and she was given a 125cc NS bolus. ABG on
bipap was 7.34/60/313/32. At 7:30am, Levophed gtt was started.
At 8am she was transitioned to a NRB and was satting 100%. Her
levophed was increased at 8:15am.
.
On arrival to the ICU, she reports comfortable breathing ever
since being placed on O2. ROS is otherwise positive for more
black stools over the past 2-3 days.
.
Of note, she was recently admitted [**Date range (3) 13475**] due to lower
GI bleed and HCT of 17. She required 6 units PRBCs that
admission and bleeding was felt to be due to lower GI
angioectasia; colonoscopy was not done due to recent scope [**1-30**]
which showed many angioectasias throughout the colon. HCT was
stable at 24.7 on discharge and most recent HCT [**3-26**] was 27.4.
She was also treated for congestive
heart failure exacerbation and acute renal failure on that
admission and was discharged on spironolactone, torsemide and
metolazone still about 40 lbs above her dry weight. At her
follow-up appointments, her weight was still stable, so
spironolactone was increased on [**3-15**] by Dr. [**Last Name (STitle) 118**] (weight 199
lbs) and her torsemide on [**3-18**] by Dr. [**First Name (STitle) 437**] (weight 196 lbs).
The pt reports medication compliance (does sometimes take
medications late) and general diet compliance although "ate more
over [**Holiday **]." She does recall an episode of left leg pain two
days ago while trying to go up stairs and feels she may have
been when she started feeling more short of breath, although the
acute episode of dyspnea was not until later.
.
Review of systems:
(+) Per HPI. Ongoing occasional nausea, vomiting with emesis
including medications at times.
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough. Denies chest pain, chest pressure,
palpitations, or weakness. Diarrhea, constipation, abdominal
pain, or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
# Diabetes
# Dyslipidemia (TG 53, Chol 145 HDL 71 LDL 63 on [**10/2107**])
# Hypertension
# atrial fibrillation off coumadin secondary to GI bleed
# severe diastolic dysfunction w/ right sided heart failure
# severe pulmonary hypertension
# severe tricuspid regurg (eval by card [**Doctor First Name **], not op candidate)
# EtOH remote history
# PFO closure ([**2108-3-21**])
# ulcerative colitis
# intermittent hyponatermia
# elevated LFTs
# angioectasia of the entire colon seen on colonoscopy [**2109-1-30**]
Social History:
-Married, separated from husband who is mentally ill, living
with son and his family currently (supportive)
-Tobacco history: No
-ETOH: +prior h/o heavy EtOH use, current intermittent EtOH use
-Illicit drugs: No
Family History:
-Father with MI at age 68
-Mother breast cancer at age 52
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Vitals: T 95.7, P 57, BP 104/71, RR 13, O2sat 100% 5L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, very promiment EJ, JVP elevated, no LAD
Lungs: Mild rales bilaterally, no wheezes, or ronchi
CV: Irregular rhythm, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: Soft, obese, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GI: Trace guaiac positive hard very dark brown stool
GU: Foley in place
Ext: warm, well perfused, 2+ pulses, 3+ edema bilateral to knees
and up posterior aspects to lower back, LLE more erythematous
with hematoma, calf tenderness bilaterally
Neuro: AAOx3, mild asterixis b/l, otherwise nonfocal
Pertinent Results:
[**2109-4-1**] 09:32PM UREA N-102* CREAT-2.4*
[**2109-4-1**] 09:32PM CK(CPK)-32
[**2109-4-1**] 09:32PM CK-MB-NotDone cTropnT-<0.01
[**2109-4-1**] 09:32PM HCT-26.8*
[**2109-4-1**] 03:32PM URINE HOURS-RANDOM UREA N-335 CREAT-27
SODIUM-84
[**2109-4-1**] 03:32PM URINE OSMOLAL-348
[**2109-4-1**] 03:32PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.007
[**2109-4-1**] 03:32PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2109-4-1**] 03:32PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2109-4-1**] 03:32PM URINE RBC-0-2 WBC-[**5-30**]* BACTERIA-FEW
YEAST-NONE EPI-0-2
[**2109-4-1**] 03:32PM URINE EOS-POSITIVE
[**2109-4-1**] 12:00PM GLUCOSE-109* UREA N-100* CREAT-2.5*
SODIUM-134 POTASSIUM-4.5 CHLORIDE-92* TOTAL CO2-26 ANION GAP-21*
[**2109-4-1**] 12:00PM ALT(SGPT)-9 AST(SGOT)-44* LD(LDH)-283*
CK(CPK)-39 ALK PHOS-194* TOT BILI-1.4
[**2109-4-1**] 12:00PM CK-MB-NotDone cTropnT-0.01 proBNP-6666*
[**2109-4-1**] 12:00PM CALCIUM-9.4 PHOSPHATE-6.5*# MAGNESIUM-2.4
[**2109-4-1**] 12:00PM TSH-4.7*
[**2109-4-1**] 12:00PM WBC-12.1*# RBC-3.33* HGB-8.9* HCT-28.8*
MCV-87 MCH-26.9* MCHC-31.0 RDW-16.3*
[**2109-4-1**] 12:00PM NEUTS-94.4* LYMPHS-3.0* MONOS-2.2 EOS-0.3
BASOS-0.1
[**2109-4-1**] 12:00PM PLT COUNT-236
[**2109-4-1**] 12:00PM PT-13.1 PTT-29.4 INR(PT)-1.1
[**2109-4-1**]: Portable CXR
INDICATION: 63-year-old female with history of CHF, shortness of
breath.
[**Month/Day/Year **] for pulmonary edema.
COMPARISON: Chest radiograph [**2109-2-26**] and multiple priors.
SINGLE PORTABLE SEMI-UPRIGHT VIEW OF THE CHEST: In comparison to
the most
recent chest radiograph as well as the recent CT, there has been
an increase
in a right pleural effusion. Lung volumes are low, accentuating
the heart
size, but even allowing for technique very stable moderate
cardiomegaly. The
bony thorax is unremarkable.
IMPRESSION: Increased right and continued left pleural effusion.
[**2109-4-1**]: Portable CXR
HISTORY: Central line placement.
FINDINGS: In comparison with the earlier study of this date,
there has been
placement of a right subclavian catheter that extends to the
mid-to-lower
portion of the SVC. Otherwise, little change.
The study and the report were reviewed by the staff radiologist.
[**2109-4-2**]: TTE
The left atrium is moderately dilated. The right atrium is
moderately dilated. A septal occluder device is seen across the
interatrial septum. The estimated right atrial pressure is
10-20mmHg. There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity size is normal. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Overall left ventricular systolic function is
low normal (LVEF 50-55%). The right ventricular cavity is
dilated with borderline normal free wall function. [Intrinsic
right ventricular systolic function is likely more depressed
given the severity of tricuspid regurgitation.] There is
abnormal septal motion/position consistent with right
ventricular pressure/volume overload.
The aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild to moderate
([**12-22**]+) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. Severe [4+] tricuspid
regurgitation is seen. There is probably significant pulmonary
hypertension although this could not be adequately quantified.
[In the setting of at least moderate to severe tricuspid
regurgitation, the estimated pulmonary artery systolic pressure
may be underestimated due to a very high right atrial pressure.]
Significant pulmonic regurgitation is seen. There is a very
small pericardial effusion. There are no echocardiographic signs
of tamponade. (Echocardiographic signs of tamponade may be
absent in the presence of elevated right sided pressures.)
Compared with the prior study (images reviewed) of [**2109-2-26**],
there is no significant change.
[**2109-4-2**]: Renal Ultrasound
INDICATION: Patient is a 63-year-old female with longstanding
hypertension.
[**Month/Day/Year **] for renal artery stenosis.
EXAMINATION: Renal ultrasound with Doppler.
COMPARISONS: Comparison is made to CT from [**2109-2-27**] and renal
ultrasound
from [**2109-2-25**].
FINDINGS: The right kidney measures 9.2 cm.
Left kidney measures 8.7 cm.
Both kidneys are relatively normal in size for patient's stated
age.
Both kidneys are unremarkable in appearance with no evidence of
hydronephrosis, nephrolithiasis, or discrete masses. Note is
made of a small
amount of pelvic free fluid. The bladder is collapsed about a
Foley catheter.
DOPPLER EXAMINATION:
Both main renal arteries demonstrate a brisk upstroke and good
diastolic flow.
There is normal venous drainage with normal venous waveforms
demonstrated.
Resistive indices were measured as ranging from 0.61 to 0.83
within the left
and 0.68 to 0.81 on the right. This is compatible with mild to
moderately
elevated resistive indices.
IMPRESSION:
1. No son[**Name (NI) 493**] evidence of renal artery stenosis. Mild to
moderately and
symmetrically elevated resistive indices bilaterally.
2. Unremarkable appearance of the kidneys.
3. Small amount of pelvic free fluid.
[**2109-4-4**]: CHEST RADIOGRAPH
INDICATION: Chronic heart failure, shortness of breath,
evaluation for
interval change.
COMPARISON: [**2109-4-3**].
FINDINGS: As compared to the previous radiograph, there is no
relevant
change. Unchanged moderate cardiomegaly with basal areas of
atelectasis and a
small right-sided pleural effusion. No newly occurred focal
parenchymal
opacity in the lung parenchyma. Unchanged course and position of
the two
right-sided central venous access lines. No pneumothorax.
Brief Hospital Course:
# Dyspnea/Hypoxia: Pt presented with dyspnea and hypoxia; she
was on Bipap and transitioned to NRB. She appeared fluid
overloaded clinically and on CXR with a BNP of 6666. Acute onset
raised concern for an inciting event, but no clear inciting
factor apparent. She did have mild leukocytosis to WBC 12 but no
fevers, cough, or clear consolidation suggestive of pneumonia.
She is in chronic atrial fibrillation but is rate controlled.
She had no chest pain to suggest ACS; EKG was at her baseline
and 2 sets of cardiac enzymes were negative. A pulmonary embolus
was considered but given no chest pain or tachycardia (on beta
blocker) this was not felt to be a concern. Thyroid dysfunction
unlikely to provoke acute decompensation. According to the
patient's daughter, the presentation may have actually been more
subacute over several days and there may have been a component
of suboptimal dietary/medication compliance in this patient with
baseline diastolic CHF that has been very difficult to manage.
She was begun on CVVH on [**2109-4-2**] and diuresis was begun. Her
admission weight was 87.6 kg and her maximum weight during
admission prior to CVVH was 92 kg. She continued on CVVH with
levophed as needed for pressure support until [**2109-4-8**]. She was
transferred to the regular floor and continued to receive
hemodialysis until discharge. She was discharged on her home
regimen of metolazone, torsemide and spironalactone. Permanent
transiton to hemodialsis had been discussed with her in detail
but she much preferred the option of an oral antidiuretic
regimen which she committed to be compliant with.
.
# Hypotension: The patient was hypotensive to the 80s systolic
in the OSH ED and she was started on levophed. She continued
requiring levophed for pressure support here in the ED and MICU
and a central venous line was placed here in her right
subclavian vein. The hypotension was felt to be cardiogenic in
the setting of worsening diastolic CHF. There was no evidence
for sepsis although the patient was found to have a UTI. Her
hematocrit did show a slight drop but blood loss and hypovolemia
were not felt to be contributing to her hypotension. Levophed
was maintained as needed while diuresing aggressively with CVVH.
.
# Hematochezia: The patient was recently admitted for anemia and
thought to have recurrent lower GI angioectasia bleeding.
During this admission she continued to have guaiac positive
stools but her hematocrit was relatively stable since her last
discharge. Her hematocrit was monitored closely and she was
transfused two units of packed red blood cells (one on [**2109-4-3**]
and one on [**2109-4-4**]) with an appropriate increase in her
hematocrit from 22.9 to 29.8. She continued taking her home
pantoprazole, and sub-cutaneous heparin was avoided in the
setting of her GI bleed.
.
# Acute renal failure: The patient was found to have BUN 100 and
Cr 2.5 (baseline 1.7). This was thought likely due to decreased
renal perfusion in the setting of decompensated heart failure.
Creatinine began trending down as patient started on CVVH.
Medications were dosed for the patient's creatinine clearance,
and the patient was followed by the renal consult team; Dr.
[**Last Name (STitle) 118**], the patient's nephrologist, saw her while in-house. She
was begun on CVVH on [**2109-4-2**] and diuresis was begun. Her
admission weight was 87.6 kg and her maximum weight during
admission prior to CVVH was 92 kg. She continued on CVVH with
levophed as needed for pressure support until [**2109-4-8**]. She was
transferred to the regular floor and continued to receive
hemodialysis until discharge. She was discharged on her home
regimen of metolazone, torsemide and spironalactone. Permanent
transiton to hemodialsis had been discussed with her in detail
but she much preferred the option of an oral antidiuretic
regimen which she committed to be compliant with.
.
# Elevated LFTs: The patient was noted to have mild AST and
Alkaline phosphate elevation with normal ALT and total
bilirubin. She had no abdominal pain and these values were felt
to be due to congestive hepatopathy; they resolved with
diuresis.
.
# Nausea: The patient had intermittent nausea, possibly related
to uremia. Abdominal exam was benign and the patient was given
zofran as needed.
.
# Atrial fibrillation: The patient remained stable with a slow
ventricular response. Her home metoprolol was held in the
setting of hypotension and she was not anticoagulated given her
history of significant GI bleeding.
.
# Diarrhea / ulcerative colitis: Dr. [**Last Name (STitle) 2987**], the patient's
gastroenterologist, was made aware of the patient's admission.
On admission, the patient had no abdominal symptoms such as pain
or diarrhea, and she did not seem to be having an acute
ulcerative colitis flare. She did develop diarrhea with
antibiotic treatment of her UTI that resolved when the
antibiotics were stopped. She continued taking her Asacol
though had some difficulties tolerating the medication without
vomiting due to the size of the pill.
Medications on Admission:
Albuterol HFA 90 mcg 2 puffs PO QID PRN
Ammonial Lactate 12% lotion [**Hospital1 **]
Dicloxacillin 500mg PO QID
Folic Acid 1 tab PO qday
Gabapentin 200mg PO qHS PRN leg spasm
Mesalamine 800mg PO TID
Metolazone 5mg PO BID
Metoprolol Tartrate 25mg PO BID
Metronidazole 0.75% cream [**Hospital1 **]
Omeprazole 20mg PO qday
Oxycodone 5mg PO 5mg PO q6H
Potassium Chloride 20meq with meals
Promethazine 12.5-25mg PO q6H PRN
Spironolactone 50mg PO qday
Torsemide 60mg PO BID
Trazodone 25mg PO qHS
ASA 81mg PO qday
Ferrous Sulfate 325mg PO BID
Miconazole 2% cream
Discharge Medications:
1. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO TID (3 times a day).
2. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Torsemide 20 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
6. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
7. Spironolactone 50 mg Tablet Sig: One (1) Tablet PO once a
day.
8. Metolazone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Methyl Salicylate-Menthol Ointment Sig: One (1) Appl
Topical QID (4 times a day) as needed for PRN PAIN.
10. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation four times a day as needed for
shortness of breath or wheezing.
11. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO QHS (once
a day (at bedtime)) as needed for leg spasm.
12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO
twice a day.
13. Promethazine 12.5 mg Tablet Sig: 1-2 Tablets PO every six
(6) hours.
14. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary
Acute on Chronic Diastolic Heart Failure.
.
Secondary
Acute Renal Failure
ulcerative colitis
Diabetes
Hypertension
Discharge Condition:
fully ambulatory with walker. Alert and oriented to person,
place and time.
Discharge Instructions:
You were admitted to the hospital because you were having
difficulty breathing. This was due to your heart failure which
also caused renal failure. You required dialysis to remove all
the extra fluid. A decision was made between you and your
nephrologist not to pursue permanent dialysis but to continue
using the diuretics you had been using at home.It is very
important that you minimize salt in your diet to less than
2g/day and that you drink less than 1.5L of fluid a day and take
all your medications.
We stopped your omeprazole as we think this lowered your
platelets.
We stopped the potassium for the time being. You can discuss
with Dr [**Last Name (STitle) 118**] when you should restart this.
We ADDED iron sulphate 325mg daily.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Department: INTERNAL MEDICINE
When: WEDNESDAY [**2109-4-17**] at 10:30 am
With: [**Last Name (NamePattern5) 6666**], MD, MPH [**Telephone/Fax (1) 4775**]
Building: [**Location (un) 2790**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
ICD9 Codes: 5849, 5119, 5990, 4280, 4168, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3834
} | Medical Text: Admission Date: [**2194-12-30**] Discharge Date: [**2195-1-5**]
Date of Birth: [**2127-12-26**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
[**2194-12-30**] - CABGx3 (Lima->Left anterior descending artery,
vein->obtuse marginal, vein->posterior descending artery);
MVR(27mm Mosaic Porcine Valve)
History of Present Illness:
66 y/o female with known [**Month/Day/Year **] artery disease and moderate
MR. Admitted for congestive heart failure. Work-up at that time
revealed severe MR [**First Name (Titles) **] [**Last Name (Titles) **] artery disease. She was thus
referred to Dr. [**Last Name (STitle) 1290**] for surgical management.
Past Medical History:
-[**Last Name (STitle) **] artery disease status post MI [**2186**], [**2191**]
-Hypertension
-Congestive heart failure (EF 20-25% in [**2186**], 50% in [**2191**], 35%
in [**2194**])
-Chronic Renal Insufficiency (baseline Cr 1.9-2.1 in [**2191**], 3.8
on discharge in [**2194-12-1**], 2.8 on discharge [**2194-12-23**])
-Diabetes Mellitus Type II
-Chronic back pain
Social History:
She has a 30 pack-year history of smoking; she quit in [**2186**].
She does not consume EtOH. Denies illicit substance use. She
lives alone and has five daughters.
Family History:
No family history of CAD or DM.
Physical Exam:
72 sr (R) 88/64 (L) 130/60
GEN: NAD
HEENT: NCAT, PERRL, Anicteric sclera, OP benign
NECK: Supple, FROM, No JVD
LUNGS: CTA
HEART: RRR, Nl S1-S2, III/VI SEM
ABD: Obese, NT, ND, NABS
EXT: No varicosities, 2+ pulses, warm, no edema.
NEURO: Nonfocal
Pertinent Results:
[**2195-1-2**] 07:05AM BLOOD WBC-6.4 RBC-2.98* Hgb-8.6* Hct-26.6*
MCV-89 MCH-28.9 MCHC-32.4 RDW-16.3* Plt Ct-188
[**2195-1-2**] 07:05AM BLOOD Plt Ct-188
[**2195-1-2**] 07:05AM BLOOD Glucose-112* UreaN-56* Creat-2.8* Na-139
K-4.5 Cl-106 HCO3-22 AnGap-16
[**2195-1-2**] 07:05AM BLOOD Calcium-8.4 Phos-4.2 Mg-2.5
[**2193-12-30**] - ECHO
PRE-CPB: 1. The left atrium is markedly dilated. No spontaneous
echo contrast is seen in the body of the left atrium. No
spontaneous echo contrast or thrombus is seen in the body of the
left atrium or left atrial appendage. No mass/thrombus is seen
in the left atrium or left atrial appendage.
2.No spontaneous echo contrast is seen in the body of the right
atrium. No atrial septal defect is seen by 2D or color Doppler.
3.Left ventricular wall thicknesses are normal. The left
ventricular cavity is moderately dilated. No left ventricular
aneurysm is seen. There is mild to moderate regional left
ventricular systolic dysfunction with global hypokinesis
especially of the anterior and inferoseptal walls.. No masses or
thrombi are seen in the left ventricle. [Intrinsic left
ventricular systolic function is likely more depressed given the
severity of valvular regurgitation.]
4.Right ventricular chamber size and free wall motion are
normal.
5.There are simple atheroma in the aortic root. There are simple
atheroma in the ascending aorta. There are simple atheroma in
the aortic arch. There are complex (>4mm) atheroma in the
descending thoracic aorta.
6.There are three aortic valve leaflets. The aortic valve
leaflets are
moderately thickened. There is mild aortic valve stenosis (area
1.2-1.9cm2). Trace aortic regurgitation is seen.
7.The mitral valve leaflets are moderately thickened. The mitral
valve
leaflets do not fully coapt. No mass or vegetation is seen on
the mitral
valve. Moderate to severe (3+) mitral regurgitation is seen. The
jet is
central. There annulus is not dilated. There is bileaflet
retraction with
moderate MAC.
POST-CPB: Pt is on epinephrine infusion. Well-seated
bioprosthetic valve in the mitral position with no mitral
regurgitation seen. LVEF now 40% on
inotropic support. Aortic valve now measures 1.9 cm2 , improved
from pre-cpb. Mild AS trace AI.
[**2195-1-1**] CXR:
There has been interval removal of a left-sided chest tube as
well as interval removal of a nasogastric tube and removal of a
Swan-Ganz catheter, with the right internal jugular sheath
remaining in place. There is no evidence of pneumothorax. The
mediastinal contours appear improved, but with a persistent
postoperative appearance. No region of consolidation is seen.
Pulmonary vascularity appears improved since the prior study.
The right costophrenic angle has been excluded from the film.
Brief Hospital Course:
Ms. [**Known lastname 29293**] was admitted to the [**Hospital1 18**] on [**2194-12-30**] for surgical
management of her mitral valve and [**Date Range **] artery disease. She
was taken to the operating room where she underwent [**Date Range **]
artery bypass grafting to three vessels and a mitral valve
replacement using a 27mm mosaic porcine valve. Postoperatively
she was taken to the cardiac surgical intensive care unit for
monitoring. On postoperative day one, she awoke neurologically
intact and was extubated. Beta blockade and aspirin were
resumed. On postoperative day two, she was transferred to the
step down unit for further recovery. She was gently diuresed
towards her preoperative weight. The physical therapy service
was consulted for assistance with he postoperative strength and
mobility. [**1-2**]
Ms. [**Known lastname 29293**] continued to make steady progress and was discharged to
rehab on postoperative day #6. She will follow-up with Dr.
[**Last Name (STitle) 1290**], her cardiologist and her primary care physician as an
outpatient.
Medications on Admission:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: 1.5 Tablet,
Chewables PO TID (3 times a day).
7. Hydralazine 25 mg Tablet Sig: 1.5 Tablets PO Q6H (every 6
hours).
8. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Continue on your home insulin dose of humalog, as before.
12. Lasix 80 mg Tablet Sig: One (1) Tablet PO once a day.
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:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. 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*
4. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 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. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
9. Calcium Carbonate 500 mg Tablet, Chewable Sig: 1.5 Tablet,
Chewables PO TID (3 times a day).
Disp:*135 Tablet, Chewable(s)* Refills:*2*
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
11. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days. Tablet(s)
12. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for
7 days. Capsule, Sustained Release(s)
13. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 25759**] & Rehab Center - [**Location (un) **]
Discharge Diagnosis:
CAD/MR s/p CABGx3 and MVR(27mm porcine)
Cardiomyopathy
CRI
HTN
Diabetes
CHF
Myocardial Infarction
Discharge Condition:
stable
Discharge Instructions:
1) Monitor wounds for signs of infection. These include redness,
drainage or increased pain.
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in
1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. No bathing or swimming
for 1 month. Use sunscreen on incision if exposed to sun.
5)No lifting greater then 10 pounds for 10 weeks.
6)No driving for 1 month.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) 1290**] in 1 month. ([**Telephone/Fax (1) 18151**]
Provider: [**Name10 (NameIs) 1344**] [**Last Name (NamePattern4) 3125**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2195-1-5**] 10:40
Follow-up with Dr. [**Last Name (STitle) 11493**] in 2 weeks.
Follow-up with Dr. [**Last Name (STitle) 27542**] in [**1-4**] weeks. [**Telephone/Fax (1) 27541**]
Call all providers for appointments
Completed by:[**2195-1-5**]
ICD9 Codes: 4240, 4280, 4254, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3835
} | Medical Text: Admission Date: [**2195-9-24**] Discharge Date: [**2195-10-14**]
Service: [**Company 191**] Medicine
at outside hospital in [**2195-9-21**] for pancreatitis secondary to
gallstones, transferred to [**Hospital1 69**]
on [**2195-9-24**] for ERCP. Post procedure patient's O2 saturation
decreased and patient was hypotensive with metabolic acidosis.
He was intubated on [**2195-9-25**] secondary to respiratory fatigue. The
patient started on Flagyl and Gentamycin on [**2195-9-24**] secondary to
increased temperatures. Vancomycin started on [**2195-9-25**], tube feeds
started on [**2195-9-26**]. The patient had episode of NSVT on [**2195-9-28**]
which resolved spontaneously. Surgery was consulted secondary to
increased temperature despite being on cholecystostomy since
patient was not a surgical candidate for cholecystitis which was
confirmed by ultrasound. The patient defervesced after drain was
placed on [**2195-10-1**]. The patient had repeat run of NSVT on [**2195-10-1**]
and was restarted on his beta blocker. On [**2195-10-2**] the patient
had new T wave inversions in anterior and lateral leads, however,
enzymes were negative. Echocardiogram showed decreased left
ventricular systolic function, inferolateral and anterior and
septal hypokinesis and 4+ MR. The patient was extubated on
[**2195-10-2**] and was started on po diet. Vancomycin was stopped.
The patient had been requiring diuresis since extubation.
The patient was transferred to floor for further management
of cardiac issues.
PAST MEDICAL HISTORY: TIAs, hypertension,
hypercholesterolemia, multifocal PVCs, diverticulosis,
coronary artery disease status post MI, CABG in [**2192**] times
five, BPH post TURP, macular degeneration.
MEDICATIONS: Home medications, Coumadin, Lipitor, Atenolol,
Lopressor. On transfer, Flagyl 500 mg IV q 8 hours,
Gentamycin 60 mg IV q 24 hours, Lopressor 12.5 mg po bid,
Nystatin swish and swallow qid, Aspirin, Protonix 40 mg po q
day, Captopril 25 mg po q 8 hours, Regular insulin sliding
scale, Ativan prn, Morphine prn, Albuterol nebs prn.
ALLERGIES: Patient allergic to Penicillin.
SOCIAL HISTORY: The patient smokes tobacco.
PHYSICAL EXAMINATION: Upon transfer heart rate 93,
respirations 22, 95% on 2 liters, temperature 97.9, blood
pressure 124/84. In general patient is sitting in chair in
no acute distress. HEENT, oropharynx with moist mucus
membranes. Neck, left subclavian line in place.
Cardiovascular, regular rate and rhythm, grade 2/6 systolic
ejection murmur heard loudest at apex. Lungs, decreased
heart sounds at the bases, left greater than right,
expiratory rhonchi. Abdomen, gallbladder drain in place,
minimal tenderness around drain site, otherwise soft,
nontender, non distended with positive bowel sounds.
Extremities, no edema in lower extremities, good pulses
bilaterally.
LABORATORY DATA: Gallbladder fluid growing rare enterococcus
gram stain, 4+ PMN's, no organisms. Chest x-ray showed
cardiomegaly with bilateral pulmonary edema, mild CHF, left
lower lobe consolidation consistent with pleural effusion and
atelectasis vs infection.
HOSPITAL COURSE: The patient was continued on Flagyl and
Gentamycin IV for cholecystitis.
The patient had episode of acute renal failure with rising
creatinine. All nephrotoxic drugs were stopped. Renal
ultrasound was normal. The patient began responding to fluid
boluses.
GI, patient had persistently elevated alkaline phosphatase and
total bilirubin throughout hospital course. After being
transferred to the floor the patient developed new abdominal
tenderness around bile drain site. CT of the abdomen was
negative for bile leak, but subsequent imaging revealed evidence
of a leak. After discussion with the patient, his wife, and his
sons, he was taken to ERCP for possible stent placement. ERCP
showed bile duct which was not dilated but contained irregular
strictures, with small stones at the junction of the cystic duct.
Multiple stones were present in the gallbladder. A plastic
stent was successfully placed. In the recovery room following
the ERCP procedure, the patient had sudden decrease in
respiratory effort with loss of consciousness and loss of pulse.
The patient was in PEA. Chest compressions were started. Despite
receiving Epinephrine, Neo-Synephrine, Ephedrine, Atropine the
patient went into new V tach, was shocked at 300 joules. The
patient then returned to slow PEA. After 30 minutes of CPR the
code was called. Time of death 2:42 p.m. The patient's son,
wife, and in-laws were notified. Autopsy was declined.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 4814**]
Dictated By:[**Name8 (MD) 7112**]
MEDQUIST36
D: [**2195-11-24**] 12:11
T: [**2195-11-26**] 09:06
JOB#: [**Job Number 36696**]
ICD9 Codes: 5185, 9971, 4275, 4280, 4271, 0389 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3836
} | Medical Text: Admission Date: [**2120-11-19**] Discharge Date: [**2094-2-8**]
Date of Birth: [**2044-8-23**] Sex: F
Service: [**Doctor Last Name 1181**] MEDICINE
CHIEF COMPLAINT: Shortness of breath and dyspnea.
HISTORY OF PRESENT ILLNESS: The patient is a 76-year-old
woman who was recently discharged from the [**Hospital1 346**], where she was evaluated for
multiple medical problems listed separately in the past
medical history, who was transferred from [**Location (un) 2716**] Point
because of increasing dyspnea, shortness of breath, and cough
for one day. The patient has chronic fevers. She denied a
battery of constitutional symptoms including headache, fever,
chills, nausea, vomiting, diarrhea, dysuria.
PAST MEDICAL HISTORY:
1. Breast cancer metastatic to [**Location (un) 500**] and spleen.
2. Fever of unknown origin likely due to malignancy or
adrenal insufficiency.
3. Left lower lobe collapse.
4. Congestive heart failure with diastolic dysfunction and
preserved ejection fraction.
5. Atrial fibrillation.
6. Adrenal insufficiency status post bilateral adrenalectomy.
7. Melanoma status post excisional biopsy.
8. Meningioma status post resection.
9. Thyroid nodules of unclear origin.
10. Inappropriate antidiuretic hormone release previously.
11. External hemorrhoids.
ALLERGIES: Opiates of unclear reaction as well as to tape,
where she develops a rash.
MEDICATIONS ON PRESENTATION:
1. Mirtazapine 50 mg in the evening.
2. Tranxene 7.5 mg daily.
3. Lorazepam 0.25 mg daily.
4. Colace 100 mg twice daily.
5. Fludrocortisone 0.1 mg daily.
6. Hydrocortisone 30 mg in the morning and 20 mg in the
evening.
7. Pantoprazole 40 mg daily.
8. Arimidex 4 mg daily.
9. Metoprolol 62.5 mg daily.
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs:
Temperature 98.4, heart rate 101 and irregular, blood
pressure of 164/67, and oxygen saturation is 89% on room air,
and 98% on 4 liters nasal cannula.
General: This is a chronically ill appearing elderly-pale
woman, who did not cooperate with the entire examination.
HEENT: Normocephalic. There is a well-healed scar from her
meningeal resection, she has anicteric sclerae and pale
conjunctivae. Pupils are equal, round, and reactive to
light. Extraocular movements are intact without nystagmus.
The throat was clear.
Neck: Supple, thyroid not palpable, the jugular veins are
flat. There is no carotid bruit.
Nodes: There is no cervical, supraclavicular, axillary, or
inguinal adenopathy.
Lungs: She had poor effort, decreased excursion, and
decreased breath sounds at the based. She had slight
wheezing and crackles diffusely.
Heart: Irregular, tachycardic, normal S1, S2, no extra
sounds.
Abdomen: She had normal bowel sounds, soft, nontender, and
nondistended. Spleen tip was palpable. The liver was not
palpable.
Extremities: The patient had +2 lower extremity edema to her
mid calf.
Vascular: The radial, carotid, and dorsalis pedis pulses
were +2 bilaterally.
LABORATORY EVALUATION ON PRESENTATION: White blood cell
count 47.4, hematocrit 26.0, platelets 209. Chemistry panel
was normal.
Electrocardiogram revealed multifocal atrial tachycardia at
95 beats per minute, there was no interval change from a
previous electrocardiograms.
HOSPITAL COURSE:
1. Cardiac: Over the course of the patient's long hospital
stay, her dose of metoprolol was sequentially increased from
62.5 mg twice daily to ultimately 75 mg every eight hours for
rate control. In consultation with the Cardiology service,
the patient was also given an ACE inhibitor. She required
periodic diuresis with furosemide, approximately every four
days she received furosemide for volume overload. Her heart
rate and blood pressure were well controlled on this regimen.
Patient underwent repeat surface echocardiography which
revealed increased pulmonary hypertension, unchanged ejection
fraction.
2. Endocrine: The patient's requirement for hydrocortisone
replacement fluctuated during the course of the hospital stay
in consultation with the Endocrine service, an attempt was
made to lower her hydrocortisone replacement, however, her
white blood cell count climbed to over 70 when decreasing the
dose of Hydrocortisone to 25 mg every 12 hours. She
ultimately required several stress doses up to 100 mg every
eight hours.
Her fingersticks were always within the normal range despite
several conventional serum glucose values below 40, this was
attributed to pseudohypoglycemia caused by high white blood
cell count.
The patient underwent ultrasonography of the thyroid gland,
which revealed nodules unchanged from previous evaluation.
Given the multiple comorbidities of this patient, the
Endocrine service did not recommend further evaluation at
this time.
3. Psychiatric: The patient had several episodes of
confusion, paranoid delusions, and visual hallucinations. In
consultation with the Psychiatric Service, she was given a
trial of Risperidone, however, the patient was overly sedated
on this medication, and was eventually withdrawn.
The patient underwent further computer tomography of the head
revealing no new mass lesions during two or three episodes of
unresponsiveness.
4. Hematology: As reviewed in previous summary, the patient
is now transfusion dependent. He received a transfusion of
[**12-12**] pack units approximately every 3-4 days while in the
hospital to maintain a hematocrit of approximately 38%. She
also required periodic diuresis with blood transfusions, no
fevers or adverse reactions occurred during transfusion.
5. Oncology: As reviewed in previous summaries, the patient
underwent [**Month/Day (2) 500**] marrow biopsy on her last admission. Her
cytogenetic evaluation revealed possible early
myelodysplastic syndrome or AML given that there were two
cells bearing the lesion that ....................
chromosome.
The Oncology service was consulted, and they deemed that the
patient does not have either myelodysplastic syndrome or AML.
The patient underwent splenic biopsy in the Interventional
Radiology suite twice. The first time the pathology specimen
revealed collection of megakaryocytes, though was not
diagnostic. The second time, a large amount of necrotic
debris, macrophages was recovered as well as neutrophils.
This was deemed to be consistent with infection.
6. Infectious Disease: Patient's fevers over the first half
of her hospital course abated, however, she did have
persistent white blood cell elevation attributed to
malignancy and adrenal insufficiency. Her large left pleural
effusion as well as her cerebrospinal fluids were sampled,
neither which shown to have an infection. However, on
[**2120-12-17**], the patient became hypotensive. Urinalysis
revealed Enterococcal urinary tract infection. She was
transferred to the Intensive Care Unit for sepsis. She was
placed on Vancomycin intravenously. After two days, her
blood pressure stabilized, and she was returned to the
General Medical Floor.
The remainder of this hospital summary will be dictated
separately.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**]
Dictated By:[**Last Name (NamePattern4) 96234**]
MEDQUIST36
D: [**2120-12-19**] 11:04
T: [**2120-12-19**] 11:03
JOB#: [**Job Number **]
ICD9 Codes: 5119, 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3837
} | Medical Text: Admission Date: [**2119-11-12**] Discharge Date: [**2119-11-21**]
Date of Birth: [**2067-3-23**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamides) / Toradol / Compazine /
Morphine
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
hematemesis
Major Surgical or Invasive Procedure:
RIJ Cordis line placement [**11-12**], changed to central line [**11-18**]
History of Present Illness:
This is a 52 y/o female with h/o UGI bleed with duodenal ulcers,
DVT/PE, afib, anticoagulated with coumadin who is admitted with
hematemesis and hematocrit of 15.4. Patient was recently
admitted [**2119-10-29**] to [**Hospital1 **] with melena and INR 5.5. She had an
EGD and colonoscopy which showed duodenitis, and features
suggestive of duodenal ulcer, and diverticulosis. She was h.
pylori negative and she never required any blood transfusion as
hct was stable at baseline to 32. Patient was sent home on
coumadin and lovenox as a bridge. She reports her INR was 1.7
last Tuesday. Beginning on Friday the patient had coffee ground
emesis, but none significant since last night. She also noticed
black stools this morning. She didn't want to come in earlier
b/c she was afraid of getting a blood transfusion. Patients InR
on admission was 4.9 and hct was 15. Blood pressure was slightly
low with systolics in the 90s, patient was not tachycardic. She
has had some intermittent epigastric abdominal pain, none on
admission. Does have some right sided chest pain since her PE 1
year ago. She got 1 L IVF and a 16 G PIV and then was
transferred up to the ICU for further transfusions and
monitoring. In the ICU patient given FFP and vitamin K to
reverse INR and transfused 6 units of PRBC. After reversal of
coumadin and blood transfusion patient's Hct remained stable. GI
following in ICU and deferred immediate EGD given recent
negative EGD. Also while in the ICU patient was complaining of
RUQ pain and an U/S was ordered which showed dialation of common
bile duct without any evidence of stones and also left mid wall
fluid collection that represents a chronically infected or
inflammatory fluid collection, and atrophic right kidney. Based
on these findings a CT scan of abdomen was ordered. Patient
currently still with abdominal pain but states the IV diluadid
is helping.
Past Medical History:
PMH:
s/p DVTs and PEs (most recently within last 3 months)
UGIB while on Coumadin (No documentation)
Myofascial pain syndrome
Migraines
Pseudotumor cerebri
Praoxysmal AFIB
GERD
PUD
Parotid Gland Tumor
Past Psych Hx:
The patient reports seeing a psychiatrist once many years ago to
work through grief over her mother's death. The patient
acknowledges that her Neurologist had her involuntarily admitted
to a psychiatric facility for reported delusion of her body
being infested with mice, but says this was a false accusation.
Social History:
Social History:
Social/Substance Abuse History:
The patient is a retired nurse (now works as organist).and has
been married for over 30 years and lives at home with husband.
The patient states she has two sons who live in the area. She
states that she smokes 2 cigarettes a day at most. She denies
any history of alcohol or drug abuse, denies detoxes, seizures
or DTs in the past. Patient did report to one nurse that she
occasionally takes extra of her oxycontin due to severe
pain.There is a history in the chart of domestic violence on the
part of her husband. She lives with her husband and 29yo son.
Family History:
Family History:
Mother had lupus and ?blood clots.
She denies any psychiatric illness among her family, however.
Physical Exam:
PE: T 99.1 HR 75 BP 99/65 RR 16 95% on 4 L NC
GEN: overweight very pale female, anxious, odd affect
HEENT: perrl, eomi, dry mucus membranes, pale conjucntiva
NECK: supple, no masses, scar from recent left ej seen.
CV: rrr s1s2
LUNgS: CTA b/l
ABD: mild tenderness in epigastric/ruq area
EXT: no edema
REctal: per GI fellow black OB+ stools
Neuro: alert and oriented x 3, otherwise grossly nonfocal
Pertinent Results:
[**2119-11-12**] 03:51PM HGB-4.6* calcHCT-14
[**2119-11-12**] 03:30PM GLUCOSE-122* UREA N-16 CREAT-0.8 SODIUM-140
POTASSIUM-4.3 CHLORIDE-108 TOTAL CO2-23 ANION GAP-13
[**2119-11-12**] 03:30PM ALT(SGPT)-34 AST(SGOT)-48* ALK PHOS-125*
AMYLASE-30 TOT BILI-0.2
[**2119-11-12**] 03:30PM LIPASE-42
[**2119-11-12**] 03:30PM TOT PROT-6.1*
[**2119-11-12**] 03:30PM WBC-8.2 RBC-1.69*# HGB-4.8*# HCT-15.4*#
MCV-91 MCH-28.1 MCHC-30.9* RDW-16.8*
[**2119-11-12**] 03:30PM NEUTS-72.9* BANDS-0 LYMPHS-22.2 MONOS-3.8
EOS-0.7 BASOS-02
[**2119-11-12**] 03:30PM PLT COUNT-359#
[**2119-11-12**] 03:30PM PT-24.2* PTT-29.8 INR(PT)-4.3
CXR: IMPRESSION: No evidence for CHF or pneumonia. The pulmonary
vasculature is unremarkable.
Brief Hospital Course:
A/P: 52 y/o F with h/o duodenal ulcers and GIB while
anticoagulated for afib/pe/, initially admitted to MICU with
hematemesis and significant hct drop with supratherapeutic inr,
now transferred to medicine floor for further management.
.
1. GI Bleed: The pt's GIB was thought likely to be resulting
from her duodenal ulcers and supratheraputic INR. It was unclear
if the pt was noncompliant with PPI therapy vs if her GIB was
secondary to PPI resistance or failure. The pt initially
required 6 units PRBCs transfusion and Vitamin K on initial
admission to the MICU but her Hct had been stable since transfer
to the floor and she remained hemodynamically stable. Records
from [**Hospital **] hospital re: prior bx results and EGD performed in
[**2116**] showed antral gastritis and prepyloric ulcer. GI followed
the patient while in house and decided to defer EGD for now as
the pt had a recent EGD and her Hct remained stable. The pt
required no further transfusions while on the medical floor she
remained on IV PPI [**Hospital1 **] until her discharge. She had very poor
IV access and had a RIJ cordis in place until this was changed
to a triple lumen catheter. Ultimately, the patient requested
that she have EGD performed under general anesthesia and she is
currently scheduled for EGD for [**Month (only) **] under general
anesthesia which was arranged by GI. Her coumadin will need to
be held 5 days prior to her procedure.
2. ?abdominal wall fluid collection: U/S on [**11-13**] showed a fluid
collection in her abd wall which was not communicating with the
bowel and likely represented a chronically inflamed or infected
fluid collection. This was thought to be likely secondary to
heparin or lovenox injections. NO further abdominal imaging was
performed.
.
3. PE/DVT: After thorough investigation into pt's history of PE,
it was found that CTA [**2119-9-29**] from OSH records showed small
subsegmental RUL and RML PE, but subsequent imaging here at
[**Hospital1 18**] had not shown PEs (CTA here at [**Hospital1 18**] [**2119-10-2**] showed
resolution of PE and CTA [**10-23**] revealed no definite PE although
there was decreased attenuation in subsegmental RML). We had
these scans re-read by radiology on this admission and radiology
confirmed that the original CTA done on [**2119-9-29**] at [**Location (un) 620**] did
show a very small subsegmental RML PE which had resolved on
subsequent CTAs here at [**Hospital1 18**] (in the interim, pt had been
treated with heparin). The radiologist had hypothesized that it
was possible that a pulmonary embolus could clear after only 3
days of therapy given how small the clot burden appeared to be
on the original CTA done at [**Location (un) 620**]. In addition, it was
confirmed that the patient only had episodes of superficial
thrombophlebitis and never had a confirmed DVT. The pt had been
anticoagulated since [**Month (only) 216**] for PE as well as afib and had had 2
episodes of GIB since requiring several PRBC transfusions. The
medicine team on this admission had an extensive discussion with
the patient re: the risk of continuing anticoagulation therapy
with no current evidence of pulmonary embolus in the setting of
a large duodenal ulcer. The patient was very focused on her
diagnosis of pulmonary embolus and after much discussion, the
decision was made to continue anticoagulation given the
patient's discomfort in stopping anticoagulation. The patient
was kept in house with heparin drip as bridge until her INR
reached 2.0. She was discharged with instructions to follow her
INR closely at her PCP's office.
4. Right pleuritic chest pain: Pt has had complaints of this
several times in the past and was being treated for a PE. EKGs
repeatedly remained unchanged. The etiology for this pain was
unclear but was thought to be likely musculoskeletal.
5. UTI: pt had evidence of a UTI on urinalyis and was treated
with Cipro [**Hospital1 **] for a 3 day course.
.
6. Afib: Pt remained in afib, rate controlled, and
anticoagulated with heparin and coumadin. She remained on a B
blocker while in house and was discharged on her outpatient dose
of Atenolol.
7. Chronic pain: Pt was continued on oxycontin and percocet prn
per her outpatient regimen for chronic pain related to her
pseudotumor cerebri.
.
8. Psych: Pt had some history of psychiatric
hospitalization/delusions in the past but this has never been
formally evaluated by psychiatry. She definitely lacked
insight into her disease process and it was often difficult to
address the complex medical issues re: her GIB risk and
anticoagulation for PE. She was continued on clonazepam and
ativan prn.
9. Hypothyroidism - She was continued on levoxyl
.
10. Code: full.
11. Access: this was extremely difficult to obtain. Pt had a
RIJ cordis placed initially on ICU admission which then was
changed to a triple lumen catheter and remained in place until
her discharge.
12. Dispo: Patient was discharged after her INR was therapeutic
with instructions to follow up the next day for a follow-up INR
check. She will need to return in [**Month (only) **] for EGD under
general anesthesia per her request.
Medications on Admission:
protonix 40 [**Hospital1 **]
levoxyl 100 qd
oxcontin 40 [**Hospital1 **]
albuterol inh rpn
atrovent inh prn
clonopin 1 tid prn
risperdal 1 po hs
atenolol 25 qd ca;coi,
coumadin and lovenox stopped friday
percocet prn
-
Discharge Medications:
1. Oxycodone 20 mg Tablet Sustained Release 12HR Sig: Two (2)
Tablet Sustained Release 12HR PO Q12H (every 12 hours).
[**Hospital1 **]:*28 Tablet Sustained Release 12HR(s)* Refills:*0*
2. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed.
[**Hospital1 **]:*21 Tablet(s)* Refills:*0*
3. Levothyroxine Sodium 100 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
[**Hospital1 **]:*7 Tablet(s)* Refills:*0*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
[**Hospital1 **]:*30 Tablet(s)* Refills:*0*
5. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day.
[**Hospital1 **]:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
6. Coumadin 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
[**Hospital1 **]:*14 Tablet(s)* Refills:*0*
7. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
[**Hospital1 **]:*14 Tablet(s)* Refills:*0*
8. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day.
[**Hospital1 **]:*14 Tablet(s)* Refills:*0*
9. Zofran 4 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for nausea.
[**Hospital1 **]:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1. GI bleed
2. Peptic ulcer disease
3. Atrial fibrillation
4. h/o PE
Discharge Condition:
Stable
Discharge Instructions:
Please continue to take all medications as you were previously
taking. You should resume your Coumadin dose at 6 mg QHs.
You will need to have your Coumadin dosage and INR monitored
very closely so that you do not have any further instances of GI
bleeding, so you should plan to go to your PCP's office tomorrow
to have your INR checked.
Please return to the ED or call your PCP if you experience any
worsening abdominal pain, nausea or vomiting, dark or tarry
stools, blood in your stool, dizziness or lightheadedness, or
any other concerning symptoms.
Followup Instructions:
You will need to have your INR checked by your PCP tomorrow and
likely every day this week for goal INR 2.0-2.5. Your PCP will
then adjust your coumadin dosage.
The gastroenterologists have set up your outpatient EGD under
general anesthesia for [**1-4**] at 2 pm (see below). Please keep
this appointment and stop taking your Coumadin 5 days prior to
your procedure. You will need to have your INR checked one day
prior to the procedure and those results should be emailed to
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] by your PCP:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Where: [**First Name8 (NamePattern2) **] [**Hospital Ward Name **] BUILDING
([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX) ENDOSCOPY SUITE Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2120-1-4**] 2:00
Provider: [**Name Initial (NameIs) **] SUITE GI ROOMS Where: GI ROOMS Date/Time:[**2120-1-4**]
2:00
Completed by:[**2119-12-3**]
ICD9 Codes: 5990, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3838
} | Medical Text: Admission Date: [**2201-6-30**] [**Month/Day/Year **] Date: [**2201-7-8**]
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / NSAIDS (Non-Steroidal
Anti-Inflammatory Drug)
Attending:[**Doctor First Name 3290**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Endoscopic retrograde pancreatography (ERCP) with stone removal
and two temporary bile duct stents placed [**2201-6-30**]
History of Present Illness:
89 year-old woman with history of multiple CBD stones and ERCP's
most recently [**2201-3-25**] in addition to HTN, gout, bioprothetic
valve replacement, hpothyroidism and GERD now transfered from
OSH with epigastric pain and elevated LFTs. Patient initially
presented to [**Hospital3 **] with a 1 day history [**8-4**]
epigastric abdominal pain. Patient further endorses 1 episode of
non bloody vomiting the morning of presentation. She reports
subjective fevers (temp of 99.3 at [**Hospital1 46**]) in addition to
anorexia and a 40 lb wt loss over the past few months. Patient
denies loose stools, melena or BRBPR. She further notes a non
productive cough. On arrival BP and pulse were elevated to
190/80 and 105 respectively in the setting of pain. Initial labs
at [**Hospital1 46**] were notable for a Tbili of 5.5. She was given Zosyn,
IVF, and morphine for pain and transferred to [**Hospital1 18**] for further
management.
In the ED, initial VS were: 98.2 92 111/39 18 97% 2L Nasal
Cannula. RUQ US was notable for severe intra and extra biliary
dilitation. Labs were notable for Tbili of 5.5 (4.8 direct),
ALT/AST of 203/243 and alk phos of 186. She was given 1 L of
IVF. The patient was evaluated by surgery who recommended
admission to medicine for ERCP tomorrow. Patient was admitted to
the [**Hospital Unit Name 153**] for further management.
On arrival to the MICU, patient's VS. 98.1 101/44 75. She
denied current discomfort.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies shortness of
breath, dyspnea or wheezing. Denies chest pain, chest pressure,
palpitations. Denies constipation, diarrhea, dark or bloody
stools. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
Bioprosthetic valve
Hypothyroidism
GERD
Hypertension -
Gout
Type II DM, currently off medication
Atrial fibrillation on aspirin only
History of stroke
Skin ca
S/p appy/chole
S/p multiple ERCPs with stent placement most recently [**3-8**]
Social History:
Patient lives alone in her trailer home. Her granddaughter helps
with her medication. She previously worked in an automobile
factory on the line and retired at 80. She reports occasionaly
smoking in the past but denies alcohol or illicit drug use.
Family History:
DM in several family members
Physical Exam:
ADMISSION EXAM:
Vitals: See metavision
General: Alert, oriented, no acute distress
HEENT: Sclera icteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, [**3-2**] holosystolic
murmur
Lungs: Crackles [**1-26**] way up bilaterally
Abdomen: Soft, non-distended, mildly TTP in LUQ bowel sounds
present, no organomegaly, No tenderness to palpation, no rebound
or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, gait deferred.
Skin: Diffuse juandice
Pertinent Results:
[**2201-6-30**] 12:01AM BLOOD WBC-8.9 RBC-3.20* Hgb-10.7* Hct-31.2*
MCV-97 MCH-33.3* MCHC-34.2 RDW-14.1 Plt Ct-112*
[**2201-6-30**] 12:01AM BLOOD Neuts-83* Bands-2 Lymphs-11* Monos-3
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0
[**2201-6-30**] 12:01AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ Schisto-1+
Tear Dr[**Last Name (STitle) **]1+
[**2201-6-30**] 12:01AM BLOOD PT-15.7* PTT-28.7 INR(PT)-1.5*
[**2201-6-30**] 12:01AM BLOOD Glucose-255* UreaN-26* Creat-1.1 Na-135
K-4.3 Cl-98 HCO3-23 AnGap-18
[**2201-6-30**] 12:01AM BLOOD ALT-203* AST-243* AlkPhos-186*
TotBili-5.5* DirBili-4.8* IndBili-0.7
[**2201-6-30**] 12:01AM BLOOD Lipase-11
[**2201-6-30**] 12:01AM BLOOD Albumin-3.9 Calcium-9.1 Phos-4.5 Mg-1.6
[**2201-7-2**] 04:40AM BLOOD CEA-1.1
[**2201-6-30**] 12:03AM BLOOD Lactate-2.9*
[**2201-7-2**] 04:40AM BLOOD CA [**08**]-9 43 (elevated)
[**2201-6-30**] BLOOD CULTURE: Negative
[**2201-6-30**] MRSA SCREEN: Negative
CXR PA AND LATERAL [**2201-6-30**]:
1. Prominence of the interstitial markings, likely due to mild
pulmonary
edema.
2. No acute cardiothoracic process.
LIVER U/S [**2201-6-30**]:
Severe intra- and extra-hepatic biliary dilatation with the CBD
measuring up to 1.3 cm and well-formed sludge in the distal CBD.
No evidence of shadowing stones.
ERCP [**2201-6-30**]:
- Evidence of a previous sphincterotomy was noted in the major
papilla.
- Cannulation of the biliary duct was successful and deep with a
sphincterotome using a free-hand technique.
- Contrast medium was injected resulting in complete
opacification.
- A single irregular stricture that was 1 cm long was seen at
the common hepatic duct. There was post-obstructive dilation in
both right and left intrahepatic bile ducts. Differential is
impacted stone vs malignancy.
- A large impacted stone was noted in the left intrahepatic duct
and a smaller stone was noted in the right intrahepatic duct.
- Cytology samples were obtained for histology using a brush in
the common hepatic duct.
- Given patient's presentation with cholangitis, impacted stones
in right and left biliary tree, a common hepatic duct stricture,
initially, a 10cm by 10FR Cotton [**Doctor Last Name **] biliary stent was placed
successfully in the right hepatic duct.
- However, that resulted in obstruction of the left hepatic duct
and a guidewire could not be advanced into the left intrahepatic
ductal system.
- This stent was then removed using a snare.
- The two guidewires were placed separately in right and left
intrahepatic ducts.
- A 10cm by 10FR double pig tail biliary stent was placed
successfully in the left main hepatic duct.
- A 14cm by 10FR Cotton [**Doctor Last Name **] biliary stent was placed
successfully in the right intrahepatic biliary branches.
CYTOLOGY, BILE DUCT BRUSHINGS [**2201-6-30**]: Common hepatic duct
brushing:
NEGATIVE FOR MALIGNANT CELLS.
FOOT XRAY, RIGHT [**2201-7-2**]: Hammertoe deformities with
degenerative disease at the first MTP joint. Diffuse osseous
demineralization.
[**2201-7-2**] 04:40AM BLOOD WBC-5.5 RBC-2.94* Hgb-9.8* Hct-29.1*
MCV-99* MCH-33.3* MCHC-33.6 RDW-13.7 Plt Ct-117*
[**2201-7-4**] 01:00PM BLOOD Glucose-173* UreaN-21* Creat-0.9 Na-142
K-3.6 Cl-107 HCO3-26 AnGap-13
[**2201-7-4**] 01:00PM BLOOD ALT-37 AST-17 AlkPhos-129* TotBili-0.7
Brief Hospital Course:
89 year-old woman with a history of multiple common bile duct
stones and ERCP's now transferred to [**Hospital1 18**] with epigastric pain,
elevated LFTs and imaging demonstration biliary dilitation c/w
biliary obstruction. Patient underwent an ERCP which revealed
hepatic duct stricture with impacted stones. Brushings of the
bile ducts were collected for cytology, the stones removed, and
2 stents placed. The patient's biliary obstruction was relieved,
abdominal pain improved, and T. bili returned to [**Location 213**].
# Biliary obstruction: Patient has extensive history of previous
obstruction requiring repeated ERCPs. RUQ US demonstrates
sludge balls which are the most likely etiology of the patients
symptoms especially given her known history obstruction due to
stones/sludge in the past. Patient is currently afebrile with a
normal white blood cell count making acute cholangitis less
likely. Recurrent nature of obstruction and recent wt loss
concerning for possible malignancy (possible cholangiocarcinoma,
pancreatic lesion. ERCP revealed common hepatic duct stricture
that was 1cm long with stricture seen at common hepatic duct
with post obstructive dilation in R and left common ducts.
Both left and right hepatic ducts had impacted stones in them.
Cytologic brushings were negative Two stents were placed in the
left and right hepatic ducts. She will be contact[**Name (NI) **] by the ERCP
team to schedule another ERCP in the beginning of [**Month (only) 205**] to remove
the stents.
She complained of abdominal cramping during the last two days of
her hospitalization, but her abdominal exam was benign and she
was eating and drinkinng well. She moved her bowels after
receiving a laxative. Last set of liver function tests were
within normal limits on [**7-4**]. I suspect that her cramping and
general dyspepsia are from the augmentin that she received after
the the ERCP. She completed a one week course of treatment, so
the ERCP team was comfortable with stopping the medication.
# Thrombocytopenia: Low 100's, unclear etiology, but stable.
# Right foot sprain: On the floor, the patient developed right
foot pain. XRAYs taken which revealed no fractures. Podiatry
consult did not think there was anything serious. Eventually her
foot pain improved, indicating that it may have been a sprain
type of injury. We applied a lidoderm patch on her foot.
OTHER STABLE ISSUES:
# Hypothyroidism: Continue levothyroixine
# Gout: Allopurinol initially held for elevated Cr, but
restarted when Cr improved.
# Hypertension: HTN meds initially held, but restarted once she
stabilized in the ICU. Continue lisinopril and metoprolol.
# Atrial fibrillation: Patient not on coumadin. Continue ASA and
metoprolol.
# Diabetes mellitus, diet-controlled
Medications on Admission:
Calcium and vitamin D daily
Allopurinol 100 mg daily
Lisinopril 10 mg daily
Amlodipine 10mg daily
Potassium 20meq daily
Lopressor 100mg [**Hospital1 **]
Levothyroxine 50 mcg daily
ASA 81 mg q2days
[**Hospital1 **] Medications:
1. Calcium 500 500 mg calcium (1,250 mg) Tablet Sig: One (1)
Tablet PO twice a day.
2. Vitamin D3 1,000 unit Tablet Sig: One (1) Tablet PO once a
day.
3. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
6. Lopressor 100 mg Tablet Sig: One (1) Tablet PO twice a day.
7. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO EVERY OTHER DAY (Every Other Day).
[**Hospital1 **] Disposition:
Extended Care
Facility:
[**Hospital **] LivingCenter - [**Location (un) 11792**] - [**Location (un) 7740**]
[**Location (un) **] Diagnosis:
PRIMARY DIAGNOSES:
- Choledocholithiasis
- Biliary stricture
- Right foot pain, NOS
SECONDARY DIAGNOSES:
- Hypothyroidism
- Gastroesophageal reflux disease
- Hypertension
- Gout
- Diabetes mellitus, type II, diet-controlled
- Atrial fibrillation
[**Location (un) **] Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
[**Location (un) **] Instructions:
You were admitted with gallstones obtructing your bile ducts.
You underwent a procedure called ERCP in which the gallstones
were removed from the bile duct and temporary bile duct stents
were placed. You will need to have these stents removed in about
one month and our ERCP team will call you to schedule their
removal in one month. Biopsies done during this procedure do
not show any signs of cancer.
MEDICATION INSTRUCTIONS:
- STOP Potassium tablets
Followup Instructions:
You will be contact[**Name (NI) **] for a repeat ERCP in one month.
Please follow up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **]
from rehab.
ICD9 Codes: 5849, 2875, 4019, 2749, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3839
} | Medical Text: Admission Date: [**2158-4-2**] Discharge Date: [**2158-4-10**]
Service: TULLUS
Ms. [**Known lastname 16968**] was transferred from the MICU to the Tullus
Medicine Service on [**2158-5-5**].
HISTORY OF PRESENT ILLNESS: This is a 74 year-old female
with a history of insulin dependent diabetes mellitus times
45 years, hypertension, who was admitted to the MICU after
being transferred from an outside hospital after being found
unresponsive at home. The outside hospital, [**Hospital 882**]
Hospital, the patient was found to have a glucose of 1224,
bicarbonate of 7 and a pH of 7.04 with positive urine
ketones. She was subsequently given 6 liters of normal
saline, 1 unit of packed red blood cells, 1 amp of
bicarbonate and insulin drip and given a dose of Ceftriaxone
and transferred to the [**Hospital1 69**]
MICU. At the [**Hospital1 69**] MICU she
was found to have an arterial blood gas of 7.29/34/112 with a
glucose of 688 and increased amylase of 789 and lipase of
1033. She was also found to have a positive troponin of 12.7
and MB of 13.4 consistent with a non ST segment elevation
myocardial infarction. Her subsequent peak CK was 207 and
peak troponin was 25.
The patient was found at home with a low level of
responsiveness and found to have blood in her mouth. There
is a question of whether she had coffee ground emesis. She
had an negative lavage that showed coffee grounds apparently
at the outside hospital that cleared upon her nasogastric
lavage at the [**Hospital1 69**] MICU. The
patient upon transfer to the floor complained of fatigue, but
no chest pain, shortness of breath or abdominal pain.
PAST MEDICAL HISTORY: Hypertension, insulin dependent
diabetes mellitus times 45 years, cerebrovascular accident,
seizure disorder, open reduction and internal fixation of her
ankle complicated by a wound infection.
MEDICATIONS ON ADMISSION TO THE MICU:
1. Plavix 75.
2. Insulin.
3. Metoprolol 50 b.i.d.
4. Meclozine.
5. Lansoprazole 30 po q.d.
6. Prinivil 5 po q.d.
7. Dilantin 300 q.h.s.
8. Multivitamin.
9. Thiamine.
10. Folate.
11. Aspirin 81 q.d.
ALLERGIES: Compazine.
SOCIAL HISTORY: The patient lives with her son. She
performs all activities of daily living. No tobacco. No
alcohol in greater then one month.
MEDICATIONS ON TRANSFER TO THE FLOOR:
1. Metoprolol 25 mg po b.i.d.
2. Aspirin 81 mg po q.d.
3. Lipitor 10 mg po q.d.
4. Regular insulin sliding scale.
5. NPH half of home dose of 10 in the a.m., 6 units in the
p.m.
6. Dilantin 150 mg q 8.
7. Ceftriaxone 1 gram q.d.
8. Flagyl 500 t.i.d.
9. Thiamine and folate.
PHYSICAL EXAMINATION ON TRANSFER: Temperature max of 100.8.
Temperature current 99.8. Pulse 80 to 101. Blood pressure
125 to 171/57 to 80. Respirations 19 to 25. Saturation 100%
on 3 liters nasal cannula. General, alert and oriented,
pleasant. HEENT extraocular movements intact. Pupils are
equal, round, and reactive to light and accommodation.
Nasogastric tube in place. Mucous membranes are moist. Neck
no JVD. Left EJ line in place. Chest rhoncherus expiratory
breath sounds with decreased sounds at the bases. Cardiac
regular rate and rhythm. S1 and S2. No murmurs, rubs or
gallops. Abdomen soft, nontender, nondistended. Normoactive
bowel sounds. No organomegaly. Extremities V boots
bilaterally. No clubbing, cyanosis or edema. Neurological
nonfocal examination.
DATA: White blood cell count 12.6 down from 16. Hematocrit
33 up from 27 after 2 units of blood. Platelets 151 down
from 242. MCV 85, sodium 135, potassium 3.9, chloride 105,
bicarb 23, BUN 16, creatinine 0.9, glucose 67. ALT 13, AST
22, LDH 195, alkaline phosphatase 80, amylase 164 down from
336, lipase 202 down from 232. Total bilirubin 1.0 up from
0.6. Calcium 8.5, magnesium 1.5, phosphorus 2.6, Dilantin
level low at 5, albumin 3.0. Cholesterol 148, HDL 104,
triglycerides 68, LDL 44. Troponin on [**4-2**] 12, [**4-3**] 25, [**4-4**]
11. Blood gas on [**4-4**] 7.42/38/57 on room air. Sputum on [**4-5**]
1+ gram positive cocci in pairs and clusters that later grew
out to be MRSA. Blood cultures no growth to date. Chest
x-ray right middle lobe opacity. Chest x-ray [**4-5**] with
bilateral lower lobe consolidations consistent with
aspiration pneumonia. Right upper quadrant ultrasound no
gallstones. No ductal dilatation. CT of the head no acute
changes with moderate atrophy. Echocardiogram [**4-3**] with an EF
of 50 to 55%, elevated pulmonary pressures of 41, no focal
wall motion abnormalities.
HOSPITAL COURSE [**2158-4-5**] TO [**2158-4-9**]: The remainder of the
hospital course will be dictated at the time of discharge.
This is a 74 year-old woman with a history of seizure
disorder, insulin dependent diabetes mellitus who was
admitted to the MICU status post question of an upper GI
bleed, non ST segment myocardial infarction leading to
diabetic ketoacidosis and increased pancreatic enzymes.
There was also a question of aspiration pneumonia.
1. Cardiac/coronary artery disease: The patient upon later
questioning had a history of a myocardial infarction in the
setting of diabetic ketoacidosis and a question of
gastrointestinal bleed one month prior to admission who is
currently in the midst of trying to obtain records from the
VA from the patient's nurse [**First Name8 (NamePattern2) 3639**] [**Last Name (Titles) 41095**]. The patient
has not complained of any chest pain. She is continued on an
aspirin, beta blocker and a statin. A cardiology consult was
obtain4d that recommended a Persantine MIBI to evaluate for
ischemia. This is currently pending.
Pump: The patient has no current sinus symptoms of
congestive heart failure. Her EF is low normal at 50%
without focal wall motion abnormalities. We will continue to
follow.
Electrophysiologic: No history of arrhythmias or
electrocardiogram changes.
Blood pressure: The patient has history of hypertension and
continued on beta blocker with good blood pressure control.
2. Endocrine: The patient has a history of 45 years of
insulin dependent diabetes mellitus and had an episode of
diabetic ketoacidosis this admission in the context of non ST
segment elevation myocardial infarction and question of upper
gastrointestinal bleed. This was corrected with 6 liters of
intravenous fluids and insulin drip. Currently the blood
sugars have been running low normal. She is continued on an
insulin sliding scale and NPH 10 units in the morning and 6
units p.m.
3. Gastrointestinal: The patient had a history of coffee
grounds and blood in her mouth upon admission to the outside
hospital. There is also a question of a gastrointestinal
bleed one month ago precipitating a similar episode. Her
hematocrit has been stable status post initial blood
transfusion from hematocrit 27 to 33. She will continue the
Protonix 40 b.i.d., considering further gastrointestinal
evaluation when cardiac issues are worked out. The elevated
pancreatic enzymes were not thought by the MICU team to be an
acute pancreatitis, rather a reaction to the severe
dehydration associated with diabetic ketoacidosis. These
have resolved with gentle hydration.
4. Pulmonary: The patient had a productive cough with
bibasilar infiltrates likely consistent with aspiration
pneumonia in the setting of being found decreased responsive.
She is continued on Ceftriaxone 1 gram q.d. and Flagyl
t.i.d. for a question of aspiration pneumonia. Her sputum
did grow out MRSA. The patient has remained afebrile and it
is likely that this is a colonizer rather then infectious
[**Doctor Last Name 360**] at this time. If she does spike a temperature she will
be started on Vancomycin.
5. Neurological: The patient has a history of seizure
disorder and is on Dilantin. Initially her level was
subtherapeutic and she was reloaded with 500 times two and is
now therapeutic on 100 t.i.d. dose. Question if seizure was
a factor in her presentation of diabetic ketoacidosis and
myocardial infarction. Question of the blood in her mouth
was a result of a tongue bite. There is no current
laceration at this time. Continue Dilantin to 100 t.i.d.
6. Fluids, electrolytes and nutrition: The patient passed a
speech and swallow study and is currently having a slowly
advanced diet at this time. We will continue to evaluate for
sufficient po intake.
7. Prophylaxis: PPI b.i.d., subcutaneous heparin, physical
therapy to get the patient out of bed.
DISPOSITION: At this time the patient will likely be
discharged to the [**Hospital3 7**] for further
rehabilitation. This is currently pending results of her
stress test.
Final medications on discharge, rest of the hospital course
and plan will be dictated as a discharge addendum upon
discharge.
[**Doctor Last Name **] [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5712**]
Dictated By:[**First Name3 (LF) 15581**]
MEDQUIST36
D: [**2158-4-10**] 11:57
T: [**2158-4-10**] 06:10
JOB#: [**Job Number 41096**]
ICD9 Codes: 5070, 2765, 5789, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3840
} | Medical Text: Admission Date: [**2140-10-30**] Discharge Date: [**2140-11-11**]
Date of Birth: [**2118-9-4**] Sex: M
Service: SURGERY
Allergies:
Cefaclor
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
S/P ATV accident with traumatic brain injury
Major Surgical or Invasive Procedure:
[**2140-10-31**] right [**Last Name (un) 8745**] bolt placed
[**2140-11-2**] right chest tube for pneumothorax
History of Present Illness:
This is a 22 y/o patient who was transferred from OSH s/p
fall off dirt bike at approximate speed of 35 mph. He was
wearing a helmet and fell over the handlebars. He was found
to be combative by EMS with GCS 6. He was intubated and sedated
at OSH, no imaging was performed. He was transferred to [**Hospital1 18**]
for further management. Mannitol 75 mg given prior to admission.
Past Medical History:
none
Social History:
+ Tobacco
ETOH -
Family History:
non contributory
Physical Exam:
On Admission:
Temp 98 HR47 BP 152/93 Intubated
HEENT Blood in both ears and oropharynx, right pupil 2mm and
reactive, left pupil 4mm and non reactive
Neck Cervicle collar in place
Chest clear and equal breath sounds bilat, no deformities
COR RRR
Abd no masses, right and left flank abrasions
Ext toes upgoing on left, feet warm
Pertinent Results:
[**2140-10-30**] 06:05PM WBC-21.6* RBC-4.85 HGB-15.0 HCT-43.6 MCV-90
MCH-30.9 MCHC-34.4 RDW-13.0
[**2140-10-30**] 06:05PM PLT COUNT-292
[**2140-10-30**] 06:05PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2140-10-30**] 06:07PM GLUCOSE-88 LACTATE-1.4 NA+-138 K+-3.3*
CL--101 TCO2-23
[**2140-10-30**] 08:11PM GLUCOSE-100 UREA N-14 CREAT-1.0 SODIUM-136
POTASSIUM-4.6 CHLORIDE-101 TOTAL CO2-23 ANION GAP-17
[**2140-10-30**] Head CT :1. Bilateral subarachnoid hemorrhage. Possible
tiny left cerebral subdural hemorrhage measuring less than 2 mm.
2. Hemorrhage within the prepontine cistern and in the pons
(anteriorly).
Linear hyperdensity anterior to the pons is likely extraaxial.
3. Bilateral longitudinal temporal bone fractures extending to
the right
carotid canal. Left lateral and medial orbital wall fractures
and left
zygomatic fracture. CTA is recommended to exclude carotid
injury.
4. Sinus opacification with fractures of the sphenoid sinus.
[**2140-10-30**] Abd/Chest CT : 1. ET and NG tubes positioned adequately.
2. Consolidation in the superior segment of the right lower lobe
and complete consolidation of the left lower lobe which reflect
aspiration.
3. Anterior mediastinal density which is most compatible with
residual thymic tissue. No evidence of aortic injury.
4. Nonspecific hypodense lesions in the liver and right kidney
which are
incompletely characterized
[**2140-10-30**] C Spine CT : 1. No cervical spine fracture.
2. Bilateral skull base fractures, better evaluated on dedicated
head CT.
3. Secretions within trachea surrounding endotracheal balloon
concerning for aspiration.
[**2140-10-31**] Left forearm : No fracture of the left forearm is
detected. Assessment of the left wrist is limited on these
views. Allowing for this, the left wrist is grossly
unremarkable. However, if there is specific clinical concern for
wrist injury, dedicated views of the wrist would be recommended.
[**2140-10-30**] CTA Head :
1. No evidence of carotid artery dissection.
2. Focal abnormality of the right ACA just superior to the
ACA/ACOM junction. This likely represents tortuosity of vessel,
although tiny focal aneurysm cannot be excluded. Repeat CTA or
MRA could be performed in two to three weeks for further
evaluation.
3. Multiple bilateral skull base fractures, unchanged.
4. Bilateral subarachnoid hemorrhage and hemorrhage anterior
to the pons
within the interpeduncular cistern is better appreciated on
non-contrast head CT performed earlier.
[**2140-11-1**] Head CT : 1. Apparent resolution of subarachnoid
hemorrhage.
2. Persistence of possible left cerebral subdural hemorrhage.
3. Bilateral longitudinal temporal bone fractures and left
lateral medial orbital wall fractures and left zygomatic
fracture (see CT fromSeptember 20, [**2140**] for details).
4. Sphenoid sinus opacification and sphenoid fractures.
5. High-density material in the bilateral maxillary sinuses is
likely
hemorrhage.
[**2140-11-1**] CT sinus/mandible :
There is partial opacification of bilateral mastoid air cells as
well as fluid seen within the left external auditory canal.
High-density
material is seen within the bilateral maxillary sinuses and
sphenoid sinuses compatible with blood. The right skull base
fracture extends longitudinally through the temporal bone
(series 2, image 39; series 401B, image 16). There is also a
fracture that extends from the right posterior wall of the
sphenoid sinus (series 401B, image 41; series 2, image 41) into
the right carotid canal. A longitudinal left temporal bone
fracture is noted that extends into the left parietal bone
superiorly series 2, image 4).There is a minimally displaced
fracture of the left zygoma (series 2, image 35) as well as the
left lateral wall of the left orbit. A thin lucency noted at the
superomedial aspect may represent a subtle fracture. No obvious
extension into the TMJ is noted, the lucency noted on the
studies in the posterior aspect of the TMJ relating to the site
of [**Hospital1 **] of the mastoid and squamous portions of the temporal
bone and seen on both sides. Thin non-displaced fracture of the
lateral pterygoid is noted on the left. Scattered foci of air
are noted including the right side of the neck , related to the
trauma. Evaluation for any other subtle
fractures may be limited.
[**2140-11-5**] CTA Chest :
1. Enlarged now moderate-to-large left pneumothorax. Left chest
tube
terminates in the anterolateral subcutaneous soft tissues of the
chest wall. Slight rightward shift of midline structures.
2. Pneumomediastinum. Subcutaneous gas along bilateral
anterior chest wall, tracking up to the thoracic inlet on the
left. Right chest wall laceration.
3. Multifocal consolidation involving all lobes of the lungs,
likely due to aspiration and pneumonia.
4. Assessment is slightly limited due to respiratory motion,
particularly along the lingula, but no evidence of PE seen.
[**2140-11-5**] MRI C Spine ;
Negative cervical spine MRI scan. Incomplete study of the
thoracic spine.
[**2140-11-8**] MRI Head and orbits :
1. Punctate hemorrhagic diffuse axonal injury in the left
parietal
subcortical white matter, and possibly also in the left
posterior frontal
subcortical white matter. Extensive diffuse axonal injury in the
splenium of the corpus callosum and associated infarction, with
a small hemorrhagic
component.
2. Probable evolving acute/early subacute infarct in the right
pons, which is nonspecific but could be related to
nonhemorrhagic axial injury.
3. Bilateral small retrocerebellar subdural hematomas.
4. Subarachnoid hemorrhage again demonstrated.
5. Unremarkable appearance of the orbits.
[**2140-11-10**] CXR : Near resolution of left apical pneumothorax.
Brief Hospital Course:
[**Known firstname **] [**Known lastname **] was admitted to the Trauma ICU for management of
his traumatic brain injury. His GCS at the scene was 3 and 7 at
the time of admission. He was seen by the Neurosurgical service
for evaluation and placement of a bolt for ICP monitoring.His
initial ICP was 10. His left pupil was fixed and dilated and he
had a left hemiparesis. His right upper and lower extremities
were moving. He did require sedation while he was intubated as
he was very agitated.
From a neurologic standpoint he has had marked improvement
during his hospitalization. He was treated with dilantin for 12
days and had no seizure activity. Following his extubation from
the respirator he was able to speak and understand, respond to
commands and his left sided weakness improved. He continued to
have a left HP though this had been improving daily. Most
recent MRI of the C and T spine showed no cord contusion. MRI
of his brainshows axonal injury parietal and frontal white
matter on left aswell as in the left corpus collosum and the
right pons infarct,likely the cause of his left hemiparesis. His
left CN III palsey is unchanged. With the help of physical
therapy he is up and walking but needs to refocus and needs
reminders to concentrate.
[**Known firstname **] developed drainage from his right ear about 1 week ago and
the consistency was old blood. He was reevaluated by the
Neurosurgery Service to assure that it was not CSF. His
drainage gradually decreased and resolved 48 hours ago. He will
continue to follow up with Neurosurgery as an outpatient.
He was treated with antibiotics in the ICU for a presumed
pneumonia. His CXR is notable for b/l atelectesis and he has
remained afebrile off antibiotcs for 24 hours. He is using his
incentive spirometer. On [**2140-11-2**] a right chest tube was placed
for a hemothotax and this drained and was removed without
difficulya few days later. There is no effusion or pneumothorax
on his post pull film.
His nutritional status is being monitored and he is tolerating a
regular diet with nectar thick liquids. He has been seen by the
Speech and Swallow Service who recommend strict aspiration
precautions and a repeat study after he gets settled in rehab.
During his hospitalization his family has been with him 24/7 and
are very supportive, attentive and concerned for his future
recovery. They will appreciate
updates as his condition improves or changes.
Medications on Admission:
none
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mls PO BID (2
times a day).
4. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One
(1) Appl Ophthalmic PRN (as needed) as needed for dry eyes.
5. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for fever/pain.
6. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
8. Olanzapine 10 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO at bedtime.
9. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush: thru [**2140-11-14**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Traumatic brain injury S/P ATV accident with
1. SAH
2. SDH
3. temporal bone fractures B/L
4. sphenoid sinus fracture
5. Maxillary fracture
6. right pneumothorax
7. pneumonia
8. left eye fixed and dilated secondary to left 3rd nerve
pupillary fibers affected by orbit fracture
Discharge Condition:
Improved, stable hemodynamics, walking with assistance,eating a
soft diet but needs direction and supervision
Discharge Instructions:
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending. Follow the Physical Therapists's
recommendations
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
Call [**Hospital 4695**] clinic at [**Telephone/Fax (1) 1669**] for a follow up
appointment in 4 weeks.
Call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 2359**] for a follow up appointment in 6
weeks
Call the Plactic Surgery Clinic at [**Telephone/Fax (1) 5343**] for a follow up
appointment in [**3-15**] wks.
Call [**Hospital 878**] Clinic at [**Telephone/Fax (1) 44**] for a follow up
appointment in 2 weeks
Call [**Hospital **] clinic at [**Telephone/Fax (1) 253**] for a follow up
appointment in 4 weeks
Completed by:[**2140-11-11**]
ICD9 Codes: 3051, 5070 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3841
} | Medical Text: Admission Date: [**2118-1-1**] Discharge Date: [**2118-1-11**]
Date of Birth: [**2072-1-2**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1055**]
Chief Complaint:
weakness, SOB with exertion and left sided chest pain
Major Surgical or Invasive Procedure:
Pericardial drainage with pigtail catheter
Left thoracentesis
History of Present Illness:
Pt is a 46 y/o man with a hx of positive PPD, and a recently
diagnosed NSCLC who presents with 3 day hx of weakness, SOB with
exertion and left sided chest pain which radiates to his back
and he describes saying "it feels like someone is poking me." He
reports that his cough is not productive of sputum, but that
when he coughs, he feels like he needs to vomit. This cough is
unchanged from the cough he has had since [**Month (only) **]. He estimates
that from his last admission he has lost apporximately 10
pounds. He denies fever, dizziness, light-headedness, HA, abd
pain, leg pain, leg swelling.
.
Pt was healthy until [**Month (only) **] when he began to notice blood in
his sputum. He also reported night sweats and weight loss, but
denied fever and shortness of breath. A chest CT was performed
in [**11-15**] which showed a 3.1 x 1.7 cm cavitary mass in the
superior segment of the right lower lobe in addition to multiple
large mediastinal lymph nodes. There were also several lytic
lesions in the thoracic and lumbar spine which were concerning
for metastases. Given the pt's hx of a positive PPD, pt was also
evaluated for TB. Spirometry was performed and was consistent
with a severe obstructive defect. Sputum cytology was negative
for AFB and malignant cells but transbronchial needle aspiration
showed atypical epithelioid and inflammatory cells suspicious
for malignancy and precarinal LN and bronchial washings were
both positive for malignant cells, consistent with NSCLC.
.
In the ED, the pt was found to have an elevated pulsus paradoxus
at 15-20. An echo showed a large echodense pericardial effusion
consistent with blood, inflammation or other cellular elements.
There was RV diastolic collapse, consistent with tamponade. In
the cath lab, 1500cc of grossly bloody pericardial fluid was
drained and a pericardial drain was sutured in place. A repeat
echo showed that the effusion had decreased in size and the RV
collapse had resolved. The pericardial fluid cytology was
positive for malignant cells consistent with non-small cell
metastatic carcinoma.
.
The pt was also found by CXR to have a large consolidation in
the left lower lobe with small bilateral pleural effusions, and
evidence of pulmonary edema.
.
The patient was transferred to the MICU for further monitoring.
In the MICU, pt was treated with CTX/azithromycin for his L.
lobe PNA. His repeat ECHO showed greatly decreased size of
pericardial effusion and the pericardial drain was pulled. Pt no
longer complains of any SOB. In the MICU, pt has also had 2
episodes of episode of A-fib. The first episode was reverted to
sinus rhythm with amiodarone. Lopressor was added after the
second episode. Amiodarone was continued as pt will likely
continue to be at risk for further episodes of a-fib. Finally,
the pt had thoracentesis before coming to the floor.
Past Medical History:
1. Positive PPD last month.
2. Asthma.
3. No history of hypertension, diabetes, or coronary artery
disease.
Social History:
Born and raised in [**Country 651**] and came to the United States in [**2100**].
He works in construction, primarily installing sheetrock and
plumbing. Reports possible exposure to asbestos and other
chemicals.
Lives with wife and 2 daughters
[**Name (NI) **] smoked one to two packs of cigarettes a day for 22 years,
however, quit two to three years ago.
He drinks alcohol socially.
Family History:
His father died at 67 from an unknown cause. His mother is 73
and alive and well. He has two brothers and one sister, who are
also healthy.
Physical Exam:
Exam: 98.1 (100.8 in ED), BP 115/80, HR 118, R 28, O2 100% on
NRB
Gen: ill appearing but no acute distress
HEENT: EOMI, MMM
Neck: elevated JVD
CV: tachy, regular, no murmur
Chest: decreased breath sounds at left base with bronchial
breath sounds; decreased breath sounds at right apex
Abd: +BS, soft, NT
Ext: trace edema bilaterally, 2+ DP
Neuro: 5/5 strength in upper and lower ext bilaterally
Pertinent Results:
Chest CT [**11-15**]:
* A 3 cm spiculated mass with cavitation, adjacent tethering and
pleural thickening with multiple enlarged conglomerate lymph
nodes, most worrisome for primary pulmonary neoplasm and less
likely infection.
* Scattered lytic lesions in the thoracic spine, worrisome for
metastases.
* Moderate pericardial effusion.
.
Studies:
[**12-31**]
AP CXR -
1. Left lower lobe pneumonia.
2. Congestive heart failure.
3. Small bilateral pleural effusions.
.
[**12-31**] EKG
Sinus tachycardia
Atrial premature complexes
Atrial fibrillation with rapid ventricular response
Indeterminate QRS axis
Generalized low voltage
Modest right ventricular conduction delay pattern
Findings are nonspecific but suggest in part chronic pulmonary
disease or possible ventricular overload
No previous tracing available for comparison
.
[**1-1**] ECHO
1. The left atrium is normal in size.
2.Left ventricular wall thicknesses are normal. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is low normal (LVEF:50-55%).
3.The aortic valve is not well seen.
4.The mitral valve leaflets are mildly thickened. Mild (1+)
mitral
regurgitation is seen.
5.There is a large pericardial effusion. The effusion is echo
dense,
consistent with blood, inflammation or other cellular elements.
There is right ventricular diastolic collapse, consistent with
impaired fillling/tamponade physiology.
.
[**1-1**] Post-Procedure ECHO
Left Ventricle - Ejection Fraction: 45% to 55% (nl >=55%)
Conclusions:
1. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. The views are limited but
the overall left ventricular systolic function is mildly
depressed with global hypokinesis.
2.The mitral valve leaflets are mildly thickened.
3.There is a moderate sized pericardial effusion. The effusion
is echo dense, consistent with blood, inflammation or other
cellular elements. No rightventricular diastolic collapse is
seen.
.
[**1-1**] CXR
Compared with the findings of the prior study (images reviewed)
of the earlier study of [**1-1**], the pericardial effusion is much
less but remains moderate.
Large left sided pleural effusion present.
Decrease in the size of the cardiac silhouette. However, it
remains enlarged. This is consistent with the
pericardiocentesis. There is overlying catheter seen across the
left chest. There remains a persistent left retrocardiac
opacity which opacifies the left lower half of the chest. There
is an opacity seen within the right base which is better seen on
today's study.
.
[**1-1**] EKG
Sinus tachycardia
Indeterminate QRS axis
Generalized low voltage
Modest right ventricular conduction delay pattern
Findings are nonspecific but suggest in part chronic pulmonary
disease or possible right ventricular overload
.
[**1-1**] EKG
Baseline artifact
Atrial fibrillation with rapid ventricular response
Generalized low voltage
Modest right ventricular conduction delay pattern
Findings are nonspecific but suggest in part chronic pulmonary
disease or possible right ventricular overload
.
[**1-2**] ECHO
1.There is low normal to mildly decreased LV function with
global hypokinesis.
2.There is a moderate sized pericardial effusion. No evidence of
cardiac tamponade.
3.There is a L sided pleural effusion w/ evidence of collapsed
lung.
.
[**1-3**] CT
1. Irregular area of consolidation in the right upper lobe
probably
pneumonia/aspiration.
2. 3-cm mass in the right lower lobe c/w known lung cancer.
3. Extensive mediastinal lymphadenopathy.
4. Large left and moderate right pleural effusion with
bilateral lower lobe atelectasis.
5. Small pericardial effusion.
6. Increasing size of the osteolytic bony lesions consistent
with metastasis.
.
[**1-4**] ECHO
Left Ventricle - Ejection Fraction: 30% (nl >=55%)
Left ventricular wall thicknesses and cavity size are normal.
There is moderate global left ventricular hypokinesis. Right
ventricular chamber size is normal with mild global free wall
hypokinesis. There is a small, circumferential, partially
echo-filled pericardial effusion.
.
MRI Brain:
No significant abnormalities detected in the MRI of the brain
with and without gadolinium
[**2117-12-31**] 04:53PM BLOOD WBC-19.2* RBC-3.54*# Hgb-10.1*#
Hct-30.0*# MCV-85 MCH-28.6 MCHC-33.7 RDW-13.8 Plt Ct-534*
[**2117-12-31**] 04:53PM BLOOD Neuts-92.6* Lymphs-4.5* Monos-2.6 Eos-0.2
Baso-0.1
[**2117-12-31**] 07:28PM BLOOD PT-15.4* PTT-29.7 INR(PT)-1.6
[**2117-12-31**] 04:53PM BLOOD CK(CPK)-141
[**2117-12-31**] 04:53PM BLOOD CK-MB-2 cTropnT-<0.01
[**2117-12-31**] 09:02PM BLOOD Lactate-3.4*
[**2118-1-3**] 04:04AM BLOOD WBC-33.3* RBC-4.04* Hgb-11.4* Hct-34.3*
MCV-85 MCH-28.1 MCHC-33.2 RDW-14.5 Plt Ct-535*
[**2118-1-1**] 04:47AM BLOOD ALT-285* AST-326* LD(LDH)-414*
AlkPhos-158* TotBili-0.7
[**2118-1-7**] 07:00AM BLOOD TotProt-6.5 Albumin-2.9* Globuln-3.6
Calcium-8.2* Phos-3.6 Mg-2.1
[**2118-1-5**] 04:55AM HBsAg NEG HBsAb POS HBcAb NEG HAV Ab POS
[**2118-1-5**] 04:55AM BLOOD HCV Ab-NEGATIVE
[**2118-1-7**]
BLOOD PEP - NO SPECIFIC ABNORMALITIES SEEN
UPEP - MULTIPLE PROTEIN BANDS SEEN, WITH ALBUMIN PREDOMINATING
IFE - NO MONOCLONAL IMMUNOGLOBULIN SEEN, NEGATIVE FOR
BENCE-[**Doctor Last Name **] PROTEIN
.
Pericardial Fluid - cytology
POSITIVE FOR MALIGNANT CELLS consistent with non-small cell
metastatic carcinoma, AFB Neg
[**1-4**]
Pleural fluid - POSITIVE FOR MALIGNANT CELLS, AFB Neg
.
[**1-9**] CXR
Bibasilar opacities are slightly improved in the interval.
Previously evident small bilateral pleural effusions have
resolved.
.
[**1-10**] Echo
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Overall
normal LVEF (>55%).
PERICARDIUM: Small to moderate pericardial effusion. Effusion
circumferential. Effusion echo dense, c/w blood, inflammation or
other cellular elements. No echocardiographic signs of
tamponade.
[**2118-1-9**] BLOOD CULTURE - AEROBIC NGTD; ANAEROBIC NGTD
[**2118-1-9**] URINE CULTURE - NGTD
[**2118-1-9**] BLOOD CULTURE AEROBIC NGTD; ANAEROBIC NGTD
[**2118-1-9**] ACID FAST SMEAR-Neg; ACID FAST CULTURE-PENDING
[**2118-1-9**] STOOL CLOSTRIDIUM DIFFICILE TOXIN Neg
[**2118-1-8**] ACID FAST SMEAR - Neg; ACID FAST CULTURE-PENDING
[**2118-1-7**] STOOL CLOSTRIDIUM DIFFICILE TOXIN Neg
[**2118-1-7**] ACID FAST SMEAR - Neg; ACID FAST CULTURE-PENDING
[**2118-1-6**] STOOL CLOSTRIDIUM DIFFICILE TOXIN Neg
[**2118-1-4**] Pleural fluid
GRAM STAIN - 1+ :POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS
SEEN.
FLUID CULTURE (Final [**2118-1-7**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2118-1-10**]): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2118-1-5**]): NO ACID FAST BACILLI
ACID FAST CULTURE (Pending):
[**2117-12-31**] - Pericardial fluid
GRAM STAIN - 4+ POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS
SEEN.
FLUID CULTURE (Final [**2118-1-5**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2118-1-7**]): NO GROWTH.
ACID FAST CULTURE (Pending):
ACID FAST SMEAR (Final [**2118-1-3**]): NO ACID FAST BACILLI
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
Brief Hospital Course:
# Pericardial effusion - Pt is a 46 y/o man with a hx of
positive PPD, and a recently diagnosed NSCLC who presents with 3
day hx of weakness, SOB with exertion and left sided chest pain
which radiates to his back and he describes saying "it feels
like someone is poking me." In the ED, the pt was found to have
an elevated pulsus paradoxus at 15-20. An echo showed a large
echodense pericardial effusion consistent with blood,
inflammation or other cellular elements. There was RV diastolic
collapse, consistent with tamponade. In the cath lab, 1500cc of
grossly bloody pericardial fluid was drained and a pericardial
drain was sutured in place. A repeat echo showed that the
effusion had decreased in size and the RV collapse had resolved.
The pericardial fluid cytology was positive for malignant cells
consistent with non-small cell metastatic carcinoma. It was
negative for AFB. A post-drainage echo showed a moderate sized
residual pericardial effusion with no signs of tamponade. Pt has
been hemodynamically since drainage, w/ no complaints of any
SOB, with a normal pulsus and with repeat echos showing no
change in size of the pericardial effusion. Pt will have a
follow up echo on [**2-16**] to assess for reaccumulation.
.
# PNA - On presentation, the pt was also found by CXR to have a
large consolidation in the left lower lobe. Pt was treated with
7 days of CTX and 4 days of azithromycin for his Left lobe PNA.
Pt continues to have non-productive cough and reports left sided
chest pain with coughing, but this cough is unchanged from the
pt's prior cough. He was afebrile from [**1-5**]. His WBC went from
17.7 on presentation to 33.3 on [**1-3**] but came down to 16.2 on
[**1-11**] on discharge.
.
# Positive PPD - Pt with recent history of positive PPD.
Bronchial washings from time of diagnosis with NSCLC were
negative for AFB. In the setting of a new infiltrate on CXR, and
relative immunosuppression with metastatic cancer, patient
needed to be ruled out for active TB. 3 induced sputums were
obtained. Three AFB smears have been negative. Mycobacterial
cultures will be followed up by ID. Pt will follow up with [**Hospital **]
clinic on [**2-16**] for treatment for his latent TB. Per ID, pt will
not require any treatment for latent TB prior to commencing
chemo.
.
# Afib - In the MICU, pt has also had 2 episodes of episodes of
A-fib. The first episode was reverted to sinus rhythm with
amiodarone. Lopressor was added after the second episode.
Amiodarone dose was decreased to 200mg [**Hospital1 **] prior to discharge.
In 2 weeks, we would recommend decreasing Amiodarone dose to
200mg per day. Pt will continue Amiodarone as he is at risk for
further episodes of a-fib secondary to irritation of the RA from
his pericardial effusion. Pt will follow up with cardiology on
[**2-16**].
.
# Low EF - Pt noted on inital echo to have a normal EF, but on
poist-drainage echo to have a low EF at 30%. Etiology of
systolic dysfuntion is unclear. Cardiology was not planning to
investigate etiology further at this time. A repeat echo on [**1-10**]
showed a normal EF. Pt will follow up with cardiology on [**2-16**].
.
# NSCLC - Pt diagnosed w/ NSCLC [**12-22**] and is followed by
Heme/Onc. Pt likely has stage IV disease given presence of
malignant pericardial effusion and osteolytic lesions in spine.
Head MRI showed no evidence of brain metastases. Pt will follow
up with Heme/Onc [**1-20**] to discuss beginning outpatient chemo. For
ostoeolytic lesions, pt was loaded with Vitamin D and Calcium
and received one dose of Zometa on [**1-9**].
.
# Pleural Effusions - Bilateral pleural effusions were noted on
presentation. Pt is s/p thoracentesis of left effusion, found to
be exuadative by protein criteria and positive for malignant
cells, with no AFB staining. Since pt was not symptomatic with
pleural effusions, no drainage of rt sided effusion or
pleurodesis was required at this time. A repeat CXR on [**1-9**]
showed resolution of bilateral pleural effusions.
.
# Thrombophlebitis - Pt developed L forearm thrombophlebitis,
with a warm, erythematous, tender cord. Pt was treated
symptomatically with warm compresses and the eryethema and
tenderness resolved.
.
# Elevated LFTs - Pt's LFTs increased the day following
admission. Etiolgy likely hepatic congestion secondary to
cardiac tamponade/failure. LFTs increased prior to beginning
[**Last Name (LF) 45231**], [**First Name3 (LF) **] amio is likely not the cause. Pt negative for
HCV, HBV and HAV is positive. LFTs are now trending down.
.
# Anemia - Hct drop likely from bleed into pericardial space.
Plan was to transfuse pt for Hct<21 but pt's Hct has increased
without transfusion. Nl SPEP, UPEP, so no evidence of myeloma.
.
# Difficulty walking - On admission, pt's wife reported that he
was having leg pain and difficulty walking. Pt reports that he
has had ankle pain but that he had been able to walk without
difficulty. Pt's neuro exam appears intact. Patient worked with
PT to improve his balance and endurance with ambulation. PT
reports that no further acute PT is needed at this time. Pt able
wot ambulate without difficulty.
.
# Code - Status changed to DNR/DNI, but pt requests aggressive
treatment for NSCLC
Medications on Admission:
cough medicine
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 13 days: take 200mg twice a day until [**1-24**]; starting [**1-25**],
take 200mg once a day.
Disp:*60 Tablet(s)* Refills:*2*
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*28 Tablet(s)* Refills:*0*
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
Disp:*90 Tablet, Chewable(s)* Refills:*0*
4. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H
(every 6 hours).
Disp:*300 ML(s)* Refills:*0*
5. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for insomnia.
Disp:*28 Tablet(s)* Refills:*0*
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
Disp:*56 Tablet(s)* Refills:*0*
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for fever or pain.
Disp:*60 Tablet(s)* Refills:*0*
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain: DO NOT TAKE WITH
TYLENOL
Do not drive or operate heavy machinery while taking this
medication.
Disp:*28 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Cardiac tamponade
PNA
Pleural effusions
****************
NSCLC
+PPD
Discharge Condition:
Stable, pericardial effusion stable with no signs of tamponade
Discharge Instructions:
Please seek medical care if you develop lightheadedness,
shortness of breath, increasing chest pain, or any other
concerning symptoms.
Please keep the follow-up appointments listed below.
Followup Instructions:
Please go to your primary care doctor, Dr. [**Last Name (STitle) **], at [**Hospital3 **]
clinic anytime on Friday [**2118-1-14**]
Provider: [**Name10 (NameIs) **],[**First Name3 (LF) **] MULTI-SPECIALTY MULTI-SPECIALTY
THORACIC UNIT-CC9 Date/Time:[**2118-1-20**] 10:30
Provider: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 2335**], MD - Infectious Disease -
Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2118-2-16**] 10:30
You are scheduled for an outpatient [**Year/Month/Day 461**] on [**2-16**]
at 9am. Afterwards, you are scheduled for followup with Dr.
[**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**](cardiology) at 10:30am the same day. Both
appointments are in the [**Hospital Ward Name 23**] building on the [**Location (un) 436**].
Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 128**] Date/Time:[**2118-2-16**]
9:00
Provider: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 2335**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2118-2-16**] 10:30
ICD9 Codes: 486, 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3842
} | Medical Text: Admission Date: [**2168-5-30**] Discharge Date: [**2168-7-16**]
Date of Birth: [**2098-3-24**] Sex: M
Service: MEDICINE
Allergies:
Levaquin
Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
bone marrow biopsy
removal of Hickman
PICC placement
Lumbar puncture
History of Present Illness:
70 year old male with history of diffuse large B cell lymphoma,
s/p 4 cycles of R-CHOP, 4 cycles of ESHAP and one cycle of [**Hospital1 **]
and Zevalin, discharged recently (2 days PTA) after elective
admission for mini-MUDS. He is now day 27 status post a
nonablative allogeneic transplant with Campath conditioning. His
recent admission was c/b febrile neutropenia (no source
identified, treated empirically with vanc, cefepime, flagyl and
caspo, then subsequently weaned off of these agents), anorexia
requiring TPN, diarrhea (c. diff negative x6) and transiently
elevated LFTs of unknown etiology (negative ultrasounds). By the
time of discharge he was tolerating po's well, had been afebrile
for >1week, was constipated and was ambulating. Today he
presented to clinic and was noted to have shaking chills and
temp to 100.6. He says yesteday he had loose stools (had been
given stool softeners on day of admission due to constipation)
and his wife feels his line "looks worse". Peripheral and line
cultures were drawn in clinic. He was given 1 gram of Vancomycin
IV and 2grams of Cefipime and a liter of normal saline with 2
grams of Magnesium Sulfate while in clinic. He was admitted for
evaluation of low grade fever.
.
The patient reports that his overall energy level and endurance
has been improving. Denies any drenching nightsweats. He denies
any fevers. He is without any pain. He denies any new or
worsening lymphadenopathy. Notes that he feels as though his
left submandibular node as well as left inguinal node has gotten
smaller. Also feels as though his splenomegaly may have improved
somewhat. He denies any cough, shortness of breath, chest pain,
palpitations, or any other cardiac or respiratory difficulties.
Denies any pain anywhere, denies any shortness of breath upon
exertion. Denies any vomiting, diarrhea, or constipation. Does
continue with a little bit of nausea. He says that he has had
intermittent R and L LQ abdominal pain with bloating that is
relieved with BMs. He is starting to feel some now and would
like a stool softener. Denies any numbness or tingling in the
fingers or toes.
Past Medical History:
1. Diffuse large cell lymphoma
- Initially presented with splenomegaly [**7-2**], found to have
bulky disease above and below diaphram
- S/p 4 cycles of R-CHOP and then switched to ESHAP due to
disease progression. Had persistent pelvic nodes and new
inguinal node after second cycle of ESHAP. Autologous transplant
planned so underwent stem cell mobilization but had poor cell
collection. Restaging PET scans revealed progressive disease
both above and below diaphram. He was therefore treated with
gemzar/navelbine/prednisone with only partial response.
- S/P 3rd cycle of ESHAP [**1-12**] discharged [**1-17**].
- S/P 4th Cycle of ESHAP ([**2168-2-3**])
- S/P [**Hospital1 **] + Zevalin ([**2168-3-22**])
- s/p CAMPATH and mini-MUDS ([**2168-5-3**])
2. s/p cataract surgery
3. left inguinal hernia
4. Right UPJ Stone
Social History:
He is married, Russian (from [**Location (un) 3156**]), was a music composer and
played the saxophone, no tobacco (quit 40 years ago), no
alcohol, no drugs. Also practices yoga on a regular basis. Was a
professional soccer player in the past.
Family History:
Two siblings are healthy. No history of malignancy.
Physical Exam:
Temp: 98.7 BP: 144/82 HR: 92 RR: 20 O2 SAT: 98%RA 144.2lbs
GEN: No acute distress, alert, oriented, thin elderly man
HEENT: Extraocular movements intact, pupils equal at ~2mm,
reactive to light. pharynx is non injected.
Neck: supple, palpable L submandibular node, small left-sided
inguinal node palpable
CV: Regular rate, no murmurs, rubs or gallops. S1, S2
auscultated
LUNGS: Clear to auscultation bilaterally, no rales, rhonchi or
wheezes.
ABD: Soft, non tender, non distended, with palpable spleen at
the left inferior costal margin, palpable hepatic edge. No
rebound tenderness.
Extr: mild puffiness in feet, no pitting edema, 2+DPs
Neuro: Cranial nerves II-XII grossly intact. [**5-30**] strenght at
biceps, triceps, quadriceps and ankle extensors.
R port c/d/i mild erythema at entry but no pus/drainage
Pertinent Results:
MICROBIOLOGY
[**2168-5-30**] 9:15 am Immunology (CMV) **FINAL REPORT [**2168-5-31**]**
CMV Viral Load (Final [**2168-5-31**]):
CMV DNA not detected.
Performed by PCR.
Detection Range: 600 - 100,000 copies/ml.
[**2168-5-30**] 12:20 pm URINE Site: CLEAN CATCH **FINAL REPORT
[**2168-5-31**]**
URINE CULTURE (Final [**2168-5-31**]): NO GROWTH.
[**2168-5-31**] ASPERGILLUS GALACTOMANNAN ANTIGEN 0.082 (NEG) < 0.5 Index
[**2168-5-31**] B-GLUCAN <31 pg/ml Negative Less than 60 pg/ml
IMAGING:
[**2168-5-30**] PORTABLE CXR- In comparison with the study of [**5-18**], there
is no interval change. Minimal streak of atelectasis at the left
base above the slightly elevated left hemidiaphragm. No evidence
of acute pneumonia or vascular congestion. Central catheter
remains in place.
.
CT TORSO W/O CONTRAST [**2168-5-31**] 2:27 PM
CT CHEST WITHOUT INTRAVENOUS CONTRAST: Multiple mediastinal
lymph nodes have slightly increased in size and number.
Bilateral axillary lymph nodes have also increased in size.
Largest left axillary lymph node measures 12 mm, compared to 8
mm in short axis diameter previously.
Central airways are patent to the segmental levels bilaterally.
Lung windows continue to demonstrate biapical scarring. Numerous
pulmonary nodules are again noted. Right upper lobe pulmonary
nodule, series 2, image 18, has slightly increased in size. Left
upper lobe pulmonary nodule, series 2, image 21, remains stable
in size. Peripheral right upper lobe pulmonary nodule, series 2,
image 24, has slightly increased in size, measuring 3 mm
compared to 1.5 mm previously. Left upper lobe pulmonary nodule,
series 2, image 33, measures 5 mm, compared to 3 mm previously.
Multiple other nodules are stable in size.
CT ABDOMEN WITHOUT INTRAVENOUS CONTRAST: Numerous hypodense
splenic lesions have increased in size and number. Multiple
hypodense lesions in the hepatic parenchyma also appear more
prominent on today's study. Right adrenal nodule is stable.
Extensive mesenteric and retroperitoneal lymphadenopathy has
significantly increased in extent when compared to the prior
study. There is no free air and no free fluid in the abdomen.
The pancreas, abdominal loops of large and small bowel are
unremarkable.
CT PELVIS WITHOUT CONTRAST: The 7-mm calculus at the right
ureterovesical junction is unchanged in size and appearance.
Marked lymphadenopathy is present in the pelvis along the
internal and external iliac chains.
BONE WINDOWS: Demonstrate no definite evidence of suspicious
lytic or sclerotic lesions.
IMPRESSION:
1. Interval significant worsening of mediastinal, axillary,
retroperitoneal and mesenteric lymphadenopathy, as well as
slight increase in size of pulmonary nodules and splenic
lesions, concerning for disease progression.
2. More prominent appearance of the hepatic lesions.
SPECIMEN: BONE MARROW ASPIRATE AND CORE BIOPSY:
DIAGNOSIS: Hypocellular bone marrow with erythroid and
megakaryocytic dysplasia. See note.
Histiocytes with ingested hematopoietic cells. See note.
No diagnostic morphologic features of involvement by lymphoma
seen.
Note 1: The dyspoiesis may be related to recent chemotherapy.
Note 2: Several histiocytes with ingested hematopoietic
precursors were noted. Findings discussed with Dr. [**Last Name (STitle) **]
and Dr [**Last Name (STitle) **]. Correlation with clinical findings as well as
other laboratory findings is needed to exclude the possibility
of an evolving hemophagocytic process.
FLOW CYTOMETRY REPORT
FLOW CYTOMETRY IMMUNOPHENOTYPING
The following tests (antibodies) were performed: Kappa, Lambda,
and CD antigens: 2, 19, 45.
RESULTS:
Three color gating is performed (light scatter vs. CD45) to
optimize lymphocyte yield.
CD45-bright mature lymphoid cells comprise 1% of total analyzed
events.
Of these, B cells are extremely scant in number precluding
evaluation of clonality.
INTERPRETATION
Cell marker analysis demonstrates an extremely scant population
of B-cells.
Clonality could not be assessed in this case due to insufficient
numbers of B cells. Correlation with clinical findings and
morphology (see S08-[**Numeric Identifier 93446**]) is recommended. Flow cytometry
immunophenotyping may not detect all lymphomas due to
topography, sampling or artifacts of sample preparation.
CT CAP:
IMPRESSION:
1. Slight increase in mesenteric and pelvic lymphadenopathy as
well as size of hepatic lesions. Stable appearance of axillary,
retroperitoneal lymphadenopathy, pulmonary nodules and splenic
lesions.
2. 5-mm calculus at the right ureterovesical junction.
3. Interval development of small ascites and worsening of the
pericardial and small right pleural effusion.
CT AP [**2168-7-7**]:
IMPRESSION:
1. Disease progression with increase in size of several liver
lesions,
splenic lesions and retroperitoneal lymph nodes as described
above.
2. Overall, more heterogeneous appearance of the liver raises
concern for
significant disease progression in the liver. Ultrasound
examination is
recommended to confirm the presence of multiple subcentimeter
hypodense
lesions as this is a new finding.
[**2168-5-29**] 09:54AM PLT COUNT-28*
[**2168-5-29**] 09:54AM NEUTS-69.8 LYMPHS-13.1* MONOS-8.5 EOS-8.0*
BASOS-0.5
[**2168-5-29**] 09:54AM WBC-4.3 RBC-3.16* HGB-9.6* HCT-27.5* MCV-87
MCH-30.3 MCHC-34.8 RDW-19.9*
[**2168-5-29**] 09:54AM CYCLSPRN-186
[**2168-5-29**] 09:54AM ALBUMIN-3.4 CALCIUM-9.4 PHOSPHATE-3.9
MAGNESIUM-1.7
[**2168-5-29**] 09:54AM ALT(SGPT)-17 AST(SGOT)-29 LD(LDH)-358* ALK
PHOS-82 TOT BILI-1.2
[**2168-5-29**] 09:54AM GLUCOSE-117* UREA N-36* CREAT-1.4* SODIUM-141
POTASSIUM-4.2 CHLORIDE-107 TOTAL CO2-24 ANION GAP-14
[**2168-5-30**] 09:15AM GRAN CT-2820
[**2168-5-30**] 09:15AM PLT COUNT-25*
[**2168-5-30**] 09:15AM NEUTS-69.4 LYMPHS-14.8* MONOS-7.9 EOS-7.3*
BASOS-0.5
[**2168-5-30**] 09:15AM WBC-4.1 RBC-3.09* HGB-9.5* HCT-26.7* MCV-86
MCH-30.9 MCHC-35.7* RDW-20.1*
[**2168-5-30**] 09:15AM CYCLSPRN-153
[**2168-5-30**] 09:15AM CALCIUM-9.3 PHOSPHATE-3.6 MAGNESIUM-1.6 URIC
ACID-5.5
[**2168-5-30**] 09:15AM ALT(SGPT)-20 AST(SGOT)-27 LD(LDH)-363* ALK
PHOS-79 TOT BILI-1.1 DIR BILI-0.5* INDIR BIL-0.6
[**2168-5-30**] 09:15AM UREA N-23* CREAT-1.2 SODIUM-139 POTASSIUM-3.7
CHLORIDE-106 TOTAL CO2-25 ANION GAP-12
[**2168-5-30**] 12:20PM URINE MUCOUS-RARE
[**2168-5-30**] 12:20PM URINE HYALINE-1*
[**2168-5-30**] 12:20PM URINE RBC-2 WBC-1 BACTERIA-FEW YEAST-NONE
EPI-0
[**2168-5-30**] 12:20PM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
[**2168-5-30**] 12:20PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.007
Brief Hospital Course:
#. Diffuse Large B-Cell Lymphoma: S/p Mini-MUDS w/ cells given
on [**2168-5-3**]. WBC recovered well, but with persistent low
platelets concerning for slow engraftment v. autoimmune
phenomena posttransplant v. disease-related issues, or GVHD
(though there were no other signs of GVHD to support this).
Given CT findings of increased size and number of [**Doctor First Name **], increased
LDH, and BM read, concern for recurrence of disease v.
hemophagocytic syndrome. BM bx day 30 concerning for
hemophagocytic cells and hemophagocytic syndrome. CT torso
([**6-7**]) to eval for further progression and for abdominal pain
etiology noted unchanged to slightly larger LNs and liver
lesions. MRI negative for leptomeningeal disease, LP results
positive for HHV-6, otherwise, non-diagnostic study given
paucity of cells. Started ETOPOSIDE/decadron/cyclosporin [**6-10**]
as per HLH protocol to treat disease as well as hemophagocytic
syndrome as patient developed mental status changes and high
fevers. Patient had significant clinical response with
recurrence of neutropenia after doses. Decadron and cyclosporin
slowly weaned down. Started on on GCSF on [**6-28**] with subsequent
increase in counts. Patient then began to develop increased back
pain and mental status changes. CT of CAP showing progression
in liver and splenic disease as well as increase in size of
lymphanopathy. Patient also began to develop increasing liver
function tests (voriconazole dc'd due to hepatotoxicity with no
improvement). Plan was for BM biopsy but patient refused. Given
increased mental status changes and fevers, concern for
recurrence of HLH. Patient was given an additional dose of
etoposide. Subsequently patient began refusing all treatment.
After much discussion, patient and family were in agreement
regarding discontinuation of care. Focus was changed to comfort
care. Patient passed away on [**2168-7-16**] comfortably and with
family at bedside.
.
#. Fever: The patient had been febrile when neutropenic during
his last admission and had been treated with cefepime (d/c'd
[**5-19**]), flagyl, caspo, and Vanco (DC'd [**5-20**]), all of which were
weaned as he defervesced. Imaging, cultures and screens for c.
diff were unrevealing and he had been transitioned to
fluconazole, acyclovir and bactrim for prophylaxis. On admission
he had no localizing symptoms, but did have a line which was a
potential infectious source. He had one day of loose stools but
this was in the context of taking stool softeners for
constipation. Suspected line infection v. fungal pulmonary
infection v. disease recurrence v. hemophagocytic syndrome. All
infectious work up was negative including CMV, EBV, parvovirus,
toxoplasma, measles, HHV-8, adenoviral PCR, salmonella stools
studies and numerous blood and urine cultures.
B-glucan/galactomannan negative. Patient did become positive
for HHV-6 both in peripheral blood and CNS. In addition to
broad spectrum antibiotics, patient was treated with Foscarnet
and one dose of Cidofovir. Given decreased calcium, foscarnet
was discontinued and patient was restarted on acyclovir for ppx
as HHV-6 had cleared in the peripheral blood. Patient then
began spiking fevers on his last week of admission despite broad
spectrum antibiotic medications including antifungal therapy.
This was thought to be due to progressive disease versus
recurrence of hemophagocytosis. Patient was given additional
dose of etoposide as above, then began to refuse further
treatment.
.
#. Bradycardia, prolonged QTC: Patient did have episode of
torsades, though due to cyclosporine and fluconazole,
respectively. EP saw patient and felt no risk of torsades now
that off fluconazole. Actually resolved with pulling back PICC
line. Patient had no further episodes.
.
#. Nutrition: Patient unable to tolerate POs. Was on TPN for the
majority of his admission. Nutrition followed on a daily basis.
.
Medications on Admission:
1. Cyclosporine Modified 25 mg Capsule Sig: Five (5) Capsule PO
Q12H
2. Folic Acid 1 mg TabletPO DAILY
3. Hexavitamin 1 Cap PO DAILY
4. Fluconazole 200 mg TabletPO Q24H
5. Acyclovir 200 mg Capsule Two (2) Capsule PO Q8H
6. Metoprolol Tartrate 25 mg Tablet 0.5 Tablet PO BID
7. Oxycodone 5 mg Tablet 1-2 Tablets PO Q4H (every 4 hours) prn
8. Nifedipine 90 mg Tab,Sust Rel Osmotic Push 24hr PO DAILY
9. Senna 8.6 mg Tablet 1 Tablet PO BID
10. Docusate Sodium 100 mg Capsule PO BID
11. Saliva Substitution Combo No.2 Thirty (30)ML Mucous
membrane QID
12. Bactrim 80-400 mg Tablet One Tablet PO once a day.
Discharge Medications:
NA - expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
ICD9 Codes: 5849, 4271, 2875, 4019, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3843
} | Medical Text: Admission Date: [**2125-6-29**] Discharge Date: [**2125-7-13**]
Date of Birth: [**2067-10-28**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5037**]
Chief Complaint:
Diarrhea, fever
Major Surgical or Invasive Procedure:
Right subclavian CVL [**2125-6-29**] -> removed during course of stay
History of Present Illness:
57 yo F with history of CKD s/p kidney transplant in [**2122**], on
immunosupressants, lymphangioleimeiomatosis, diabetes, who was
admitted with one week of diarrhea, fever to 102.7 and shortness
of breath. She started having watery diarrhea about one week
ago. She denies abd pain, nausea, vomiting, BRBPR, dark stools.
She does have decrased appetite and poor PO intake. She also
complains of SOB, DOE and orthopnea since about the same time.
She has a nonproductive cough and chills adn increased lower
extremity edema. She denies dysuria, hematuria, chest pain,
rash. In the ED, Temp 102.7, HR 113, 183/67, 18, 84%2L - >
100%NRB, lactate 2.3, elevated WBC to 14 with left shift,
elevated creatinine to 4.1 from baseline of 3.2, + anion gap of
17. She was given 2 L of IVF and had abdominal CT that was
unrevealing. She was started on Levofloxacin and flagyl for
presumed gastroenteritis. She was admitted to the ICU becuase of
her oxygen requirement. In ICU ABG showed profound metabolic
acidosis (anion gap and non anion gap) 7.17/45/268 on NRB.
Past Medical History:
Hepatocellular carcinoma, dx [**5-/2125**], grade 2 (focal clear cell
differentiation, immunohistochemical stains highlight
canalicular patterns by CEA, the tumor cells are focally
positive for CAM 5.2 and negative for cytokeratin A1/A3, the
tumor cells are positive for Hep PAR1 and TTF-1). [**Last Name (un) 36065**] scan in
[**4-/2125**] negative for mets.
s/p Splenectomy
Diabetes
ESRD (secondary to DM and HTN), s/p renal transplant [**2122**] on
immunosuppressants, episode of allograft nephropathy documented
by biopsy, basleine creatinine 3
Hypertension
b/l thoracotomy for spontaneous PTX, [**2110**]
Hyperlipidemia
Lymphangioleimyomatosis (cystic dz) of lung, on home oxygen 2L
NC all the time
Pulmonary Artery Hypertension
Cardiac stress test (P MIBI) in [**4-/2125**] with no perfusion defects
Seizures in setting of hypertensive emergency
Social History:
Pt was raised in the Phillipines, immigrated to the US in
[**2096**]. Married lives with husband. 2 kids. No tob/etoh/drugs.
Family History:
FH - Mother died from pancreatic ca
Physical Exam:
99, 82, 154/68, 20, 97%NRB
GENL: mild distress
HEENT: no elevated JVP, OP clear with slightly dry membranes
CV: RRR +systolic murmur best heard at apex.
Lungs: crackles at R base, otherwise clear without rhonchi
Abd: tender over transplanted kidney and in R LQ, but soft, no
hepatomegaly, +BS
Ext: 2+ edema to kness bl, 1+ DP pulses
Pertinent Results:
[**2125-6-29**] 05:55AM BLOOD WBC-14.3*# RBC-3.05* Hgb-8.5* Hct-27.7*
MCV-91 MCH-27.7 MCHC-30.5* RDW-18.6* Plt Ct-312
[**2125-6-29**] 07:59PM BLOOD WBC-10.7 RBC-2.83* Hgb-7.9* Hct-25.8*
MCV-91 MCH-28.1 MCHC-30.8* RDW-18.0* Plt Ct-242
[**2125-6-29**] 11:52PM BLOOD Hct-28.2*
[**2125-6-30**] 02:21AM BLOOD WBC-13.2* RBC-2.97* Hgb-8.4* Hct-26.9*
MCV-91 MCH-28.3 MCHC-31.2 RDW-18.4* Plt Ct-263
[**2125-7-1**] 03:50AM BLOOD WBC-10.1 RBC-2.84* Hgb-8.0* Hct-25.4*
MCV-89 MCH-28.2 MCHC-31.6 RDW-18.5* Plt Ct-226
[**2125-7-3**] 03:13AM BLOOD WBC-7.8 RBC-2.82* Hgb-7.8* Hct-25.1*
MCV-89 MCH-27.7 MCHC-31.2 RDW-18.0* Plt Ct-221
[**2125-7-5**] 03:34AM BLOOD WBC-8.8 RBC-3.02* Hgb-8.3* Hct-26.5*
MCV-88 MCH-27.4 MCHC-31.2 RDW-17.8* Plt Ct-257
[**2125-7-6**] 05:15AM BLOOD WBC-9.8 RBC-3.09* Hgb-8.5* Hct-27.2*
MCV-88 MCH-27.7 MCHC-31.4 RDW-18.0* Plt Ct-265
[**2125-7-7**] 05:20AM BLOOD WBC-9.1 RBC-3.07* Hgb-8.7* Hct-27.1*
MCV-88 MCH-28.2 MCHC-32.0 RDW-18.1* Plt Ct-301
[**2125-7-8**] 05:45AM BLOOD WBC-8.6 RBC-3.11* Hgb-8.8* Hct-27.6*
MCV-89 MCH-28.1 MCHC-31.7 RDW-17.8* Plt Ct-334
[**2125-7-9**] 06:15AM BLOOD WBC-7.1 RBC-3.22* Hgb-9.0* Hct-28.6*
MCV-89 MCH-27.8 MCHC-31.3 RDW-18.3* Plt Ct-375
[**2125-7-11**] 05:30AM BLOOD WBC-8.3 RBC-3.40* Hgb-9.2* Hct-30.5*
MCV-90 MCH-27.1 MCHC-30.3* RDW-18.1* Plt Ct-456*
[**2125-7-2**] 04:14AM BLOOD Glucose-130* UreaN-42* Creat-4.5* Na-141
K-4.0 Cl-108 HCO3-20* AnGap-17
[**2125-7-3**] 03:13AM BLOOD Glucose-128* UreaN-44* Creat-4.7* Na-137
K-3.7 Cl-105 HCO3-20* AnGap-16
[**2125-7-3**] 03:50PM BLOOD Creat-4.7* Na-135 K-3.8
[**2125-7-3**] 09:45PM BLOOD Na-134 K-3.9
[**2125-7-4**] 02:48AM BLOOD Glucose-112* UreaN-46* Creat-4.8* Na-134
K-3.6 Cl-101 HCO3-20* AnGap-17
[**2125-7-7**] 05:20AM BLOOD Glucose-213* UreaN-57* Creat-4.9* Na-137
K-3.2* Cl-103 HCO3-26 AnGap-11
[**2125-7-8**] 05:45AM BLOOD Glucose-206* UreaN-60* Creat-4.4* Na-139
K-3.4 Cl-103 HCO3-24 AnGap-15
Brief Hospital Course:
This is a 57 yo F with ESRD s/p renal transplant,
lymphangioleimeiomatosis, admitted with fever, diarrhea, acute
renal failure and metabolic acidosis. The patient was sent to
the Medical Intensive Care Unit from the emergency department
because of increased oxygen requirement.
.
Her MICU course was notable for an ongoing AG and non-AG
acidosis attributed to the combination of renal failure/ketosis
and diarrhea, which has since improved with HD x 1, lessening
diarrhea, bicarb, and lasix. She also had an ongoing respiratory
acidosis from hypercarbia, likely [**2-22**] underlying poor lung
reserve and fatigue. She required BiPAP several times during her
course for ventilation assistance. Intubation was considered at
several points, but was not required. ID and renal were involved
in the care of this patient. CT studies of the abdomen were
unremarkable for an infectious source. Blood, urine cultures
were negative while patient was in the MICU. Stool cultures were
also negative. The patient was continued empirically on
levo/flagyl for a presumed GI source, given diarrhea. Urine
legionella was negative. CMV and EBV were checked given
immunosuppression, but were negative. Her course was also
notable for a fluid overload state given evidence of pulmonary
edema on CXR and exam, requiring agressive diuresis with lasix
gtt and IV chlorothiazide.
After her diarrhea, fever, ARF and metabolic acidosis improved,
she was transferred to medicine floor for further care with a
5.5 L oxygen requirement.
1. Fever - resolved after transfer to the medical service. Blood
cultures from [**2125-7-6**] subsequently grew [**1-24**] Coag negative staph
(sensitivities pending) from the central line site. The central
line was d/c'd and the patient was started on vancomycin
empirically (1 gram dosed for daily levels<15). Surveillance
cultures remained negative, patient remained stable without a
fever or white count. The positive cultures may be [**2-22**]
contamination, but it is unclear. She was treated with 5 days
of IV vancomycin and transitioned to oral therapy with
Doxycycline for a further 8 days on discharge. Her urine on
[**2125-7-6**] also grew out <10,000 Enterococcus senstive to IV vanc
and IV ampicillin. Although this is not a true UTI as it is less
than <10,000 and her u/a was sterile, it was decided to treat
with vanc as she is a renal transplant patient. Given her CRI,
she should be dosed 750 mg/qd and have levels checked in [**1-22**]
days to ensure therapeutic levels - done for 5 days as above,
and no evidence UTI on d/c. Her initial fever on presentation
was attributed to a GI source, give negative blood, urine, and
stools cx. She was treated with levofloxacin and flagyl
empirically for 14 days. CMV negative.
.
2. Hypoxia - required 6 L -> NRB on admission from her baseline
of 2 L NC. This was all most likely [**2-22**] lymphangioleimeimatosis
combined with fluid overload; no sign of pneumonia on CXR. With
diuresis, her pulmonary edema removed and her oxygenation status
returned to baseline of 2 L NC. She shoudl continue aggressive
pulmonary toilet to improve her lung function as much as
possible. On d/c to rehab she was subjectively near her
baseline, but allowed to remain on 3L since she is not at risk
for oxygen toxicity at that level
.
3. ESRD s/p transplant with ARF - likely intrinsic process as
FENa of 1.21% and FeUrea = 47.8; no evidence of obstruction on
U/S; creatinine stable at 4.0
- cont immunosuppressants for now
- restrict phosphate and potassium intake
- may require HD in the future, patient refusing currently;
transplant renal followed during course
- need to follow renal function carefully as pt may require HD
in the near future
.
4. NIDDM - initially on a HISS during her course, added NPH due
to elevated BS on a HISS. Currently suguars controlled with 12 U
NPH in AM, 6 U NPH at dinner, and HISS. Continued diabetic diet
with FS QACHS.
.
5. HTN - continued norvasc and metoprolol, BP well controlled
.
6. F/E/N - The patient was placed on a diabetic, low sodium
diet. She was restricted to < 1.5L/day fluid intake, 1 gram
phosphate as patient was hyperphosphatemic on admission, and
2grams of potassium daily. Nutritional status should be
carefully monitored.
Medications on Admission:
MEDS (at home) -
Crestor 5 mg qd
Alendronate QW
Bactrim 3 x per wk
Prednisone 5 mg QD
Metoprolol 100 [**Hospital1 **]
Regular Insulin sliding scale plus 70/30,
Iron
Norvasc 10 mg qd
CellCept 1 g [**Hospital1 **]
Calcitriol 0.5 mcg qd
Procrit
Was on prgraf previously but pt says not anymore.
.
MEDS (on transfer) -
Tylenol prn
Albuterol prn
Amlodipine 10 mg qd
Calcitriol 0.25 mcg qd
Chlorothiazide 500 mg IV bid
Levoflox 250 mg IV q48
Ativan prn
Metoprolol 100 mg tid
Flagyl 500 mg tid
CellCept [**Pager number **] mg IV bid
Protonix 40 mg IV qd
Lasix gtt
Hep SC
RISS
Labetolol gtt
Prednisone 5 mg qd
Bactrim SS 3x/week
Discharge Medications:
1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Furosemide 40 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
4. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
5. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
6. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO 3X/WEEK (MO,WE,FR).
7. Ferrous Sulfate 325 (65) mg Tablet Sig: 325mg Tablets PO once
a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Epoetin Alfa 10,000 unit/mL Solution Sig: 10,000 units
Injection QMOWEFR (Monday -Wednesday-Friday).
9. Calcium Carbonate 500 mg Tablet, Chewable Sig: Three (3)
Tablet, Chewable PO once a day.
Disp:*90 Tablet, Chewable(s)* Refills:*2*
10. Calcitriol 0.25 mcg Capsule Sig: 0.25 microgram Capsule PO
DAILY (Daily).
11. Insulin
Please see attached sliding scale sheet
12. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours) for 8 days: Do not take within two hours
of taking Iron or calcium.
Disp:*16 Capsule(s)* Refills:*0*
13. Colace 100 mg Capsule Sig: One (1) Capsule PO once a day.
Disp:*30 Capsule(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 23973**] [**Location (un) 1110**]
Discharge Diagnosis:
Primary: Fever, acute renal failure, diarrhea, pulmonary edema
.
Secondary: LAM, hypertension, NIDDM, HCC
.
Discharge Condition:
afebrile, oxygen saturation 94-100% on 2L Nasal cannula, other
vital signs stable
Discharge Instructions:
-Please follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in 2 weeks; your
appointment has already been set
-Take all medications as prescribed
-Please call your doctor or return to the ER if you experience
fever, increased shortness of breath, or if you have any other
symptoms that concern you.
Followup Instructions:
Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2125-7-30**] 2:40
[**Name6 (MD) 2105**] [**Name8 (MD) 2106**] MD [**MD Number(2) 5038**]
ICD9 Codes: 5849, 2762, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3844
} | Medical Text: Admission Date: [**2149-9-24**] Discharge Date: [**2149-11-19**]
Date of Birth: [**2086-9-12**] Sex: M
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
Diagnostic Paracentesis
History of Present Illness:
62M with ETOH cirrhosis, recent prolonged hospitalization from
[**Date range (1) 97340**] for right axillary hematoma requiring massive blood
product resuscitation, readmission on [**9-4**] for continued
right groin bleed which achieved hemostasis with DDAVP and
aminocaproic acid, presenting one day after discharge with
altered mental status. His sister reports picking him up from
the hospital the evening of [**9-22**] and reports he had normal
mental status. The following morning he appeared confused with
decreased PO intake and not using bathroom. His symptoms of
confusion progressed throughout the day and by evening he was
awake but not verbal. He was thus brought by his sister to the
[**Name (NI) **] for further evaluation.
In ED vitals were 97.8 73 127/68 24 100% 2L. Paracentesis was
performed which was negative. A RUQ-US showed gallbladder sludge
and a patent portal vein. He received 200cc of NS and flagyl
500mg IV X1, and transferred to the ICU. On admission he had
put our 300cc urine.
Past Medical History:
-ETOH cirrhosis with ESLD, ascites with possible fibrosis and
steatohepatitis via Bx however patient denies hx of Bx. He is
currently being evaluated for transplant at [**Hospital1 1774**].
-ETOH abuse - quiescent x 6 mo per pt with occasional relapse
-Pancytopenia - admitted [**Month (only) **]-[**Month (only) **] to [**Hospital1 112**] with "severe anemia",
given vit K, FFP, PRBCs. EGD and colonoscopy performed which
showed few polyps
-HTN
-ARF
-GERD
Social History:
[**Doctor Last Name **] professional NBA basketball player, then basketball coach
at [**University/College **]. Worked with suicidal individuals.
+ ETOH - sober x 6 months except for few days of relapse with
last drink on [**9-17**], denies hx of ETOH withdrawal symptoms
No smoking. No drugs.
Family History:
Cardiac arrhythmia and stroke - mother
Hypertension - sister
Physical Exam:
Admission Exam
General: cachectic, awake, eyes open, somnolent, awakens to
voice, not responding to qustions or name.
HEENT: scleral icterus
Neck: no LAD
Lungs: CTA b/l
CV: RRR, noi m/g/r
Abdomen: large ascites, non-tender
Ext: 3+ pitting edema, right groin without bruit. well healed
scar of old puncture site over right groin
Neuro: Awake, opens eyes when spojken to, not responding to name
or questions.
Pertinent Results:
Admission Labs
[**2149-9-24**] 02:00AM BLOOD WBC-7.5# RBC-2.99* Hgb-10.1* Hct-29.9*
MCV-100* MCH-33.9* MCHC-33.9 RDW-18.9* Plt Ct-125*
[**2149-9-24**] 02:00AM BLOOD Neuts-75.9* Lymphs-16.6* Monos-5.2
Eos-1.5 Baso-1.0
[**2149-9-24**] 02:00AM BLOOD PT-23.4* PTT-80.2* INR(PT)-2.2*
[**2149-9-24**] 02:00AM BLOOD Glucose-115* UreaN-30* Creat-1.9* Na-137
K-3.8 Cl-106 HCO3-15* AnGap-20
[**2149-9-24**] 02:00AM BLOOD ALT-14 AST-53* CK(CPK)-108 AlkPhos-69
TotBili-10.8*
[**2149-9-24**] 02:00AM BLOOD Lipase-82*
[**2149-9-24**] 10:19AM BLOOD Calcium-9.8 Phos-3.0 Mg-1.6
[**2149-9-24**] 10:19AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2149-9-24**] 10:30AM BLOOD Type-[**Last Name (un) **] Temp-37.7 pO2-123* pCO2-37
pH-7.29* calTCO2-19* Base XS--7 Intubat-NOT INTUBA
[**2149-9-24**] 03:47AM URINE Color-Amber Appear-Clear Sp [**Last Name (un) **]-1.008
[**2149-9-24**] 03:47AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-1 pH-6.5 Leuks-NEG
[**2149-9-24**] 09:24AM URINE Hours-RANDOM UreaN-497 Creat-108 Na-59
[**2149-9-24**] 09:24AM URINE Osmolal-372
[**2149-9-24**] 06:00AM ASCITES WBC-158* RBC-1185* Polys-3* Lymphs-18*
Monos-77* Mesothe-2*
[**2149-9-24**] 06:00AM ASCITES TotPro-3.4 Glucose-122 Albumin-1.6
Imaging:
-[**2149-9-24**] CT Head: IMPRESSION: Study limited due to patient
movement in the scanner due to altered mental status, however,
no large acute hemorrhage is seen. No obvious fractures are
seen.
NOTE ON ATTENDING REVIEW:
1. There is expanded, slightly lobulated appearance to the
medulla and ponto medullary and cervico-medullary junctions on
the axial images. It is unclear if this is real/artifactual
related to the motion/angulation. Repeat study when the pt. is
co-operative and if persistent, MR [**Name13 (STitle) 430**] can be considered.
2. Degenerative changes are noted at the dens on the right
side and a small osteoma in the right side of the frontal sinus.
-[**2149-9-24**] Abdominal Ultrasound: 1. Coarsened liver in keeping
with diagnosis of cirrhosis. Small hypoechoic round lesion at
the dome of the liver, likely a small cyst.
2. Main portal vein is patent.
3. Ascites.
4. Sludge in the gallbladder.
5. Residual pleural effusion.
-[**2149-9-24**] CXR: Basal consolidation is new since [**9-11**].
Since there is appreciable leftward mediastinal shift this could
be collapsed. A lesser volume of abnormality is present in the
infrahilar right lower lobe. Small bilateral pleural effusions
could be present but not appreciated on conventional
radiographs. Mild cardiomegaly is longstanding. Nasogastric tube
ends in the region of the pylorus. Substantial intestinal
distention is noted in the imaged portion of the upper abdomen.
-[**2149-9-24**] KUB: NG tip within the stomach, with the sidehole above
the GE junction and with minimal purchase in the stomach.
Recommend advancement
further into the stomach. This result was communicated by Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] to the primary medical team.
-[**2149-9-30**] CT Pelvis:
1. Colonic ileus with dilated loops of transverse colon.
Contrast passes
through the transverse colon into the descending colon and
sigmoid.
2. Stable hepatic hypodenities and apparent new tiny
hypodensity, too small to characterize, statically likely to be
cysts.
3. Massive and increased ascites.
4. Right middle lobe pulmonary nodule. Consider chest CT
followup in 12
months.
5. Findings consistent with cirrhotic liver.
6. Decreased pleural effusions and associated relaxation
atelectasis.
7. Persistent right chest wall hematoma and associated probable
right tenth rib fracture.
-[**2149-10-3**] KUB:
1. Worsening colonic ileus.
2. Massive ascites.
3. Bilateral pleural effusions and airspace disease.
-[**2149-10-4**] KUB: Compared to the prior study, there is a stable
substantially air distended colon, but no evidence for
progressive distention. Relative paucity of bowel gas distally
is seen with thin rim of air consistent with the compressed
sigmoid colon from the ascites as was demonstrated on the recent
CT scan of [**2149-9-30**]. There is no free air or pneumatosis.
-[**2149-10-7**] KUB:
1. Stable colonic ileus.
2. Ascites.
-[**2149-10-9**] KUB: Isolated dilatation of large bowel, suggestive of
colonic ileus. Low colonic obstruction is a less likely
possibility, given temporal stability.
-[**2149-10-10**] KUB: Severe colonic distention, the caliber of which is
not significantly changed, most suggestive of ileus.
-[**2149-10-11**] KUB: Severe distention of the colon, not significantly
changed compared to prior examinations, most suggestive of
ileus.
-[**2149-10-11**] Lower extremity U/S: No evidence of DVT seen in either
lower extremity
-[**2149-10-13**] KUB: No definitive evidence of ileus or obstruction
-[**2149-10-15**] Chest CT: 1. No change in size of a large right chest
wall hematoma, however presence of high-attenuation areas within
the collection indicates recent rebleeding.
2. Interval increase in bilateral pleural effusions.
3. Abnormal appearance of renal parenchyma, correlate with renal
function, as this appearance can be seen in the setting of acute
renal failure such as ATN.
4. Number of noncalcified pulmonary nodules, largest 5 mm solid
nodule in the right middle lobe. In absence of risk factors,
followup in one year is
recommended to document stability.
5. Large abdominal ascites.
-[**2149-10-15**] KUB: Overall no appreciable change in gaseous
distention of large
bowel loops.
-[**2149-10-16**] Paracentesis Guided U/S: Ultrasound-guided diagnostic
and therapeutic paracentesis yielding 2 liters of clear
dark-yellow fluid.
-[**2149-10-17**] KUB: Persistent gaseous distention of large bowel loops
without
appreciable change.
-[**2149-10-18**] KUB: Two distended segments of colon are present in
the mid abdomen. There is probably increased gaseous distention
since the prior study. There is overall haziness and
under-penetration of this film.
-[**2149-10-19**] CT Abd/Pelvis:
1. Small hematoma of the abdominal wall muscles in the right
lower quadrant.
2. Hematoma of right internal obturator muscle.
3. Large hematoma in the right lateral thorax and abdominal
wall, stable
compared to the previous exam.
4. A large amount of ascites.
5. Small to moderate amount of pleural effusion bilaterally.
6. Dilatation of the transverse colon up to 8.2 cm with fluid in
its lumen
and collapsed distal large bowel.
-[**2149-10-20**] KUB: There is a stable marked distention of the
ascending and transverse colon measuring up to 10 cm in maximal
diameter. There is mild interval increase in gas distention of
small bowel loops. Patient has known ascites
-[**2149-10-24**] KUB: The new right-sided PICC line tip is satisfactory
at the cavoatrial junction.
Consolidation in the middle lobe is slightly worse than on the
previous chest radiograph from [**2149-9-9**] and there is new
left lower lobe atelectasis. The remaining lungs are clear with
no pneumothorax or pleural effusion. Cardiomediastinal
silhouette is unchanged and within normal limits. There is
progressive distention of the large bowel without no obvious
bowel wall thickening.
-[**2149-10-26**] Chest CT: 1. Very minimal increase in the size of the
large right chest wall hematoma as described above. The presence
of high-attenuation areas within the collection indicates
re-bleeding.
2. Stable bilateral pleural effusions and basal atelectasis.
3. Non-calcified pulmonary nodules, largest 5-mm nodule in the
right middle lobe. In the absence of risk factors, followup in
one year is recommended to document stability.
4. Cirrhotic liver and large abdominal ascites is stable
-[**2149-10-27**] KUB: Again identified is marked distention of the
ascending, transverse and descending colon, not significantly
changed. Air-fluid levels are identified. Loops of bowel
measuring up to 10 cm in maximal diameter, unchanged.
-[**2149-10-27**] CXR: Left PICC transverses the midline and
subsequently terminates in the right subclavian vein as
communicated to [**First Name8 (NamePattern2) 8513**] [**Last Name (NamePattern1) **] on [**2149-10-27**]. Appearance
of the chest is relatively unchanged compared to the recent
radiograph except for slight worsening of left retrocardiac
opacification. Within the abdomen, distended loops of bowel are
incompletely imaged but probably slightly improved.
-[**2149-10-28**] CXR: As compared to the previous examination, the
position and course of the left PICC line is unchanged, the line
placed over the left upper extremity crosses the midline and is
located in the distal right brachiocephalic vein. There is no
evidence of pneumothorax or other complications
-[**2149-10-28**] Fluoro: Uncomplicated fluoroscopically guided PICC
line exchange for a new 5-French double lumen PICC line. Final
internal length is 46 cm, with the tip positioned in the SVC.
The line is ready to use.
-[**2149-10-30**] Right Upper Extrem U/S: No evidence of DVT of the
right upper extremity
-[**2149-10-30**] KUB: Persistent colonic dilatation without significant
interval
change.
-[**2149-10-30**] CXR: Appropriate position of PICC line, no evidence of
new acute pulmonary infection.
-[**2149-10-31**] KUB: Unchanged colonic distention
-[**2149-11-3**] CXR: Left PICC is again seen, now terminating at the
brachiocephalic junction. Again noted are bibasilar opacities,
left retrocardiac opacity is dense, and may represent
atelectasis, however, superimposed infection may not be
excluded.
Again, marked elevation of both diaphragms is present, as well
as significant air distention of the large bowel.
BLOOD BANK: [**2149-10-19**]: Mr. [**Known lastname **] has a new diagnosis of Anti-E
antibody. E-antigen is a member of the Rhesus blood group
systems. Anti-E antibody is clinically significant and capable
of causing a hemolytic transfusion reaction. In the future, Mr.
[**Known lastname **] should receive E-antigen negative products for all red
cell transfusions. Approximately 71% of ABO compatible blood
will be E-antigen negative. A wallet card and a letter stating
the above will be sent to the patient.
Micro:
-[**2149-9-24**] Ascites: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES. NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2149-9-27**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2149-9-30**]): NO GROWTH.
-[**2149-9-24**] Blood x 2: No growth
-[**2149-9-27**] Urine: No growth
-[**2149-9-29**] Stool/C. Diff: Negative
-[**2149-9-30**] Urine: YEAST 10,000-100,000 ORGANISMS/ML
-[**2149-10-2**] Urine: YEAST >100,000 ORGANISMS/ML
-[**2149-10-7**] Stool/C. Diff: Negative
-[**2149-10-9**] Stool/C. Diff: Negative
-[**2149-10-12**] URINE CULTURE: ENTEROCOCCUS SP 10,000-100,000
ORGANISMS/ML..
SENSITIVITIES: MIC expressed in MCG/ML
ENTEROCOCCUS SP.
AMPICILLIN <=2 S
NITROFURANTOIN <=16 S
TETRACYCLINE =>16 R
VANCOMYCIN <=1 S
-[**2149-10-15**] Urine: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES),
CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION.
-[**2149-10-16**] Ascites: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO
MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2149-10-19**]): NO GROWTH
ANAEROBIC CULTURE (Final [**2149-10-22**]: NO GROWTH
-[**2149-10-18**] Blood x 2: No growth
-[**2149-10-27**] Blood: No growth
-[**2149-10-30**] Blood: No growth
-[**2149-10-31**] Blood: No growth
-[**2149-11-2**] Stool/C. Diff: Negative
-[**2149-11-2**] Urine: No growth
-[**2149-11-4**] Blood x 2: ________
-[**2149-11-4**] Urine: No growth
Brief Hospital Course:
Mr. [**Known lastname **] is a 63 yo man with alcoholic cirrhosis, complicated
by ascites, coagulopathy, and hepatic encephalopathy, who
initialy presented with altered mental status and was admitted
to the ICU. His mental status improved and he was transferred
to the liver service for continued management.
.
# Altered Mental Status: Likely due to hepatic encephalopathy.
At admission, a diagnostic paracentesis was performed by the ED
which was not suggestive of infection. A RUQ US was also
performed which did not show any acute biliary pathology. Serum
and urine toxicologies were negative. In the ICU Lactulose and
Rifaximin were started for likely hepatic encephalopathy. A CT
head without contrast was performed but was substantially
hampered by motion artifact. Stool output began to pick up on
lactulose regimen and mental status substantially improved.
Lactulose and rifaximin were continued with improvement of
mental status back to baseline. Lactulose was then stopped
because of concern regarding his colonic pseudoobstruction and
his continued diarrhea. The patient had an acute decline in
mental status on the morning of [**2149-10-18**], with physical exam
findings suggestive of hepatic encephalopathy, including
asterixis. Additionally, he had received two doses of morphine
for pain and appeared oversedated. He received narcan IV x3,
and became substantially more alert. He was restarted on
lactulose, and then stopped after stabilization of his mental
status. On [**2149-10-30**] the patient again had a change in mental
status, this time consistent with delerium and felt to be
secondary to underlying infection. The patient was started on
Vanc/CTX [**10-30**] out of concern for possible RUE cellutitis and
possible other occult infection.
His mental status was then generally clear for several days,
with occasional confusion or disorientation. With his liver and
kidney functioning worsening daily, both encephalopathy and
uremia became an etiologic factor in his altered mental status.
Lactulose was not restarted, given the patient's regular bowel
movements. He was continued on rifaximin through [**11-11**], when his
code status had changed to Comfort Measures Only. The patient's
mental status also waxed and waned in the setting of receiving
opioid analgesia. The patient and family members showed good
understanding that he may be increasingly somnolent with fewer
and shorter lucid intervals, and he called his HCP and other
family members to relay this message, in advance of starting
more aggressive comfort measures on [**11-11**]. He was admitted to an
inpatient hospice service and was given increasing doses of
morphine. He was eventually started on a morphine drip,
scopalomine patch, and atropine sublingual drops, when he
developed large amounts of oropharyngeal and nasal secretions.
He expired early in the morning of [**11-19**].
.
# Acute Renal Failure: Initially, the patient presented with Cr
1.9 elevated from a baseline value of 0.8. On clinical exam the
patient appeared itravascullary depleted supported by a lactate
of 4.3 with decreased to 3.8 after initial fluid bolus. His UA
in the ED was negative. Renal function was reponsive to initial
fluid boluses suggesting that this was pre-renal in etiology.
Creatinine continued to trend down with fluids reaching at nadir
at his baseline of 0.9 on [**9-26**]. However, his renal function
again began to decline and became unresponsive to fluid
challenges. Initially, it was felt that there was a prerenal
component to his ARF, because he had been intermittently NPO for
procedures and bowel rest in relation to his ileus. However,
renal function did not improve with several days of albumin
administration, and it was felt to be due to hepatorenal
syndrome. All diuretics were stopped, and the patient was
initiated on treatment for HRS including octreotide, midodrine
and daily albumin. Additionally, the differential for renal
failure included abdominal compartment syndrome, given the
patient's significant ascites and colonic distension. A bladder
pressure was transduced at 14-17 mmHg; elevated but
nondiagnostic for compartment syndrome.
The patient was not considered a candidate for hemodialysis,
given the frequent episodes of bleeding that he had demonstrated
with even minor interventions. On [**11-5**], the decision was made
to keep checking daily BUN and creatinine levels, to help the
family know how much of the patient's mental status they could
attribute to his uremia. It was clearly communicated to the
patient and the family members that the patient's kidneys were
failing and were likely to continue worsening daily. On [**11-11**],
the patient was made CMO and all lab checks, including BUN and
creatinine, were discontinued.
# Diarrhea - On transfer from ICU, patient was noted to have
dark, watery diarrhea. Initially attributed to lactulose, which
was continued. TTG WNL and C. Diff was negative. Flexiseal was
discontinued with some improvement in diarrhea. Diet was changed
to lactose and gluten free despite negative results for celiac.
On physical exam, concern for obstruction given high-pitched
"tinkling" bowel sounds. CT A/P was consistent with large bowel
ileus with megacolon (9 cm loops) that were filled with air (see
pseudoobstruction below). Diarrhea was felt to be
multifactorial, due to a combination of lactulose and
non-obstructing ileus. The diarrhea remained throughout his
hospital stay and was felt to be responsible for a chronic
metabolic acidosis.
# Colonic Ileus - Abdomen with tympany to percussion on exam and
diarrhea concerning for obstruction. CT A/P with megacolon
(9cm) with repeat KUBs stable with possible 14cm loop of bowel.
Out of concern for partial obstruction, flex sigmoidoscopy was
performed on [**10-6**]; the bowel was decompressed and reaccumulated
air within several hours. Bowel rest and rectal tube
decompression was also attempted, without success. He was
closely monitored with serial abdominal exams and KUBs over
several weeks, with no significant change in colonic distention.
Additionally, he continued to have bowel movements. As his
condition became increasingly terminal, he occasionally seemed
to indicate abdominal discomfort, and was treated with
increasingly aggressive comfort measures.
# Traumatic foley placement: As above, abdominal compartment
syndome was considered on the differential for renal failure. A
foley catheter was placed, with trauma to the urethra because of
difficulty advancing the catheter past the prostate. Urology
placed a coude catheter, with a plan to leave the foley in place
for at least one week to tamponade bleeding. Post procedure,
the patient continued to bleed from the urethra, and required
many units of PRBCs and FFP (see coagulopathy). He occasionally
passed clots through his Foley catheter, manipulation of the
Foley was kept to a minimum, given the aforementioned bleeding
complications. His Foley was kept in place until he passed away.
# Coagulopathy: Multifactorial from lupus anticoagulant and
liver dysfunction. Large chest wall hematoma with CT suggesting
component of rebleed. Also developed urethra bleed from
traumatic foley placement (see above), as well as abdominal wall
bleeding from para site which required several brief ICU stays
for hemodynamic monitoring. During ICU stay from [**10-19**]/-[**10-21**]
received FFP, DDAVP, thrombin dressing to paracentesis site with
continued oozing, which resolved after stitch and pressure
dressing by surgery. He was again sent to the MICU from
[**Date range (1) 11301**] after appearing to have passed a large clot per
rectum, and a 7 pt Hct drop. The patient was guaiac negative
and subsequently had a formed brown stool so it is believed that
the blood was actually pooled blood from his penis that had
collected in his perineum. The patient subsequently had
significant bleeding from his penis that lasted throughout the
day and following night. He received FFP, PRBCs, Cryo and
vitamin K. Urology was contact[**Name (NI) **] who recommended continuing his
Foley and correcting his coagulopathy. Upon returning to the
medicine floor, the patient continued to require daily
transfusions of PRBCs and FFP. On [**2149-11-2**] he was also given
DDAVP to treat for uremic platelets and Factor 7. His
coagulation studies did not show any significant change, and his
hematocrit did not stabilize. A subsequent blood transfusion
caused low grade temperatures and increased work of breathing,
and was stopped early. With increasing focus on the patient's
comfort, it was decided to not give further transfusions.
# UTI - yeast on urine culture. U/A from [**10-12**] now grew
enterococcus and pt completed 7 day course of ceftriaxone from
[**Date range (1) 1195**].
# ESLD: Complicated by ascites and encephalopathy. Presented
with hepatic encephalopathy that improved with lactulose and
rifaximin, and then declined again for unclear reasons;
progression of liver disease versus infection versus stopping
lactulose. Additionally, the patient underwent several
diagnostic paracenteses, which showed no evidence of any
infection. During his hospitalization, he was evaluated for
liver transplantation and a decision was made that he was not a
candidate of transplantation due to the severity of his
coagulopathy.
# Guaiac Positive Stools: Patient with history of Guaiac
positive stools during prior hospitalization which was atributed
to hemorrhoids. Initial HCT of 26.5 in ED which appears to be at
baseline with prior levels. Pt placed on 5 day course of
ceftriaxone for SBP prophylaxis in setting of GIB. Serial
hematocrits were followed with a tendency to drift down and
require periodic transfusions. He had one further episode
BRBPR, which was self-limited and felt to be hemorrhoidal in
origin.
# Hypokalemia - Likely secondary to diuretics and diarrhea.
Diruetics held intermittantly, potassium replaced prn.
Hypokalemia resolved with improvement of diarrhea. In spite of
his ESRD, his potassium remained borderline low when checked on
[**11-10**].
Medications on Admission:
1. Folic Acid 1 mg DAILY
2. Pantoprazole 40 mg Tablet, Q24H
3. Thiamine HCl 100 mg once a day.
4. Lactulose Thirty (30) ML PO TID
5. Spironolactone 100 mg DAILY
6. Lasix 80 mg once a day
7. Aminocaproic Acid 1,000 mg Tablet One (1) Tablet PO every six
(6) hours for
11 days
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Kidney injury [**2-10**] end-stage liver disease
Discharge Condition:
Expired
ICD9 Codes: 5849, 5119, 2762, 5990, 2768 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3845
} | Medical Text: Admission Date: [**2145-12-10**] Discharge Date: [**2146-1-15**]
Date of Birth: [**2145-12-10**] Sex: M
Service: NB
HISTORY OF PRESENT ILLNESS: Baby boy [**Known lastname **] [**Known lastname 5433**] - twin #1 -
delivered at 32 weeks gestation. He was admitted to
the newborn intensive care nursery for management of
respiratory distress and prematurity. Birth weight is 1685
grams.
Mother is a 34-year-old G1/P0 (now 2) mother with in [**Last Name (un) 5153**]
fertilization, diamniotic-dichorionic twin gestation.
Prenatal screens included blood type A+, antibody negative,
hepatitis B surface antigen negative, rubella immune, RPR
nonreactive, and group B strep status unknown. The maternal
medications during pregnancy included Prozac 40 mg daily and
Pepcid AC. She presented with preterm labor and bleeding on
day of delivery. She was treated with magnesium sulfate, but
due to increased bleeding she was delivered by emergent C-
section secondary to abruptio placenta. Membranes were
ruptured at delivery. She received 1 dose of betamethasone
shortly prior to delivery. [**Known lastname **] emerged vertex. He required
several positive pressure breaths and then free flow oxygen.
His Apgar scores were 8 at one minute and 8 at five minutes.
PHYSICAL EXAMINATION ON ADMISSION: In general, an infant
with increased work of breathing and intermittent grunting.
Weight of 1685 grams (50th percentile), head circumference of
30 cm (50th percentile), length of 42.5 cm (50th percentile).
Head normocephalic/atraumatic. Anterior fontanel open/flat.
Palate intact. Red reflex present bilaterally. NECK: Supple.
CHEST: Lungs with shallow respirations, intercostal
retractions. CARDIOVASCULAR: Regular rate and rhythm. A grade
1/6 systolic murmur. Femoral pulses 2+ bilaterally. ABDOMEN:
Soft with active bowel sounds. No masses. No
hepatosplenomegaly. EXTREMITIES: Warm, well perfused, brisk
capillary refill. Anus patent. Spine midline. No sacral
dimple. GENITOURINARY: Normal premature genitalia. Testes
still high. Hips stable. Clavicles intact. NEURO: Decreased
tone.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS:
1. RESPIRATORY: Was intubated on admission and placed on
assisted ventilation. Received one dose of surfactant.
Was extubated to nasal continuous positive airway
pressure on day of life 1; initially requiring 30% to 38%
on continuous positive airway pressure. His oxygen
requirement gradually decreased down to room air. He
transitioned off nasal continuous positive airway
pressure on day of life 4. He has remained in room air
since with comfortable work of breathing with just very
mild intercostal retractions. Respiratory rates have
ranged in the 30s to the 60s. He was started on caffeine
citrate for apnea of prematurity.
Caffeine was D'Cd on [**2145-12-29**]. He has been free of any
significant episodes for at least 5 days prior to
discharge.
2. CARDIOVASCULAR: He has been hemodynamically stable since
admission with normal blood pressures and heart rate. A
murmur heard on admission has not been heard since. He
has had no signs of a patent ductus arteriosus. His heart
rate ranges in the 130s to 160s.
3. FLUIDS, ELECTROLYTES, NUTRITION: Was initially n.p.o..
Was receiving IV fluids and parenteral nutrition through
a double lumen umbilical venous catheter. Enteral feeds
were started on day of life 3 with breast milk or
Premature Enfamil formula. The feeds were gradually
increased until he reached full volume feeds on day of
life 8. His double lumen umbilical venous catheter was
discontinued on day of life 7. His caloric density was
gradually increased to maximum of breast milk 28 with
ProMod. His electrolytes were followed and were within
normal ranges. His glucose's have been followed and have
been within normal ranges. He is voiding and stooling
appropriately. Curently he is on breast milk
24 ad lib feeding.
His weight prior to discharge was 2.465 kgs.
4. GASTROINTESTINAL: He was treated with phototherapy for
indirect hyperbilirubinemia. His peak bilirubin was on
day of life 8. The total was 9.1, direct 0.3. His
phototherapy was discontinued on day of life 10. A
rebound bilirubin on day of life 11 was a total of 6.4,
direct 0.3.
5. HEMATOLOGY: His hematocrit on admission was 46%. He has
not received any blood transfusions. His most recent Hct
on [**1-7**] was 29 with a retic count of 4.8 . He is on
FerInSol.
6. INFECTIOUS DISEASE: A CBC and blood culture were drawn on
admission, and he received 48 hours of ampicillin and
gentamicin for rule out sepsis. His CBC was normal. Blood
culture was negative. He has had drainage from his left
eye previously treated with erythromycin and on [**12-30**] placed
on gentamycin eye ointment for 7 days with an eye culture
positive for klebsiella.
7. NEUROLOGY: A head ultrasound done on day of life 6 showed
a grade 1 intraventricular hemorrhage. It was repeated
again on day of life 13, showing resolving grade 1
intraventricular bleed. He has 2 small cysts in the R
frontal white matter and 1 on the L,that are
periventricular significance is uncertain. Repeat HUS done
on [**1-6**]
8. IMMUNIZATIONS:Hep B and Synagis on [**1-13**]. Synagis given
because an infant in the NICU had RSV.
9. Hearing screen passed.
DISCHARGE MEDICATIONS:Ferrous Sulfate 0.4 cc PO q Day.
Multivitamins 1cc PO q day.
NAME OF PRIMARY PEDIATRICIAN: [**Hospital 47763**] Medical
Associates in [**Location (un) 15749**], [**State 350**], Dr. [**First Name (STitle) **].
CARE AND RECOMMENDATIONS:
F/U with VNA day post discharge and within 3-5 days with
Dr. [**First Name (STitle) **]. If any future developmental delays to do MRI as
outpatient given presence of periventricular cysts.
DISCHARGE DIAGNOSES:
1. Appropriate for gestational age 32-week preterm male
infant (twin #1).
2. Respiratory distress syndrome; resolved.
3. Rule out sepsis.
4. S/P Apnea of prematurity.
5. Indirect hyperbilirubinemia
6. Grade 1 intraventricular hemorrhage with periventricular
cysts.
7. S/P R eye conjunctivits.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 37691**], [**MD Number(1) 55783**]
MEDQUIST36
D: [**2146-1-18**] 17:02:55
T: [**2146-1-18**] 19:03:20
Job#: [**Job Number 65088**]
ICD9 Codes: 769, 7742, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3846
} | Medical Text: Admission Date: [**2121-12-7**] Discharge Date: [**2121-12-9**]
Date of Birth: [**2080-1-11**] Sex: F
Service: NEUROLOGY
Allergies:
Iodine
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Tingling of left side
Major Surgical or Invasive Procedure:
None
History of Present Illness:
41 year old woman hx DM, TIA, 100% occlusion of the left
internal carotid artery, who was in her usual state of health
when she awoke at 4am, and shortly thereafter had acute onset of
tingling of the left fingers which marched up the left arm and
left face. She had tingling of the left leg. This quickly became
numbness. She had dysarthria. She felt heaviness of the left arm
and leg. Pt tried to stand up but she felt as if her left leg
was
shuffling and heavy. She sat back down. At 5:10am, she still had
tingling and heaviness of the left arm but the other symptoms
had
resolved.
Patient was taken to the [**Hospital1 18**] ED. NIHSS was 1 for left
pronator drift. Head CT showed a small bleed in the genu of the
right internal capsule. She had a SBP of 218/114. Patient was
given Labetalol 10mg iv once. Patient was admitted to ICU for BP
control.
ROS:
+tinnitus at times for 4 yrs
+floaters
+monocular diplopia s/p eval by Dr. [**Last Name (STitle) 27348**]
+lt sensitivity
+diarrhea and constipation alternating
+abd pain at times
+urinary urgency, occasional accidents (stress incont)
+occ. CP
+occ. palpitations
+occ. sob
+occ. DOE
Other ROS was negative
Past Medical History:
-CAD s/p MI at 37
-DM1 (retinopathy, neuropathy, nephropathy)
-autonomic dysfunction, s/p eval by autonomic team
-irritable bowel syndrom
-anemia
-depression
-migraines
-hypothyroidism
-recent TAH
-s/p CCY
-Acne
-ER visit [**8-8**] with same sx, thought to be possibly migraine vs
TIA
-prior [**Female First Name (ambig) 27349**]: [**7-8**] with BL LE heaviness and R-arm
heaviness;
She has had 2-3 episodes of right arm tingling, numbness and
right facial numbness and tingling
She describes sx as numbness and tingling starting in one finger
and spreading over minutes to including the whole hand and then
moving to the left side of the mouth - sx last 10 minutes total.
During the sx, when she tries to speak, speech is thick and
garbled, sometimes saying the wrong word in addition to
slurring,
and she has frustration with finding the right word -
comprehension is completely normal. This resolves within 10
minutes, and about 50% of the time she then experiences the
gradual onset of a throbbing, L-sided headache with photophobia,
mild phonophobia and nausea, sometimes with dry heaving, lasting
hours. She had an episode last week, and an episdode today -
compazine helped the headache.
patent extracranial R-ICA, with possible R-supraclinoid
narrowing; complete occlusion of the L-ICA; LVEF>55%, no PFO or
ASD; no dwi on MRI, but signs of small vessel disease
Social History:
She lives with husband and has a 4 year old son. She is a
homemaker. Denies smoking. Occ. etoh.
Family History:
No migraines, strokes, or seizures. Her father has DM and CAD.
Physical Exam:
VS: Tc 98.0 BP 218/114 to 167/101 P 114 R 16 O2 100%
Gen: WD/WN
Heent: supple neck, no carotid bruits, no lymphadenopathy
Chest: lungs clear to auscultation bilaterally, no wheezes,
rales, or rhonchi
Heart: regular rate and rhythm, no murmurs,
Abd: soft, non-distended, non-tender, no mass, positive bowel
sounds
Ext: no cyanosis, clubbing, or edema
Skin: no erythema
Neuro: MS: alert and oriented x3, fluent, intact comprehension,
intact naming, repetition, nowledge, follows crossed body
commands, no neglect
CN: visual fields full to confrontation, no papilledema, pupils
equal, round, and reactive,
extraocular movements intact, intact light touch, intact facial
strength and symmetry,
intact t/u/p, [**4-6**] SCM and trapezius
Motor: normal tone and bulk of all four extremities, no tremor
Mild pronator drift of the left arm
D B T WE WF
Left 5 5 5 5 5
Right 5 5 5 5 5
IP Q H DF PF
Left 5 5 5 5 5
Right 5 5 5 5 5
Sensory: intact light touch and pinprick of all four extremities
decreased vibration and proprioception of LE in a
stocking glove distribution
no extinction
negative Romberg
Reflex: T BR B K A toes
Left 2 2 2 2 2 down
Right 2 2 2 2 2 down
Coord: Intact finger-nose-finger, heel-shin bilaterally
Gait: deferred
Pertinent Results:
[**2121-12-7**] 06:00AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.008
[**2121-12-7**] 06:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2121-12-7**] 05:46AM GLUCOSE-307* UREA N-35* CREAT-1.8* SODIUM-137
POTASSIUM-4.4 CHLORIDE-100 TOTAL CO2-25 ANION GAP-16
[**2121-12-7**] 05:46AM estGFR-Using this
[**2121-12-7**] 05:46AM CK(CPK)-191*
[**2121-12-7**] 05:46AM cTropnT-<0.01
[**2121-12-7**] 05:46AM CK-MB-4
[**2121-12-7**] 05:46AM CALCIUM-9.2 PHOSPHATE-4.0 MAGNESIUM-1.8
[**2121-12-7**] 05:46AM WBC-7.0 RBC-5.09# HGB-13.8 HCT-43.1 MCV-85
MCH-27.1 MCHC-32.1 RDW-15.9*
[**2121-12-7**] 05:46AM NEUTS-54.1 BANDS-0 LYMPHS-32.8 MONOS-6.0
EOS-5.9* BASOS-1.2
[**2121-12-7**] 05:46AM HYPOCHROM-1+ ANISOCYT-OCCASIONAL
POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-OCCASIONAL
POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
[**2121-12-7**] 05:46AM PLT COUNT-414
[**2121-12-7**] 05:46AM PT-11.2 PTT-22.9 INR(PT)-0.9
[**2121-12-8**] 05:44AM BLOOD %HbA1c-10.3*
[**2121-12-8**] 05:44AM BLOOD Triglyc-134 HDL-68 CHOL/HD-2.5 LDLcalc-77
[**2121-12-8**] 05:44AM BLOOD ALT-24 AST-30 LD(LDH)-211 CK(CPK)-80
AlkPhos-112 TotBili-0.3
CT head [**2120-12-7**]:
FINDINGS: There is a focal linear region of hyperattenuation
measuring 8 mm
in greatest dimension within the periventricular white matter
and involving
the lateral margin of the right internal capsule consistent with
acute
hemorrhage. There is a smaller adjacent focus. No significant
mass effect is
present. The major intracranial cisterns are preserved. There
is no
hydrocephalus.
No acute fracture is detected. The paranasal sinuses and
mastoid air cells
are clear except for mild mucosal thickening in the left
maxillary sinus.
IMPRESSION:
Two linear foci of hyperattenuation within the right corona
radiata
consistent with an acute parenchymal hemorrhage. No significant
mass effect
or midline shift is demonstrated.
MRI/MRA head [**2120-12-7**]:
Comparison is made with CT head on the same day and from MRI,
MRA performed
[**2121-4-22**] and [**2120-8-16**].
There is mucosal thickening and mucous retention cyst in the
left maxillary
sinus.
Acute hemorrhages are again noted in the right corona radiata,
unchanged from
the previous CT. There is no significant surrounding edema, or
mass effect.
There is no associated diffusion restriction. There is no
enhancement to
suggest an underlying lesion. There is lack of flow related
enhancement in
the left petrous and cavernous ICA and in the right supraclinoid
ICA. This is
unchanged from the prior report. There are multiple scattered
subcortical and
periventricular hyperintensities which likely represent small
vessel ischemic
sequela in this patient with diabetes.
IMPRESSION:
Small foci of hemorrhage in the right corona radiata with
minimal surrounding
edema and no midline shift.
Probable small vessel ischemic sequela related to underlying
diabetes in the
subcortical and periventricular white matter.
Lack of normal flow voids in the left petrous, cavernous and
supraclinoid ICA
and the right supraclinoid ICA, reportedly unchanged from prior
examination.
Images from the previous MRI from [**2120-8-16**] are pending at this
time.
ECG [**2120-12-7**]:
Sinus tachycardia. Poor R wave progression, probably a normal
variant.
Left ventricular hypertrophy by voltage criteria. Compared to
the previous
tracing of [**2121-6-23**] there is no significant diagnostic change.
Brief Hospital Course:
Given the patient's severe hypertension in the setting of
hemorrhage, the patient was admitted to ICU for BP control. Her
blood pressure was quickly controlled in the unit, and she was
called out to the floor for further management and observation.
MRI of the head showed a stable bleed, with no underlying mass
or vascular anomaly as the source for the right corona radiata
bleed. It also revealed stable (previously known) 100% left ICA
occlusion and an occlusion in the right supraclinoid ICA. Risk
stratification showed an A1C of 10.3 and a fasting lipid profile
with LDL 77 and HDL 65 while on lipitor 80 mg/d and zetia 10 mg
qod.
She was transferred out of the ICU to the floor on [**12-8**] and
observed for 24 hours. Overall, her exam had improved: she was
found to have left arm 5-/5 UMN pattern weakness (deltoid and
triceps, full distally) with pronator drift, and full strength
in the left leg, though still with a wide-based, slightly
cautious gait, favoring the right side. She was evaluated by PT
and OT and felt to be safe to go home with outpatient PT/OT.
She was restarted on her home dose of aspirin in addition to the
[**Month/Day (4) 4532**], considering her prior history, and the intracranial
hemorrhage was ultimately felt to be related to elevated ICP
with coughing, coupled with hypertension.
Medications on Admission:
Nortripyline 10mg qhs
Retin A 0.025%
Spectazole 1%
traZODONE HCl 50 mg PO HS
Escitalopram Oxalate 40 mg PO DAILY
Atorvastatin 80 mg PO DAILY
Doxycycline Hyclate 100 mg PO Q12H
Ezetimibe 10 mg PO QOD
Doxercalciferol 0.5 mcg PO DAILY
Aspirin 325 mg PO DAILY
Procardia 30mg qd
Toprol XL 50mg
Aranesp 0.3mL - off recently due to insurance problems
[**Name (NI) **] 75mg [**Name2 (NI) **] daily
Synthroid 50mcg po qday
Nitroglycerin 0.4mg prn cp
Reglan 10mg prn nausea (rarely takes)
Insulin pump - basal rate 13u
Hecterol 0.5mcg daily
RISS
Tesselon Perles
Xanax 0.25mg qhs
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
2. Nortriptyline 10 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
3. Retin-A 0.025 % Gel Sig: One (1) Topical once a day: or as
prior.
4. Spectazole 1 % Cream Sig: One (1) Topical once a day: or as
prior.
5. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed: or as prior.
6. Escitalopram 20 mg Tablet Sig: Two (2) Tablet PO once a day.
7. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
8. Doxycycline Hyclate 100 mg Tablet Sig: One (1) Tablet PO
every twelve (12) hours: or as prior.
9. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO QODHS (every
other day (at bedtime)).
10. Doxercalciferol 0.5 mcg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
11. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
12. Procardia XL 30 mg Tab,Sust Rel Osmotic Push 24hr Sig: One
(1) Tab,Sust Rel Osmotic Push 24hr PO once a day: or as prior.
13. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day: or as prior.
14. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual three times a day as needed for chest pain: for chest
pain as prior.
17. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed.
18. Insulin Pump IR1250 Kit Sig: One (1) Miscellaneous once
a day: use insulin pump as prior.
19. Hectorol 0.5 mcg Capsule Sig: One (1) Capsule PO once a day.
20. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: One (1)
Subcutaneous four times a day: Regular insulin sliding scale as
prior.
21. Tessalon Perles 100 mg Capsule Sig: One (1) Capsule PO three
times a day as needed for cough.
22. Xanax 0.25 mg Tablet Sig: One (1) Tablet PO at bedtime.
23. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
24. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*60 Tablet(s)* Refills:*0*
25. Outpatient Physical Therapy
status post hemorrhagic infarct, needs PT for gait/balance
training
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Intracranial hemorrhage - right corona radiata
Discharge Condition:
Improved over admission - improved left sided strength, but with
residual weakness.
Discharge Instructions:
Please return to ER if weakness worsens, or if you have new
neurological symptoms including visual or hearing changes,
trouble speaking or swallowing, numbness, new weakness,
clumsiness, vertigo, or worsened walking. Please call if
headache worsens.
Followup Instructions:
Provider: [**Name10 (NameIs) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 657**]
Date/Time:[**2121-12-16**] 3:00
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2122-1-23**] 11:20
Provider: [**First Name11 (Name Pattern1) 2747**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 1971**]
Date/Time:[**2122-5-12**] 10:00
Follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 4390**] in [**1-6**]
weeks - call [**Telephone/Fax (1) 3070**] for appointment.
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
Completed by:[**2121-12-9**]
ICD9 Codes: 3572, 311, 2449, 4019, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3847
} | Medical Text: Unit No: [**Numeric Identifier 97356**]
Admission Date: [**2113-1-17**]
Discharge Date: [**2113-1-19**]
Date of Birth: [**2048-5-19**]
Sex: M
Service: MED
CHIEF COMPLAINT: Shortness of breath.
HISTORY OF PRESENT ILLNESS: A 64-year-old male with a
history of chronic obstructive pulmonary disease requiring 3
admissions in the year [**2111**], on chronic home oxygen
treatment, presented with 3 days of worsening dyspnea. He
complained of a productive cough and stated that he was
treated for sinusitis a few weeks ago. He also complained of
feeling hot but no objective fevers documented. He denied
chest pain, nausea, vomiting, headache or any other symptoms.
In the emergency room, he was diagnosed as having COPD
exacerbation and was admitted to the intensive care unit
given his history of multiple intubations in the past.
PAST MEDICAL HISTORY:
1. COPD, last PFTs [**2111-5-31**], FEV1 was 45% of predicted,
FEV1/FVC 72% of predicted.
2. Anemia, last colonoscopy in our records from [**2107**], with
diverticula, however, he does state he has had a normal
colonoscopy less than 2 years ago.
3. On home oxygen 2 liters, supposed to be using 24 hours,
however, states uses it only at night.
4. Vocal cord squamous dysplasia.
5. Hypertension.
6. Obstructive sleep apnea, however, does not use CPAP.
7. Myocardial infarction diagnosed in [**2112-7-30**], as per the
patient.
8. Lower extremity venous stripping at age 28.
9. C7 neuroma.
10. History of esophageal obstruction.
11. Status post knee surgery.
12. Alcohol abuse and dependence, status post several
rehabilitation stays.
MEDICATIONS: At home, Flovent, albuterol, Atrovent, [**Doctor First Name **],
folate, Zoloft, Singulair, Norvasc, verapamil and aspirin.
ALLERGIES: Tetanus shot and ACE inhibitor causing
angioedema.
SOCIAL HISTORY: Drinks 8-10 beers per day, no history of
severe withdrawals. Smokes 8 cigarettes per day, former 80
pack year history of smoking. He is married and lives with
wife with no pets and no drug use.
FAMILY HISTORY: Mother had a DVT and diabetes. Father died
of coronary artery disease at age 35.
PHYSICAL EXAMINATION: On admission, vital signs: Temperature
98.3, pulse 101, blood pressure 190/71, respiratory rate 20,
oxygen saturation 91% on 3.5 liters oxygen. Head and neck
exam: Clear, PERRL, extraocular muscles intact, no pallor,
icterus. Lungs: Decreased bilateral breath sounds, scattered
wheezing diffusely. Cardiovascular exam: Regular rate and
rhythm, no murmurs, rubs or gallops. Abdomen: Soft,
nontender, no masses palpable, good bowel sounds.
Extremities: No edema, good pulses, no clubbing.
Neurologically, alert and oriented x3.
LABORATORY DATA, X-RAYS AND PERTINENT REPORTS: White count
on admission 7.9, at discharge was 11. This could probably be
the effect of steroids. BNP was not significant. CK mildly
elevated. Cardiac enzymes normal. Sputum culture showed some
PMNs with epithelial cells, gram positive cocci, most likely
oropharyngeal flora. Chest x-ray done on admission revealed
emphysema, however, no evidence of infiltrate.
HOSPITAL COURSE: COPD exacerbation. The patient was
initially admitted to the intensive care unit because of the
oxygen need, however, did not require intubation or BiPAP. He
was treated with nebulization, erythromycin for COPD
exacerbation as well as IV steroids with marked improvement
in his shortness of breath. He was thereafter transferred to
the floor after a day of watching in the ICU. On the floor,
he was transitioned to oral steroids and is scheduled to
complete a taper over the next few days. Nebulizations were
changed to MDIs. Azithromycin will be completed for a total
of 5 days. The patient required 2 liters of oxygen at all
times. He states at home he uses oxygen only nocturnally,
however, he was advised that he should use oxygen in the day
as well, especially during ambulation. Smoking cessation was
discussed by the hospitalist as well as social worker and
information regarding smoking cessation was provided to the
patient. Nicotine patches were offered as well. He said he
had a prescription for Nicotine patches at home. Some
education about self treatment with prednisone during the
next flare was also advised. He is up to date with the flu
shot as well as Pneumovax.
Hypertension. Home dose of Norvasc and verapamil were
continued.
Alcohol withdrawal. He was placed on a CIWA scale and needed
some amount of Ativan. However, prior to discharge, his CIWA
scale was zero. Social worker was consulted who also
counseled him regarding alcohol abstinence. The patient is
advised to make a follow-up appointment with his primary care
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 2204**], in the next 7 days.
CONDITION ON DISCHARGE: Status at discharge stable.
DISCHARGE INSTRUCTIONS: To the patient as follows:
1. Please continue your steroid taper, prednisone taper, as
prescribed.
2. You should try to quit alcohol as alcohol is severely
affecting your health.
3. You should use oxygen at home at all times, day and
night, especially during walking and ambulation.
4. Please follow-up with your primary care physician [**Last Name (NamePattern4) **] 4
days.
5. Do not smoke as this will worsen your wheezing.
6. Complete the course of antibiotics as prescribed.
7. Call [**Telephone/Fax (1) 97357**] to schedule an appointment in the next
1 week.
DISCHARGE DIAGNOSES:
1. Chronic obstructive pulmonary disease exacerbation.
2. Smoking.
3. Alcohol withdrawal resolved.
4. Hypertension.
[**Name6 (MD) **] [**Name8 (MD) 21386**], MD [**MD Number(2) 26878**]
Dictated By:[**Name8 (MD) 26879**]
MEDQUIST36
D: [**2113-1-19**] 18:12:54
T: [**2113-1-19**] 20:01:24
Job#: [**Job Number 97358**]
ICD9 Codes: 4019, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3848
} | Medical Text: Admission Date: [**2201-4-3**] Discharge Date: [**2201-4-4**]
Date of Birth: [**2171-2-5**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2763**]
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
Intubation [**2201-4-3**]
Lumbar Puncture [**2201-4-3**]
History of Present Illness:
Ms. [**Known firstname **] [**Known lastname 10935**] is a 30 yo woman who was found wandering the
streets with altered mental status. She was brought to the
hospital by EMS who reported persistently low blood pressures
and waxing and [**Doctor Last Name 688**] mental status. She was able to tell EMS
her name and that she has a history of HIV, Hepatitis C, and
substance abuse.
.
In the ED, initial VS: 100.1 BP 108/69 HR 114 RR 16 SpO2 97%.
She received a total of 8 L NS for her hypotension (SBP in the
80s)with little response. The decision was made to undergo
elective intubation to protect her airway given her poor mental
status. She was started on fentanyl/versed for sedation. After
intubation her blood pressures normalized. NG tube was placed,
suction yeilded 500 cc yellow bilious fluid. Given her fever,
altered mental status and HIV status she underwent CT head
followed by LP. Head CT showed no acute lesions or bleeds. LP
showed mildly elevated WBC count with significant lymphocytic
predominance. She was started on empiric meningitis therapy with
decadron, ceftriaxone, vancomycin, ampicillin, and acyclovir.
Patient's lung exam and mental status were concerning for
aspiration and she was started on flagyl. She received 1 gram of
acetaminophen for fever.
.
On arrival to the ICU patient is hemodynamically stable, she is
intubated but becoming more alert. Her belongings were searched
and several recent prescription medications were indentified.
Past Medical History:
1) HIV: no history of being on HAART; reports she is monitored
at [**Hospital1 2177**], last CD4 > 1000
2) HCV: No history of treatment; considering starting IFN
3) Polysubstance Abuse
Social History:
Unable to assess. Patient told ED staff that her mother was
watching her children.
Family History:
Unable to assess
Physical Exam:
Vitals - T: BP: 121/76 HR: 63 RR: 16 02 sat: 100%
GENERAL: intubated, sedated
HEENT: mmm, PERRL, pupils 4mm, anicteric sclera, no
conjunctival pallor
CARDIAC: RRR, no MRG
LUNG: CTA anteriorly
ABDOMEN: soft, obese, + bs, ntnd, no HSM
EXT: warm, dry, 2+ distal pulses
NEURO: unable to assess
DERM: No rashes, no track marks
Pertinent Results:
[**2201-4-3**] 11:30PM CEREBROSPINAL FLUID (CSF) PROTEIN-46*
GLUCOSE-93
[**2201-4-3**] 11:30PM CEREBROSPINAL FLUID (CSF) WBC-6 RBC-23*
POLYS-0 LYMPHS-86 MONOS-0 MACROPHAG-14
[**2201-4-3**] 11:30PM CEREBROSPINAL FLUID (CSF) WBC-14 RBC-114*
POLYS-6 LYMPHS-86 MONOS-0 MACROPHAG-8
.
[**2201-4-3**] 10:40PM URINE UCG-NEGATIVE
[**2201-4-3**] 10:40PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.019
[**2201-4-3**] 10:40PM URINE BLOOD-NEG NITRITE-POS PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-5.0 LEUK-SM
[**2201-4-3**] 10:40PM URINE RBC-0 WBC-[**6-25**]* BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2201-4-3**] 05:25PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020
[**2201-4-3**] 05:25PM URINE BLOOD-NEG NITRITE-POS PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-2* PH-5.5 LEUK-SM
[**2201-4-3**] 05:25PM URINE RBC-0 WBC-21-50* BACTERIA-MOD YEAST-NONE
EPI-[**12-5**]
[**2201-4-3**] 05:25PM URINE HYALINE-[**6-25**]*
.
[**2201-4-3**] 05:25PM WBC-14.3* RBC-4.83# HGB-13.6# HCT-41.6#
MCV-86 MCH-28.2 MCHC-32.7 RDW-14.8
[**2201-4-3**] 05:25PM NEUTS-48.3* LYMPHS-42.9* MONOS-5.0 EOS-3.2
BASOS-0.5
[**2201-4-3**] 05:25PM PLT COUNT-348#
[**2201-4-3**] 09:40PM PT-13.0 PTT-27.2 INR(PT)-1.1
[**2201-4-3**] 08:59PM LACTATE-1.6
[**2201-4-3**] 05:25PM GLUCOSE-129* UREA N-15 CREAT-1.1 SODIUM-134
POTASSIUM-4.1 CHLORIDE-99 TOTAL CO2-23 ANION GAP-16
[**2201-4-3**] 05:25PM ALT(SGPT)-150* AST(SGOT)-124* CK(CPK)-5715*
ALK PHOS-135* TOT BILI-0.5
[**2201-4-3**] 05:25PM LIPASE-31
[**2201-4-3**] 05:25PM proBNP-7
[**2201-4-3**] 05:25PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2201-4-3**] 05:25PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
.
MICRO:
Urine Legionella: Negative
Influenza A & B: Negative
MRSA Screen: Negative
CSF Gram Stain: no organisms
CSF cx: No growth
Blood cx: pending
Urine cx:
ESCHERICHIA COLI
|
AMIKACIN-------------- <=2 S
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- =>16 R
.
IMAGING:
[**2201-4-3**] CT head:
1. No acute intracranial abnormality.
2. Trace fluid layering in the maxillary sinuses. Aerosolized
material in the pharynx, likely related to intubation.
.
[**2201-4-3**] CXR:
1. New endotracheal tube terminates 3 cm from the carina.
2. Increased conspicuity of nodular opacities and retrocardiac
consolidation concerning for multifocal pneumonia or aspiration
sequelae. Less likely, this could represent pulmonary edema.
Brief Hospital Course:
30 yo woman with reported history of HIV, HCV and substance
abuse is brought to the hospital by EMS when found with altered
mental status, low grade fevers, and hypotension.
# Sepsis: Patient presents with fever, hypotension,
leukocytosis, positive UA, and altered mental status concerning
for sepsis. She initially responded poorly to IVF boluses in
the ED. She was electively intubated to maintain an airway and
blood pressure subsequently improved. Patient was
hemodynamically stable on arrival to the ICU. The following
worming patient was weaned off sedation and promptly extubated.
She confirmed that she was feeling very lethargic the day of
presentation and had left posterior thigh pain that was making
it difficult for her to walk. She states her drowsiness and
difficulty walking prompted bystanders to call EMS. She denied
abusing any drugs on the day of presentation. She admits she
occasionally does take additional klonopin but denies this is
related to her admission. She reports having a recent UTI that
was being treated with bactrim. She had completed four out of
five days of treatment on the day of admission. Patient denied
any complaints after extubation and was hemodynamically stable.
She did not feel that she required hospitalization and insisted
on leaving the hospital. She signed out of the hospital AMA.
.
# Altered Mental Status: Patient initially felt to be
intoxicated as she was stumbling in the street an largely
incoherent. She did admit to history of substance abuse. Urine
and serum toxicology screens, however, are positive only for
benzodiazepines. Benzo intoxication may explain her increased
somnolence and hypotension. It does not explain her fever and
increased CSF WBC count. Her fever, hypotension, altered mental
status and history of HIV is very concerning for meningitis.
Her LP revealed slightly elevated WBC with lymphocytic
predominance concerning for aseptic (viral) meningitis or
encephalitis. She was started empirically on broad spectrum
antibiotics and acyclovir. After extubation the following
morning patient had no evidence of altered mental status,
meningismus, or encephalitis. She had no focal neuro deficits.
.
# Transaminitis: Patient reports history of Hepatitis C.
Unclear baseline LFTs. Patient may have chronically elevated
enzymes due to underlying HCV infection. Transaminitis may also
represent shock liver in the setting of prolonged hypotension.
Recommend continued follow up at outpatient clinic.
.
# HIV: Per EMS report patient stated she was positive for HIV.
Currently no known history of HAART therapy. Most recent CD4
count and VL are unknown. Attempts to obtain collateral
information were unsuccessful as patient left AMA.
DISPO: Patient left AMA; Patient was counseled extensively on
the risks of leaving the hospital without appropriate medical
evaluation and treatment. Patient was deemed competent. She
was able to restate risks of leaving AMA including life
threatening infection. Patient provided her phone number to be
reached should her the final cultures reveal an infection that
needed to be treated.
PHONE NUMBER [**Telephone/Fax (1) 14044**]
Medications on Admission:
Gabapentin 800 mg po tid
Clonidine 0.1 mg po tid
Promethazine 50 mg po daily
Suboxone (unknown dose)
Discharge Medications:
Patient left against medical advice without any additional
medications.
Discharge Disposition:
Home
Discharge Diagnosis:
Altered Mental Status
Urinary Tract Infection
Discharge Condition:
Alert, oriented, no focal neurologic deficits, hemodynamically
stable.
Discharge Instructions:
Patient left against medical advice.
Followup Instructions:
Patient left against medical advice. Strongly advised her to be
seen by her primary care provider and hepatologist as soon as
possible.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**]
ICD9 Codes: 5990, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3849
} | Medical Text: Admission Date: [**2106-1-25**] Discharge Date:
Service: Critical Cardiac Care Unit
HISTORY OF PRESENT ILLNESS: The patient is an 81 year old
male with cardiomyopathy, hypertension, diabetes Type 2,
status post recent cardiac admission for catheterization in
the setting of increased shortness of breath. The patient
has clean coronary arteries, positive cardiomyopathy with an
ejection fraction of about 30%, clinically right heart
failure, symptoms greater than left heart failure who notes
bilateral minimal activity secondary to lower extremity pain
and swelling, increased over the past four to five days with
increased scrotal/penis edema, no dosing changes and no
medical noncompliance.
PAST MEDICAL HISTORY: Coronary artery disease,
cardiomyopathy, congestive heart failure, atrial
fibrillation, status post pacer in [**2103**], patient with
prostate cancer, embolic cerebrovascular accident,
lymphedema, chronic renal insufficiency, degenerative joint
disease, and hypertension and diabetes Type 2
MEDICATIONS ON ADMISSION: Amiodarone 200 mg once a day;
Protonix 40 mg once a day; Aspirin 325 once a day; Colace;
Lopressor 12.5 twice a day; insulin sliding scale, NPH 25 q.
AM; Hydralazine 400 mg four times a day; Imdur 30 mg twice a
day; Lasix 80 mg twice a day; Coumadin 5 mg once a day,
alternating with 7 mg once a day, on alternating days.
ALLERGIES: The patient with allergies to Penicillin, Sulfa
drugs, intravenous dye and shellfish.
SOCIAL HISTORY: No tobacco or alcohol history.
REVIEW OF SYSTEMS: No weight loss, no fever, nightsweats or
anorexia, no blurry vision, diplopia and no tinnitus, sinus
pain or sore throat. No chest pain or palpitations, positive
lower extremity edema, positive fatigue, no orthopnea or
paroxysmal nocturnal dyspnea. Positive dyspnea on exertion.
Positive cough, dry, no nausea or vomiting, hematemesis,
positive hematochezia, no abdominal diarrhea, constipation,
no easy bruising, no dysuria or hematuria, no rash, no
pruritus, no change in skin or hair, positive energy loss,
positive weakness in extremities. No back pain, no vertigo,
no dizziness.
PHYSICAL EXAMINATION: Blood pressure is 164/90, heartrate
72, weight 268 lbs, blood sugar 143, 96% oxygen saturation on
2 liters, afebrile. The patient is alert and oriented times
three. Head, eyes, ears, nose and throat shows pupils are
equal, round, and reactive to light and accommodation.
Mucous membranes dry. Neck is supple, no left anterior
descending. Respiratory, slight bibasilar crackles,
nonlabored breathing. Cardiovascular, regular rate and
rhythm via pacer, no mitral regurgitation, normal pulses.
Abdomen, soft, normoactive bowel sounds, soft nontender,
nondistended, no rebound or guarding. Lower extremities are
2+ edema. Cranial nerves II through XII intact.
LABORATORY DATA: Labs on admission from [**1-25**], sodium
136, potassium 4.1, chloride 100, bicarbonate 22, BUN 65,
creatinine 2.9, glucose 161, white blood cells 6, hematocrit
32.6, platelets 136, PT 25.3, INR 4.5, PTT 44.4, ALT 20, AST
41, alkaline phosphatase 28, albumin 2.7, calcium 8.6,
phosphorus 3.8, magnesium 2.0, amylase 33, CK 157, MB 5.
Catheterization on [**2105-12-18**] showed normal coronaries,
moderate systolic and diastolic ventricular dysfunction,
moderate pulmonary hypertension. Blood cultures times two
are pending, urine culture is pending. Echocardiogram shows
paced rhythm at 70 with left bundle branch block. No changes
from [**2105-12-31**]. Chest x-ray shows cardiomyopathy
with overt congestive heart failure. Basal small effusions.
IMPRESSION/PLAN: An 81 year old with nonischemic
cardiomyopathy who presents with increased scrotal edema,
pain in the lower extremities, increased lower extremity
edema, decreased exercise tolerance, acute and chronic renal
failure.
Cardiovascular - Evaluate the cause of cardiomyopathy,
congestive heart failure, unclear. Pulmonary hypertension,
question pulmonary function tests. Need for pulmonary
evaluation. Continue to diurese. The patient should be 1
liter negative over 24 hour period. Check right atrial
saturation at rest. Continue with Hydralazine, Imdur,
Aspirin, Amiodarone, Coumadin, beta blocker.
Renal - Acute and chronic renal insufficiency, workup not
suggested of urinary tract infection. Continue Lasix.
Suspect chronic low flow state secondary to cardiomyopathy.
Kidneys with mild prerenal status at baseline, avoid
nephrotoxic drugs. Check eos, consider renal ultrasound.
Genitourinary - Evaluate scrotal edema, meticulous skin care
to avoid ulcerations and breakdown. History of anemia,
workup baseline, check iron studies, reticulocyte count if
not done.
Endocrinology - Check fingersticks q.i.d. NPH dose as above.
Physical therapy consult please.
HOSPITAL COURSE: The patient was transferred from the [**Hospital Ward Name 8559**] Acove [**Hospital1 **] to the Coronary Care Unit for management of
his worsening edema and congestive heart failure for
Swan-Ganz catheter and intravenous Milrinone therapy. There
was an 82 year old male with multiple medical problems,
congestive heart failure with an ejection fraction of 40% by
echocardiogram with moderately elevated right-sided
pressures, no wall-motion abnormalities, clean indices by
recent catheterization, diabetes Type 2, atrial fibrillation
status post pacer who has had many recent admissions for
congestive heart failure exacerbation. The patient was
recently 202d, admitted to [**Hospital6 2018**] for symptoms of congestive heart failure accentuated
by prominent lower extremity edema. At that time he was
ruled out by myocardial infarction, diuresed and switched
from an ACE inhibitor to Hydralazine in the setting of an
elevated creatinine. The patient was discharged to
rehabilitation on [**2106-1-5**] until five days ago prior
to admission on [**2106-1-25**]. He presented with evaluation
with worsening lower extremity edema and new scrotal edema.
On presentation he denied any chest pain, shortness of
breath, fevers, chills, nausea, vomiting or diarrhea. The
patient denied dietary indiscretions, not certain. He noted
he has been taking his medications as described. The
patient's review of systems were essentially negative, no
orthopnea or paroxysmal nocturnal dyspnea as above. The
patient denied palpitations. He has never smoked nor drank
alcohol. The patient was initially admitted to the [**Hospital Ward Name 8559**], Acove Service for management of congestive heart
failure. Summary of the first few days as follows - He was
ruled out for an myocardial infarction by enzymes. He had no
telemetry event. Chest x-ray read as no evidence of failure.
Repeat echocardiogram showed an increased ejection fraction
of 40%, up from 30% in [**Month (only) 956**] with mild mitral
regurgitation, 1+, moderate tricuspid regurgitation 2+ and no
PCD. The patient managed on increasing doses of Lasix and
Zaroxolyn to a maximum of Lasix 200 mg b.i.d. with Zaroxolyn
before each use with difficulty keeping him negative, given
his rise in creatinine. The patient had lower extremity
dopplers negative for deep vein thrombosis, abdominal
ultrasound was negative for hepatosplenomegaly, ascites,
portal hepatic obstruction and PPD dilation. The kidneys
were within normal limits without enlargement and/or
hydronephrosis. Bilateral pleural effusions were
incidentally noted. Renal was consulted and they recommended
diuresis and plus/minus possible ultrafiltration if there was
no response to the diuresis. Eos were positive, Phena 1%,
dopplers negative. Congestive Heart Failure Service was
consulted and they recommended aggressive diuresis with Lasix
alone as tolerated. They initiated Digoxin workup for
etiology of pulmonary hypertension and possible sleep apnea
evaluation. The patient was transferred to the CCU on [**2106-2-2**] for tailored therapy with Milrinone plus/minus
Natrecor.
MEDICATIONS ON ADMISSION TO CCU:
1. Trazodone 25 to 50 prn
2. NPH 16 q. AM
3. Colace 100 mg b.i.d.
4. Digoxin .125 q.o.d.
5. Epogen 5000 units subcutaneously three times a week
6. Imdur 30 mg q.d.
7. Lasix 200 mg b.i.d.
8. Zaroxolyn
SOCIAL HISTORY: The patient lives with his oldest daughter.
[**Name (NI) **] does not smoke or use alcohol.
PHYSICAL EXAMINATION TO CCU: General, alert and oriented
times three in no acute distress. Head, eyes, ears, nose and
throat showed normocephalic, atraumatic, pupils are equal,
round, and reactive to light and accommodation, oropharynx
clear. No jugulovenous distension, no thyromegaly or bruits.
Pulmonary, bibasilar rales one third of the way up, no
wheezes, rales or rhonchi. Cardiovascular, regular rate and
rhythm, I/VI systolic murmur best heard at the left upper
sternal border with no radiation. Abdomen, obese, nontender,
nondistended, normoactive bowel sounds, no fluid. Scrotum,
marked edema with 1 by 3 cm upper superior skin breakdown
with necrotic base, no erythema. Extremities, bilateral
lymphedema associated with chronic venous stasis skin
changes. No calf tenderness, pitting edema of thighs.
Pulses trace, nonpalpable.
LABORATORY DATA ON ADMISSION TO CCU: White blood cell count
6.4, hematocrit 29.1, platelets 166, sodium 137, potassium
3.1, chloride 98, bicarbonate 28, BUN 95, creatinine 3.0,
glucose 161. Arterial blood gases was 7.51 PH, 38 carbon
dioxide and 70 oxygen. INR is 2.3. While in the CCU the
patient had a right internal jugular cordis placed and
Swan-Ganz catheter placed, will initiate chemotherapy with
Nasreotide, Natrecor, continue drops and aspirin/Amiodarone,
anticoagulate with Coumadin for atrial fibrillation and hold
off on calcium channel blockers, diuretics and beta blockers
for now. Follow inputs and outputs strictly and follow
Swan-Ganz catheter numbers. Lower extremity edema, the
patient with a history of lymphedema and congestive heart
failure. Findings were negative, no evidence of cellulitis.
Check feasibility if given lymphogram. Check abdominal
computerized tomography scan to rule out intra-abdominal
large vessel clot, elevate legs as much as possible.
Hematology, anemia of chronic disease, versus low epo state
from chronic renal failure, hold off on transfusion, given no
coronary artery disease. Overall fluid status, overloaded
for now. Check AM hematocrit. Continue Epogen. Consider
increasing dose. Transfuse if hemodynamic but unstable.
Renal, acute and chronic renal failure, likely
multifactorial, possible interstitial nephritis with positive
urine eos versus aggressive diuresis, versus worsening
intrinsic diabetic nephropathy. Dopplers negative for post
obstructive causes. Renally dose all medications. Continue
to check electrolytes for now.
Fluids, electrolytes and nutrition, we will recheck potassium
after AM repletion of potassium to 3.1. Goal inputs and
outputs is to be 1 to 1.5 liters negative. Continue cardiac
diet and diabetic diet. Protonix and Colace. The patient is
a full code. The patient has a left arterial line placed, a
right internal jugular with Swan-Ganz catheter and right
peripheral intravenous.
Swan-Ganz catheter measurements on admission to CCU are as
follows: CVT 26, PA pressure 58/23 with a mean of 36, wedge
pressure 17, cardiac output by thick 13.8 with cardiac index
of 5.66. SVR was 968. The patient seen by Dermatology on
day #2 of CCU. The patient's lower extremity lesions are
consistent with elephantiasis verrucosa nostra. This is a
variable severe lymphedema, recommended topical emollient
b.i.d./Aquaphor with Pneumoboots or other compression
treatment for congestive heart failure. The patient on
admission to the CCU was started on Natrecor at 180 mcg
intravenous bolus and then .9 microgram drip per minute. The
patient was given Lasix 80 mg intravenously for diuresis.
Lopressor was restarted at 12.5 b.i.d. The patient's low
hematocrit was given transfusion 1 packed red blood cells.
Diamox was started 250 mg b.i.d. for bicarbonate diuresis
with alkalosis. Nutrition was consulted. Nutritions
recommendations for 700 cc free water, Respalor at 50 cc/hr
for 24 hours. Check laboratory data and replete electrolytes
prn. Consider nasogastric tube placement. The patient on
day #2 of CCU doing well, diuresed approximately 400 cc after
the first day. Lasix drip was started for diuresis.
Anticoagulations were held due to INR of 2.7. The patient
will continue to receive blood transfusions for the low
hematocrit of 27.9. The patient still remains total volume
overloaded, diuresis continued. More packed red blood cells
to increase narcotic pressure for better diuresis. Increase
Natrecor drip. The patient on day #3, continue Natrecor at
present dose. The patient is without good diuresis.
Continues to be fluid overloaded. Lasix drip at 20 mg/hr.
[**2106-2-5**], Swan-Ganz catheter #s reveal PA pressure
57/24, wedge pressure 21, cardiac output 15.1, cardiac index
of 6.11 with SVR of 262, PA saturation 84. Arterial blood
gases 7.41 pH/46 CO2 and 99 for O2. The patient's inputs and
outputs on day #3 was positive 50 cc. [**2-5**], Diamox was
discontinued as alkalosis resolved. The patient had
hematocrit stable, status post packed red blood cell
transfusion. Hematocrit 31.9, above 30 which was the goal.
Swan-Ganz catheter was discontinued. On [**2106-2-5**] the
patient doing well, diuresing well. The patient was negative
2 liters overnight. The patient was responding to Natrecor
and Zaroxolyn and Lasix. Swan-Ganz catheter was removed.
The patient had slight metabolic alkalosis but will be given
potassium repletion. If this does not improve, we will readd
Diamox. The patient's blood saturations prior to pulling
Swan-Ganz catheter showed superior vena cava, first
measurement 82%, second measurement 80%; right arterial first
measurement 80%, second measurement 82%; right ventricle
first measurement 85%, second measurement 81%; [**MD Number(3) 108502**]
measurement 91, second measurement 90 with a mixed VNS oxygen
saturation, first measurement 79% second 84%. The patient on
[**2106-2-8**] in the CCU, overnight events, no deep vein
thrombosis via lower extremity ultrasound. The patient
diuresing well overnight, -1.7 liters. Hemodynamically the
patient is stable, diuresing well. Current regimen still on
Natrecor and Lasix as well as Zaroxolyn. The patient was
started on heparin intravenously, Diamox was restarted.
Psychiatry was consulted for depression evaluation. The
patient on [**2-9**], overnight events had a fever to 102.8
with hypertension, culture grew out gram positive cocci. The
patient was shown to have Methicillin-resistant
Staphylococcus aureus via blood culture. Line was pulled.
The patient was started on Vancomycin 750 mg intravenously
and Levaquin 250 mg intravenously q. 24 hours. The patient's
urine culture from [**2106-2-10**] showed less than 10,000
organisms. Recent blood culture showed no growth. The
patient's right internal jugular culture showed mixed
bacterial types, greater than 3 colonies. The patient's
sputum culture on [**2106-2-8**] showed no predominance of
respiratory pathogens, moderate oropharyngeal Flora growth
and moderate growth of Staphylococcus aureus coagulase
positive. The patient had right upper quadrant ultrasound on
[**2106-2-9**] which showed a right pleural effusion without
evidence of ascites. The patient on [**2106-2-10**] in the
CCU Nasreotide and diuretics discontinued. The patient
continued to autodiurese effectively with -730 cc on this day
inputs and outputs. Diamox was discontinued for now.
Ongoing ultrasound showed results as above. The patient
subsequently failed a swallowing study and nasogastric tube
was placed for tube feeds. The patient on [**2106-2-11**] was
transferred from the CCU to a regular cardiac floor. The
patient on [**2-11**] continues to improve, is 1 liter negative
on that date, over 6 liters negative total for his hospital
stay per care view notes. The patient now is showing a free
water deficit of approximately 3 liters. The patient now
will be repleted with D5/W intravenously as well as free
water via his nasogastric tube. The patient continues to
autodiurese well, watching his potassium closing and replete
as needed. The patient's Methicillin-resistant
Staphylococcus aureus positive blood culture, he is being
continued on Vancomycin and recultured. The patient is on
tube feeds, doing well. The patient was started on Remeron
50 mg p.o. q.h.s. per Psychiatry for depressive symptoms.
The patient on [**2-12**], put back on Diamox for alkalosis.
The patient continues to need free water for hyponatremia,
sodium up to 150 on [**2106-2-12**]. This will be monitored
per renal and we will continue to use free water to bring
down this hyponatremia. Vancomycin peak and troughs were
checked closely. The patient was changed to 1 gm q. 24
hours. The patient on [**2106-2-12**] with noted low
platelets at 87. The patient had HIT thrombocytopenia
workup. DIC labs were sent as well as coagulation screen.
Discussed with the patient and the patient's daughter the
possible need for right heart catheterization with biopsy to
explore potential causes of right ventricular failure. The
patient's right upper quadrant ultrasound as stated before
showed no ascites. Computerized tomography scan of the
abdomen showed small nodule of liver consistent with
cirrhosis, questionably caused by right ventricular failure.
Currently continue workup for possible cirrhosis. AST and
ALT are within normal limits on this day. The patient's
laboratory data for possible causes of thrombocytopenia
showed FTP of 80-100, D-dimer of greater than [**2103**],
fibrinogen 221, haptoglobulin 67. The patient will be
monitored for possible DIC picture. The patient's platelets
up to date at 100 up from 87, trending upward. They will be
monitored. The patient's platelets will be checked again in
the afternoon. The patient's sodium dipping down to 148, now
back up, elevated at 150. Will continue to use free water
via nasogastric tube which is working well and that replete
the intravenous fluid, D5/W for a free water deficit of
approximately 4 liters at this point. The patient's blood
cultures on [**2106-2-12**] show as again positive for
Methicillin-resistant Staphylococcus aureus, continue on
Vancomycin. Blood cultures are pending from [**2-12**], times
two, no growth to date. The patient's diuretics have all
been discontinued. The patient's creatinine seems to be
improving, down to 2.5 from previously 2.7. Patient's
pulmonary status, pneumonia/effusion, the patient continues
to be Vancomycin and Levofloxacin. Vancomycin dose now at 1
gm q. 36 hours for an elevated peak. Will be rechecked to
follow this and may be redosed as needed. The patient's HIT
has been sent pending. The patient continues on Remeron for
depression with slight improvement in affect. The patient
continues on tube feeds with good residuals.
End of summary up until [**2106-2-14**], patient's continued
care to be dictated for dates following [**2106-2-14**] up
until possible date of discharge.
[**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **], M.D.
Dictated By:[**Last Name (NamePattern1) 4724**]
MEDQUIST36
D: [**2106-2-20**] 18:02
T: [**2106-2-20**] 19:56
JOB#: [**Job Number 108503**]
ICD9 Codes: 4280, 486, 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3850
} | Medical Text: Admission Date: [**2133-8-4**] Discharge Date: [**2133-8-26**]
Date of Birth: [**2061-5-11**] Sex: M
Service: SURGERY
Allergies:
Heparin Agents / Ativan
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Cecal colon cancer and infected abdominal wall mesh, EtOH
cirrhosis
Major Surgical or Invasive Procedure:
Exploratory laparotomy, right colectomy and excision of infected
mesh, repair ventral hernia [**2133-8-4**]
Past Medical History:
ETOH cirrhosis
grade 1 esoph varices
h/o encephalopathy
DM-2 diagnosed 20 years ago
grand mal seizures in the setting of hypoglycemia ([**2132-7-31**]).
pneumonia hospitalized [**2132-7-1**] with sepsis, admission also
complicated by UTI.
vocal cord polyps s/p surgery
cataracts surgery
hypertension
right foot drop following discectomy surgery [**44**] years ago
heparin-induced thrombocytopenia
Social History:
Patient lives with his wife in [**Name (NI) 2312**]. He is her
primary caretaker. Former [**Name2 (NI) **], retired 16 years ago when
he
sustained a back injury.
50 pk.yr tobacco use; 1ppd for 50 years from age 13 to 63.
Denies illicit drug use. h/o Alcohol abuse.
Family History:
diabetes
grandmother w/ h/o CVA
Physical Exam:
afebrile, vss
NAD
no flap/asterixis
not icteric
rrr
ctab
soft, nt, nd
warm
Pertinent Results:
[**2133-8-4**] 05:57PM BLOOD WBC-10.8 RBC-4.03* Hgb-12.3* Hct-35.4*
MCV-88 MCH-30.5 MCHC-34.8 RDW-14.7 Plt Ct-138*
[**2133-8-7**] 06:33AM BLOOD WBC-4.2 RBC-2.94* Hgb-9.0* Hct-25.8*
MCV-88 MCH-30.7 MCHC-35.0 RDW-15.2 Plt Ct-76*
[**2133-8-8**] 06:00AM BLOOD WBC-5.5 RBC-3.49* Hgb-10.8* Hct-30.0*
MCV-86 MCH-30.9 MCHC-35.9* RDW-14.7 Plt Ct-131*
[**2133-8-13**] 03:15AM BLOOD WBC-11.0 RBC-2.65* Hgb-8.5* Hct-23.6*
MCV-89 MCH-32.0 MCHC-36.0* RDW-17.6* Plt Ct-97*
[**2133-8-14**] 11:05AM BLOOD WBC-11.5* RBC-3.56* Hgb-10.8* Hct-31.0*
MCV-87 MCH-30.3 MCHC-34.7 RDW-17.6* Plt Ct-64*
[**2133-8-22**] 03:25AM BLOOD WBC-4.5 RBC-3.39* Hgb-10.5* Hct-31.8*
MCV-94 MCH-30.9 MCHC-32.9 RDW-17.7* Plt Ct-63*
[**2133-8-26**] 10:06AM BLOOD WBC-13.4* RBC-2.89* Hgb-9.2* Hct-28.4*
MCV-98 MCH-31.7 MCHC-32.4 RDW-18.8* Plt Ct-124*
[**2133-8-4**] 11:45AM BLOOD PT-14.3* PTT-26.5 INR(PT)-1.3
[**2133-8-6**] 04:51AM BLOOD PT-16.9* PTT-35.7* INR(PT)-1.9
[**2133-8-8**] 06:00AM BLOOD PT-14.8* PTT-31.2 INR(PT)-1.4
[**2133-8-12**] 06:53PM BLOOD PT-19.9* PTT-39.4* INR(PT)-2.6
[**2133-8-13**] 04:05PM BLOOD PT-17.6* PTT-45.3* INR(PT)-2.1
[**2133-8-15**] 04:00AM BLOOD PT-25.1* PTT-46.0* INR(PT)-4.2
[**2133-8-16**] 09:54AM BLOOD PT-18.3* PTT-42.4* INR(PT)-2.2
[**2133-8-24**] 03:41AM BLOOD PT-17.3* PTT-41.7* INR(PT)-2.0
[**2133-8-26**] 12:08PM BLOOD PT-20.2* PTT-50.6* INR(PT)-2.7
[**2133-8-11**] 06:40AM BLOOD Glucose-94 UreaN-31* Creat-3.6*# Na-133
K-4.0 Cl-96 HCO3-20* AnGap-21*
[**2133-8-12**] 06:53PM BLOOD Glucose-70 UreaN-48* Creat-5.5* Na-134
K-4.4 Cl-100 HCO3-14* AnGap-24*
[**2133-8-15**] 03:43PM BLOOD Glucose-160* UreaN-52* Creat-3.0* Na-140
K-3.7 Cl-103 HCO3-23 AnGap-18
[**2133-8-16**] 02:11PM BLOOD Glucose-118* UreaN-55* Creat-2.1* Na-144
K-3.9 Cl-110* HCO3-24 AnGap-14
[**2133-8-19**] 03:53AM BLOOD Glucose-101 UreaN-44* Creat-1.1 Na-141
K-3.7 Cl-113* HCO3-22 AnGap-10
[**2133-8-23**] 04:04AM BLOOD Glucose-124* UreaN-38* Creat-1.0 Na-128*
K-4.4 Cl-107 HCO3-15* AnGap-10
[**2133-8-25**] 05:45AM BLOOD Glucose-142* UreaN-58* Creat-1.3* Na-131*
K-5.4* Cl-105 HCO3-17* AnGap-14
[**2133-8-26**] 05:20AM BLOOD Glucose-203* UreaN-64* Creat-2.0* Na-128*
K-6.5* Cl-103 HCO3-9* AnGap-23*
[**2133-8-4**] 07:42PM BLOOD Ammonia-79*
[**2133-8-23**] 04:57PM BLOOD Ammonia-39
[**2133-8-25**] 04:43PM BLOOD Ammonia-94*
[**2133-8-26**] 04:50AM BLOOD Ammonia-161*
[**2133-8-23**] 04:23AM BLOOD Type-ART pO2-92 pCO2-34* pH-7.36
calHCO3-20* Base XS--5
[**2133-8-26**] 06:28AM BLOOD Type-ART pO2-124* pCO2-25* pH-7.13*
calHCO3-9* Base XS--19 Intubat-NOT INTUBA
[**2133-8-26**] 01:14PM BLOOD Type-ART pO2-142* pCO2-30* pH-7.13*
calHCO3-11* Base XS--18
[**2133-8-26**] 03:52PM BLOOD Type-ART pO2-81* pCO2-50* pH-7.06*
calHCO3-15* Base XS--16
Brief Hospital Course:
The pt tolerated the procedure well, please see the operative
note for details. The pt was extubated and transferred to the
floor in a stable condition. The pt's diet was advanced and his
immediate post op course was remarkable only for hypoglycemia.
[**Doctor First Name 8392**] was consulted. The pt developed nausea and vomiting on
POD 6 and his urine output began to decline. He was bolused
with IVF with some improvement. His abdomen was distended and a
therapeutic paracentiesis was performed. Fluid analysis was
consisted with SBP and ceftriaxone was started. A ct abdomen
was performed (see results below). His renal function
deteriorated and he developed acute renal failure. His hepatic
function also decompensated and his INR rose to > 2.5. He was
transferred to the ICU for further monitoring on [**2133-8-12**]. A
CVL/swan ganz catheter/NGT/Aline were placed. He became
hypotension despite fluid resusitation on POD 9 and neo ggt was
started. The pt was given FFP/vit k for his coagulopathy. He
became increasingly acidotic and was intubated for respiratory
distress. Broad spectrum antibiotics were started. The pt's
clinically condition slowly improved; his liver/renal function
and coagulopathy improved, his urine output increased, he was
weaned from the vent and off pressors. TPN was initiated and
continued throughout most of his hospital stay. He was
extubated without difficulty on POD15.
He passed a video swallow study and was started on PO's. He was
doing well and transferred to the floor in a stable condition on
POD22. On [**8-26**], the pt'd urine output began to decrease. IVF
boluses were given without response.
CT abd [**2133-8-13**]: Redemonstration of bowel wall thickening to the
segment of distal small bowel just proximal to the anastomosis.
Contrast study reveals lack of bowel wall enhancement, and lack
of enhancement to mesenteric vasculature draining this segment
of small bowel. The findings are thereby highly concerning for
bowel ischemia/New left lower lobe consolidation, likely
secondary to aspiration/Increase to intra-abdominal ascites and
mesenteric edema, mildly increased
Echocardiogram [**2133-8-13**]: EF 55%, 1+MR, mild pulm HTN
OR Pathology [**2133-8-4**]:
Adenocarcinoma, Low-grade (well or moderately differentiated)
Primary Tumor: pT3: Tumor invades through the muscularis
propria into the subserosa or the nonperitonealized pericolic or
perirectal soft tissues. No regional lymph node metastasis.
Proximal margin: Uninvolved by invasive carcinoma: Distance of
tumor from closest margin: 185 mm.
Distal margin: Uninvolved by invasive carcinoma: Distance of
tumor from closest margin: 40 mm.
Circumferential (radial) margin: Uninvolved by invasive
carcinoma: Distance of tumor from closest margin: 7 mm.
Medications on Admission:
[**Last Name (un) 1724**]: aldactone 50'', nadolol 20', prilosec 40', dilantin 400'
qMTh and 500' qSuTuWFSa, lactulose 30'''', insulin 70/30 38qam
and 18qpm, MVI, thiamine 100', folate 1', vit c 1000', Fe 650'.
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
cecal adenocarcinoma
infected adominal wall mesh
ventral hernia
Exploratory laparotomy, right colectomy and excision of infected
mesh, repair ventral hernia [**2133-8-4**]
ESLD
ETOH cirrhosis
ARF requiring CVVH
respiratory failure requiring intubation
arrythmia-bradycardia/atrial fibrillation
severe acidosis
coagulopathy requiring blood products
death
Discharge Condition:
expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
Completed by:[**2133-9-14**]
ICD9 Codes: 5849, 0389, 2762, 2765, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3851
} | Medical Text: Admission Date: [**2173-7-23**] Discharge Date: [**2173-8-10**]
Date of Birth: [**2113-9-21**] Sex: M
Service: MEDICINE
Allergies:
erythromycin / Heparin Agents / Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 3256**]
Chief Complaint:
Hip fracture
Major Surgical or Invasive Procedure:
Left hip hemiarthroplasty
Endotracheal Intubation and Mechanical Ventilation
History of Present Illness:
59yoM with a history of mitral valve prolapse, atrial
fibrillation s/p MAZE and mitral valvuloplasty in [**10/2171**] at [**Hospital1 112**]
that was complicated by a right MCA CVA, RLE DVT treated with
coumadin presenting status post fall during transfer and
fracture of his left hip.
Patient underwent arthroplasty of the left hip on [**2173-7-23**].
After the operation, he developed a new oxygen requirement and
was on 4L NC for the past 2 days until he was found to have a HR
of 140s on tele on [**2173-7-25**] at 1830 and an O2 sat of 71% on 4L NC.
He was given 40mg IV lasix and 5mg IV lopressor, which was
repeated when heart rates did not decrease with another 5mg IV
lopressor. He diuresed 1 L of urine and his oxygen saturations
increased to 100% on the non-rebreather.
On arrival to the MICU, O2 sats are 100% on non-rebreather and
patient has a new fever of 101.2. Patient denies chest pain,
dyspnea, headache, or pleuritic pain. He is only AAO x name,
and is unclear where he is or why he is here. His family is
very involved in his care and were involved with this history
taking.
Past Medical History:
- [**2171-11-26**]: AFib and went to [**Hospital1 756**] were mitral
valvuloplasty/L atrial maze and L atrial appendage resection
were done. After this surgery on post-po day 1 he suffered a
long-standing post-op seizure tonic clonic and found on imaging
a R+ MCA CVA.
--- Pt reports that his Vimpat is being de-escalated and that he
hasn't had a seizure since his initial seizure.
- [**2172-1-13**]: pseudoaneurysm from R common femoral artery
(discovered after going to the hospital bc swelling of L+ ankle)
and DVT in R+ lower extremity.
- Mitral valve prolapse
- h/o DVT on Coumadin
- Bilateral inguinal hernia repair
- L+ knee arthroscopic surgery
- h/o heparin-induced thrombocytopenia
Social History:
Lives in [**Location 745**] with his wife. [**Name (NI) **] 2 children that live in
[**Country **]. [**Hospital1 **] Orthodox. Retired from financial management.
Denies tobacco, alcohol, illicits.
Family History:
non-contributory
Physical Exam:
Vitals: T: 101.2 BP:100/52 P:118 R:21 O2: 100% on
non-rebreather
General: Alert, oriented only to person, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: tachycardic, regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Lungs: Clear to auscultation anteriorly, no wheezes, rales,
ronchi, although upper airway sounds throughout.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, teds and SCDs in place
Neuro: CNII-XII intact, 4+/5 strength upper/lower extremities on
right, 3+ on left, grossly normal sensation, 2+ reflexes
bilaterally, gait deferred
Discharge exam:
Pertinent Results:
[**2173-7-23**] 07:05PM GLUCOSE-115* UREA N-12 CREAT-0.7 SODIUM-139
POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-25 ANION GAP-14
[**2173-7-23**] 07:05PM CALCIUM-8.3* PHOSPHATE-3.9 MAGNESIUM-1.6
[**2173-7-23**] 07:05PM WBC-21.8*# RBC-3.79* HGB-11.4* HCT-34.0*
MCV-90 MCH-30.2 MCHC-33.6 RDW-12.7
[**2173-7-23**] 07:05PM PLT COUNT-223
[**2173-7-23**] 07:05PM PT-12.8* PTT-27.5 INR(PT)-1.2*
[**2173-7-23**] 12:48PM HCT-36.6*
[**2173-7-23**] 12:48PM HCT-36.6*
[**2173-7-23**] 11:50AM GLUCOSE-87 UREA N-12 CREAT-0.8 SODIUM-139
POTASSIUM-4.4 CHLORIDE-101 TOTAL CO2-29 ANION GAP-13
[**2173-7-23**] 11:50AM estGFR-Using this
[**2173-7-23**] 11:50AM WBC-10.8# RBC-4.34*# HGB-13.0*# HCT-38.1*#
MCV-88 MCH-29.9 MCHC-34.1 RDW-12.5
[**2173-7-23**] 11:50AM NEUTS-82.4* LYMPHS-13.6* MONOS-3.0 EOS-0.9
BASOS-0.1
[**2173-7-23**] 11:50AM PLT COUNT-247
[**2173-7-23**] 11:50AM PT-11.3 PTT-30.0 INR(PT)-1.0
[**2173-7-23**] 11:50AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.004
[**2173-7-23**] 11:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-NEG
[**7-23**] Path Gross: The specimen is received fresh in a container
labeled with the patient's name, "[**Known lastname **], [**Known firstname 43984**]", the medical
record number, and additionally labeled "left femoral head".
It consists of a normally shaped femoral head without a portion
of femoral neck that measures 5.5 x 4.5 x 4.5 cm. The articular
surface is unremarkable. Osteophytes are not present. The
femoral neck margin is irregular. The specimen is cut along
its length perpendicular to the articular cartilage. The cut
surfaces reveal yellow-tan hemorrhagic cut surfaces. A fragment
of femoral neck is also received in the container and measures
4.5 x 4.0 x 2.5 cm. It is cut perpendicular to the articular
surface to reveal hemorrhagic bone marrow. Tissue is not
present. Representative sections of the specimen are submitted
for decalcification as follows: A= representative sections of
femoral head, B = representative sections of femoral neck.
[**7-23**] ECG: Sinus bradycardia. Intraventricular conduction defect.
Left axis deviation, possibly due to left anterior fascicular
block. Diffuse non-specific ST-T wave abnormalities. Compared to
tracing #1 the heart rate is decreased but there are no other
significant changes.
TRACING #2
Intervals Axes
Rate PR QRS QT/QTc P QRS T
56 0 132 468/461 0 -57 85
[**7-23**] Hip Xray:
FINDINGS: Single frontal view of the pelvis and three views of
the left hip were obtained. a complete fracture of the left
femoral neck is present with mild varus angulation. No
dislocation is identified. Vague lucencies of the left femoral
shaft is suggestive of osteopenia. No radiopaque foreign
bodies.
IMPRESSION:
1. Left femoral neck fracture with mild varus angulation.
2. Left femoral shaft lucencies suggestive of osteopenia in the
setting of decreased weght bearing from prior stroke.
[**7-23**] CXR: FINDINGS: Single portable view of the chest compared
to previous exam from [**2172-3-20**]. The lungs are clear of
focal consolidation or effusion. Cardiomediastinal silhouette is
within normal limits. Median sternotomy wires are again noted.
The osseous and soft tissue structures otherwise unremarkable.
IMPRESSION: No acute cardiopulmonary process.
[**7-25**] Knee xray
No prior studies for comparison.
FINDINGS: Three views of the left knee demonstrate no evidence
of acute
fracture, dislocation, joint effusion, or soft tissue foreign
body.
[**7-25**] Cpine xrays
CERVICAL SPINE, [**2173-7-25**]
No prior studies for comparison.
On the lateral view, all seven cervical vertebral bodies are
visualized, but the superior aspect of T1 is obscured and cannot
be assessed. Prevertebral soft tissue structures are within
normal limits. Bone mineral density is apparently slightly
decreased throughout. Multilevel degenerative changes are
present with small anterior osteophytes particularly at the C3
through C6 levels, as well as very minimal disc space narrowing.
Reversal of the normal cervical lordosis is evident at C4-C5.
Flexion and extension views demonstrate no evidence of
instability. Incidental note is made of an oval-shaped
calcification posterior to the spinous processes of C4 and C5,
which may represent ossification or calcification of the
posterior longitudinal ligament.
IMPRESSION:
1. Multilevel degenerative changes in the cervical spine as
described. No acute fracture or dislocation identified, but CT
of the cervical spine is much more sensitive than conventional
radiographs for detecting traumatic abnormalities and would be
suggested if there is persistent clinical suspicion for a
cervical spine injury.
2. Exam is limited by absence of an odontoid view and lack of
visualization of C7-T1 disc space and top of T-1.
AP CXR on [**7-25**]
IMPRESSION: AP chest compared to [**7-23**]:
Lungs are appreciably smaller and there is greater but symmetric
opacification in the lower lungs. Contributing to elevation of
the diaphragm is a stomach severely distended with air and
fluid. Since there is also increased upper lobe vascular
congestion, and new small left pleural effusion, appearance
could be explained by either bibasilar pneumonia or a
combination of atelectasis and edema. Subsequent chest CT
reported separately has findings of left lower lobe atelectasis,
right lower lobe pneumonia and multifocal small regions of
peribronchial opacification, probably bronchopneumonia. It
shows vascular congestion but no pulmonary edema, and a stomach
severely distended with air and fluid.
CT Chest: FINDINGS: The thyroid gland, aorta and major
branches, heart and pericardium are unremarkable with the
exception of changes of mitral valve annuloplasty. No
pericardial effusion is seen. The esophagus is patulous and
fluid filled. There is no axillary, hilar, or mediastinal
adenopathy. Gynecomastia is noted bilaterally. Though this
study is not tailored for subdiaphragmatic evaluation, imaged
upper abdomen reveals distended stomach.
The trachea and central airways are patent to the segmental
level. The
pulmonary arterial tree is well opacified without filling defect
to suggest
pulmonary embolism, though evaluation of the subsegmental
vessels is limited due to respiratory motion. Small bilateral
pleural effusions are dependent and nonhemorrhagic. Right
greater than left basal opacities with milder opacification of
the dependent segment of the right upper lobe and right middle
lobe are concerning for multifocal pneumonia which likely
includes the anterior subpleural opacities.
OSSEOUS STRUCTURES: There is no lytic or sclerotic bony lesion
to suggest
osseous malignancy.
IMPRESSION:
1. No pulmonary embolism or acute aortic pathology.
2. Multifocla pneumonia with opacities in the lower lobes and
left upper
lobe.
3. Patulous esophagus, correlate with symptoms of dysphagia and
outpatient
esophagram can be obtained if indicated.
Echo [**7-26**]
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). The estimated cardiac
index is normal (>=2.5L/min/m2). Right ventricular chamber size
and free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. The mitral
valve leaflets are myxomatous. A mitral valve annuloplasty ring
is present. The mitral annular ring appears well seated with
normal gradient. Mild (1+) mitral regurgitation is seen. There
is moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Well seated mitral annuloplasty ring with normal
gradient and mild mitral regurgitation. Pulmonary artery
hypertension. Normal biventricular cavity sizes with preserved
global and regional biventricular systolic function.
AP CXR [**7-26**]
FINDINGS: As compared to the previous radiograph, there is a
substantial
increase in extent and severity of the pre-existing multifocal
pneumonia.
These changes are evident at both lung bases. The lung apices
are bilaterally spared from the pathologic process. Unchanged
borderline size of the cardiac silhouette. Minimal fluid
overload cannot be excluded. No larger pleural effusions. No
pneumothorax. Mild over distention of the stomach, unchanged
normal alignment of the sternal wires.
ECG [**7-28**]
Sinus tachycardia. Left anterior fascicular block. Non-specific
ST-T wave
abnormalities. Compared to the previous tracing of [**2173-7-23**] the
heart rate has increased, ST-T wave abnormalities have improved.
TRACING #1
Intervals Axes
Rate PR QRS QT/QTc P QRS T
103 146 128 336/411 47 -45 78
AP CXR [**7-28**] Last of 3 for the day
There is again seen diffuse air space opacities bilaterally,
more confluent in the right lung and have increased slightly
since the prior study. Atelectasis at the left lung base is
again seen. There are low lung volumes with poor inspiratory
effort. There are no pneumothoraces. Median sternotomy wires
are present.
AP CXR [**7-30**]
FINDINGS: A new left PICC terminates approximately 1 cm beyond
the cavoatrial junction. Dense consolidation of the entire
right lung as well as right-sided pleural effusion are
unchanged. There is a persistent retrocardiac opacity as well
as worsening consolidation of the left upper lobe when compared
to the prior study from yesterday. There is improved aeration
at the left costophrenic angle. There is no pneumothorax.
Heart size is top normal and unchanged. Sternotomy cerclage
wires are intact.
IMPRESSION:
1. New left PICC should be withdrawn by 1.5 cm to ensure proper
positioning
in the lower SVC.
2. Multifocal pneumonia, slightly worse in the left upper lobe.
BAL [**7-31**]
Bronchioalveolar lavage:
NEGATIVE FOR MALIGNANT CELLS.
Numerous neutrophils, bronchial cells, and pulmonary
macrophages.
No viral cytopathic changes or fungi seen.
AP CXR [**7-31**]
CHEST, SINGLE AP PORTABLE VIEW
The patient is status post sternotomy. An ET tube is present,
tip in
satisfactory position approximately 4.3 cm above the carina. A
left-sided
PICC line is present, tip over distal SVC. An NG tube is
present, tip and
side port beneath diaphragm, extending off film.
There is diffuse alveolar opacity and air bronchograms
throughout the right
lung, with relative sparing of the right lung apex and minimal
residual
lucency at the right base. This has progressed compared with
[**2173-7-30**].
Possibility of an associated effusion cannot be excluded.
There is also prominent focal interstitial and alveolar opacity
in the left upper zone, which appears more confluent than on the
earlier film. There is increased retrocardiac density, with
obscuration of the left hemidiaphragm, unchanged. The small
left effusion is slightly more prominent on this exam. There is
relative lucency at the left lung apex. However, I doubt this
represents a pneumothorax.
IMPRESSION:
Interstitial and alveolar opacities in both lungs, progressed
compared with
[**2173-7-30**] at 12:09 p.m. Differential diagnosis includes multifocal
pneumonic
infiltrates, ARDS and CHF.
CHEST: Imaged portions of the thyroid gland appear within
normal limits.
There is a left upper extremity PICC line with its tip
terminating in the SVC. The patient is status post endotracheal
intubation with the tip of the ET tube lying approximately 4.9
cm above the carina. An NG tube is seen with its tip
terminating in the stomach.
There is no axillary, mediastinal, or hilar lymphadenopathy.
The cardiac
[**Doctor Last Name 1754**] appear grossly within normal limits. There are no
filling defects
within the central pulmonary arterial tree. The patient is
status post median sternotomy and mitral valve replacement.
There are large bilateral pleural effusions with adjacent
compressive
atelectasis, right greater than left. Patchy pulmonary
opacities are noted in the remainder of the inflated upper lobes
with hint of appearance of crazy pavement (series 2, image 13)
in the left upper lobe and also within the right upper lobe
(series 2, image 17) suggestive of pulmonary edema. There is no
pneumothorax.
Additional scattered regions of ground-glass opacification are
also seen
scattered within the lungs, for example, on series 2, image 35,
suggestive of edema.
FINDINGS IN THE ABDOMEN AND PELVIS: In the liver, there are two
focal
hypodensities seen centrally (series 2, image 56), which are
less than a
centimeter in size and are not well characterized on the current
examination.
There is no intra- or extra-hepatic biliary ductal dilatation.
The portal
vein is patent.
The spleen is within normal limits in size. The adrenal glands,
pancreas, and kidneys appear unremarkable. There is no
mesenteric or retroperitoneal
lymphadenopathy.
There is minimal quantity of perihepatic fluid as well as a
small quantity of fluid tracking into the right paracolic
gutter. The gallbladder is distended and there is a small
quantity of pericholecystic fluid (2, 82). Minimal periportal
edema is seen in the liver.
There is a small quantity of fluid in the dependent pelvis (2,
108).
The urinary bladder demonstrates no obvious abnormalities. A
Foley catheter
is seen in place.
No obvious abnormalities are seen in the colon. The stomach is
slightly
decompressed with NG tube in place, limiting evaluation. Small
bowel appears within normal limits.
There is subcutaneous soft tissue edema, most predominantly
noted in the
gluteal region as well as in the upper thighs.
There are flame-shaped opacities involving the retroareolar
regions suggestive of gynecomastia.
Left hip replacement arthroplasty is seen. There are no
suspicious osteolytic or osteoblastic lesions seen to suggest
tumor.
Surgical staples are seen in the left gluteal region.
IMPRESSION:
Large bilateral pleural effusions with adjacent compressive
atelectasis.
Crazy pavement changes in the lungs suggestive of mild pulmonary
edema.
Additional multifocal regions of atelectasis and consolidation,
underlying
pneumonia is not excluded.
No intra-abdominal abscess.
Distended gallbladder with small amount of pericholecystic
fluid. Findings
are nonspecific. If there is clinical concern for acute
cholecystitis, this can be further evaluated with right upper
quadrant son[**Name (NI) **].
Minimal quantity of perihepatic and pelvic fluid, which could be
related to
third spacing.
Additional diffuse regions of subcutaneous soft tissue edema in
the pelvic
girdle.
CXR [**8-4**]
INDICATION: Pneumonia, questionable ET tube placement.
COMPARISON: [**2173-8-4**].
FINDINGS: As compared to the previous radiograph, the
monitoring and support devices are constant. The tip of the
endotracheal tube projects 4.9 cm above the carina. The
parenchymal opacity at the left lung apex is minimally
decreasing in extent. The extensive right-sided opacity is
unchanged. Moderate cardiomegaly with borderline size of the
cardiac silhouette and unchanged minimal blunting of the left
costophrenic sinus, potentially reflecting a small pleural
effusion. No evidence of pneumothorax.
Brief Hospital Course:
59 y/o M with a history of mitral valve prolapse, atrial
fibrillation s/p MAZE and mitral valvuloplasty in [**10/2171**] that
was complicated by a right MCA CVA and a RLE DVT presented
status post fall and fracture of his left hip on [**2173-7-23**]. His
hip was repaired with a L hemiarthroplasty on [**2173-7-23**], and in
the post-operative setting, he had persistent high oxygen
requirements. He progressed to respiratory failure secondary to
multifocal pneumonia and pulmonary edema, requiring
re-intubation and transfer to the MICU. He was treated with a 10
day course of antibiotics and aggressive diuresis, as well as
vasopressors until he improved. He was extubated and gradually
weaned off oxygen. Once medically stable, PT advised further
inpatient physical therapy in subacute rehab.
Active Problems:
# Respiratory Failure: Multifocal PNA (aspiration?) and
pulmonary edema. Following extubation from his orthopedic
procedure, patient was maintained on 5L nasal canula on the
floor. The evening of [**2173-7-25**], he developed respiratory
distress, not responsive to lasix. Patient was then transferred
to the MICU, meeting SIRS criteria by RR, temperature, and heart
rate. Pt was evaluated for a PE; CTA showed no evidence of PE,
but did show a multifocal PNA. He was placed on broad-spectrum
antibiotics (including vancomycin, and, at different points,
cefepime, levofloxacin, and Meropenem). Blood, urine, and
sputum cultures did not grow out any organism. The patient also
developed hypotension and was volume-recusitated aggressively.
His tachypnea increased, and he became hypoxic on BiPAP and
required intubation on [**2173-7-31**]. Cultures from bronchoscopy
following intubation were unremarkable, and visual inspection of
the airways did not demonstate purulence. Further imaging with
chest CT showed large bilateral pulmonary effusions, multifocal
PNA, and pulmonary edema. He received a 10-day course of
antibiotics for VAP coverage. As his pneumonia improved,
concern lingered for pulmonary edema. He was started on Lasix
drip for diuresis, and was extubated on [**2173-8-5**]. By [**2173-8-6**], he
was was able to oxygenate well on 2L by NC. By [**2173-8-9**] he was
stable on room air.
.
# Hip Fracture: His hip was repaired with a L hemiarthroplasty
on [**2173-7-23**]. Orthopedic surgery followed the patient throughout
his stay in the MICU. His surgical wound healed well, and
staples were removed on [**2173-8-6**], there was no concern for
infection. Physical therapy began working with the patient when
he was weaned off sedation prior to being extubated. They
continued working with him during the remainder of his
hospitalization and recommended subacute rehab after discharge.
.
# Pain Control: Patient had post-operative pain in his left
thigh and hip. Before and during intubation and after
extubation, the patient had pleuritic chest pain as well. At
different points during his hospitalization, his pain was
controlled with morphine, fentanyl, ibuprofen, IV Tylenol,
and/or lidocaine patch. He will be discharged on tylenol and
morphine prn.
.
# Fever/Thrombocytosis: Likely reactive to pneumonia versus drug
reaction. The patient continued to spike fevers during his MICU
stay. Initially the fever was c/w PNA and sepsis. However,
even as his PNA resolved, he continued to spike fevers. He also
developed a thrombocytosis to the 900s. The fever and
thrombocytosis are thought to be due to systemic inflammation in
the setting of resolving PNA. His platelets were down-trending
by day of discharge. He has been afebrile for several days.
.
# Persistent sinus tachycardia in the MICU: This tachycardia was
likely due to hypovolemia versus sepsis versus hypoxia. The
patient's home metoprolol was held in the setting of
hypotension. Troponins were sent and were negative. When the
patient was extubated and his tachycardia resolved, he was
restarted on metoprolol, and switched to metoprolol 75mg XL
daily the day of discharge. However his dose was held on
discharge due to his SBP in the ~90s.
.
# Hypotension: In the setting of SIRS and multifocal PNA. He
required norepinephrine drip, but this was discontinued in the
MICU when his BP improved with MAPs in the 70s. He was
normotensive on transfer to the floor and his Metoprolol was
held with his SBP in the ~90s.
.
# Nausea/GERD: Likely mutifactorial, with components of GERD,
clinical illness, and not taking POs for several days. Patient
with history of GERD. Pt was initially on IV Protonix, then was
switched to PO PPI. He was treated with Zofran, calcium
carbonate, Aluminum-Magnesium Hydrox, and simethicone. On CTA
of the chest, patulous esophagus was also seen (see transitional
issues below), which may have also contributed to his difficulty
taking POs. His symptoms had resolved by day of discharge.
.
# Rash: Over back, consistent with heat-induced follicullitis.
First noted and resolved in the MICU.
.
# Altered mental status: On arrival to MICU, question hypoxia
precipitating versus history of previous stroke. Per family,
patient was initially off baseline, but improved with oxygen
saturations, although patient still having episodes of confusion
prior to intubation. He was treated with quetiapine, and his
mental status improved while he weaned off sedation when he was
intubated and then improved further after extubation. On
transfer to the medical floor he was stable and remained
oriented.
.
# Dropping HCT: HCT dropped from 28 on [**7-30**] to 22 on [**8-2**] without
a source of bleeding. This may have been dilutional, but the
patient was transfused with 1 unit PRBCs on [**8-2**]. From that
point, his HCT has been increasing.
.
Chronic Problems:
# History of DVT: Pt has a hx of DVT and was treated previously
with Coumadin. This was held during his hospitalization. Due
to his history of being HIT antibody +, he was not treated with
unfractionated heparin. He was treated with aspirin 81 mg PO/NG
DAILY and Fondaparinux Sodium 2.5 mg SC DAILY.
.
# BPH: On Flomax at home. This was initially held, but was
restarted on [**8-6**] The patient's Foley was removed on [**8-7**] and he
maintained urine output on discontinuation of the Foley.
.
# History of stroke and seizures: The patient remained
clinically stable on his home Lacosamide 50 mg PO/NG DAILY,
Pravastatin 20 mg PO HS, and Aspirin 81 mg PO/NG DAILY.
.
# History of seasonal allergies: Inactive during this
hospitalization. Home medications were initially held, but were
restarted on discharge.
.
# History of depression: The patient remained clinically stable.
His home Duloxetine 60 mg PO DAILY was held initially but
restarted on [**8-5**] .
.
# Skin conditions: Pt on several home medications that were
continued, including Hydrocortisone Cream 0.5% 1 Appl TP TID:PRN
intching, Ketoconazole 2% 1 Appl TP DAILY, and Triamcinolone
Acetonide 0.1% Cream 1 Appl TP [**Hospital1 **] to scalp as needed.
.
Transitional issues:
# The patient responds well to diuresis with IV furosemide 20mg
if there are signs of fluid overload.
# The patient's metoprolol 25mg tid was consolidated to
metoprolol succinate 75 once a day, but his SBP has been in the
high 90s towards the end of his hospital stay, so
antihypertensives had been held.
# Patulous esophagus seen on CTA Chest [**7-25**]: outpatient
esophagram can be obtained if indicated
# The patient will need rehab for his left hip surgery.
Medications on Admission:
-Lacosamide (VIMPAT) 100 mg Oral Tablet [**1-25**] tab daily
-Fluticasone 50 mcg/actuation Nasal Spray, Suspension Use 2
sprays in each nostril once daily
-Tamsulosin (FLOMAX) 0.4 mg Oral Capsule, Ext Release 24 hr 1
tablet daily 30 minutes after breakfast
-Nystatin (MYCOSTATIN) 100,000 unit/g Topical Powder use [**Hospital1 **]
-Duloxetine (CYMBALTA) 60 mg Oral Capsule, Delayed Release(E.C.)
1 tab qd
-Fluocinonide 0.05 % Topical Solution Apply twice daily as
directed
-Fexofenadine ([**Doctor First Name **]) 180 mg Oral Tablet Take 1 tablet daily
as needed. Available over the counter.
-Pravastatin (PRAVACHOL) 20 mg Oral Tablet 1 tablet in the
evening
-Metoprolol Tartrate 25 mg Oral Tablet 3 tablets daily total
75mg
-Ketoconazole (NIZORAL) 2 % Topical Cream Apply twice daily
-Ketoconazole (NIZORAL) 2 % Topical Shampoo Shampoo 5 minutes 2
to 5 times per week or as directed
-Dantrolene (DANTRIUM) 25 mg Oral Capsule as directed
-Triamcinolone Acetonide 0.1 % Topical Lotion apply [**Hospital1 **] to the
scalp as needed
-Lorazepam (ATIVAN) 0.5 mg Oral Tablet [**1-25**] tablet q 6hrs as need
for anxiety
-Acetaminophen (TYLENOL EXTRA STRENGTH) 500 mg Oral Tablet 2
tablets [**Hospital1 **]
-Docusate Sodium (COLACE) 100 mg Oral Capsule once daily
-SENNOSIDES (SENNA LAXATIVE ORAL) one tablet daily as needed for
constipation
-MULTIVITAMIN ORAL once a day
-ASPIRIN 81 MG TAB
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H pain or fever
patient may refuse
2. Albuterol Inhaler [**4-30**] PUFF IH Q6H:PRN SOB, wheezing
3. Aspirin 81 mg PO DAILY
4. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
5. Calcium Carbonate 500 mg PO BID calcium supplement
please do not administer within 2 hours of Cipro doses
6. Docusate Sodium 100 mg PO BID
7. Duloxetine 60 mg PO DAILY
8. Fluticasone Propionate NASAL 2 SPRY NU DAILY
9. Fondaparinux Sodium 2.5 mg SC DAILY
10. Hydrocortisone Cream 0.5% 1 Appl TP TID:PRN intching
11. Ketoconazole 2% 1 Appl TP DAILY
12. Lacosamide 50 mg PO DAILY
13. Lidocaine 5% Patch 1 PTCH TD DAILY
14. Miconazole Powder 2% 1 Appl TP [**Hospital1 **]
15. Morphine Sulfate IR 7.5 mg PO Q6H:PRN pain
16. Multivitamins 1 TAB PO DAILY
17. Omeprazole 40 mg PO DAILY
18. Ondansetron 4 mg IV Q6H:PRN nausea
19. Pravastatin 20 mg PO HS
20. Prochlorperazine 10 mg PO Q6H:PRN nausea
Caution oversedation
21. Quetiapine Fumarate 25 mg PO TID:PRN agitation
22. Senna 1 TAB PO BID
23. Simethicone 40-80 mg PO QID:PRN abdominal discomfort
24. 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.
25. Tamsulosin 0.4 mg PO DAILY
26. Triamcinolone Acetonide 0.1% Cream 1 Appl TP [**Hospital1 **] to scalp as
needed
27. Vitamin D 800 UNIT PO DAILY
28. Metoprolol Succinate XL 75 mg PO DAILY
Hold if SBP<100, HR<60
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Nursing & Therapy Center - [**Location 1268**] ([**Location (un) 86**] Center
for Rehabilitation and Sub-Acute Care)
Discharge Diagnosis:
Primary: Left Hip Fracture, Respiratory Failure, Pneumonia,
Pulmonary Edema
Secondary: Depression, Congestive Heart Failure, Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure caring for you at [**Hospital1 827**]. You were admitted because you had a broken hip
which required surgery. Your recovery was complicated by
pneumonia, pulmonary edema (fluid in your lungs), and
respiratory failure, which required that we insert a breathing
tube and provide mechanical ventilations in the medical ICU. We
also treated you with oxygen, antibiotics for the pneumonia and
diuretic medications, which remove fluid from your body. We also
gave you medications to maintain your blood pressure.
.
You responded to treatment well, except for some confusion known
at ICU delirium. Once you improved, we transferred you to the
general medicine floor and monitored you for several more days
until your oxygen was stopped completely.
Please note the following changes in your medications:
You should START Fondaparinux to prevent blood clots, as managed
by your orthopedic surgeon.
You should CHANGE Metoprolol to Metoprolol 75mg XL once a day
for high blood pressure.
You should START the skin ointments and powders for your rashes,
as needed, for 1-2 weeks until they resolve.
You may START acetaminophen and morphine for pain control, as
needed.
You may continue the rest of your medications as previously
prescribed.
Followup Instructions:
*Please schedule a PCP appointment on discharge from your Rehab
facility.
*Please schedule an appointment with a dermatologist if your
skin rashes do not resolve in [**1-25**] weeks.
Orthopedic Surgery followup:
Department: ORTHOPEDICS
When: THURSDAY [**2173-8-26**] at 10:20 AM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: THURSDAY [**2173-8-26**] at 10:40 AM
With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2173-8-10**]
ICD9 Codes: 0389, 486, 5119, 4280, 2851, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3852
} | Medical Text: Admission Date: [**2196-4-28**] Discharge Date: [**2196-4-29**]
Date of Birth: [**2120-3-31**] Sex: F
Service:
CHIEF COMPLAINT: Internal carotid artery stenosis.
HISTORY OF PRESENT ILLNESS: This is a 76-year-old female
with multiple medical problems including coronary artery
disease, peripheral vascular disease, hypertension,
insulin-dependent diabetes mellitus, hypercholesterolemia
(with critical stenosis of the of the right internal carotid
artery of 80% to 99%) who was admitted for stenting and for
angiography.
A preoperative computerized axial tomography of the head on
[**2196-4-19**] was negative for any major vascular and
territorial infarction but was positive for heavy
atherosclerotic calcifications within the cavernous portions
of the internal carotid arteries.
A subclavian angiography, as well as carotid and cerebral
angiography, showed proximal left subclavian disease,
hypoplastic left vertebral artery, tortuous right
brachiocephalic artery with a full 360-degree loop in the
common carotid artery and right subclavian artery. There was
an 80% calcified lesion at the origin of the internal carotid
artery and a tortuous right common carotid artery. Due to
the tortuosity of her vessels, angioplasty and stent of the
right internal carotid artery was unsuccessful. Of note, a
small type A dissection of the proximal carotid artery from
the sheath position occurred during the procedure.
The patient was admitted to the Coronary Care Unit for
observation after the procedure.
REVIEW OF SYSTEMS: No fevers or chills. No chest pain.
The patient denies any shortness of breath, nausea, vomiting,
or lightheadedness. She also denies abdominal pain,
diarrhea, and constipation.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Insulin-dependent diabetes mellitus.
3. Hypercholesterolemia.
4. Right shoulder surgery.
5. Hysterectomy.
6. Bilateral vein stripping and ligation.
7. Right femoral artery pseudoaneurysm repair.
8. Coronary artery disease with an inferior myocardial
infarction in [**2183**] and a non-Q-wave myocardial infarction in
[**2192**]. In [**2193-12-23**], coronary artery bypass graft times
two with left internal mammary artery to left anterior
descending artery and right internal mammary artery to first
obtuse marginal. She was admitted most recently in [**2195-10-23**] for chest pain. A catheterization at that time
showed patent grafts.
9. Class III congestive heart failure with biventricular
pacemaker and an ejection fraction of 20%.
10. Gastrointestinal bleed with urgent colectomy in [**2194-9-22**].
11. Chronic anemia.
12. Chronic renal insufficiency (with a baseline creatinine
of 1.3 to 2).
13. Peripheral neuropathy.
14. Peripheral vascular disease and claudication.
15. Neurogenic bladder.
ALLERGIES: She has no known drug allergies.
MEDICATIONS ON DISCHARGE: (At home she is on)
1. Toprol-XL 50 mg p.o. twice per day.
2. Imdur 30 mg p.o. twice per day.
3. Lipitor 20 mg p.o. q.h.s.
4. Neurontin 600 mg p.o. three times per day.
5. Protonix 40 mg p.o. once per day.
6. Lasix 80 mg p.o. three times per day (recently increased
from twice per day).
7. Aldactazide 25 mg/25 mg p.o. once per day.
8. Humalog sliding-scale.
9. NPH insulin 55 units subcutaneously q.a.m. and 32 units
subcutaneously q.p.m.
10. Ciprofloxacin 250 mg p.o. twice per day (started on [**2196-4-27**] for a urinary tract infection).
SOCIAL HISTORY: She denies any tobacco history. She has
occasional alcohol. She lives with her husband and her
daughter. She has occasional [**Hospital6 407**]
services.
FAMILY HISTORY: No family history of coronary artery
disease.
PHYSICAL EXAMINATION ON PRESENTATION: On examination, the
patient's temperature was 99.8, blood pressure was 132/73,
heart rate was 96, respiratory rate was 12, and oxygen
saturation was 98% on room air. She was a pleasant, obese,
elderly woman in no acute distress. Obese neck, difficult to
assess neck veins. She had bilateral carotid bruits (left
greater than right). The lungs were clear to auscultation
bilaterally anteriorly. The heart was regular in rate and
rhythm. Distant heart sounds. The abdomen was obese, soft,
and nontender. She had no clubbing, cyanosis, or edema in
her extremities. She had warm extremities with trace
palpable dorsalis pedis pulses. She was alert and oriented
times three. Cranial nerves II through XII were grossly
intact. Motor strength was [**4-25**] in all extremities.
PERTINENT LABORATORY VALUES ON PRESENTATION: White blood
cell count was 12.2 on admission, hematocrit was 44, and
platelets were 286. INR was 1.2 and partial thromboplastin
time was 24. Sodium was 137, potassium was 4.3, chloride was
92, bicarbonate was 30, blood urea nitrogen was 45,
creatinine was 1.9, and blood glucose was 150.
HOSPITAL COURSE: The patient remained stable throughout her
hospital course. She was given heparin six hours after the
sheaths were removed. Aspirin and Plavix were added to her
regimen. She had neurologic checks every two hours, which
were stable.
The patient's creatinine bumped to 2.1 but again trended down
to 1.9. She was also given post catheterization intravenous
fluids with Lasix as well as Mucomyst for its renal
protective affects.
The patient's hematocrit status post catheterization drifted
down to 37.1, but she remained asymptomatic.
CONDITION AT DISCHARGE: She was discharged in good
condition.
DISCHARGE STATUS: Discharge status was to home with [**Hospital6 3429**] services.
DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was to follow
up with Dr. [**First Name (STitle) **], Dr. [**Last Name (STitle) 2578**], and with her neurologist.
DISCHARGE DIAGNOSES:
1. Cerebral atherosclerosis.
2. Native coronary artery disease.
3. Subclavian carotid and cerebral angiography unsuccessful.
4. Attempted angioplasty and stent of the right internal
carotid artery requiring critical care observation overnight.
MEDICATIONS ON DISCHARGE:
1. Toprol-XL 50 mg p.o. twice per day.
2. Imdur 30 mg p.o. twice per day.
3. Lipitor 20 mg p.o. q.h.s.
4. Neurontin 600 mg p.o. three times per day.
5. Protonix 40 mg p.o. once per day.
6. Lasix 80 mg p.o. three times per day (recently increased
from twice per day).
7. Aldactazide 25 mg/25 mg p.o. once per day.
8. Humalog sliding-scale.
9. NPH insulin 55 units subcutaneously q.a.m. and 32 units
subcutaneously q.p.m.
10. Ciprofloxacin 250 mg p.o. twice per day (started on [**2196-4-27**] for a urinary tract infection).
11. Aspirin 325 mg p.o. once per day.
12. Plavix 75 mg p.o. once per day.
DR [**First Name8 (NamePattern2) **] [**Name (STitle) **] 12.953
Dictated By:[**Name8 (MD) 6371**]
MEDQUIST36
D: [**2196-4-29**] 13:24
T: [**2196-5-3**] 08:45
JOB#: [**Job Number 109789**]
ICD9 Codes: 4280, 4240, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3853
} | Medical Text: Admission Date: [**2118-1-3**] Discharge Date: [**2118-1-7**]
Service: MICU
CHIEF COMPLAINT: Nausea, vomiting, diarrhea.
HISTORY OF THE PRESENT ILLNESS: The patient is an
81-year-old man presenting to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Hospital Emergency
Department with nausea, vomiting, and diarrhea times one day.
At the time of presentation, he was unable to give an
accurate history. He was transferred to [**Hospital1 18**] for
questionable ischemia and was noted to have an acute
myocardial infarct with a troponin of 20. On initial
presentation, he complained of diffuse abdominal pain without
fever or chills. When he was admitted to the outside
hospital, he was found to have a distended gallbladder on a
CT of the abdomen and transferred to the Intensive Care Unit
at that time.
While in the Intensive Care Unit, an arterial blood gas was
performed which showed a pH of 7.29, PC02 35, P02 58, and an
increased white blood cell count to 24. While in the
Intensive Care Unit there, he was given a dose of Levaquin
and Flagyl and an ultrasound was performed which was
reportedly negative for cholelithiasis. Initially on
presentation, his transaminases were normal, however, bumped
to the mid 500s while in the Intensive Care Unit. He was
also found to have an elevated lactate level and, therefore,
was transferred to [**Hospital6 256**] to
rule out bowel ischemia and was placed initially on the
Surgical Intensive Care Unit.
PAST MEDICAL HISTORY:
1. Carcinoid tumor of the duodenum.
2. GERD.
3. COPD.
4. Hypothyroidism.
5. Hiatal hernia.
6. Bilateral inguinal hernia repair.
7. Status post right hip surgery.
8. Status post appendectomy.
9. Workup for lymphoma approximately one year ago per family
was reportedly negative.
SOCIAL HISTORY: Per family, no tobacco, alcohol, or drug
use. He lives in an [**Hospital3 **] facility with his wife.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON TRANSFER TO THE MICU SERVICE:
1. Aspirin 81 mg.
2. Protonix 40 q.d.
3. Synthroid 75 micrograms q.d.
4. Heparin drip.
5. Flagyl 500 t.i.d.
6. Unasyn 3 grams q. 12 hours.
7. Fentanyl 100 micrograms per hour.
8. Albuterol and Atrovent nebulizers p.r.n.
9. Ativan 1 mg q. eight hours.
PHYSICAL EXAMINATION ON TRANSFER TO THE MICU SERVICE: Vital
signs: Temperature 98.4, blood pressure 133/62, respiratory
rate 13, oxygen saturation 94% with ventilator settings, SIMV
500 cc by 20 breaths per minute, PEEP 10, FI02 50%. Swan
numbers: Pulmonary artery pressure 54/26, pulmonary
capillary wedge pressure 15, CVP 16, cardiac output 6.6,
index 3.5, SVR 848. General: The patient was intubated and
sedated. HEENT: His ENT tube was in place. He blinks eyes
on occasion but not to commands. The sclerae were anicteric.
The pupils were pinpoint. On chest auscultation, he had
diminished breath sounds at the bilateral bases.
Cardiovascular: Regular rate and rhythm, normal S1, S2, no
murmurs, rubs, or gallops. Abdomen: Soft, distended,
diffusely tender to palpation with hypoactive bowel sounds.
Extremities: He had 2+ lower extremity pitting edema, 2+
dorsalis pedis and posterior tibial pulses bilaterally and
was extremely anasarcic. Neurological: He was intubated and
sedated. He did not follow commands and was unresponsive to
sternal rub.
LABORATORY VALUES ON ADMISSION: White count 25.3, hemoglobin
10, hematocrit 31. The differential revealed 72%
neutrophils, 17% bands, 5% lymphocytes, platelets 108,000.
INR 2.2. Fibrinogen 320. FDP elevated at 80:160. Sodium
141, potassium 5.2, chloride 108, bicarbonate 14, BUN 40,
creatinine 3.2. LFTs: ALT 3242, AST 3868, LDH 6084,
alkaline phosphatase 110, amylase 140, total bilirubin 0.7,
lipase 75. Cardiac enzymes: CK 529, CK MB 12, MB index 2.3,
troponin 24.1. Hepatitis panel: Hepatitis A IgG positive,
hepatitis A IgM negative, hepatitis B surface antibody
positive, hepatitis B surface antigen negative, hepatitis C
antibody negative.
PERTINENT RADIOGRAPHIC EXAMINATION DURING ADMISSION:
1. Chest x-ray showed left upper lobe opacity and right
lower lobe infiltrate.
2. CT of the abdomen and pelvis on admission, [**2118-1-3**],
showed small areas of low-density in the liver which likely
represented simple liver cysts, bilateral pleural effusions
with bibasilar consolidations, left kidney perinephric
changes from renal failure.
IMPRESSION: This is an 81-year-old man presenting to the
outside hospital with a history of nausea, vomiting, and
diarrhea times one day transferred to [**Hospital1 18**] Surgical
Intensive Care Unit Service initially for question of gut
ischemia with leukocytosis and elevated lactate level. He
was then transferred to the MICU Service with acute renal
failure, non-ST elevation MI, and shock liver.
HOSPITAL COURSE: The patient was initially followed by the
Surgical Intensive Care Unit Service who performed an
ultrasound-guided aspiration of fluid surrounding at the
gallbladder. There were no organisms shown by Gram's stain
and the culture was negative. As there was no indication for
cholecystectomy at this time, attention was then focused on
whether surgical intervention would be indicated for possible
gut ischemia. Given the patient's significant comorbid
illnesses at that time, it was felt that even if there were
signs of gut ischemia surgery could not safely be performed
and, therefore, he was transferred to the MICU Service for
optimization of medical management.
Cardiology was consulted as the patient ruled in for an acute
myocardial infarct with elevated troponin levels but no EKG
changes. He was then evaluated by the Cardiology Consult
Team who felt that the non-ST elevation MI in the setting of
hypertension, tachycardia, and acidosis with relative
hypovolemia represented myocardial damage around the setting
of fixed CAD. It was felt that optimizing medical treatment
would be appropriate. Heparin was not felt necessary at this
time and, therefore, was discontinued.
The patient's condition continued to deteriorate despite
medical management and he became anuric by hospital day
number three. His acidosis continued to worsen and his
lactate level peaked at approximately 9.2 with signs of
multiorgan failure including significant elevated
transaminases at 3,000, creatinine continued increasing and
anuria as well as myocardial infarct.
The grim prognosis was discussed with the family. The
patient's daughter then brought in his advance directive
which stated that he had no wishes to be artificially kept
alive should a significant recovery not appear likely. Life
sustaining support was then discontinued including withdrawal
of pressors and extubation on [**2118-1-7**]. The patient expired
at [**2118-1-7**] at 13:42.
The family member, [**Name (NI) 2127**] [**Name (NI) 3065**], who is the patient's
daughter was [**Name (NI) 653**] and a request for an autopsy was made.
At the time of dictation, it is unclear the initiating event
of the patient's death; however, it seemed unlikely that this
was secondary to acute hepatitis given the normal hepatitis
serologies which were performed. The autopsy results should
clarify the cause of death.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7585**]
Dictated By:[**Last Name (NamePattern1) 6240**]
MEDQUIST36
D: [**2118-2-3**] 12:44
T: [**2118-2-3**] 13:47
JOB#: [**Job Number **]
ICD9 Codes: 0389, 5849, 2765, 496, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3854
} | Medical Text: Admission Date: [**2181-7-30**] Discharge Date: [**2181-8-7**]
Date of Birth: [**2126-6-27**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5552**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
bilateral pleurex catheters were placed
History of Present Illness:
55 yo female with metastatic adenocarcinoma with unknown primary
on C2D1 gemcitabine/irinotecan and with history DVT/PE with IVC
filter placement, history of malignant pleural and pericardial
effusions who presents with 2 days worsening shortness of breath
and orthopnea. She also reports right sided pleuritic chest
pain. She endorses new lower extremity edema for past 2 days.
Also reports non-productive cough. Denies any fevers, chills,
nausea, vomitting, or urinary symptoms. + Constipation.
.
Of note, she has had had 3 recent admissions: on [**5-16**] for dyspnea
and [**6-6**] and [**6-14**] for dizziness/syncope. On admission [**6-6**], the
patient had pericardiocentesis and balloon pericardiotomy with
removal of 520 cc of bloody fluid. [**Month/Year (2) **] on [**6-4**] showed stable
loculated pericardial effusion. [**Month/Year (2) **] [**6-11**] (EF>55%) suggestive of
pericardial constriction, although unchanged in size since prior
admission.
.
Pt. presented to ED with above complaints, and also found to be
tachycardic to 130s. Patient has h/o resting tachycardia
115-120. Electrocardiogram in the ED showed sinus tachycardia
unchanged from prior. In the ED, patient was seen by cardiology
given history of pericardial effusions and bedsided
echocardiogram was performed, and showed moderate effusion but
did not reveal any RV diastolic collapse or significant AV
respirophasic variation to suggest tamponade physiology. Chest
x-ray demonstrated re-accumulated large right-sided pleural
effusion and moderate left-sided effusion. Patient was admitted
due to tachypnea, tachycardia, and difficult course with
previous thoracentesis, which was complicated by post-procedure
pulmonary oedema requiring diuresis.
.
She has is s/p b/l thoracentesis and is now being considered for
pleurx catheter placement on Monday.
.
Currently, she is with mild SOB, pain controlled, no other
complaints
Past Medical History:
- Tuberculosis treated in [**2145**] with normal chest x-ray at [**Hospital1 2025**] in
[**2162**].
- GYN: G2 P2. Tubal ligation [**2156**]. Stopped menstruating at age
50, normal pap's per patient
- Hypertension.
- History of mild asthma, inhalers not used for several years.
- normal mammogram less than one year ago.
- normal colonoscopy 2/[**2178**].
- recent pericardial effusion/tamponade
- right pleural effusion
- large common femoral DVT
- adenocarcinoma of unclear primary
Social History:
She works as a nursing assistant. Lives with her husband, who
keeps very early hours, working at the [**Location (un) **] food market.
Children are 18 and 19.
Family History:
Her father died of stomach cancer at age 72. Mother died of
colon cancer at age 63. She is the 10th of 13 children. She has
lost 3 siblings to motor vehicle accidents.
Physical Exam:
Vitals: 98.3 119/82 118 94-95 2L 18
Gen: Comfortable,
HEENT: Sclera anicteric. PERRL, EOMI. No oral lesions
Neck: Supple
CV: Tachycardic, regular, no M/R/G.
Chest: Decrease B/S b/l R>L
ABD: Soft, NT, ND, +BS. No HSM or tenderness.
Ext: 1+ edema b/l
Neuro: non-focal, CN II-XII grossly intact, moves all
extremities well
Skin: no rash or petechiae noted
Pertinent Results:
[**2181-7-30**] 09:45PM NEUTS-55.6 BANDS-0 LYMPHS-37.4 MONOS-3.5
EOS-1.8 BASOS-1.7
[**2181-7-30**] 09:45PM WBC-2.0*# RBC-3.57* HGB-11.9* HCT-35.4*
MCV-99* MCH-33.3* MCHC-33.5 RDW-19.4*
[**2181-7-30**] 09:45PM CK(CPK)-59
[**2181-7-30**] 09:55PM LACTATE-1.2
[**2181-7-30**] 09:45PM GLUCOSE-104 UREA N-5* CREAT-0.6 SODIUM-134
POTASSIUM-4.7 CHLORIDE-100 TOTAL CO2-24 ANION GAP-15
Brief Hospital Course:
55 y/o woman with metastatic adenocarcinoma of unknown primary
with malignant pleural effusions and constrictive pericardial
effusions s/p thoracocentesis with reaccumulation of effusions,
admitted for pleurx catheter placement
.
1. Respiratory distress - Secondary to R-sided malignant
effusion. s/p therapeutic thoracentesis [**8-1**]. SOB was only
transiently relieved by thoracentesis. Pleurx catheter was felt
to be a better plan than pleurodesis as SIRS reaction could
complicate pleurodesis. Pt received her pelurx catheter
placement on [**8-6**] without complications. Pt tolerated the
procedure well and with symptomatic improvement of her dyspnea.
.
2. Constrictive pericardial effusions: [**Month/Year (2) **] [**7-31**] showed chronic
effusion but without tamponade physiology. Pt was seen by
cardiology with recommendations for potential procedure in the
future, but no immediate intervention was thought to be
warranted. Pt was hemodynamically stable throughout admission.
.
3. Mucinous adenocarcinoma of unknown primary: The patient began
chemotherapy on [**2181-6-15**] with Gemzar and CPT-11 for metastatic
disease of unknown primary. Pt was discharged with follow up
appointment with her primary oncologist for resumption of
chemotherapy.
.
4. UTI: Pt was found to have a UTI on admission. She was
discharged with a 10 day course of ciprofloxacin.
Medications on Admission:
1. Lidocaine 5 % DAILY
2. Fentanyl 25 mcg/hr Patch 72 hr
3. Ondansetron 4 mg every 6-8 hours as needed.
4. Docusate Sodium 100 PO BID
5. Enoxaparin 60 mg/0.6 mL Q12H
6. Lorazepam 0.5 mg PO DAILY PRN nausea
7. Megace Oral 40 mg/mL PO once a day.
8. Senna 8.6 mg PO BID as needed for constipation.
9. Metoprolol Tartrate 25 mg PO TID
10. Lomotil 2.5-0.025 mg Tablet PO every 4-6 hours as needed for
diarrhea.
11. Albuterol Sulfate every six (6) hours.
12. Ipratropium Bromide every six (6) hours
Discharge Medications:
1. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical QDAILY ().
2. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
3. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every 6-8 hours as needed for nausea.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) injection
Subcutaneous Q12H (every 12 hours).
6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for PRN Nausea.
7. Megestrol 40 mg/mL Suspension Sig: Ten (10) mL PO DAILY
(Daily).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
10. Lomotil 2.5-0.025 mg Tablet Sig: One (1) Tablet PO every [**3-16**]
hours as needed for diarrhea.
11. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 4 days.
Disp:*7 Tablet(s)* Refills:*0*
12. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
treatment Inhalation Q6H (every 6 hours) as needed.
13. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
nebulizer treatment Inhalation Q6H (every 6 hours) as needed.
Discharge Disposition:
Home With Service
Facility:
Physicians Home Care [**Hospital1 392**]
Discharge Diagnosis:
1.) Malignant pleural effusion
2.) Metastatic adenocarcinoma
3.) Urinary tract infection
4.) Pericardial effusion
Discharge Condition:
stable, maintaining O2 sats
Discharge Instructions:
You were admitted because of shortness of breath. You were
found to have a reaccumulation of fluid near your lung. You
underwent a procedure called thoracentesis, or drainage of the
pleural fluid. You also had catheters placed in your lungs to
help drain the fluid. Also while you were in the hospital you
were found to have a urinary tract infection and treated with
antibiotics.
.
Please continue to take all medications as instructed and keep
all health care appointments as scheduled.
.
If you have worsening shortness of breath, chest pain,
lightheadedness, dizziness, fevers, chills, abdominal pain or
vomiting, or if you feel worse in any way, seek immediate
medical attention.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4425**], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2181-8-8**]
10:00
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 13145**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2181-8-15**] 9:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4425**], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2181-8-15**]
9:30
Completed by:[**2181-8-15**]
ICD9 Codes: 5990, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3855
} | Medical Text: Admission Date: [**2148-10-13**] Discharge Date: [**2148-10-15**]
Date of Birth: [**2097-9-27**] Sex: M
Service: [**Doctor First Name 147**]
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Dislodged Dophoff feeding tube
Major Surgical or Invasive Procedure:
Placement of dophoff catheter under fluro
History of Present Illness:
Pt with episode of hiccups, which pt had c/o for many months,
resulting in the dislodging of his dophoff feeding tube
Past Medical History:
anemia
Hepatitis C
CHF
CRI
DVT
portal hypertension
Depression
Social History:
Lives at [**Hospital 106240**] Rehab Centersmoking 15pack year hitoryno
etohremote IVDformer [**Company 2318**] worker
Family History:
noncontributary
Physical Exam:
NAD
AAO times 3
RRR S1+S2
CTA Bilat
Soft NT/ND, incision healing well
Pertinent Results:
US ABD LIMIT, SINGLE ORGAN [**2148-10-14**] 2:33 PM
REPORT: There is a dumb-bell shaped collection in the
gallbladder fossa which contains complex internal echoes. Each
of the limbs of the collection measure approximately 4 cm in
diameter each. The lesion passes close to the stomach
posteriorly but is extragastric.
The liver parenchyma appears normal throughout. No focal hepatic
mass is identified otherwise. No subcapsular lesion is seen.
Status post cholecystectomy. The common bile duct measures 7 mm
in maximum dimensions. The right kidney appears normal in size
shape and echotexture.
Doppler ultrasound. Doppler ultrasound was performed of the
anastomosed vessels. The hepatic veins appear normal. There
appears to be a clip intimately related to the middle hepatic
vein which appears narrowed at this point. Portal vein is patent
with centrifugal flow. The hepatic arteries have not been
examined.
Brief Hospital Course:
Pt admitted on [**10-13**] after dophoff tube was accidentally d/c'd
after a episode of hiccups. A NG tube was placed on admission.
Pt had an episode of nausea and emesis around the tube. A
dophoff was placed on [**10-14**] and the nausea and emesis resolved.
A RUQ US was performed which showed an evolving collection in
the gallbladder fossa but was otherwise unremarkable. Pt
improved and was D/C'd to return to rehab on [**10-15**]
Discharge Medications:
1. CellCept [**Pager number **] mg Capsule Sig: One (1) Capsule PO twice a day.
2. Megestrol Acetate 40 mg/mL Suspension Sig: One (1) PO QID (4
times a day).
3. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO QD (once a day).
4. Methylphenidate HCl 5 mg Tablet Sig: 1.5 Tablets PO QD (once
a day).
5. Hydralazine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours).
6. Levothyroxine Sodium 150 mcg Tablet Sig: One (1) Tablet PO QD
(once a day).
7. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. Ribavirin 200 mg Capsule Sig: Two (2) Capsule PO QD (once a
day).
9. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
10. Valganciclovir HCl 450 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO QD (once a day).
12. Interferon alfacon-1 30 mcg/mL Injectable Sig: One (1)
Subcutaneous TIW ().
13. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO twice a day.
14. Prednisone 2.5 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
15. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Dislodged Dophoff feeding tube
Discharge Condition:
stable
Discharge Instructions:
Please return for all follow-up appointments
Take all medications as directed, and resume all previous
medications
Return to the ER if any increased pain, nausea and vomitting,
fevers, diarrhea, chest pain, or shortness of breath
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Where: LM [**Hospital Unit Name 5628**]
Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2148-10-16**] 2:20
Completed by:[**2148-10-15**]
ICD9 Codes: 2851, 5849, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3856
} | Medical Text: Admission Date: [**2188-8-16**] Discharge Date: [**2188-8-18**]
Date of Birth: [**2112-8-8**] Sex: M
Service: UROLOGY
Allergies:
Ace Inhibitors
Attending:[**First Name8 (NamePattern2) 19908**]
Chief Complaint:
fever, abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a 76M w/ Hx of bladder ca s/p cystoprostatectomy,
bilateral lymph node dissection and urinary ileal conduit on
[**2188-8-5**] who presents from rehab (he was d/c'd from the [**Hospital1 **] on
[**2188-8-13**]) with c/o abdominal pain and fever. At the rehab center,
he reportedly had a temperature to 100.5, poor po intake
requiring PPN, and abdominal distension prompting NGT and rectal
tube placement. Per the patient's family, the NGT emptied
bilious fluid intially but the output appeared coffee-ground and
melanotic this morning. (Of note, the NGT had a single suction
port and no air port which may have caused some trauma). His
wife notes that the patient was having some small bowel
movements daily but no substantial output. Her greatest concern
was his ongoing abdominal discomfort which had been present at
the time of discharge and attributed to a slight ileus. He did
not have any vomiting or unusual diarrhea. He was on keflex at
discharge for slight wound erythema but that had improved - no
purulent drainage was reported. Of note, he does have an
extensive history of UTIs, urosepsis and pyelonephritis.
The patient could not be fully interviewed as he was wearing a
nonrebreather O2 mask and eventually became intubated.
Past Medical History:
-Bladder Carcinoma
-Diabetes Type II
-Hypertension
-Frequent UTI
-Pulmonary hypertension
-Diastolic congestive heart failure (EF>55% on [**2188-2-5**])
Social History:
Lives with his wife in [**Name (NI) 1411**], MA. Now retired. Occasional
alcohol use,
with distant history of tobacco use.
Family History:
Noncontributory.
Physical Exam:
100.5 on arrival, 102 during assessment 120-160s afib
110/73 on arrival but dropped to systolics in the 90s, 89 on RA,
98 on 100% NRB
Moderate distress, anxious, dyspneic
Irreg, irreg
Clear with limitied inspiratory effort and rapid rate
Distended abdomen, tympanitic, diffusely tender, no peritoneal
signs
High pitched bowel sounds
Stoma pink and functioning, urine concentrated
Exam limited by elective intubation
Pertinent Results:
139 99 48 167 AGap=16
4.0 28 1.9
CK: 54 MB: Notdone Trop-T: 0.09
Ca: 8.7 Mg: 2.5 P: 3.4
ALT: 20 AP: 80 Tbili: 0.6 Alb: 3.0
AST: 16 LDH: Dbili: TProt:
[**Doctor First Name **]: 29 Lip: 31
25.5 D 10.3/31.2 704 D
N:88.8 L:7.6 M:2.4 E:0.7 Bas:0.5
PT: 15.0 PTT: 23.8 INR: 1.3
UA: Color Yellow Appear Clear SpecGr 1.019 pH 6.0 Urobil Neg
Bili Neg Leuk Mod Bld Lg Nitr Neg Prot 30 Glu Neg Ket Neg
RBC [**5-4**] WBC 21-50 Bact Mod Yeast None Epi 0-2
Urine and blood cultures pending
Past urine and blood cultures have grown MRSA, VRE, multidrug
resistent klebsiella
IMAGING:
CT C/A/P (prelim report): 11cm fluid collection in the lower
pelvis. Bil. ureteral stents and cysts. Lung nodules due to
metastasis. note that lung nodules are new and dedicated chest
imaging is recommended after stabilization of the acute issue.
CT head (prelim): Generalized brain atrophy, without acute
intracranial hemorrhage or mass effect.
Brief Hospital Course:
The patient was admitted to the SICU for possible urosepsis. He
required intubation and admission due to respiratory distress.
He did improve clinically in the ICU and was able to extubate
successfully. He was doing ok on [**8-18**] other than some
tachycardia. However, in the afternoon around noon his
tachycardia began to worsen to the 160s-180s. He became
agitated and dyspneic complaining of belly pain but no chest
pain. His blood pressure began to drop at this point with a
systolic of 70. Eventually the patient required intubation.
During intubation the patients pulse was lost and his BP dropped
to less than 50. CPR was initiated and a code was called. In
the ensuing hours the patient regained vital signs on and off
requiring CPR, multiple pressors to maintain his blood pressure,
and even a few shocks from the defibrillator. He never regained
consciousness throughout the code. An echo was done during this
time which showed hardly any ventricular filling on either side
of the heart. His Hct also appeared to be dropping. It was
unclear if the patient was hypovolemic from some type of
possible intraabdominal bleeding as his belly became more and
more distended. There was also the possibility that he had an
MI or PE. Unfortunately, the clinical picture was not clear and
it was poorly understood what manifested this event. Eventually
the patients family arrived and they requested to stop any
additional heroic efforts. At that point he had a blood
pressure and pulse and was not requiring CPR. However, his MAP
continued to fall over the next hour or so. At 1759 the patient
was pronounced dead. The family did not want an autopsy and the
medical examiner did not require one either. The attending and
chief residents were aware of the situation the entire time. I,
the intern, was present for most of the code and assisted as
much as possible and relayed information to the attending and
chief as much as possible.
Discharge Disposition:
Expired
Discharge Diagnosis:
deceased
Discharge Condition:
deceased
ICD9 Codes: 0389, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3857
} | Medical Text: Admission Date: [**2120-6-14**] Discharge Date: [**2120-6-24**]
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
s/p fall with resulting rib fractures
Major Surgical or Invasive Procedure:
none
History of Present Illness:
[**Age over 90 **] year old female s/p mechanical fall two days earlier at her
nursing home. She was sent in by her nursing home for worsening
pain. On evaluation in the ED she was found to have multiple
right-sided rib fractures and small perisplenic fluid. She was
admitted for pain control and observation.
Past Medical History:
anemia, frequent falls, bipolar, renal failure, hypothyroid,
COPD, fibromyalgia, hyperlipidemia, GERD, PVD, GIB, macular
degeneration, CVA, thoracic aortic aneurysm
Social History:
Lives in [**Hospital3 **], ambulates with walker. She smoked for
15 years remotely, but denies past/current etoh, illicit drug
use.
Family History:
Per OMR: Father with history of CAD, sister with [**Name2 (NI) 499**] cancer in
her 70s.
Physical Exam:
(On morning of death)
97.1/96.5 66 118/58 22 94% on 15L
NAD
RRR
coarse bs bilaterally, dimished breath sounds at bases
distended abdomen, nontender
no peripheral edema
Pertinent Results:
[**2120-6-14**] 08:00AM BLOOD WBC-9.5# RBC-3.03* Hgb-10.5* Hct-30.1*
MCV-99* MCH-34.8* MCHC-35.0 RDW-15.7* Plt Ct-151
[**2120-6-15**] 04:29AM BLOOD WBC-21.1*# RBC-3.00* Hgb-10.4* Hct-30.0*
MCV-100* MCH-34.7* MCHC-34.7 RDW-15.6* Plt Ct-156
[**2120-6-15**] 09:09AM BLOOD WBC-19.4* RBC-3.26* Hgb-11.2* Hct-33.4*
MCV-102* MCH-34.3* MCHC-33.4 RDW-15.6* Plt Ct-172
[**2120-6-15**] 08:06PM BLOOD WBC-24.6* RBC-2.98* Hgb-10.0* Hct-29.5*
MCV-99* MCH-33.6* MCHC-33.9 RDW-15.3 Plt Ct-160
[**2120-6-16**] 01:53AM BLOOD WBC-18.3* RBC-2.53* Hgb-8.7* Hct-24.9*
MCV-98 MCH-34.2* MCHC-34.8 RDW-15.3 Plt Ct-137*
[**2120-6-16**] 09:17AM BLOOD WBC-16.3* RBC-2.54* Hgb-8.8* Hct-24.9*
MCV-98 MCH-34.8* MCHC-35.5* RDW-15.2 Plt Ct-125*
[**2120-6-17**] 01:49AM BLOOD WBC-11.8* RBC-2.46* Hgb-8.6* Hct-24.1*
MCV-98 MCH-35.0* MCHC-35.7* RDW-15.2 Plt Ct-154
[**2120-6-18**] 01:46AM BLOOD WBC-10.4 RBC-2.35* Hgb-8.3* Hct-23.0*
MCV-98 MCH-35.4* MCHC-36.2* RDW-15.3 Plt Ct-137*
[**2120-6-14**] 08:00AM BLOOD PT-14.0* PTT-28.7 INR(PT)-1.2*
[**2120-6-14**] 08:00AM BLOOD Glucose-101* UreaN-24* Creat-1.2* Na-139
K-4.5 Cl-101 HCO3-27 AnGap-16
[**2120-6-15**] 08:06PM BLOOD Glucose-161* UreaN-30* Creat-1.3* Na-139
K-4.5 Cl-109* HCO3-17* AnGap-18
[**2120-6-18**] 01:46AM BLOOD Glucose-170* UreaN-43* Creat-1.4* Na-139
K-3.4 Cl-106 HCO3-22 AnGap-14
[**2120-6-19**] 01:44AM BLOOD Glucose-140* UreaN-54* Creat-1.5* Na-145
K-3.3 Cl-106 HCO3-24 AnGap-18
[**2120-6-22**] 01:47PM BLOOD Glucose-79 UreaN-65* Creat-1.4* Na-153*
K-4.5 Cl-114* HCO3-27 AnGap-17
[**2120-6-24**] 02:01AM BLOOD Glucose-173* UreaN-82* Creat-1.6* Na-147*
K-4.1 Cl-110* HCO3-27 AnGap-14
Brief Hospital Course:
- [**6-15**]: She was initially admitted to the floor and then
transferred to ICU for respiratory distress on the floor. NGT
placed for abdominal distension. A-line placed. In the AM pt's
respiratory status worsened (RR 30s, O2 sats 80s, cyanotic,
white out R lung), and she was intubated. BAL performed.
[**Name (NI) 96158**] pt was hypotensive, and was unable to be weaned
off of neo. She seemed to be in septic shock - placed on broad
spectrum antibiotics, a CVL was placed, and volume resuscitated
continued. Her trops were elevated, thought to be due to cardiac
stress.
- [**6-16**]: CT chest with significant consolidation, collapse,
moderate effusions; bedside echo by intensivist showed global
hypokinesis with severe dilated cardiomyopathy, ef~10-15%;
bronch showed frothy secretions, CXR improved after bronch
- [**6-17**]: Lopressor started for intermittent tachycardia (SVT vs.
afib). Lasix drip continued. TF started. Aspirin and statin
started per cards. Cipro dc'ed, vanco/cefepime continued.
- [**6-18**]: Continued Lasix GTT and TFs during the day. Patient
self-extubated at [**2054**]. Maintained O2sats on 50% venti mask for
1.5 hours but ultimately developed increasing WOB (grunting) and
mild cyanosis so was re-intubated. Significant glottic edema was
noted at time of re-intubation (likely [**3-6**] self-extubation w.
inflated cuff). Required levophed for a few hours after
intubation, but now weaned off. Lasix drip is being held due ot
hypotension. Attempted replacement of arterial line
unsuccessfully.
- [**6-19**]: Right sided thoracic pig tail placed: drained about
800cc serosanguinous fluid
- [**6-20**]: pigtail pulled. Attempt to wean unsuccessful
- [**6-21**]: Lasix gtt restarted at low dose with albumin. Free water
flushes increased via NGT for hypernatremia. Propofol restarted
for agitation. Tolerated CPAP 5/5 throughout day and did well
with SBT in afternoon - extubated. Required BiPAP, also
carvedilol and digoxin for afterload reduction.
- [**6-22**]: Increased free water flushes. Stable respiratory status
w. shovel mask. Dc'ed lasix GTT for rising BUN/Cr. Gave albumin
25g x1.
- [**6-23**]: Increased free water to 300mL q4hr for hypernatermia;
family meeting held with Dr. [**Last Name (STitle) 15426**], Dr. [**First Name (STitle) 2816**] and Dr. [**First Name (STitle) **].
Family updated to prognosis and goals of care addressed. She
was made DNI.
- [**6-24**]: In the morning she was desaturating despite 100%
facemask with low MV on BIPAP. Family contact[**Name (NI) **] and made patient
[**Name (NI) 3225**]. Patient put on versed for comfort as well as a scopalamine
patch and expired later that morning.
Medications on Admission:
amitryptiline 50, lipitor 40, estradiol creme, omeprazole 20,
pentoxifylline 400", trazodone 50, ASA 81, colace
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
Death
Discharge Condition:
Death
Discharge Instructions:
Death
Followup Instructions:
Death
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
ICD9 Codes: 0389, 2760, 5119, 4254, 5990, 496, 4280, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3858
} | Medical Text: Admission Date: [**2164-7-28**] Discharge Date: [**2164-8-1**]
Date of Birth: [**2134-9-2**] Sex: M
Service: Medicine, [**Hospital1 **] Firm
HISTORY OF PRESENT ILLNESS: This patient is a 29-year-old
male who was transferred from an outside hospital for
pneumonia and respiratory failure. The symptoms began on
[**7-18**] when he had fever, chills, sweats, and a
nonproductive cough. His fevers ranged around 102 degrees
Fahrenheit but reached 104 degrees Fahrenheit at times. He
also had a mild headache. His girlfriend took the patient to
the Emergency Department at [**Location (un) 8641**] on Saturday, [**7-21**].
At that time he was diagnosed with a flu-like viral illness
and given symptomatic treatment as well as amantadine. He
had no nausea, vomiting, diarrhea, constipation, abdominal
pain, dysuria, joint or muscles aches at that time.
His symptoms did not improve, and on [**7-23**] he presented
to his primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 24913**], with
central cyanosis and an abnormal chest examination. He was
admitted to [**Hospital3 26615**] Hospital in [**Location (un) 5028**] where a chest
x-ray showed moderate-sized left lingular infiltrate, and the
patient's oxygen saturation was 90% on 100 nonrebreather
mask. Sputum culture at that time showed likely oral flora
as well as abundant gram-negative rods. The patient was
given Levaquin but had phyletic reaction, so his antibiotics
were changed to azithromycin and ceftriaxone. However, the
patient was still febrile after 48 hours.
He underwent bronchoscopy and bronchoalveolar lavage on
hospital day three at the outside hospital. Bronchoalveolar
lavage Gram stain showed a nonspecific inflammatory exudate,
and culture showed oral flora with a small number of mucous
gram-negative rods. Fungal cultures were negative to date.
Silver stain for Pneumocystis carinii pneumonia was negative,
and his urine antigen for Legionella was also negative. The
patient's respiratory status continued to worsen and he was
intubated. At that time, azithromycin and ceftriaxone were
discontinued and Zosyn, Bactrim, and gentamicin were started.
The patient was then transferred to the [**Hospital1 190**] Medical Intensive Care Unit on [**7-28**] for
further evaluation.
PAST MEDICAL HISTORY: Unrevealing except for a question of
mild childhood pneumonia. No history of asthma. No history
of frequent upper respiratory infections.
ALLERGIES: Question of phlebitic reaction to LEVAQUIN.
MEDICATIONS ON TRANSFER: Azithromycin intravenously, Zosyn
intravenously, Bactrim intravenously, vancomycin
intravenously.
FAMILY HISTORY: No history of cardiac disease, diabetes or
cancer. Two grandparents who had emphysema. Mother, father,
and siblings are in good health. No history of recurrent
infections or blood disorders.
SOCIAL HISTORY: The patient was previously a business
analyst for a software company. He lives with his
girlfriend. [**Name (NI) **] human immunodeficiency virus risk factors.
He was tested one year ago with his girlfriend. [**Name (NI) 6419**] were
human immunodeficiency virus negative at that time. No
history of intravenous drug use. He never smoked. Five to
seven alcoholic drink per week.
PHYSICAL EXAMINATION ON ADMISSION: Admission physical
examination showed vital signs of temperature 97.6, heart
rate of 91, blood pressure 125/67. The patient was
ventilated with a respiratory rate of 12. In general, the
patient was a well-appearing tanned, young, Caucasian male
ventilated, alert, in no acute distress. HEENT revealed
moist mucosa. Pupils were 4 mm and equal, round, and
reactive to light. Chest examination showed bilateral
crackles in the lower one-third of the lung field. Late
inspiratory squeaks bilaterally. No wheezes. Cardiac
examination showed normal S1 and S2, a regular rate. No
murmurs. Abdomen revealed bowel sounds were present. The
abdomen was soft and nontender. No evidence of
hepatosplenomegaly. Extremities revealed bounding posterior
tibialis pulses bilaterally. No edema. Neurologically,
alert and oriented, answered questions with hand signals.
Full range of motion. Strength was [**4-7**] throughout.
LABORATORY DATA ON ADMISSION: Admission laboratories
revealed a white blood cell count of 10.8, hemoglobin 13,
hematocrit 37.5, platelets 497. PTT 26.4, INR 1.1.
Sodium 136, potassium 5.2, chloride 102, bicarbonate 23,
BUN 13, creatinine 0.7, glucose 112. Urinalysis showed
specific gravity of 1.015, a small amount of blood, 6 to 10
red blood cells, 0 to 2 white blood cells.
RADIOLOGY/IMAGING: Chest x-ray showed bilateral lower lobe
opacities still evident.
HOSPITAL COURSE: The patient's condition continued to
improve.
1. PULMONARY: The patient's respiratory status steadily
improved. He was weaned from the ventilator and extubated
successfully on [**7-29**] around noon. His respiratory
status continued to be stable on nasal cannula, and he was
transferred to the floor.
On the floor he was tachypneic but comfortable on 3 liters
nasal cannula. His oxygen was weaned over 24 hours, and he
was able remain comfortable on room air, satting 94% to 96%.
He did become tachypneic and tachycardic with ambulation, but
maintained his oxygen saturation.
2. INFECTIOUS DISEASE: The patient's antibiotics were
changed to intravenous ceftriaxone 2 g intravenously q.d. and
azithromycin 500 mg intravenous q.d. The patient was
afebrile on admission and continued to be afebrile throughout
his stay. His antibiotics were changed to p.o. beginning on
[**8-1**] in the morning. He was switched to
azithromycin 250 mg p.o. q.d. and cefpodoxime 300 mg p.o.
b.i.d. The patient will be discharged with a 10-day course
of these two medications for a total of a 14-day course.
3. HEMATOLOGY/ONCOLOGY: The patient presented to an outside
hospital with a white blood cell count of 6 with 40% bands.
His bandemia had resolved by the time he was admitted to the
[**Hospital1 69**]. However, differential
on [**2164-7-31**], showed numerous immature white blood cell
forms and 1% blasts. Hematology/Oncology was consulted. A
peripheral smear was reviewed with Hematology attending, and
no blast was evident. His smear was noted to be consistent
with a reactive leukocytosis and thrombocytosis in the wake
of a life-threatening infection. A Monospot test was
performed which was positive, Cytomegalovirus and
[**Doctor Last Name 3271**]-[**Doctor Last Name **] virus serologies were pending and should be
followed up as an outpatient. Additionally, the patient
should follow up in one and a half to two weeks after
discharge with his primary care physician for [**Name Initial (PRE) **] repeat
complete blood count and peripheral blood smear. At that
time, if his counts have not normalized please have him
follow up with the Hematology/[**Hospital **] Clinic at the [**Hospital1 1444**].
4. PROPHYLAXIS: For prophylaxis, for gastrointestinal
symptoms, the patient will be discharged on Zantac 150 mg
p.o. b.i.d. for 10 days.
CONDITION AT DISCHARGE: His condition on discharge was
stable. He was afebrile, satting 92% to 94% on room air.
DISCHARGE STATUS: He was to be discharged to home.
DISCHARGE DIAGNOSES:
1. Pneumonia.
2. Respiratory failure.
MEDICATIONS ON DISCHARGE:
1. Azithromycin 250 mg p.o. q.d. for 10 days.
2. Cefpodoxime 300 mg p.o. b.i.d. for 10 days.
3. Zantac 150 mg p.o. b.i.d. for 10 days.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **], M.D. [**MD Number(1) 35524**]
Dictated By:[**Name8 (MD) 35525**]
MEDQUIST36
D: [**2164-8-1**] 14:10
T: [**2164-8-5**] 08:09
JOB#: [**Job Number 35526**]
cc:[**Numeric Identifier 35527**]
ICD9 Codes: 486 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3859
} | Medical Text: Admission Date: [**2142-10-5**] Discharge Date: [**2142-10-18**]
Date of Birth: [**2076-1-1**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2142-10-12**] CABG x 4 (LIMA->LAD, SVG->Diag, SVG->OM, SVG->PLB)
History of Present Illness:
Mr. [**Known lastname 55623**] is a 66 year old male who had not seen a physician
in over 10 years. He presented to the emergency department with
progressive dyspnea on exertion. He ruled in for a non ST
elevation myocardial infarction with a troponin level of 1.6. He
was subsequently admitted for further evaluation and treatment.
Past Medical History:
Denies significant PMH
Social History:
Lives in lost cost Housing in [**Location (un) 86**]. Retired government worker.
Former 1ppd smoker for 20-30 years. No alcohol in the last two
months as well, though used to drink daily.
Family History:
Denies premature coronary artery disease.
Physical Exam:
Vitals: 97.8, 171/92, 70, 24, 96% on 6L
Middle aged male in no acute distress. Pleasant, mood
appropriate.
Oropharynx benign
Neck supple with FROM. No JVD. Carotids 2+ without bruits
Bibasilar rales noted
Regular rate and rhythm. normal s1s2 without murmur or rub
Abdomen benign
Extrem warm, trace edema, no varicosities
Distal pulses 2+ bilaterally. Bilateral femoral bruits noted.
Pertinent Results:
[**2142-10-5**] 03:45PM BLOOD WBC-9.6 RBC-5.18 Hgb-16.0 Hct-47.3 MCV-91
MCH-30.9 MCHC-33.9 RDW-13.8 Plt Ct-287
[**2142-10-5**] 03:45PM BLOOD PT-11.9 PTT-25.0 INR(PT)-1.0
[**2142-10-5**] 03:45PM BLOOD Glucose-123* UreaN-20 Creat-1.1 Na-140
K-4.1 Cl-101 HCO3-29 AnGap-14
[**2142-10-5**] 09:40PM BLOOD CK-MB-8 cTropnT-1.62*
[**2142-10-6**] 06:50AM BLOOD CK-MB-7 cTropnT-1.45*
[**2142-10-7**] 06:30AM BLOOD CK-MB-8 cTropnT-1.14*
[**2142-10-8**] 06:35AM BLOOD CK-MB-6 cTropnT-1.02*
[**2142-10-6**] 06:50AM BLOOD Triglyc-75 HDL-33 CHOL/HD-3.8 LDLcalc-78
[**2142-10-6**] 06:50AM BLOOD TSH-2.1
[**2142-10-6**] ECHO: The left atrium is mildly dilated. The right
atrium is moderately dilated. Left ventricular wall thicknesses
are normal. The left ventricular cavity is mildly dilated. There
is mild global left ventricular hypokinesis (LVEF = 45-50 %).
Tissue Doppler imaging suggests an increased left ventricular
filling pressure (PCWP>18mmHg). Right ventricular chamber size
and free wall motion are normal. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild to moderate
([**2-13**]+) mitral regurgitation is seen. There is mild pulmonary
artery systolic hypertension. The pulmonic valve leaflets are
thickened. There is no pericardial effusion.
[**2142-10-8**] Abdominal Ultrasound: The liver shows no focal or
textural abnormalities. There is no biliary dilatation and the
common duct measures .5 cm. The portal vein is patent with
hepatopetal flow. The gallbladder is normal without evidence of
stones. The pancreas and spleen are unremarkable and the spleen
measures 10.7 cm. The aorta is ectatic with eccentric mural
thrombus but no AAA is identified. The widest measurement of the
infrarenal aorta is 2.8 x 2.5 cm. There is no evidence of
ascites. Noted on this exam is a large right pleural effusion.
[**2142-10-8**] Cardiac Cath: 1. Coronary angiography in this left
dominant system demonstrated 2 vessel disease. The LMCA had
mild disease. The LAD had a 40% proximal occlusion and was
occluded after D1. The LCx had a 90% proximal occlusion with an
occluded OM. The RCA was occluded proximally with collaterals
to the LAD from a conus branch. 2. Resting hemodynamics
revealed slightly elevated filling pressures with RVEDP of 10
mmHg and LVEDP of 23 mmHg. There was mild pulmonary arterial
systolic hypertension with PASP of 33 mmHg. The cardiac index
was preserved at 2.7 L/min/m2. There was mild systemic arterial
systolic hypertension with an SBP 144 mmHg and a DBP of 68 mmHg.
3. Lower extremity angiography revealed patent iliac arteries,
a patent right renal artery and severe left renal artery
stenosis.
[**2142-10-9**] Renal Ultrasound: The right and left kidneys measure
9.3 and 10.5 cm respectively. There is no hydronephrosis,
cortical thinning, shadowing stones, or masses. The bladder
appears normal. Both ureteral jets were demonstrated.
[**2142-10-9**] CArotid Ultrasound: There is less than 40% stenosis
within bilateral internal carotid arteries.
Brief Hospital Course:
He was admitted to cardiology with new onset heart failure after
ruling in for a non ST elevation myocardial infarction. He was
initially maintained on intravenous Nitro and started on beta
blockade and diuretics. He was also started on antibiotics for a
suspected community acquired pneumonia. An echocardiogram was
notable for mild global left ventricular systolic dysfunction
(EF 45-50%) with elevated left ventricular filling pressures. It
also revealed mild to moderate mitral regurgitation, mild
pulmonary hypertension, and a mildly dilated ascending aorta -
see result section. Subsequent cardiac catheterization revealed
severe two vessel coronary artery disease, and severe left renal
artery stenosis. Based upon the above, cardiac surgery was
consulted and further preoperative evaluation was performed -
please see result section. He remained stable on intravenous
therapy and was eventually cleared for surgery. On [**10-12**],
Dr. [**Last Name (STitle) **] performed coronary artery bypass grafting surgery.
Within 24 hours, he awoke neurologically intact and was
extubated without incident. He maintained stable hemodynamics
and transferred to the SDU on postoperative day one. He remained
in a normal sinus rhythm. Over several days, beta blockade was
advanced as tolerated and he continued to make clinical
improvements with diuresis. An ACE inhibitor was eventually
started for hypertension. Once medical therapy was optimized, he
was eventually cleared for discharge to home on postoperative
day six.
Medications on Admission:
None on admission. Occasional Motrin prn headache
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Lisinopril 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0*
10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Coronary Artery Disease - s/p CABG
LV Dysfunction with Congestive Heart Failure
Non STEMI
Severe Left Renal Artery Stenosis
Community Acquired Pneumonia
Hypertension
Discharge Condition:
Good
Discharge Instructions:
keep wounds clean and dry. OK to shower, no bathing or swimming.
Take all medications as prescribed.
Call for any fever, redness or drainage from wounds
Followup Instructions:
[**Hospital 409**] clinic in 2 weeks
Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Hospital1 778**] Healthcenter) [**10-25**] at 10 am - [**Last Name (un) **],Phone: [**Telephone/Fax (1) 2393**]
Dr. [**First Name (STitle) **] 2 weeks [**Telephone/Fax (1) 4022**]
Dr [**Last Name (STitle) **] [**11-26**] at 1130 - [**Doctor First Name **] [**Hospital Unit Name **]
[**Telephone/Fax (1) 170**]
Completed by:[**2142-12-4**]
ICD9 Codes: 4280, 4240, 4254, 496, 486, 3051, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3860
} | Medical Text: Admission Date: [**2110-12-18**] Discharge Date: [**2110-12-21**]
Date of Birth: [**2045-3-5**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor First Name 1402**]
Chief Complaint:
Ventricular tachycardia
Major Surgical or Invasive Procedure:
elective VT ablation
History of Present Illness:
a 65M with a history of inferior posterior MI s/p three vessel
CABG in [**2094**] with a large residual scar and recurrent VT who
underwent a VT ablation today. He had an initial event of VT
within a year of his MI and had an ICD placed at that time. He
did well until this past summer when his ICD fired twice, once
for Afib and once for VT. Today he underwent an extensive
ablation of his scar. At the end of the procedure he developed a
slow VT which was broken with lidocaine 150 mg IV x1. He was
started on mexilitine and transfered to the CCU for further
management. EKG NSR 82bpm RSR' c/w right intravenricular
conduction delay TWI V4-V6 when compared with [**2110-10-31**] EKG, no
significant changes are noted.
Past Medical History:
1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY:
-CABG: CAD, inferior lateral posterior MI treated with
thrombolytics in [**2094-3-9**] complicated by ventricular
tachycardia, subsequent three-vessel CABG in [**2094-3-9**] at
[**Hospital1 18**]. Anatomy unclear.
-PERCUTANEOUS CORONARY INTERVENTIONS: None
-PACING/ICD: AICD implantation for ventricular tachycardia in
[**2094-6-9**] at [**Hospital1 18**], generator placement in [**2098**] upgraded device
due to battery depletion in [**2106-6-10**] with [**Company 1543**] AICD and
new RV lead
placement.
3. OTHER PAST MEDICAL HISTORY:
- Paroxysmal atrial fibrillation with evidence of inappropriate
firing of defibrillator.
- Hypertension.
- Hypercholesterolemia.
- Cardiomyopathy, EF 30% seen on echocardiogram in [**2107-5-10**].
- Moderate mitral regurgitation.
- Mild obesity.
- Obstructive sleep apnea treated with CPAP.
Social History:
- Married. He has two children from his first marriage. He is
self employed as a computer analyst
- Tobacco: Denies
- ETOH: One glass of wine twice a week
Family History:
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
Physical Exam:
Admission:
GENERAL: Middle aged male intubated and sedated.
HEENT:non injected sclera. no lymphadenopathy.
NECK: JVP not appreciated due to body habitus
CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
CHEST: Well healed midline sternotomy and left pacer scars
LUNGS: CTAB in anterior fields, no rales, wheezes or rhonchi.
ABDOMEN: overweight, soft nondistended, liver border smooth,
normoactive bowelsounds.
EXTREMITIES: Right sheath in place, no drainage, no erythemia.
1+ pretibial edema to mid calf BL, no venous stasis changes.
SKIN: no rash
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
Pertinent Results:
EKG
[**2110-12-19**] Normal sinus rhythm. Leftward axis at minus 25
degrees. Q waves in leads III, aVF and in leads V1-V2.
Non-specific ST-T wave changes in
leads I, II, aVL and V5-V6. Compared to the previous tracing of
[**2110-12-15**] no
diagnostic interval change.
.
Admission labs
[**2110-12-18**] 04:50PM BLOOD Hct-43.8
[**2110-12-18**] 07:00PM BLOOD Hct-43.4
[**2110-12-19**] 04:45AM BLOOD WBC-8.6 RBC-4.54* Hgb-15.1 Hct-42.3
MCV-93 MCH-33.2* MCHC-35.7* RDW-13.5 Plt Ct-167
[**2110-12-19**] 04:45AM BLOOD PT-13.2 PTT-22.3 INR(PT)-1.1
[**2110-12-18**] 07:00PM BLOOD Glucose-83 UreaN-15 Creat-0.6 Na-140
K-3.3 Cl-107 HCO3-27 AnGap-9
[**2110-12-19**] 04:45AM BLOOD Glucose-115* UreaN-14 Creat-0.7 Na-140
K-4.4 Cl-108 HCO3-24 AnGap-12
[**2110-12-19**] 04:45AM BLOOD Calcium-8.2* Phos-3.8 Mg-2.1 Cholest-155
[**2110-12-19**] 04:45AM BLOOD Triglyc-307* HDL-40 CHOL/HD-3.9
LDLcalc-54
.
Discharge Labs
[**2110-12-21**] 06:10AM BLOOD WBC-7.2 RBC-4.54* Hgb-14.0 Hct-41.6
MCV-92 MCH-30.9 MCHC-33.8 RDW-13.6 Plt Ct-152
[**2110-12-20**] 05:40AM BLOOD PT-13.1 PTT-23.5 INR(PT)-1.1
[**2110-12-21**] 06:10AM BLOOD Glucose-95 UreaN-14 Creat-0.7 Na-144
K-4.2 Cl-107 HCO3-28 AnGap-13
[**2110-12-21**] 06:10AM BLOOD Calcium-8.9 Phos-3.3 Mg-1.9
Brief Hospital Course:
65M with CAD s/p MI and CABG, CHF, HTN, HLD, VT s/p ablation
with recurrent VT admitted to the CCU after repeat ablpation and
intubation for airway protection.
.
# RHYTHM: Patient admitted for a repeat ablation of focus of
ventricular tachycardia. On the day of admission, patient went
to the cath lab and a focus was identified and ablated.
Immediatetly after ablation, patient entered a slow VT and was
intubated for airway protection. VT converted to sinus rhythm
with a lidocaine bolus and he was extubated without complication
on HD2. He remained in sinus rhythm for the remainder of his
hospitalization. He was started on mexilitine 150mg TID and
sotalol was increased to 120mg [**Hospital1 **]. Metoprolol XL 50mg PO Daily
was continued. Given risk of thromboembolism post VT ablation,
he was started on coumadin with a lovenox bridge. He will follow
up with [**Hospital1 **] anticoagulation and his PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) 7325**]
for INR monitoring. He was started on lovenox with and he was
discharged with plan to follow up with Dr. [**Last Name (STitle) **] in EP
within 1 month.
.
# CORONARIES: CAD s/p MI and CABG x3 in [**2094**]. He was continued
on aspirin 325mg PO daily, simvastatin 80 daily, as well as
metoprolol as above.
.
# PUMP: CHF with EF 30%. Euvolemic on exam on admission to CCU.
He was continued on lisinopril 5mg PO Daily and metoprolol.
.
# Hypertension: Continued home metoprolol and lisinopril.
COMM: [**Name (NI) **] [**Name (NI) 1355**] (wife): [**Telephone/Fax (1) 7326**]
Medications on Admission:
- LISINOPRIL 5 mg PO daily
- METOPROLOL SUCCINATE 50 mg PO daily
- SIMVASTATIN 80 mg PO daily
- SOTALOL 80 mg PO BID
- ASPIRIN 325 mg PO daily
- ERGOCALCIFEROL (VITAMIN D2) 1,000 unit PO daily
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*90 Tablet(s)* Refills:*3*
3. metoprolol succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*3*
4. simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
5. mexiletine 150 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours): 90 day Rx.
Disp:*270 Capsule(s)* Refills:*3*
6. sotalol 120 mg Tablet Sig: One (1) Tablet PO twice a day: 90
day Rx.
Disp:*180 Tablet(s)* Refills:*3*
7. Lovenox 100 mg/mL Syringe Sig: One (1) Subcutaneous twice a
day for 14 days: until INR > 2 for two consecutive days.
Disp:*28 syringes* Refills:*0*
8. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. Outpatient Lab Work
Please have INR checked on Monday [**12-22**]
10. Outpatient Lab Work
INR Checks per protocol. Goal INR [**2-12**]. Bridge with Lovenox 100
mg [**Hospital1 **]. Indication: Afib, VT ablation. Contact:
[**Name (NI) 7327**],[**First Name3 (LF) **] R. Phone: [**Telephone/Fax (1) 7328**] Fax: [**Telephone/Fax (1) 7329**]
11. mexiletine 150 mg Capsule Sig: One (1) Capsule PO three
times a day: 30 day Rx.
Disp:*90 Capsule(s)* Refills:*2*
12. sotalol 120 mg Tablet Sig: One (1) Tablet PO twice a day: 30
day Rx.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Recurrent ventricular tachycardia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You presented for VT ablation for management of recurrent
ventricular tachycardia and admitted to the CCU afterwards for
monitoring. You were continued on sotalol at a higher dose, and
you were started on mexilitine. Please have your INR checked on
Monday.
Medication changes:
Sotalol INCREASED to 120mg twice a day.
Mexilitine STARTED at 150mg three times a day.
START Lovenox until INR > 2 for two consecutive days
START Coumadin 5mg daily
Please call your PCP to arrange for monitoring of your INR
(warfarin/Coumadin "level"). His contact info is:
[**Name (NI) 7327**],[**First Name3 (LF) **] R.
[**Location (un) 7330**], [**Location (un) **],[**Numeric Identifier 7331**]
Phone: [**Telephone/Fax (1) 7328**]
Fax: [**Telephone/Fax (1) 7329**]
Please weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up
more than 3 lbs.
Followup Instructions:
Please schedule follow up with Dr. [**Last Name (STitle) **] within 1 month.
His office number is [**Telephone/Fax (1) 7332**].
.
Please schedule follow up with your PCP [**Name Initial (PRE) 176**] 1 month. His
office number is [**Telephone/Fax (1) 7328**].
ICD9 Codes: 4271, 4254, 2724, 4019, 412, 4240, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3861
} | Medical Text: Admission Date: [**2152-7-12**] Discharge Date: [**2152-7-22**]
Date of Birth: [**2076-1-25**] Sex: F
Service: CSU
SERVICE: Cardiac Surgery.
HISTORY OF PRESENT ILLNESS: This is a 76 year old woman with
a past medical history significant for diabetes mellitus,
asthma and hypertension who presented to an outside hospital
with six hours of chest pain that woke her up at night,
occurred at rest and continued. At the outside hospital, the
patient was found to be in rapid atrial fibrillation. She
was treated with 25 mg of intravenous Diltiazem. She
converted to normal sinus rhythm. Cardiac enzymes were
negative. She was transferred to [**Hospital1 190**] for further workup.
PAST MEDICAL HISTORY: Hypertension.
Diabetes mellitus.
Obesity.
Hypercholesterolemia.
Lyme Disease.
Pulmonary nodules.
ALLERGIES: She is allergic to ACE inhibitors which give her
a cough and she is allergic to codeine which causes shortness
of breath.
MEDICATIONS: Preoperative medications include:
1. Adalat 60 mg p.o. q day.
2. Diovan 80 mg p.o. twice a day.
3. Aspirin 81 mg p.o. q.o.d.
4. Flovent 110 micrograms, two puffs twice a day.
5. NPH insulin 14 units subcutaneously q a.m. and 20 units
subcutaneously q p.m.
HOSPITAL COURSE: The patient was taken for a cardiac
catheterization on [**7-14**] which showed three vessel coronary
artery disease. The patient was seen by Dr. [**Last Name (STitle) **] in
consultation and the decision was made to take the patient to
the Operating Room for a coronary artery bypass grafting.
The patient was taken to the Operating Room on [**7-17**] with
Dr. [**Last Name (STitle) **] for a coronary artery bypass graft times four,
left internal mammary artery to left anterior descending;
saphenous vein graft to the distal right coronary artery;
saphenous vein graft to obtuse marginal and saphenous vein
graft to ramus as well as a RF Maze procedure which included a
radiofrequency ablation of the pulmonary vein. Please see
Operative Note for full details.
The patient tolerated the procedure well and she was
transferred to the Intensive Care Unit in stable condition.
The patient was weaned and extubated from mechanical
ventilation on the evening of postoperative day zero,
required moderate amount of aggressive pulmonary toilet
initially. On postoperative day number one, the patient was
started on beta blockers and remained hemodynamically stable.
The patient was noted to have an elevated white blood cell
count of 20 postoperatively. This subsequently decreased to
11 the day prior to discharge. The patient was transferred
from the Intensive Care Unit to the regular part of the
hospital on postoperative day number two.
In the evening of postoperative day number two, the patient
was noted to be in rapid atrial fibrillation. The patient
received intravenous Lopressor and Amiodarone and
subsequently converted into sinus rhythm. The patient
remained in sinus rhythm for the remainder of her hospital
stay.
The patient began working with Physical Therapy. It was
decided that the patient would benefit from a stay at a short
term rehabilitation facility. The decision was made by Dr.
[**Last Name (STitle) **] not to place the patient on any anti-coagulation for
the atrial fibrillation as she had been in continued sinus
rhythm since her one postoperative event. The patient's
chest tubes were removed without incident. The patient was
tolerating her Lopressor and by postoperative day number
four, she was cleared for discharge to a rehabilitation
facility by postoperative day number five.
CONDITION ON DISCHARGE: Temperature max 98.7 F.; pulse 56 in
sinus rhythm; blood pressure 119/50; room air oxygen
saturation 95 percent. Neurologically, the patient is awake,
alert, and oriented times three with a nonfocal neurological
examination. Heart is regular rate and rhythm without rub or
murmur. Respiratory: Breath sounds are decreased at
bilateral bases. Gastrointestinal: Positive bowel sounds,
soft, nontender, nondistended, tolerating a regular diet.
The extremities are warm and well perfused with one to two
plus pitting edema of bilateral lower extremities. Right
lower extremity vein harvest site is clean, dry and intact.
Sternal incision with staples are intact. The incision is
clean and dry. The sternum is stable.
LABORATORY DATA: White blood cell count 11.0, hematocrit
29.1, platelet count 251. Sodium 142, potassium 4.5,
chloride 106, bicarbonate 28, BUN 17, creatinine 0.6 and
glucose 135.
DISCHARGE MEDICATIONS:
1. Lopressor 50 mg p.o. twice a day.
2. Lasix 20 mg p.o. twice a day times ten days.
3. Potassium chloride 20 mEq p.o. twice a day times ten days.
4. Colace 100 mg p.o. twice a day.
5. Zantac 150 mg p.o. twice a day.
6. Enteric coated aspirin 325 mg p.o. twice a day.
7. Plavix 75 mg p.o. q day.
8. Valsartan 80 mg p.o. twice a day.
9. Flovent MDI, 110 micrograms, two puffs p.o. twice a day.
10. Dilaudid 2 to 4 mg p.o. q four to six hours p.r.n.
11. Amiodarone 400 mg p.o. q day times one month.
12. NPH insulin 14 units subcutaneously q a.m. and 14
units subcutaneously q p.m.
13. Regular insulin sliding scale.
DISCHARGE INSTRUCTIONS:
1. The patient is to be discharged to rehabilitation in
stable condition.
2. The patient is to followup with her Cardiologist, Dr.
[**Last Name (STitle) **], in one to two weeks.
3. The patient is to followup with her primary care
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 665**], in one to two weeks.
4. The patient is to followup with Dr. [**Last Name (STitle) **] in three to
four weeks.
5. The patient's staples in her sternal incision should be
discontinued three weeks after the date of surgery, which
is on or about approximately [**8-7**].
DISCHARGE DIAGNOSES:
1. Coronary artery disease.
1. Paroxysmal atrial fibrillation.
1. Hypertension.
1. Diabetes mellitus.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1714**], [**MD Number(1) 1715**]
Dictated By:[**Last Name (NamePattern4) 8524**]
MEDQUIST36
D: [**2152-7-21**] 17:18:57
T: [**2152-7-21**] 18:35:21
Job#: [**Job Number 106138**]
ICD9 Codes: 4111, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3862
} | Medical Text: Admission Date: [**2123-12-28**] Discharge Date: [**2124-1-1**]
Date of Birth: [**2052-5-29**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Erythromycin Base / Percocet
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Fatigue, cough
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Patient is a 71 year old male with history of bilateral
spontaneous pneumothoraces, LUL blebectomy, found to have a LLL
PNA on admission. He presented with c/o six days of fatigue and
productive cough and a day of L sided pleuritic chest pain. On
the day PTA, he was seen by his PCP who prescribed him a
tetracycline. In the ED, the patient was saturating 100%RA and
CXR revealed a LLL infiltrate, so he was started on
Levofloxacin. His initial BP was 94/47 so he was given 2 L of
NS, causing his oxygen saturation to drop to the low 90s on NC.
His SBP transiently dropped to 67/32 and improved to the
90s-100s systolic after another L of NS. He was noted to have
diffuse rales, and was given CTX 1 gm IVx1 and started on CPAP.
.
In the MICU, he was quickly weaned to 2 L NC and his SBP came up
to the 100s. He received Lasix 10 mg IV x1. He was continued on
levofloxacin for treatment of PNA. His Creatinine improved from
1.7 back down to 1.3 after IV hydration. TTE performed on
[**2123-12-29**] showed a normal EF of 55% and no focal wall motion
abnormalities (although a poor quality study). Prior to
transfer, he was satting 95% 2LNC at rest, but would desat to
84% on 3LNC with ambulation. He remained afebrile in the MICU,
SBP 90s-110s, and HR 45-55.
.
At this time, the patient states he continues still have a mild
left lower chest pain with inspiration (improved from prior). He
also continues to have a productive cough with yellow sputum.
His appetite is improving again and his headaches have resolved.
.
Review of Systems:
He reports several pounds of weight loss over the past week. He
denies n/v, dysuria, diarrhea, constipation, headache.
Past Medical History:
#numerous spontaneous bilateral pneomothoraces; s/p LUL
blebectomy and right-sided decortication
#hypothyroidism
#hyperlipidemia
#s/p pharyngocele resection
#chronic renal insufficiency (baseline creatinine 1.3-1.5);
etiology unclear
Social History:
Former smoker since his teens until ~20 yrs ago; smoked 1 ppd
and [**3-6**] cigars/day. Drinks rare alcohol. Retired; formerly
worked as a retail manager. Lives with his wife and is
[**Name (NI) 6268**].
Family History:
Denies any family history of pneumothoraces or lung disease.
Denies any family history of diabetes or cancer.
Physical Exam:
T 96.1 BP 115/55 HR 58 RR 12 Sat 88% on ra, 95% on 2L nc
General: well-appearing elderly man, breathing comfortably and
speaking easily in full sentences
HEENT: OP clear; no scleral icterus
Neck: no carotid bruits; JVP 8cm; no cervical/clavicular
lymphadenopathy
Chest: coarse rales extending ~5-6cm from left lung base and
~1cm from right lung base; (+) egophany at left base
CV: regular rate and rhythm; normal s1s2; no murmurs, rubs, or
gallops
Abdomen: soft, nontender, nondistended, normal bowel sounds;
liver edge palpable ~1cm below costal margin; no splenomegaly
Extremities: warm, no cyanosis or edema, 2+ PT pulses
Back: no CVA tenderness
Skin: no rashes or jaundice
Neuro: alert, oriented x3, CN 2-12 intact, 5/5 strength in both
arms and legs
Pertinent Results:
Chest x-ray (portable) [**2123-12-28**]:
IMPRESSION: Worsening left parahilar and left lower lobe
pneumonic consolidation and new interstitial abnormality due to
interstitial pulmonary edema, most evident in the right lung.
.
Chest X-ray PA and Lateral [**2123-12-28**]:
IMPRESSION: Left lower lobe opacity concerning for pneumonia.
.
EKG [**2123-12-28**]:
Sinus bradycardia. Borderline P-R interval prolongation. J point
and
ST segment elevation diffuseness raises the possibility of
pericarditis.
However, ST segment elevations were present on tracing of [**2120-3-8**]
but
to a lesser degree. Left ventricular hypertrophy persists.
.
Transthoracic Echo [**2123-12-29**]:
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size, and systolic function are normal
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
The estimated pulmonary artery systolic pressure is normal.
There is a very small posterior pericardial effusion without
evidence of hemodynamic compromise.
IMPRESSION: Suboptimal image quality. Normal biventricular
cavity sizes with preserved global and regional biventricular
systolic function.
Compared with the report of the prior study (images unavailable
for review) of [**2120-1-23**], a very small posterior pericardial
effusion is now present.
.
[**2123-12-31**]:
EKG
Sinus bradycardia. The P-R interval is prolonged. Diffuse ST
segment
elevation. Non-specific anterior ST-T wave changes. Compared to
the prior
tracing anterior ST-T wave changes are new. ST segment elevation
persists.
Brief Hospital Course:
Patient is a 71 year old man with a history of spontaneous
pneumothoraces and subsequent LUL lobectomy, who presented with
cough and pleuritic chest pain, found to have a LLL PNA, with
asymptomatic hypotension.
.
# LLL PNA: Patient presented with community-acquired bacterial
pneumonia, however there could have been a component of
post-obstruction in nature. He received levofloxacin while in
MICU, after getting dose of ceftriaxone in ED. Urine was
negative for legionella. Viral antigen test was negative for
influenza.
- He was to complete a 10 day course of levofloxacin 500 mg po
daily.
- Viral and sputum cultures demonstrated no significant growth
aside from oropharyngeal flora. Blood and urine cultures were
negative.
- Patient received influenza vaccination and Pneumovax
vaccinations.
- Patient was weaned off of oxygen with ambulatory saturation of
92-97% on room air at time of discharge.
-
.
# Hypotension: Patient's hypotension was of unclear in etiology
and he remained asymptomatic without tachycardia,
lightheadedness, or other symptoms. Orthostatics were checked
and were positive. Hypotension appeared finally respond to
several intravenous fluid boluses given over the course of his
stay. His output remained good, no lightheadedness, mentation at
baseline, intact.
.
Appears as though the patient's blood pressure was checked daily
after he got out of bed to chair, and it was felt that the low
readings obtained had to do with a strong component of
orthostatic hypotension. Patient did not have DM, Parkinsons,
MS, or other clear reason for autonomic dysfunction and did not
appear to be septic. A cortisol stimulation test was within
normal limits.
.
An echo completed during his MICU stay did not reveal any
significant pericardial effusion, and his EKG was relatively
unchanged. His primary care physician related his usual systolic
blood pressure was in the 100s to 110s, and at time of
discharge, his SBP was >100.
.
# Hypoxia: Patient needed oxygen initially, however he was able
to be weaned off of it by time of discharge. He remained
asymptomatic and did not feel short of breath. In the ED, he had
acute desaturation that was felt to be related to volume
resusitation, which may have just been too rapid. His TTE showed
normal EF and no focal WMA or diastolic dysfunction, but it was
a poor study. It is suspected that his hypoxia is likely
secondary to his PNA with possible mild pulmonary edema, but his
JVP is normal without other evidence of volume overload on exam.
.
# Chronic renal insufficiency: His baseline creatinine is
1.3-1.5. On admission his Cr was 1.7, which improved with
intravenous fluids and returned to his baseline at time of
discharge.
.
# Anemia: His hematocirt remained stable, although down to the
high 20s (29), from his baseline is 33-35. He had no evidence of
bleeding, and it was felt that at least in part the anemia was
worsened by dilutional effect.
- Iron studies, retic count, B12, folate were checked, and
studies consistent with anemia of chronic disease (low iron, low
TIBC).
.
# Sinus bradycardia: This appears to be chronic, per reports
from prior ECGs on the OMR. Nodal agents were avoided.
.
# Hyperlipidemia: Patient's statin was continued.
.
# Hypothyroidism: Levothyroxine was continued.
.
# Depression: Sertraline at 100mg was continued.
.
# Patient was full code during his admission. He was evaluated
by physical therapy and felt to be safe for discharge. Follow up
was arranged with his primary care physician.
Medications on Admission:
levothyroxine 88 mcg daily
atorvastatin (dose uncertain; "low dose" per patient)
sertraline (dose uncertain)
clonazepam ("low dose") qhs prn
Discharge Medications:
1. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Resume your home dose.
3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
4. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Please resume your home dose.
5. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed: Please resume home dose as needed.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
- Left lower lobe pneumonia
Secondary Diagnoses:
- Prior spontaneous pneumothoraces
- Hypothyroidism
- Chronic renal insufficiency
- Hyperlipidemia
Discharge Condition:
Stable, evaluated by physical therapy and felt to be safe for
discharge.
Oxygen saturation 92% on room air and with ambulation. Systolic
blood pressure in 90s-100s.
Discharge Instructions:
You were admitted due a cough and fatigue. It was found that you
had a pneumonia. You were admitted to the intensive care unit
initially due to low blood pressure and low oxygen levels, both
of which returned to [**Location 213**] prior to discharge.
.
Please call Dr. [**Last Name (STitle) **] or return to the emergency room if you
experience any chest pain, shortness of breath, worsening
cough, fevers, chills, lightheadedness, dizziness, or other
concerning symptoms.
Followup Instructions:
Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 2048**]
[**Last Name (NamePattern1) **], at an appointment scheduled for you:
- Monday, [**1-10**] at 9:15 am.
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
ICD9 Codes: 486, 5859, 2449, 2859, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3863
} | Medical Text: Admission Date: [**2142-4-5**] Discharge Date: [**2142-4-10**]
Date of Birth: [**2084-9-17**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
Admission for elective drainage of pericardial effusion
Major Surgical or Invasive Procedure:
[**2142-4-5**] Pericardiocentesis
History of Present Illness:
57 year old male with past medical history of mild
hyperlipidemia, who presents for drainage of enlarging
pericardial effusion. Serial ECHO today showed moderate-large
pericardial effusion with elevated intracardial pressures,
persistent brief right atrial collapse.
Right heart catheterization today showed early tamponade
physiology and 430cc of bloody fluid was drained by left
posterior approach with a pericardial drain left in place.
.
Patient had been recently hospitalized [**Date range (1) **]/[**2142**] for concern
of STEMI vs. pericarditis. Briefly, he had developed acute
retrosternal chest pain while talking on the phone, improved
with leaning forward, worse when leaning back/upper body
movement/deep inspiration and had presented to [**Hospital **]
Hospital. He was transferred to [**Hospital1 18**] given concern for STEMI by
EKG, with mild leukocytosis (WBC 14.3) and negative troponin X1.
CTA was negative for pulmonary emboli and cardiac enzymes
remained flat during his [**Hospital1 18**] stay. Post-catheterization,
patient was kept on prasugrel PO, integrillin gtt and heparin
gtt given concern for proximal left circumflex lysed
thrombus/STEMI vs. pulmonary emboli. His course was complicated
by significant retroperitoneal bleed requiring urgent covered
stenting of right common femoral artery by left femoral
approach. ECHOs prior to discharge were notable for enlarging
pericardial effusion with initial right atrial and ventricular
dysfunction suggestive of early tamponade. As follow-up ECHOs
showed less right-sided dysfunction and patient never had pulsus
paradoxus, he was discharged with close follow-up with new
primary cardiologist.
.
Of note, the patient presented to the [**Hospital1 18**] ED yesterday evening
with abdominal pain which his wife described as severe,
preventing him from tolerating POs, with new back/bilateral
flank pain and low grade fevers. As CT abdomen/pelvis with
contrast showed no signs of hematoma superinfection or worsening
bleed, it was felt his pain was likely due to ongoing presence
of retroperitoneal blood and he was discharged with Percocet.
.
On review of systems, he endorses intermittent left shoulder and
left lateral chest incision site pain. He endorses abdominal
discomfort, especially with palpation but denies any more
abdominal or flank pain. He denies prior history of stroke, TIA,
deep venous thrombosis, pulmonary embolism, myalgias, joint
pains, cough, hemoptysis, black stools, or red stools. He denies
recent fevers, chills or rigors, runny nose, cough, sore throat.
All of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope. He has had some positional
retrosternal chest pain presumably due to pericarditis which has
responded at home to advil>tylenol.
Past Medical History:
1. CARDIAC RISK FACTORS: (-)Diabetes, (+)Dyslipidemia,
(+)Hypertension, previously on Diovan, off this past year after
blood pressures improved with weight loss
2. CARDIAC HISTORY:
- PERCUTANEOUS CORONARY INTERVENTIONS: [**2142-3-29**]
Right dominant. LMCA with no obstructive disease. LAD has bridge
in proximal LAD. LCx thrombus after first OM but no lesion. RCA
without obstructive disease.
3. OTHER PAST MEDICAL HISTORY:
- Duodenal ulcer, H.pylori positive treated 14 years ago
- ?OSA, had sleep study but not formally diagnosed, not on CPAP
Social History:
Pt with lives his wife. [**Name (NI) **] has two grown children 30 and 35yo,
and 4 grandchildren. He works full-time as a software engineer
for [**Company 378**]. His wife states that he tries to adhere to a South
Beach diet and to eat healthy.
-Tobacco history: denies
-ETOH: once per week, 2 shots of whiskey or glass of wine
-Illicit drugs: denies
Family History:
His grandmother had an MI at 64yo. Great-aunt with CVA.
Otherwise no early MI, DVT's, or PE's.
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Admission:
VS: T=101.3 BP=146/73 HR=104 --> 91 RR=19 O2 sat= 97% on RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva pink, no pallor
of the oral mucosa.
NECK: Supple with no JVD.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No murmurs/gallops/rubs
LUNGS: No chest wall deformities, scoliosis or kyphosis.
Respirations unlabored but patient endorses left incision site
pain with deep breaths. CTAB, no wheezes/rhonchi/rales
ABDOMEN: Soft, nontender, nondistended although uncomfortable
with palpation.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Left
lateral chest drain site c/d/i with sutures and drain in place.
Large right groin ecchymosis (3X6 inches) without fluctuance,
warmth, skin breakdown. Mildly tender to gentle palpation.
PULSES: Right: DP 2+ PT 2+, Left: DP 2+ PT 2+
Pertinent Results:
[**2142-4-6**] Pericardial Fluid:
NEGATIVE FOR MALIGNANT CELLS.
CT Abdomen [**2142-4-5**]:
1. Resolving right retroperitoneal hematoma without radiographic
evidence of superinfection, or active extravasation.
2. Moderate-sized pericardial effusion, stable.
ECHO: [**2142-4-5**]
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). There is a
moderate to large sized pericardial effusion (1.8 cm outside of
mid-RV free wall in diastole in the subcostal view). There is
brief right atrial diastolic collapse, without RV diastolic
collapse.
IMPRESSION: Moderate to large pericardial effusion with evidence
of elevated intrapericardial pressures but no frank tamponade
ECHO [**2142-4-6**]:
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
There is a small pericardial effusion, primarily lateral to the
left ventricle. The effusion is echo dense, consistent with
blood, inflammation or other cellular elements. There are no
echocardiographic signs of tamponade. There is significant,
accentuated respiratory variation in mitral/tricuspid valve
inflows, which togetgher with a septal "bounce" and absence of a
large pericardial effusion suggests pericardial constrictive
physiology.
IMPRESSION: Small residual pericardial effusion with evidence of
effusive-constrictive physiology.
[**2142-4-7**]:
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). There is
abnormal septal motion/position. There is a small pericardial
effusion. The effusion appears loculated.
IMPRESSION: Residual small pericardial effusion located at the
lateral and inferior left ventricular wall. The effusion appears
loculated. There is abnormal septal motion likely reflecting
effusive-constrictive physiology. This phenomenon can be seen
shortly after pericardiocentesis and usually resolves within a
few weeks.
Brief Hospital Course:
57 year old male with past medical history of hyperlipidemia and
likely recent pericarditis (?viral etiology) who presented for
large pericardial effusion drainage.
# PERICARDIAL EFFUSION: Patient had a recent admission and had
known pericardial effusion without tamponade physiology. On
repeat echo, the pericardial effusion was larger and he was
admitted for pericardial drain placement. Etiology of effusion
is unclear but is most likely viral. Autoimmune, neoplastic,
tuberculosis and Dressler's are much less likely given
presentation. Pericardial effusion was consistent with exudate,
likely from inflammatory process. Cytology did not show any
malignant cells. TSH was negative. Pleural fluid cultures were
negative. His pericardial drain output was monitored and it was
removed on [**2142-4-6**]. He was transferred from the CCU to the floor
on [**2142-4-7**]. He has several repeat echos which did showed
effusive-constrictive physiology and only small amount of
residual fluid. He initially had pleuritic chest pain which was
improved after drainage of fluid and initiation of NSAIDS. Pt
initially started on colchicine as well to help prevent
recurrance but in light of below GI symptoms which were possibly
due to the colchicine, this medication was stoppped and should
be readdressed as an outpatient.
#FEVERS: Patient had several fevers during this admission (Tm
101.7). His pericardial effusion and pericarditis were thought
be the most likely etiology of his fevers. Blood cultures, urine
cultures and percardial fluid cultures were also sent and
returned negative. CXR did not show signs of pneumonia. CT
abdomen did not show any sign of infection. He began to have
nausea and vomiting on [**2142-4-8**] as well as diarrhea. His fevers
may have been related to GI source. C. diff was sent and was
negative.
#NAUSEA/ VOMITING/ DIARRHEA: Patient began having nausea,
vomiting, diarrhea on [**2142-4-8**] which was likely secondary to his
colchicine and high dose aspirin use. He was treated with zofran
and simethicone with some improvement in his symptoms. He then
developed diarrhaa on [**2142-4-8**]. His famotidine was changed to
pantoprazole for improved GI prophylaxis. C. diff was sent and
was negative. His colchicine was stopped and he was discharged
home only on high dose aspirin.
# COMMON FEMORAL ARTERY INJURY WITH HEMMORHAGE: Patient had
recent post-operative course complicated by active right common
femoral artery bleed resulting in hypovolemic shock, stabilized
by coated stent placement. During this admission, the patient
was hemodynamically stable and his hematocrit was stable. He was
continued on aspirin, but at an increased dose for his
pericarditis.
# Hyperlipidemia: Lipid panel with LDL 64 during last
hospitalization. He was continued on atorvastatin 10mg daily and
omega 3 fatty acids daily.
#Code: Full (confirmed with patient)
Medications on Admission:
* Aspirin EC 325mg daily
* Omega 3 fatty acids twice daily
* Vitamin D 1000 units daily
* Atorvastatin 10mg daily
* Acetaminophen 325mg 1-2 tablets every 4 hours daily PRN pain
* Percocet 5-325mg q4-6 hours PRN pain (started [**2142-4-4**] for
abdominal pain)
* prevacid prn
Discharge Medications:
1. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO BID (2 times a day).
Disp:*120 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. omega-3 fatty acids Capsule Sig: One (1) Capsule PO BID
(2 times a day).
3. Vitamin D 1,000 unit Capsule Sig: One (1) Capsule PO once a
day.
4. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
6. Prevacid Oral
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Pericardial Effusion
Secondary:
Retroperitoneal Bleed
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 because you had a fluid
collection in the sac that surrounds your heart called a
pericardial effusion. The fluid was drained by a procedure
called pericardiocentesis and this decreased the pressure around
the heart.
You will need to have a repeat echocardiogram (ultrasound of the
heart) in one week to evaluate the fluid collection.
The following changes were made to your medications:
-INCREASED aspirin from 325 mg once a day to 650 mg twice a day
You will need to have your liver function tests rechecked when
you see Dr. [**Last Name (STitle) 171**].
Followup Instructions:
You will need to follow up with Dr. [**Last Name (STitle) 171**] next week. His
office will call you to reschedule your appointment. If you do
not hear from them, please call [**Telephone/Fax (1) 1989**].
ICD9 Codes: 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3864
} | Medical Text: Admission Date: [**2114-4-9**] Discharge Date: [**2114-8-17**]
Date of Birth: [**2114-4-9**] Sex: F
Service: NBB
HISTORY OF PRESENT ILLNESS: Baby Girl [**Known lastname 72701**] was born at 28
weeks gestation, weighing 485 grams. She was born to a 25
year-old, G1, P0 now 2 mother with [**Name2 (NI) **] type A positive,
antibody negative, HBSAG negative, RPR nonreactive.
Maternal history was remarkable for migraine headaches,
anxiety and irritable bowel syndrome. Mother was treated with
[**Name (NI) 34491**] for migraines during pregnancy.
Antepartum was remarkable for twin gestation. Intrauterine
growth restriction of this twin was noted 10 days prior to
delivery. Mother was treated with betamethasone on [**2112-3-31**].
There was absent diastolic flow of this twin, prompting
rehospitalization of the mother on [**2114-4-5**] and monitoring. Non
reassuring tracing of this twin prompted Cesarean section
delivery.
This infant emerged breech and had Apgars of 6 and 7. The
infant was intubated in the delivery room. Surfactant was
administered. UVC was placed. Infant was started on ampicillin
and gentamycin and transferred to [**Hospital3 1810**] [**Location (un) 86**] due
to no NICU beds at [**Hospital1 18**].
At [**Hospital3 1810**] [**Location (un) 86**],the infant received 2 doses of
surfactant and was placed on high frequency ventilation due to
pulmonary hemorrhage. She transitioned to conventional
ventilation on [**2114-4-16**] prior to return to [**Hospital1 18**] NICU.
CV: Echo on [**2114-4-11**] showed PDA. She was treated with 3 doses of
indomethacin. Repeat echo [**2114-4-14**] showed no PDA. Repeat echo
on [**2114-4-16**] showed no PDA.
Rx inotropic Dopamine: [**4-10**] to [**2114-4-16**] for hypotension.
Fluids, electrolytes and nutrition: PICC line placed [**2114-4-15**].
Trophic feedings initiated [**2114-4-17**].
Gastrointestinal: Phototherapy [**4-9**] to [**2114-4-20**], peak
bilirubin=3.5.
Infectious disease:
1. R/O sepsis (1st 48 hrs of life) [**Year (4 digits) **] cultures neg. Rx
ampicillin/gentamycin discontinued after 48 hrs.
2. R/O Sepsis. Rx Vancomycin and gentamycin ([**Date range (1) 72705**])
Hematology: Transfused packed red [**Date range (1) **] cells at [**Hospital3 18242**] for pulmonary hemorrhage on [**2114-4-12**]. She has received
numerous [**Year (4 digits) **] product transfusions since that time.
Neurology: head ultrasounds ([**2114-4-13**] & [**2114-4-16**]) wnl.
[**Hospital 18**] HOSPITAL COURSE ([**2114-4-20**] - [**2114-8-17**])
Respiratory: Severe CLD (chronic lung disease)
Conventional ventilation until day of life 23 ([**2114-5-2**]),
changed to HiFi ventilation due to worsening respiratory status
and increasing cmv parameters.
Initiated IV systemic steroids day 29 ([**2114-5-8**])
due to severe CLD and inability to wean HiFi ventilation and
oxygenation. She then weaned to CPAP [**2114-5-11**]; remained on CPAP
until [**2114-7-14**] (day of life 96) when she transitioned to high
flow nasal cannula. She has remained on nasal cannula since that
time.
Due to CLD with increased work of breathing, a pulmonary
consult on [**2114-7-4**] by Dr. [**First Name4 (NamePattern1) 4468**] [**Last Name (NamePattern1) 37305**]. Rx with inhaled
Combivent and po diuretic therapy. Prednisolone was initiated on
[**2114-7-25**], day of life 107. Prednisolone was tapered to present
dose (1 mg/kg/day every other day) which she will continue at
home after discharge. Rx aldactone began [**2114-8-7**].
([**Hospital3 1810**]: Rx methylxanthine until [**2114-5-22**].)
Home respr care:
1. Nasal cannula oxygen= 1 liter flow, 100% FI02. she has
stable oxygen saturations on that.
2. Respr medications:
Prednisolone every other day,
Aldactone daily
Lasix: Monday, Wednesday and [**Known lastname 2974**].
Apnea/bradycardia: none since end of [**6-/2114**]
Cardiovascular:
Echocardiograms [**4-16**], [**4-26**], [**6-29**]/ [**2113**] wnl, no PDA, no
pulmonary hypertension. Cardiology consultation [**2114-6-28**]
obtained due to severe respiratory issues. Peds Cardiology had no
new recommendations. At discharge, [**Known lastname 72706**] has no murmur, normal
[**Known lastname **] pressures and heart rate.
Feeds and nutrition:
Feedings initiated and advanced at [**Hospital3 1810**].
Episode of feeding intolerance [**2114-4-25**]. N.p.o.
Enteral feedings reinitiated [**2114-4-29**] and advanced well.
She achieved full enteral feedings [**2114-5-6**] and advanced to
breast milk30 cal/oz + Beneprotein. [**2114-6-21**]: formula changed
to Special Care 30 cals/oz (mother stopped pumping breast milk).
All feeds by pg until [**Known lastname 72706**] weaned from CPAP to Nasal Canula.
Her first p.o. feed [**2114-7-15**]. She has fed po/pg since. PO
feedings improved. But [**Known lastname 72706**] did not achieve all oral feedings
consistently. Gastrointestinal consultation [**2114-8-10**], gastrostomy
tube (GT) placed [**2114-8-14**].
Feeding options at discharge:
1. Allow [**Known lastname 72706**] to feed all po as tolerated. GT is present to
ensure sufficient nutritional intake when she is not able to po
feed full volume consistently.
2. When [**Known lastname 72706**] does not take (and retain) full volume of a
feeding(s), the volume not taken during daytime feeds can be
infused per GT during the night.
3. GT feedings may be infused throughout nighttime if necessary
to ensure adequate enteral nutrition.
4. Nutrition: Neosure concentrated to 28 cal/oz, 140 ml/kg/day
(provided by [**Hospital 28334**] Medical).
5. Based on ([**2114-8-17**]) discharge wt= 3.24 kg, her 24 hr total
intake at 140 cc/kg/day = 454cc.day (~76 cc/feed for every 4 hr
feeding). She has had consistent weight gain (~140gm over 7 days
([**8-10**]/-[**8-17**]).
***** Electrolytes: NOTE comment re: Se K:
[**2114-8-16**]: Na=133, K=6.3(reported non hemolyzed, Cl=93, HCO3=38.
[**2114-8-17**]: Na=137, K=6.0, Cl=95, HCO3=35.
KCl supplementation discontinued [**2114-8-2**].
Aldactone began [**2114-8-1**].
Infant continues on Lasix.
Se K levels ranged 4.8-5.4 from [**2114-7-23**] through [**2114-8-12**].
Most recent se K: [**2114-8-12**] = 4.8; [**8-14**] = 5.7, repeat =3.8;
[**2114-8-16**] =6.3; [**2114-8-17**] repeat = 6.0. Infant shows no cardiac
evidence of hyperkalemia.
electrolytes warrant ongoing monitoring.
*** Recommend repeat electrolytes (especially to evaluate K
level) prior to [**2114-8-21**].****
Calculated aldactone dose ~1.3 mg/kg/day (based on discharge wt).
If se K level (non-hemolyzed) remains ~6, recommend discussion
with Dr. [**First Name4 (NamePattern1) 4468**] [**Last Name (NamePattern1) 37305**] (Pulmonary MD) re: discontinuing aldactone.
(clinic number: [**Telephone/Fax (1) 61252**]; or via [**Hospital3 1810**]
([**Telephone/Fax (1) 29830**]) and ask to page Dr. [**Last Name (STitle) 37305**].
We recommend that Pediatrician (or physician covering
Pediatrician) obtain electrolytes before [**2114-8-21**].
Gastrointestinal: [**Known lastname 72706**] was restarted on phototherapy on
[**2114-4-21**] after returning from [**Hospital3 1810**]. She
remained on phototherapy for 2 more days after that and then
her hyperbilirubinemia resolved thereafter. As previously
mentioned, the G tube was placed on [**2114-8-14**]. The site has
been followed for redness and erythema at the base.
Gastrointestinal has been evaluating. Keflex was started to
help heal that on [**2114-8-15**].
Hematology: [**Known lastname 72706**]'s [**Known lastname **] type is A positive, DAT negative.
She has received numerous [**Known lastname **] product transfusions of
packed red [**Known lastname **] cells only. She received packed red [**Known lastname **]
cells on [**2114-6-25**]. Her most recent hematocrit is 30 with a
reticulocyte count of 4.2 and that was on [**2114-8-12**]. Coags
were drawn prior to surgery for G tube placement on
[**2114-8-14**]. Her PT was 11.4, PTT 29.1. [**Known lastname 72706**] was started on
elemental iron, ferrous sulfate on [**2114-8-9**]. She remains on
iron at the time of discharge.
Infectious disease: On [**2114-4-25**] due to clinical
deterioration, increased ventilator needs and abdominal
distention, she received a CBC and [**Year (4 digits) **] culture to rule out
sepsis. The CBC was benign at that time. She received 48
hours of Vancomycin and gentamycin which were subsequently
discontinued when the [**Year (4 digits) **] culture remained negative at 48
hours. Due to nasal prong CPAP, [**Known lastname 72706**] developed an area of
nasal bridge cellulitis on [**2114-5-18**], at which time a CBC and
[**Year (4 digits) **] culture were drawn. The [**Year (4 digits) **] culture remained
negative. CBC was benign at that time. She received a 7 day
course of Oxacillin for the cellulitis. [**Known lastname 72706**] also received
Erythromycin eye ointment from [**2114-6-29**] through [**2114-7-4**]
for mild conjunctivitis. Keflex was started on [**2114-8-15**] due
to erythema at G tube site. She will be discharged on Keflex
and needs to receive a total of 7 days of Keflex.
Neurologic: [**Known lastname 72706**] has received numerous head ultrasounds.
The head ultrasounds at [**Hospital3 1810**] were all within
normal limits. Head ultrasound on [**2114-4-13**], [**2114-4-16**],
[**2114-5-9**] and [**2114-6-21**] were all within normal limits. [**Known lastname 72706**]
will need to be followed by early intervention after
discharge.
Sensory:
Audiology: A hearing screening was performed with automated
auditory brain stem responses and the infant passed in both
ears.
Ophthalmology exams for ROP:
[**2114-5-21**]: Immature retina zone 2.
[**6-4**]: Stage 1, Zone 2 (OD:6 hrs; OS: 9 hr)
[**6-11**]: max ROP Stage 2, Zone 2 (5 hrs OU) with evidence of plus
dz. All subsequent eye exams revealed regressing ROP.
Her last eye exam ([**2114-8-14**]) prior to discharge:
ROP: Stage 2. Zone 2 (OD: 3 hr; OS: 2 hr). Although [**Known lastname 72706**]'s ROP
appears to be regressing, she must have eye exams (for ROP) until
her ROP has completely resolved.
Ophthalmologist: Dr.[**First Name9 (NamePattern2) **] [**Name (STitle) **].
Ophthalmology appt after discharge: week of [**2114-8-27**]
Psychosocial:[**Hospital1 18**] social worker has been in contact with
the family. There are no specific issues at this time. If
concerns arise, contact SW (phone: [**Telephone/Fax (1) 8717**]).
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Home with the parents.
NAME OF PRIMARY PEDIATRICIAN: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, [**Hospital 246**]
Pediatrics. Telephone number [**Telephone/Fax (1) 37501**].
CARE AND RECOMMENDATIONS:
Feeds p.o. at 140 ml/kg per day of NeoSure 28 calorie per
ounce. PO feed as tolerated. Feed remainder per GT.
MEDICATIONS:
1. Prednisolone 1 mg/kg/day every other day (3 mg every other
day).
2. Keflex 75 mg three times/day for total of 7 days (21 doses)
([**2114-8-15**] - [**2114-8-22**]).
3. Lasix 6 mg po once daily (2 mg/kg/dose) on Monday, Wednesday
and [**Known lastname 2974**] (3 days per week).
4. Aldactone 6 mg po (2 mg/kg/day) once daily (every day).
5. Ferrous sulfate 0.5 ml p.o. once daily (4 mg/kg per
dose).
6. Iron supplementation is recommended for preterm and low
birth weight infants until 12 months corrected age. All
infants fed predominantly breast milk should receive
Vitamin D supplementation at 200 i.u. (may be provided
as a multi-vitamin preparation) daily until 12 months
corrected age.
Car seat position screening:passed
MA Newborn screens: Most recent ( [**2114-6-18**]): normal.
IMMUNIZATIONS RECEIVED:
1. Received hepatitis B vaccine on [**2114-6-8**] and [**2114-7-11**].
2. She received the PediaRix on [**2114-6-8**] and [**2114-8-9**].
3. She received Hib on [**2114-6-9**].
4. She received DPT on [**2114-8-9**].
IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be
considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet
any of the following four criteria: (1) Born at less than 32
weeks; (2) Born between 32 weeks and 35 weeks with two of the
following: Day care during RSV season, a smoker in the
household, neuromuscular disease, airway abnormalities or
school age siblings; (3) chronic lung disease or (4)
hemodynamically significant congenital heart disease.
Influenza immunization is recommended annually in the Fall
for all infants once they reach 6 months of age. Before this
age, and for the first 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out-of-home caregivers.
This infant has not received ROTA virus vaccine. The American
Academy of Pediatrics recommends initial vaccination of
preterm infants at or following discharge from the hospital
if they are clinically stable or at least 6 weeks but fewer
than 12 weeks of age.
FOLLOWUP:
1. Pediatrician appt: Dr. [**Last Name (STitle) **] [**2114-8-18**].
2. Pediatric pulmonary, Dr. [**First Name4 (NamePattern1) 4468**] [**Last Name (NamePattern1) 37305**], [**Hospital3 1810**]
pulmonary clinic [**2114-8-24**], 9:45 am. (phone: [**Telephone/Fax (1) 61252**])
3. [**Hospital 6283**] clinic appt with GI nurse 9/7/[**2113**],11 a.m. at
[**Hospital3 1810**] phone [**Telephone/Fax (1) 72707**]).
4. Eye appt for follow-up of ROP: Dr. [**Last Name (STitle) **], pediatric
ophthalmologist, week of [**2114-8-27**]. Parent will make appt.
5. Early intervention referral made. EI Telephone ([**Location (un) 2199**])
[**Telephone/Fax (1) 72708**].
6. Visiting nurse [**8-20**] or [**2114-8-21**]. phone 1-[**Telephone/Fax (1) 45165**].
7. Infant follow-up program referral was made 2 days prior to
discharge ([**2114-8-15**]).
DISCHARGE DIAGNOSES:
1. Prematurity, GA 27 and [**4-23**] wks
2. Intrauterine growth restriction, small for GA
3. Respiratory distress syndrome
4. Severe CLD
5. Patent ductus arteriosus resolved.
6. Hypotension resolved.
7. Sepsis ruled out.resolved.
8. Nasal cellulitis resolved.
9. Localized inflammation around G tube site, Rx with Keflex as
noted above.
10.Pulmonary hemorrhage, resolved.
11.Retinopathy of prematurity: Stage 2, Zone 2. not resolved.
12.Apnea of prematurity, resolved.
13.Electrolyte instability, Se K still needs to be followed.
14.Anemia, ongoing.
[**First Name8 (NamePattern2) 1154**] [**Last Name (NamePattern1) **], MD [**MD Number(2) 56585**]
Dictated By:[**Name8 (MD) 62299**]
MEDQUIST36
D: [**2114-8-17**] 01:34:00
T: [**2114-8-17**] 05:42:18
Job#: [**Job Number 72709**]
ICD9 Codes: 769, 7742, V053, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3865
} | Medical Text: Admission Date: [**2114-6-21**] Discharge Date: [**2114-6-27**]
Date of Birth: [**2056-10-31**] Sex: M
Service: NEUROLOGY
Allergies:
Dilantin
Attending:[**First Name3 (LF) 2090**]
Chief Complaint:
Status epilepticus
Major Surgical or Invasive Procedure:
Mechanical ventilation
Arterial line
History of Present Illness:
57 year-old right-handed gentleman with a history of
frontotemporal dementia and epilepsy (with prior episode of
status epilepticus) who presented with seizure. The pt is
nonverbal at baseline, therefore the following history is er
the medical record and the primary team.
.
Per the record, the pt was at in the dining room at his nursing
facility the day of admission and was seen to abruptly begin
convulse. The activity was described as "grand mal." Exactly how
long he was convulsing prior to EMS arrival is unknown, however
he was seizing for at least 25 minutes after they did arrive. He
was given 20mg of intravenous valium without effect and multiple
attempts were made at intubation but ultimately failed. He was
taken to [**Hospital1 **] [**Location (un) 620**] where he was noted to have rhythmic
movements of his head and neck. He was given paralytic agents
(etomidate and succinylcholine) at 11:15am and was intubated. He
was also given ativan, total amount unknown. His seizure
activity was noted to cease after about 60 minutes total. He was
then started on a proprofol gtt, however he became hypotensive
to the 70's systolic. The rate was decreased, and his pressure
stabilized. He was also given 1g of IV phenytoin. He was
transferred to [**Hospital1 18**] for further care. En route, EMS
administered an additional 2mg of intravenous lorazepam for
prophylaxis.
.
On arrival to the [**Hospital1 18**] ED, he was intubated. No abnormal
movements were noted on arrival.
.
The pt was unable to offer complaints nor a review of symptoms.
Past Medical History:
-frontotemporal dementia, followed by Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]. He is
now nonverbal and fully dependent on his caretakers in all of
his ADLs.
-Seizure disorder. Pt was admitted to [**Hospital1 18**] in [**2113-7-6**],
presenting after episode of generalized status epilepticus
lasting 70 minutes. Seizure was thought to occur in setting of
pneumonia and fever, and standing Tylenol was given to prevent
recurrent fever. Initially his Keppra dose was increased, and he
was monitored on continuous EEG, which demonstrated no
additional seizure activity. He had a head CT that showed no
acute changes, persistent ventriculomegaly and cortical atrophy.
Trileptal was also added to his antiepileptic regimen after
another seizure on day 3 of hospitalization. Of note, hospital
course was also notable for treatment of RUL pneumonia, C.
difficile enterocolitis, NSTEMI, and rhabdomyolysis.
-coronary artery disease, with history of myocardial infarction,
angioplasty and stent placement
-anxiety
-depression
-hyperlipidemia
-status-post prostate resection
-obstructive sleep apnea, on CPAP
-admitted to [**Hospital **] Hospital in [**2-10**] with pyelonephritis
-clostridium difficile enterocolitis
Social History:
The pt is currently living in a nursing home. He has a distant
history of cigarette use. No history of alcohol or illicit drug
abuse. He previously worked in real estate. He is fully
dependent on his caretakers for all of his ADLs.
Family History:
Remarkable for mother with frontotemporal dementia. No history
of seizure in other family members.
Physical Exam:
Vitals: T: 99.8F P: 81 R: 14 BP: 108/74 SaO2: 100% ventilated
General: Lying in bed with eyes closed, intubated.
HEENT: NC/AT, no scleral icterus noted, MMM, laceration and
dried blood on lips
Neck: No carotid bruits appreciated.
Pulmonary: Lungs with transmitted sounds bilaterally
Cardiac: RRR, S4 gallop noted, no murmur noted
Abdomen: soft, NT/ND, normoactive bowel sounds
Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses
bilaterally.
Skin: no rashes or lesions noted.
.
Neurologic:
-mental status: Lying in bed with eyes closed. Spontaneously
opens eyes, but not to command. He follows no commands.
.
-cranial nerves: PERRL 3.5 to 2mm and brisk. Funduscopic exam
revealed no papilledema, exudates, or hemorrhages. EOM full to
oculocephalic maneuver. There is horizontal nystagmus with
possible torsional component bilaterally. Facial musculature
appears symmetric. Corneal reflex intact bilaterally. Gag reflex
intact.
.
-motor: Normal bulk throughout. Tone slightly increased on the
left. No adventitious movements noted. The pt withdrew right
upper and lower extremity more briskly than left upper and lower
extremity to noxious stimuli.
.
-sensory: Pt grimaced to noxious stimuli bilaterally.
.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 3 4
R 2 2 2 3 2
.
Plantar response was extensor bilaterally.
Pertinent Results:
Laboratory Data ([**Hospital1 **] [**Location (un) 620**]):
WBC 10.6 Plt 194 Hct 48.7
INR 1.1 PTT 25.9
148| [**Age over 90 **]|17 /175
4.7|14.5|1.5\
Ca 8.3 Mg 2.1
ALT 68 AST 24 AP 99 Tbili 0.34 Tprot 7.2 Alb 3.9
Dilantin <0.5
Urine and serum tox negative.
.
Other pertinent values:
[**2114-6-21**] 02:40PM BLOOD CK(CPK)-884*
[**2114-6-21**] 07:51PM BLOOD CK(CPK)-2599*
[**2114-6-22**] 02:17AM BLOOD CK(CPK)-3921*
[**2114-6-22**] 01:22PM BLOOD CK(CPK)-4107*
CXR [**6-21**]: Endotracheal tube terminates 5 cm above the carina,
and nasogastric tube terminates below the diaphragm. Cardiac and
mediastinal contours are within normal limits. Patchy and linear
opacities have developed at both bases, most likely due to
atelectasis, although coexisting aspiration is also possible in
this patient with history of seizure.
CXR [**6-22**]: The [**6-21**] film may show a large cavity in the left
perihilar lung. On today's examination, lung volumes are lower
and mild interstitial pulmonary edema has developed creating a
region of heterogeneous consolidation in the same area. Findings
are suggestive of pneumonia, perhaps due to aspiration. CT
scanning is recommended for clarification once the
cardiovascular situation improves. Heart size top normal,
increased since [**6-21**]. Tip of the ET tube is at the upper
margin of the clavicles, at least 5 cm from the carina and the
nasogastric tube passes below the diaphragm and out of view.
.
Chest CT:
FINDINGS: Lung volumes are low. Heterogeneous opacification in
the dependent portions of the lung could be either atelectasis
or, less like, mild aspiration, but there is no consolidation to
suggest pneumonia or any
bronchiectasis to suggest chronic aspiration. Lungs are
otherwise clear.
.
A 15 x 29 mm central cyst expands the right lobe of the thyroid
gland at the expense of the subglottic trachea for a length of 2
cm, deforming the trachea and narrowing the coronal diameter
from 20 to 14 mm while elongating the sagittal diameter.
.
There is no pathologic enlargement of central lymph nodes by
size criteria. LAD coronary stent is noted. Small pericardial
effusion is physiologic, and there is only a miniscule amount of
left pleural effusion, clinically insignificant. Feeding tube
passes into the second portion of the duodenum and beyond the
field of view.
.
IMPRESSION:
1. No evidence of pneumonia. Dependent atelectasis, less
likely mild
aspiration.
2. Stented, atherosclerotic LAD coronary artery.
3. Moderate right goiter deforms and mildly narrows the
trachea.
.
Head CT:
FINDINGS: The study is compared with most recent examination
dated [**2113-7-18**]; the overall appearance is unchanged. Again
demonstrated is moderately severe and relatively uniform
ventriculomegaly, which appears disproportionate to the moderate
degree of cerebral atrophy. This is unchanged and likely
represents either underlying communicating hydrocephalus or
relatively selective central atrophy. A cavum septum pellucidum
et vergae is redemonstrated. There is confluent low-attenuation
in bihemispheric periventricular white matter, likely
representing chronic microvascular infarction. There is no
intra- or
extra-axial hemorrhage, the midline structures are in the
midline, and there is no evidence of acute cerebral edema. No
space-occupying lesion is seen. Incidentally noted are
relatively minor inflammatory changes involving the right
maxillary and bilateral sphenoid sinuses and bilateral ethmoidal
air cells.
.
IMPRESSION:
1. No acute intracranial abnormality.
2. Disproportionate ventriculomegaly suggestive of either
underlying
communicating hydrocephalus or selective central atrophy.
3. Moderate chronic microvascular infarction in periventricular
white matter.
.
EEG:
ABNORMALITY #1: As the recording began, the background was very
slow
and of very low voltage. About 10 minutes after the beginning of
the
record, there was a more widespread faster background rhythm,
still of
relatively lower voltage. This appeared symmetric and without
focal
findings. Clinically noted movements of the limbs did not have
an EEG
correlate. Later in the recording, along with the widespread low
voltage fast activity, there were some bursts of generalized
slowing.
HYPERVENTILATION: Could not be performed.
INTERMITTENT PHOTIC STIMULATION: Could not be performed.
SLEEP: No normal waking or sleeping morphologies were seen.
CARDIAC MONITOR: Showed a generally regular rhythm.
IMPRESSION: Markedly abnormal portable EEG due to the very low
voltage
and generally slow background throughout. This finding suggests
a
widespread encephalopathy. Medications, metabolic disturbances,
and
infection are among the most common causes. The widespread
faster
rhythms raise concern for medication effect. No prominent focal
abnormalities were evident, but encephalopathies may obscure
focal
findings. There were no epileptiform features.
.
Admission Labs:
[**2114-6-21**] 08:04PM TYPE-ART PO2-262* PCO2-33* PH-7.45 TOTAL
CO2-24
[**2114-6-21**] 07:51PM GLUCOSE-108* UREA N-12 CREAT-0.8 SODIUM-146*
POTASSIUM-3.2* CHLORIDE-113* TOTAL CO2-24 ANION GAP-12
[**2114-6-21**] 07:51PM CK(CPK)-2599*
[**2114-6-21**] 07:51PM CALCIUM-8.3* PHOSPHATE-1.4*# MAGNESIUM-2.2
[**2114-6-21**] 07:51PM WBC-11.0# RBC-4.46* HGB-14.4 HCT-40.2 MCV-90
MCH-32.4* MCHC-35.9* RDW-13.5 PLT COUNT-124*
[**2114-6-21**] 07:51PM PT-13.6* PTT-28.6 INR(PT)-1.2*
[**2114-6-21**] 05:53PM URINE COLOR-LtAmb APPEAR-SlCloudy SP
[**Last Name (un) 155**]-1.018
[**2114-6-21**] 05:53PM URINE BLOOD-LGE NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2114-6-21**] 02:40PM CK(CPK)-884*
Brief Hospital Course:
Mr. [**Known lastname 107818**] is a 57yo man with frontotemporal dementia and
seizure disorder admitted from an OSH after status epilepticus.
He was admitted to the neurology ICU. Hospital course is
detailed below by problem.
.
1. seizures: On arrival, Mr. [**Known lastname 107818**] did not appear clinically
to be seizing, and he had no further seizures in house. EEG was
performed the night of admission and showed no evidence of
seizure activity (see report above). He had a head CT, which was
negative. Urinalysis was borderline positive and was thought to
have been a possible trigger for his seizures. He also had
evidence of an aspiration PNA on initial CXR which was treated
which was another possible trigger of seizures. He was given an
extra 500mg dilantin and started on dilantin 100mg tid as well
as continued on his home dose of keppra. He was given additional
dilantin for goal level 15 given subtherapeutic levels on 100
TID and his dose was increased to 100/100/130. He should have a
Dilantin trough drawn on Friday [**6-29**] then once a week, and the
dose should be adjusted as needed for goal level 15-20. LP was
attempted to definitely r/o meningitis, but was unsuccessful.
Given low suspicion for meningitis (afebrile, no meningismus,
UTI or PNA more likely triggers for seizures) LP under flouro
was not pursued.
2. elevated CK: He was noted to have elevated CK on arrival,
which initially continued to rise. He was started on IVF with
goal UOP 100-200cc/hr to prevent rhabdomyolysis. It trended down
over the next few days with the IV fluids.
3. pneumonia: The patient was extubated the day after admission,
but was noted on a follow up CXR to have a blossoming pneumonia,
thought to be secondary to aspiration. He was started on flagyl
in addition to the ceftriaxone for UTI (see below). Chest CT
was later performed (see report above) and showed atelectasis
but no evidence of pneumonia. Given that Chest CT was negative
for pneumonia, Ceftriaxone and Flagyl were stopped on [**6-27**], and
it was felt that CXR finding were more c/w a chemical
pneumonitis from aspiration.
.
4. UTI: He was noted to have a borderline urinalysis and was
started on ceftriaxone for treatment. Urine culture ultimately
came back negative, so Ceftriaxone was stopped after a 5 day
course.
Medications on Admission:
-prevacid 30mg po daily
-lisinopril 5mg po daily
-keppra 1000mg po bid (no recent missed doses per NH [**Month (only) 16**])
-metoprolol 37.5mg po tid
-acetaminophen prn
-MVI 1 tab daily
-folate 1mg po daily
-zetia 10mg po daily
-lipitor 10mg po daily
-zoloft 25mg po daily
-MOM prn
Discharge Medications:
1. Phenytoin 50 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO Q 8H (Every 8 Hours).
2. Phenytoin Sodium Extended 30 mg Capsule Sig: One (1) Capsule
PO DAILY (Daily): with PM dose to make total PM dose 130 mg.
3. Levetiracetam 100 mg/mL Solution Sig: 1000 (1000) mg PO BID
(2 times a day).
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Sertraline 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Prevacid 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
9. Multi-Vitamin Tablet Sig: One (1) Tablet PO once a day.
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 1036**] - [**Location (un) 620**]
Discharge Diagnosis:
Status Epilepticus
Discharge Condition:
Improved
Discharge Instructions:
Please call your doctor if you fevelop any fevers, chills,
cough, chest pain, shortness of breath, seizures, or any other
symptoms that concern you.
Followup Instructions:
Neurology: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 11771**], M.D.
Phone:[**Telephone/Fax (1) 26488**] Date/Time:[**2114-9-4**] 11:30
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43**] MD [**MD Number(1) 2107**]
Completed by:[**2114-6-27**]
ICD9 Codes: 5070, 5990, 5180, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3866
} | Medical Text: Admission Date: [**2123-12-7**] Discharge Date: [**2123-12-20**]
Date of Birth: [**2057-3-6**] Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3645**]
Chief Complaint:
Neck pain
Major Surgical or Invasive Procedure:
1. Open treatment of pathologic fracture dislocation C7,
T1, T2, T3.
2. Posterior arthrodesis C4-T6.
3. Posterior instrumentation T4-T6.
4. Application of allograft.
5. Left iliac crest bone graft, morselized.
History of Present Illness:
This is a patient with a history of metastatic breast cancer to
her cervicothoracic junction. She was seen at an outside
institution by a spine specialist who did not recommend any
further intervention. She has muscle spasms and scapular pain.
She is in a cervicothoracic brace since [**Month (only) 547**] or since early
[**Month (only) 116**].
Her past medical history is diagnosis of breast cancer in [**2112**]
with lumpectomy, chemo and radiation, not BRCA 1 or 2. She was
diagnosed with spinal metastases in [**2123**] and had radiation.
Her other medical problems are hypertension and high
cholesterol.
No other significant medical issues.
Her medications included lisinopril, folic acid, Crestor,
calcium, multivitamin, Arimidex, Exgeva, Ativan, and Tegretol.
She has no known drug allergies.
She has a husband and two children. She does not smoke. She is
currently not working.
Review of systems is negative. However, she is 5 feet 4 inches,
147 pounds with systolic blood pressure 172/105, pulse 89. No
chest pain, headaches, nausea, or vomiting.
Notes were reviewed from MCCM from [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9969**] from
[**2123-8-6**].
It is noted that she was using Duragesic patches at that time.
She remains neurologically intact. She was on Femara at that
point.
A PET scan done on [**2123-6-22**] shows extensive metastases, no
visceral metastases. She was on hormonal therapy as well as
Exgeva. Studies were reviewed. PET scan done from [**2123-5-25**]
done at [**Hospital 1727**] Medical Center, department of radiology shows
markedly improved appearance since the last exam _____ vast
majority of previously recent osseous lesions no longer
demonstrating hypermetabolism with residual uptake destructive
lesions in T1-T2.
The images were reviewed. Unfortunately, the cervicothoracic
junction is a cutoff point for the thoracic and no other
cervical
study, no good overlap study is noted.
On physical examination, she appears to be tolerating her brace
well. She is neurologically intact in upper and lower
extremities. No spasticity. No atrophy. Distal pulses intact.
Fine hand motor function is intact. Gait is within normal
limits.
In brief, this is a patient with multiple osseous metastases
from
breast cancer status post radiation to her spine as well as
hormonal therapy. I recommended a new CT of her cervicothoracic
junction and follow up with me. The goal of the reconstruction
would be to free her from her brace. I do think her life
expectancy is significant enough to consider surgical
stabilization given the remaining option, which would be to
leave
her in a brace indefinitely.
Past Medical History:
see HPI
Social History:
see HPI
Family History:
See HPI
Physical Exam:
see HPI
Pertinent Results:
[**2123-12-7**] 09:02PM GLUCOSE-170* UREA N-13 CREAT-0.5 SODIUM-130*
POTASSIUM-3.7 CHLORIDE-97 TOTAL CO2-22 ANION GAP-15
[**2123-12-7**] 09:02PM CALCIUM-8.0* PHOSPHATE-3.3 MAGNESIUM-1.3*
[**2123-12-7**] 09:02PM WBC-7.0 RBC-3.07* HGB-10.3* HCT-28.9* MCV-94
MCH-33.5* MCHC-35.5* RDW-12.5
[**2123-12-7**] 01:25PM WBC-5.3 RBC-3.71* HGB-12.5 HCT-34.7* MCV-94
MCH-33.7* MCHC-35.9* RDW-12.5
[**2123-12-7**] 01:25PM PLT COUNT-192
Brief Hospital Course:
Patient was admitted to the [**Hospital1 18**] Spine Surgery Service and
taken to the Operating Room for the above procedure. Refer to
the dictated operative note for further details. The surgery
was without complication and the patient was transferred to the
ICU in a stable condition. After a 24 hours observation in ICU
the patient was transferred to the floor. TEDs/pnemoboots were
used for postoperative DVT prophylaxis. Intravenous antibiotics
were continued for 24hrs postop per standard protocol. Initial
postop pain was controlled with a PCA. Diet was advanced as
tolerated. The patient was transitioned to oral pain medication
when tolerating PO diet. Foley was removed on POD#2. Physical
therapy was consulted for mobilization OOB to ambulate. She had
significant episodes of orthostatic hypotension on PT. [**Hospital 91413**]
medical consult was sought, who suggested restriction of free
fluid intake due a suspicion on SIADH. Over a period of one week
this improved and patient is able to move the chair without
symptoms of dizziness of hypotension. Hospital course was
otherwise unremarkable. On the day of discharge the patient was
afebrile with stable vital signs, comfortable on oral pain
control and tolerating a regular diet.
Medications on Admission:
lisinopril, folic acid, Crestor,
calcium, multivitamin, Arimidex, Exgeva, Ativan, and Tegretol.
Discharge Medications:
1. carbamazepine 100 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day).
2. rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. anastrozole 1 mg Tablet Sig: One (1) Tablet PO daily at 5 pm
().
4. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*180 Tablet(s)* Refills:*0*
11. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for fever or pain.
12. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 24402**], ME
Discharge Diagnosis:
1. Metastatic breast cancer.
2. Pathologic fracture with instability and dislocation at
C7, T1, T2, T3.
3. Status post radiation
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:
Immediately after the operation:
- Activity:You should not lift anything greater than 10 lbs
for 2 weeks. You will be more comfortable if you do not sit in a
car or chair for more than ~45 minutes without getting up and
walking around.
- Rehabilitation/ Physical Therapy:
o 2-3 times a day you should go for a walk for 15-30 minutes as
part of your recovery. You can walk as much as you can
tolerate.
- Swallowing: Difficulty swallowing is not uncommon after
this type of surgery. This should resolve over time. Please
take small bites and eat slowly. Removing the collar while
eating can be helpful ?????? however, please limit your movement of
your neck if you remove your collar while eating.
- Cervical Collar / Neck Brace: You need to wear the brace
at all times until your follow-up appointment which should be in
2 weeks. You may remove the collar to take a shower. Limit
your motion of your neck while the collar is off. Place the
collar back on your neck immediately after the shower.
- Wound Care:Remove the dressing in 2 days. If the
incision is draining cover it with a new sterile dressing. If
it is dry then you can leave the incision open to the air. Once
the incision is completely dry (usually 2-3 days after the
operation) you may take a shower. Do not soak the incision in a
bath or pool. If the incision starts draining at anytime after
surgery, do not get the incision wet. Call the office at that
time. If you have an incision on your hip please follow the same
instructions in terms of wound care.
- You should resume taking your normal home medications.
- You have also been given Additional Medications to
control your pain. Please allow 72 hours for refill of narcotic
prescriptions, so plan ahead. You can either have them mailed
to your home or pick them up at the clinic located on [**Hospital Ward Name 23**] 2.
We are not allowed to call in narcotic (oxycontin, oxycodone,
percocet) prescriptions to the pharmacy. In addition, we are
only allowed to write for pain medications for 90 days from the
date of surgery.
- Follow up:
o Please Call the office and make an appointment for 2 weeks
after the day of your discharge if this has not been done
already.
o At the 2-week visit we will check your incision, take
baseline x rays and answer any questions.
Please call the office if you have a fever>101.5 degrees
Fahrenheit, drainage from your wound, or have any questions.
Physical Therapy:
see discharge instructions
Treatments Frequency:
see discharge instructions
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 89824**], MD Phone:[**Telephone/Fax (1) 3736**]
ICD9 Codes: 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3867
} | Medical Text: Admission Date: [**2127-2-27**] Discharge Date: [**2127-3-17**]
Date of Birth: [**2061-4-21**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Morphine / Dilaudid
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Staph bacteremia, lead extraction
Major Surgical or Invasive Procedure:
[**2127-3-6**] ICD Lead Extraction and ASD closure via right
thoracotomy
[**2127-3-6**] Removal of Port-A-Cath
[**2127-3-4**] Cardiac Catheterization
[**2127-3-10**] Insertion of PICC Line
History of Present Illness:
65 yo M with CAD s/p CABG, ischemic cardiomyopathy with EF 25%
s/p ICD in [**2125**], admitted to [**Hospital6 33**] in [**Month (only) 956**]
with MSSA bacteremia. Port-a-cath was placed and he completed a
4 week course of Cephazolin (d/c'd 1 week PTA). He was scheduled
to have his port-a-cath removed as an outpatient, but developed
fevers to 103, nausea and vomiting. He was readmitted to [**Hospital1 34**] on
[**2-24**] and was found to be bacteremic with Staph and in mild CHF.
He was diuresed and started on Oxacillin Q4H. TEE was performed
which was significant for a vegetation on an ICD lead. INR was
2.8. Pt was given 5 mg vitamin K sc x 1. He was transferred to
the [**Hospital1 18**] for lead extraction and device removal.
ROS: +Fevers/N/V. No CP. +SOB, HA. No neck stiffness.
+rhinorrhea, no ST. Minimal cough. No abd pain, changes in
urination or bowel movements. No orthopnea/PND.
Past Medical History:
1. Ischemic CM 25%
2. CAD s/p CABG [**40**] y ago, left ventricular apical aneurysm
3. s/p AICD placement in [**2125**] ([**Company 1543**] Maximow VR single
chamber ICD)(last fired in [**Month (only) 956**])
4. s/p embolic CVA in [**2113**] with mild expressive aphasia and
right hemiparesis on coumadin
5. Hypothyroidism/h/o [**Doctor Last Name 933**] disease s/p radioactive iodine
ablation
6. DMII
7. MSSA bacteremia [**1-13**] treated with 4 weeks of abx
8. HTN
9. High Cholesterol
Social History:
Lives with his wife, disabled truck driver, quit smoking in [**2112**]
(80 py history), no ETOH or illicit drugs
Family History:
Father with prostate ca, grandparents with CAD in their 50s.
Physical Exam:
VS: 97.0, 104/60, 79, 20, 95RA
GEN: A+O x 2 (not to place), pleasant gentleman in NAD
HEENT: PERRLA, EOMI, OP clear +dentures
CV: RRR, I/VI diastolic murmur at LLSB
LUNGS: +crackles [**12-9**] way up bilaterally
ABD: soft, NTND, +BS
EXT: no edema, decreased pulses bilaterally, amputated 2nd toe
on right foot
NEURO: 3/5 strength right arm, [**4-11**] in legs and left arm
Pertinent Results:
[**2127-3-14**] 03:35AM BLOOD Hct-29.6*
[**2127-3-13**] 05:12AM BLOOD WBC-11.1* RBC-3.09* Hgb-9.7* Hct-27.3*
MCV-88 MCH-31.4 MCHC-35.5* RDW-18.1* Plt Ct-280
[**2127-2-27**] 08:52PM BLOOD WBC-9.1 RBC-3.44* Hgb-10.7* Hct-31.0*
MCV-90 MCH-31.1 MCHC-34.5 RDW-15.0 Plt Ct-258
[**2127-3-17**] 04:40AM BLOOD PT-24.6* INR(PT)-2.5*
[**2127-3-17**] 09:40AM BLOOD UreaN-33* Creat-1.7* K-4.4
[**2127-3-15**] 05:39AM BLOOD UreaN-39* Creat-1.8*
[**2127-3-14**] 03:35AM BLOOD UreaN-44* Creat-2.0* K-3.7
[**2127-2-27**] 08:52PM BLOOD Glucose-283* UreaN-40* Creat-1.8* Na-137
K-4.3 Cl-98 HCO3-27 AnGap-16
[**2127-3-13**] 05:12AM BLOOD Calcium-7.9* Phos-5.1* Mg-2.8*
[**2127-3-10**] 04:59AM BLOOD Digoxin-1.2
Brief Hospital Course:
Mr. [**Known lastname 66100**] was admitted and remained on Oxacillin for his MSSA
bacteremia. Repeat blood cultures remained negative. Warfarin
continued to be held. As his INR dropped below 2.0, intravenous
Heparin was initiated. He otherwise remained stable on medical
therapy. A transesophogeal echocardiogram on [**3-3**] was
notable for a large secundum atrial septal defect and
approximately a 7 millimeter vegetation on the right ventricular
lead. There was continuous flow across the atrial septal defect.
The ASD was a new finding, as it was not documented on outside
echocardiogram. Due to the ASD, blind extraction of the RV lead
and port-a-cath was not recommended as there was substantial
risk for paradoxical embolism. Cardiac surgery was there for
consulted for surgical intervention. Prior to surgical
intervention, cardiac catheterization was performed. Coronary
angiography showed native three vessel disease, with a patent
LIMA to LAD. No patent vein grafts were visualized and left
ventriculography was deferred. Preoperative carotid noninvasive
studies revealed no stenosis in the right internal carotid
artery with an insignificant stenosis of less than 40% in the
left internal carotid artery. On [**3-6**], Dr. [**Last Name (STitle) 914**]
performed a surgical repair of his atrial septal defect and ICD
lead extraction under cardiopulmonary bypass while Dr.
[**Last Name (STitle) **] performed concomitant removal of his port-a-cath.
Operative cultures were obtained. The operation was otherwise
uneventful and he was brought to the CSRU for monitoring. Within
24 hours, he was extubated. He remained at his neurologic
baseline. Due to incisional discomfort, he was started on a
Dilaudid PCA. He remained in a junctional rhythm with rate 50-70
but otherwise maintained stable hemodynamics. He transferred to
the SDU on postoperative day two. Oxacillin was continued and
Warfarin anticoagulation was resumed. Low dose beta blockade was
resumed for periods of atrial fibrillation which he tolerated
well. On [**3-10**], a left basilic vein PICC line was placed
without complication for long term antibiotics. Over several
days, he was noted to have periods of bradycardia and conversion
pauses, with periods of atrial tachycardia/fibrillation on
telemetry. He was concomitantly noted to have a decline in renal
function. His creatinine peaked to 2.5. The ACE inhibitor was
therefore discontinued. Due to the potential for temporary
pacing wire secondary to bradycardia, Warfarin was temporarily
stopped and Heparin was utilized for anticoagulation. With close
consultation with the EP service, all nodal agents were titrated
accordingly. Over several days of adjusted medical therapy, his
heart rate and rhythm improved. Warfarin was eventually resumed
as was beta blockade for rate control. He continued to
experience bouts of atrial fibrillation. Due to suboptimal
control of his diabetes mellitus, the [**Last Name (un) **] Center was
consulted to assist in the management of his blood sugars. The
remainder of his hospital course was unremarkable. His renal
function gradually improved. Due to explantation of his ICD
system, he was fitted for the LifeVest external defibrillator
system prior to discharge. He will continue to require
intravenous antibiotics for an additional four weeks and then
return for an AICD in six weeks.
Medications on Admission:
MEDS (on Transfer):
- Oxacillin 2gm q 4 hours (has peripheral 22 g. IV in hand, poor
access, port a cath)
- Lasix 80mg IV daily
- Lisinopril 20mg daily
- Procardia XL 30mg daily
- Digoxin .25 daily
- Zocor 40 daily
- Protonix 40 daily
- KCL 20 meq daily
- Lopressor 25mg twice daily
- Doxepin 200 mg qhs
- Sliding scale insulin
- NPH 50 units QAM, 40 u QPM
- Vicodin prn
- Phenergan prn
- Ambien prn
- Ativan 1mg prn
- Tylenol prn
- Nitroglycerin 1 inch Q6H
.
MEDS (OP)
- Lasix, Zestril, Coumadin, Procardia, Lanoxin, Insulin,
Doxepin, Zocor, Prevacid, KCL, Lopressor (wife to bring in med
list)
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Oxacillin 10 g Recon Soln Sig: Two (2) grams Injection Q4H
(every 4 hours): 4 weeks - last dose [**2127-4-11**].
Disp:*QS 1 month* Refills:*0*
3. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
4. Levothyroxine 75 mcg Tablet Sig: Three (3) Tablet PO once a
day: take three tabs for a total of 225 mcg/day.
Disp:*90 Tablet(s)* Refills:*2*
5. 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*
6. Doxepin 100 mg Capsule Sig: Two (2) Capsule PO at bedtime.
Disp:*60 Capsule(s)* Refills:*0*
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 6-8 hours as needed for pain.
Disp:*60 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:*2*
9. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
10. Warfarin 1 mg Tablet Sig: One (1) Tablet PO QPM: Take daily
Disp:*60 Tablet(s)* Refills:*2*
11. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: 52 QAM
and 40 QPM units Subcutaneous once a day: take as directed.
12. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
13. Ativan 1 mg Tablet Sig: One (1) Tablet PO four times a day
as needed for anxiety.
Disp:*20 Tablet(s)* Refills:*0*
14. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO once a day.
Disp:*60 Capsule, Sustained Release(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
MSSA bacteremia/ICD lead vegetation/Atrial Septal Defect - s/p
ASD closure and ICD and Port-a-cath removal, Coronary artery
disease - s/p CABG [**40**] years ago, left Ventricular Apical
Aneurysm, Ischemic Cardiomyopathy, Diabetes Mellitus, s/p AICD
placement in [**2125**] ([**Company 1543**] Maximow VR single chamber ICD)(last
fired in [**Month (only) 956**]), s/p embolic CVA in [**2113**] with mild expressive
aphasia and right hemiparesis on coumadin, Hypothyroidism/h/o
[**Doctor Last Name 933**] disease s/p radioactive iodine ablation, Hypertension,
High Cholesterol, Renal Insufficiency
Discharge Condition:
Good
Discharge Instructions:
1)Please be sure to take all medications as directed.
2)You will need to take your Oxacillin antibiotic through your
PICC line - last doses will be on [**2127-4-11**].
3)You should continue taking your coumadin as previously, and
have your blood drawn at your usual coumadin lab to adjust your
dose. INR should be checked within 72 hours of discharge.
4)If you have chest pain, shortness of breath, changes in your
speech or new weakness, or fever or chills please call your
doctor or come to the emergency room.
5)Have thyroid function tests checked in 2 weeks following
discharge. You should contact your PCP for appropriate blood
draw.
6)Please checky lytes, BUN and Cr weekly - arrange with VNA or
local PCP.
Followup Instructions:
Cardiac surgeon, Dr. [**Last Name (STitle) 914**] - call for appt([**Telephone/Fax (1) 170**])
EP service, Dr. [**Last Name (STitle) **] in 4 weeks, call for appt([**Telephone/Fax (1) 14967**])
PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) 14966**] in 2 weeks, call for appt([**Telephone/Fax (1) 14967**])
Completed by:[**2127-5-1**]
ICD9 Codes: 4280, 7907, 9971, 5859, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3868
} | Medical Text: Admission Date: [**2123-4-22**] Discharge Date: [**2123-5-14**]
Date of Birth: [**2123-4-22**] Sex: F
HISTORY OF PRESENT ILLNESS: Baby Girl #2 [**Known lastname **] was born on [**2123-4-22**] as the 1560 gm product of a 31 week gestation to an
18 year old gravida 1, Para 0 mother whose pregnancy was
notable for preterm labor at 27 weeks treated with
development of pregnancy-induced hypertension at 30 weeks.
Delivery was by cesarean section at 31 weeks secondary to
worsening pregnancy-induced hypertension. Prenatal
laboratory studies were notable for hepatitis B surface
antigen negative, RPR nonreactive and GBS unknown, rupture of
membranes at the time of the delivery and there were no known
sepsis risk factors. Antibiotics were given to the mother
active with [**Name (NI) **] of 8 and 8. CPAP was provided for mild
respiratory distress and the patient was admitted to the
Newborn Intensive Care Unit.
PHYSICAL EXAMINATION ON ADMISSION: Weight was 1560 gm. The
patient was active and nondysmorphic. Moderate respiratory
distress was noted. Skin was warm, pink without lesions.
Oropharynx was clear. Palate was intact. Chest was coarse
but well aerated. Heart was regular rate and rhythm without
murmurs. Abdomen was soft with active bowel sounds. Hips
were normal. Tone and movement were appropriate.
HOSPITAL COURSE: 1. Respiratory - The infant exhibited mild
respiratory distress and was placed on CPAP. This was weaned
off to room air within 12 to 24 hours of life. The patient
was restricted in room air without any increased work of
breathing. The patient has not been treated with caffeine
and no apneic or bradycardiac episodes have been noted.
2. Cardiovascular - The patient has remained hemodynamically
stable throughout. No murmur has been detected.
3. Fluids, electrolytes and nutrition - The patient was
initially maintained on intravenous fluids. Enteral feeds
were begun at day of life 2 to 3 and advanced without
difficulty. Currently on Neosure 24 cals / oz. Discharge weight
1940g.
4. Gastrointestinal - The patient exhibited mild
hyperbilirubinemia of prematurity and was treated with
phototherapy for approximately five days.
5. Infectious disease - Initial complete blood count
revealed a white count of 12.6 with 13 polys and 0 bands.
Initial platelet count was 275. The patient was treated with
Ampicillin and gentamicin for 48 hours pending a negative
blood culture and benign clinical course.
6. Heme - Initial hematocrit was 41.5. Discharge Hct 36.1.
Mother's blood type was 0 positive.
7. Neurological - Head ultrasound on day of life #7 was
normal. Neurological examination has been appropriate
throughout.
8. Opthomology- Eye exam normal, f/u in 8 months.
9. Hepatitis immunization deferred until infant and twin reach
2 kgms.
DISCHARGE DIAGNOSIS:
1. Prematurity at 31 weeks
2. Twin gestation
3. Mild respiratory distress resolved
4. Hyperbilirubinemia of prematurity
5. Status post sepsis evaluation
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 38370**]
Dictated By:[**Name8 (MD) 38043**]
MEDQUIST36
D: [**2123-4-29**] 17:04
T: [**2123-4-29**] 17:19
JOB#: [**Job Number 42364**]
ICD9 Codes: 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3869
} | Medical Text: Admission Date: [**2153-6-9**] Discharge Date: [**2153-6-14**]
Date of Birth: [**2101-2-9**] Sex: M
Service: MED
CHIEF COMPLAINT: Hypertensive episode with hypoxia.
HISTORY OF PRESENT ILLNESS: The patient is a 52-year-old
male with multiple medical problems and complex past medical
history recently discharged from [**Hospital1 190**] in early [**2153-5-26**] after extensive two month
hospital stay initially for dyspnea on exertion/shortness of
breath with right-sided heart catheterization showing fluid
overload, initially improved with palliative therapy using
Swan in the Coronary Care Unit. However, [**Hospital 228**] hospital
course was complicated by intubation for hypercapnia and
sedation and then subsequent difficulty in being off a
ventilator. He was subsequently transferred to the Medical
Intensive Care Unit for respiratory failure management at
which point he was treated for a right lower lobe pneumonia,
presumed Staph in origin, with intravenous vancomycin. He
subsequently underwent placement of a trach for prolonged
respiratory care and also underwent a percutaneous endoscopic
gastrostomy tube. These procedures were ultimately
complicated at the PEG by a large gastric hematoma requiring
multiple units of packed red blood cells. Ultimately, the
patient required aggressive body fluid resuscitation and
several units of packed red blood cells and was returned to
the Intensive Care Unit for symptoms of volume overload. He
was then diuresed again to near euvolemia. His hospital
course was mired by difficulties in managing his fluid
balance; he was constantly fluctuating between hyper and
hypovolemia and congestive heart failure versus acute renal
failure. Ultimately, he did develop increased renal failure
of unclear etiology and ultimately was started on
hemodialysis. Later during his hospital course from a
respiratory standpoint, he developed a Pseudomonas and
Enterobacter pneumonia for which he was treated with
ceftazidime and Levaquin. Also during his hospital course he
had an Enterococcus bacteremia. Ultimately he was discharged
off of trach ventilation support to [**Hospital1 **] on [**2153-5-28**].
He had been weaned off the ventilator for five days.
However, on this admission the patient presented with an
increased lethargy and was found to have acute desaturations
into the 60's and 70's on trach mask 50 percent while being
on the commode. The patient was noted to become cyanotic and
was thought to be unresponsive. The patient was subsequently
bagged with a recovery of oxygen saturations but systolic
blood pressures dropped into the 60's and 70's. The patient
then received one liter of normal saline and was transferred
to the [**Hospital1 69**] Emergency
Department where patient had improvement in his pressures
into the 70's and 80's and was asymptomatic at this point;
however, patient received additional three liters of
intravenous fluids, aspirin, heparin, empiric vancomycin and
was transferred to the Intensive Care Unit. Currently the
patient is comfortable without complaints. He denies any
shortness of breath, coughing, fever or chills. He denies
chest pain currently but does report fleeting chest pain at
the time of the hypoxia and hypotension episode subsequently
resolved spontaneously. No abdominal pain, nausea or
vomiting.
PAST MEDICAL HISTORY:
1. Coronary artery disease status post one vessel coronary
artery bypass graft in [**2132**], left internal mammary artery
to left anterior descending artery with subsequent
catheterization in [**2153-3-26**] showing patent graft and 30
percent lesion in his circumflex.
2. Status post mitral valve replacement times two, one in
[**2142**] and one in [**2133**], St. Jude valve.
3. Congestive heart failure. Ejection fraction [**11-9**] percent
in [**2153-4-26**].
4. Staph endocarditis necessitating mitral valve replacement
complicated by septic emboli and brain abscesses.
5. Atrial fibrillation on Coumadin.
6. Type 2 diabetes mellitus.
7. Upper GI bleed and history of duodenal ulcers.
8. Unclear interstitial restrictive lung disease.
9. Gout.
10. Left lower extremity cellulitis.
11. Respiratory failure status post tracheostomy in
[**2153-3-26**].
12. Status post percutaneous endoscopic gastrostomy tube
placement in [**2153-3-26**] complicated by hematoma.
13. Acute renal failure, persistent, now on hemodialysis
via Quinton left subclavian.
14. History of nonsustained ventricular tachycardia in
the setting of electrolyte abnormalities and pressors.
15. History of anemia.
16. Sacral decubiti.
17. Recent Enterobacter bacteremia and ventilator-
associated pneumonia.
18. History of questionable ankylosing spondylitis HLAB-
27 negative and now thought to be DISH.
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Coumadin 3 q. hs.
2. Lentis 23 q. hs. sliding scale.
3. Digoxin 0.125 q. three days.
4. Coreg 3.125 b.i.d.
5. Epogen 5000 units with dialysis.
6. Reglan 5 q. hs.
7. Vitamin B.
8. Zinc.
9. Albuterol and Atrovent nebs.
10. Oxycodone p.r.n.
11. Ativan p.r.n.
12. Lexapro 10 q. day.
PHYSICAL EXAMINATION ON ADMISSION: Afebrile, 97.3. Blood
pressure 91/57, pulse 54, respiratory rate 20 on control of
20, tidal volume 400, PEEP 5, FiO2 0.4. Satting in the mid
90's. General: Lethargic but responding appropriately to
questions. HEENT: Significant jugular venous pressure to
tragus of ear. Cardiovascular: Irregularly irregular with
3/6 systolic ejection murmur. Lungs: Coarse breath sounds
bilaterally. Abdominal examination shows J-tube PEG site
with mild erythema and exudate, not purulent. Otherwise soft
and non-distended. Extremities: Trace lower extremity
edema.
LABORATORY: White count 13.3, hematocrit 30.9 at baseline,
platelet count 208,000. INR 1.6, PTT 31.9. His chemistry
shows sodium 145, potassium 4.9, chloride 107, bicarb 25, BUN
77, creatinine 4.4, sugar 238. Calcium, magnesium and
phosphorus: 8.8, 2.1 and 1.7. His ABG was 7.53 and 26.3 at
the time of admission. Lactate was 4.1 and 3.2. His CK was
41, troponin-I 0.26. Digoxin level was 1.1. He had ALT 8,
AST 21, amylase 45, alk phos 181 chronic, lipase 26, total
bilirubin 0.5.
RADIOLOGY: Chest x-ray showed a small right-sided pleural
effusion unchanged, cardiomegaly and question of mild
____________ on chest x-ray.
ELECTROCARDIOGRAM: Shows atrial fibrillation 103-94, low
voltage. Question of old inferior Q-waves and old T-wave
inversions in anterolateral leads.
HOSPITAL COURSE:
1. Hypotension. It is unclear as to the exact etiology of
his hypotension. Initially, there were concerns about
possible sepsis given particularly the elevated lactate.
However, patient's blood cultures were negative. A
cortisol level was checked as patient's cortisol has been
_____________ in the past which were all within normal
limits. Possible concerns for hypotension with hypoxia
with aggressive positive pressure ventilation therefore
decrease in preload. Other thoughts were possible
pulmonary embolism which could possibly explain hypoxia
and hypotension. At any rate, however, by the time he
returned to the Emergency Department had pressures that
were running into the 80's and 90's which is near his
baseline. A further workup for pulmonary embolism was not
sought after. He needed to be heparinized for his
mechanical valve and for question of troponin leak. Given
the fact that they were concerned about preserving
possible kidney function, contrast dye with CT was not
desired. As mentioned above, the patient has low blood
pressures into the 70's and 80's but has been
asymptomatic. He will be given cautious amounts of a beta
blockade as per his initial outpatient regimen.
1. Congestive heart failure. Patient with a history of
cardiomyopathy of [**11-9**] percent and by time of Intensive
Care Unit evaluation was grossly overloaded although
compensated on positive pressure ventilation with sats in
the mid 90's. The patient was challenging in terms of
marginal blood pressures and also being anuric. Renal
team was consulted and patient underwent dialysis with
removal of approximately two liters with each session. He
will also continue on his Coreg and will continue on his
digoxin dosing by levels. At the current time he is being
dosed every three days.
1. Troponin leak. It is unclear the etiology of the
patient's troponin leak. His ECG is unremarkable for
impressive ischemic changes. Furthermore, he had a
catheterization in [**2153-3-26**] which was essentially
unremarkable. His CK's remained flat. He was given
aspirin and beta blockade and he was heparinized also in
the setting of having a subtherapeutic INR for his mitral
mechanical valve.
1. Subtherapeutic INR. As mentioned above, patient has
several reasons to be anticoagulated, namely atrial
fibrillation and his mechanical mitral valve. There is
also a question of troponin leak in an individual with
several high risk cardiovascular features. He was started
on heparin and was later converted to Coumadin at 1 mg q.
hs. His final dose of Coumadin remains to be determined
at this time. Again, it was a delicate balance between
making him therapeutic with INR avoiding supertherapeutic
given the fact that he has history of gastrointestinal
bleed. His goal INR will be 2 to 2.5 per review of all
notes from previous admissions.
1. Respiratory failure. As mentioned above, patient
initially admitted with hypoxia of unclear etiology. This
eventually improved with bag ventilation and by the time
of patient's arrival to the Intensive Care Unit he was
satting well into the mid 90's on his traditional assist
control ventilation. The patient has a history of being a
difficult wean from mechanical ventilation. The etiology
of his desaturation remains unclear. Several theories
have been proposed including mucus plugging, possible
pulmonary embolism or even a question of aspiration
pneumonia. He was dialyzed for his congestive heart
failure. His sputum ended up growing out Pseudomonas for
which he has been treated with Ceptaz. Furthermore, he
has been treated with intravenous heparin for his
subtherapeutic INR on mechanical valve. At the current
time he remains on positive pressure ventilation, assist
control with the use of a tracheostomy. It will be the
goal of the team possibly weaning him to pressure support
and then trach collar. Please see discharge diagnoses for
this information.
1. End-stage renal disease. The patient was followed by the
Renal team. During this admission he was dialyzed for
removal of excess fluid. Also during this admission,
discussions had been made for pursuit of a more long term
site for hemodialysis. He is to undergo vein mapping of
his upper extremities during this admission and presumably
Renal will be in touch with Transplant Surgery for
possible placement of a long term dialysis catheter.
1. Anemia. The patient did receive one unit of packed red
blood cells initially during his hospital course for a
hematocrit dropped into the mid 20's in the setting of
increased body fluids and also in the setting of a
troponin leak. His hematocrit had remained stable
thereafter. It is believed that his baseline hematocrit
is about 30. He is receiving Epogen at this time per
Renal recommendations. He has a history of
gastrointestinal bleeding but his stools have been guaiac
negative to this point.
1. Atrial fibrillation and mechanical valve. As mentioned
above, patient came in with subtherapeutic INR on Coumadin
for his mechanical valve. Given his history of
gastrointestinal bleed, suitable INR for him has been
changed to 2.5. His exact doses of Coumadin will be
dictated at the time of discharge.
1. Sacral decubiti. The patient has been evaluated by Wound
Care nurse and will begin receiving DuoDerm dressing
changes. He will also be started on long dose pain
regimen. The exact medication and doses will be dictated
at the time of discharge.
1. Question of depression. The patient was re-evaluated by
Psychiatry for question of depression. It is felt that a
large component of his depression is difficulty he has
dealing with his many severe medical conditions. At this
point his Lexapro will be increased from 10 to 15 mg q.
day.
1. Code status remains full at this point.
1. Access. Patient at this point continues with a left
subclavian Quinton catheter. As mentioned above, talks
have been initiated for looking into a longer term more
permanent access for his hemodialysis.
DISPOSITION: He will return to [**Hospital **] Rehabilitation.
CONDITION ON DISCHARGE: Fair.
DISCHARGE DIAGNOSES:
1. Hypoxia and respiratory failure of unclear etiology.
2. Transient hypotension.
3. Congestive heart failure.
4. End-stage renal disease.
5. Diabetes mellitus.
6. Depression.
7. Subtherapeutic INR for mitral mechanical valve.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **], [**MD Number(1) 4546**]
Dictated By:[**Last Name (NamePattern1) 11267**]
MEDQUIST36
D: [**2153-6-14**] 17:05:01
T: [**2153-6-14**] 17:59:04
Job#: [**Job Number 100558**]
ICD9 Codes: 4280, 4589, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3870
} | Medical Text: Admission Date: [**2161-1-25**] Discharge Date: [**2161-1-30**]
Service: NEUROSURGERY
Allergies:
Darvocet-N 100 / Codeine / Lactose
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Transfer with SAH and contusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
86 year old female presented s/p slip and fall on [**1-26**]. She
was seen at an outside hospital where a CT scan showed bilateral
SAH and a right sided contusion. The patient does not have a
headache or dizziness. She does have pain over her right hip and
under her right breast. She reports that she fell onto her right
side. The patient does not have chest pain or SOB.
Past Medical History:
dementia, cardiac disease, valvular heart disease,
arrhythmia, MVP, spinal stenosis, IBS, depression
Social History:
Nieces as HCP
Family History:
Not known
Physical Exam:
T:97.8 BP:112/61 HR:67 RR:16 O2Sats:98% 2LNC
Gen: Thin, elderly lady laying on the stretcher.
HEENT: Pupils: left surgical, left pinpoint EOMs-right eye
deviates to the right (this is an old finding)
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: Irregularly irregular.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. 2+ bilateral pedal edema.
Right lower extremity has an area of red discoloration.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Slightly difficult to understand her speech.
Cranial Nerves:
I: Not tested
II: Left pupil is surgical, right is pinpoint.
III, IV, VI: Right eye deviates to the right.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**6-1**] throughout. No pronator drift.
Sensation: Intact to light touch bilaterally.
Toes downgoing bilaterally
Pertinent Results:
[**2161-1-29**] 06:55AM BLOOD Plt Ct-169
[**2161-1-29**] 06:55AM BLOOD Glucose-116* UreaN-22* Creat-1.4* Na-146*
K-4.7 Cl-104 HCO3-34* AnGap-13
[**2161-1-29**] 06:55AM BLOOD Calcium-7.9* Phos-3.1 Mg-2.0
[**2161-1-29**] 06:55AM BLOOD CK-MB-17* MB Indx-16.0* cTropnT-0.76*
[**2161-1-28**] 03:30PM BLOOD CK-MB-NotDone cTropnT-0.04*
[**2161-1-26**] 04:51AM BLOOD Digoxin-1.0
[**2161-1-25**] 03:35AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Brief Hospital Course:
86 year old female presented s/p slip and fall om [**1-26**] and
suffered a bilateral SAH and a right sided contusion. She was on
Aspirin and Plavix. She had nieces as health care proxy and made
her wishes known to them that she would never want intubation.
She She had been experiencing worsening health and did not want
any life sustaining measures. She was monitored closely in the
ICU follow up head CTs were stable and eventually transferred to
the floor and was doing relatively well until [**1-28**] she
developed acute respiratory distress. In discussing her
condition with her family they decided to make the patient CMO.
She died on [**2161-1-30**].
Medications on Admission:
Digoxin 0.125 mg MWF
Aspirin 81 mg daily
Gabapentin 200 mg [**Hospital1 **]
Detrol 2 mg daily
Zoloft 25 mg daily
Plavix 75 mg daily
Famotidine 20 mg daily
Simvastatin 40 mg daily
Ferrous Sulfate 325 mg daily
Levothroid 25 milliequivalents daily
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Traumatic SAH and Contusions
Discharge Condition:
Expired
Discharge Instructions:
None
Followup Instructions:
None
Completed by:[**2161-3-5**]
ICD9 Codes: 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3871
} | Medical Text: Admission Date: [**2183-6-11**] Discharge Date: [**2183-7-1**]
Date of Birth: [**2128-1-12**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Sulfonamides
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion.
Major Surgical or Invasive Procedure:
[**2183-6-24**] - CABGx3 (Left internal mammary artery to left anterior
descending artery, vein graft to posterior descending artery,
vein graft to ramus)
[**2183-6-11**] - Cardiac Catheterization
History of Present Illness:
Ms. [**Known lastname 449**] is a 55 year-old female with a history of diabetes,
hypertension, hyperlipidemia and current tobacco use who
presents with dyspnea and chest discomfort for cardiac cath.
Recently admitted ([**2183-4-28**] - [**2183-5-2**]). At that time, she had
complaints of SOB, cough and chest discomfort. A pneumonia was
diagnosed. In addition, an echo was done and showed and LVEF of
40% with severe focal hypokinesis of the distal half of the
septum and apex. Since that admission, she underwent stress
testing which showed a reversible anterior wall and fixed apical
defects. LVEF was noted to be 31%.
Over the last two weeks, the patient notes worsening DOE and
occasional exertional chest discomfort. She can recall one
specific episode approximately 2 weeks ago when she had severe
DOE during which she could not walk more than [**3-15**] steps without
severe shortness of breath. She also noted "heart fluttering"
during this time. That evening she felt exhausted and slept for
the rest of the day.
In addition to the above, the patient also reports nightly PND
(wakes up hours after falling asleep). After waking, she will
sit up and her symptoms improve. She used one pillow at night.
She is being admitted for cardiac cath and possible PCI.
Past Medical History:
1. Coronary artery disease:
- Cardiac Risk Factors: (+)Diabetes, (+)Dyslipidemia,
(+)Hypertension, (+)Tobacco use
2. Diabetes mellitus: Diagnosed [**2170**]
- Complicated by neuropathy
- A1c ([**4-16**]) 10.4%
3. Hypertension
4. Hyperlipidemia
- TC 267, LDL 184, HDL 71, TG 58 ([**4-16**])
- Statin started [**4-16**]
5. Hypothyroidism
- TSH 8.7 ([**2-16**]) levothyroxine increased 150 --> 175mcg/day
6. Asthma
7. Depression
8. Hepatitis C:
- Genotype 3a
- Viral load 6,050,000 IU/mL ([**11-14**])
- Chronically elevated LFTs
- Albumin 3.2, INR 1.1 ([**6-16**])
- Liver bx ([**3-/2175**]): Portal chronic inflammation with lymphoid
nodule formation, interface hepatitis, increased fibrosis with
early septa, lobular necroinflammation activity and patchy
steatosis consistent with chronic hepatitis C, grade [**3-15**],
Stage2.
9. Alcohol and substance abuse (history of)
10. Arthritis
11. Uterine fibroid, s/p Myomectomy
12. s/p removal of a benign tumor from the back
13. s/p ear surgery
[**90**]. s/p resection of a benign cyst from the axilla
Social History:
Patient is single and lives alone. Her son [**Name (NI) **] [**Name (NI) 449**] will
accompany her to the hospital. He can be reached on his cell at
[**Telephone/Fax (1) 98624**] or at home: [**Telephone/Fax (1) 98625**]. Patient is followed by
Caregroup VNA. She has a smoking history (currently 1 pack every
other day); previously quit 5 years ago but restarted in [**2180**].
Previous history of alcohol and drug use; none for 16 years. She
is not currently working, in part because she has bad peripheral
neuropathy.
Family History:
No family history of cancer. No history of DM, HTN,
hyperlipidemia.
Physical Exam:
Physical exam on admission [**2183-6-11**]:
vitals - T 97.3, BP 127/50, HR 76, RR 16, 96% on 2 liters.
gen - obese female, lying flat in no distress
heent - no carotid bruits, no conjunctival palor, no icterus
cv - rrr, no murmurs, rubs, gallops, no S3/S4
pulm - clear bilaterally, no wheeze
abd - soft, non-tender, obese
ext - warm, 1+ edema bilaterally
pulses - 2+ femoral, DP/PT
groin - no hematoma, bruit, midly TTP
Discharge
Vitals 97, 135/73, 80 SR, 18, 98% RA, wt 111 kg
Neuro A/O x3 generalized weakness nonfocal
Pulm CTA except decrease left base
Cardiac RRR no murmur/rub/gallop
Sternal incision healing no erythema no drainage
Abd Soft, NT, ND, + BS BM [**7-1**]
Ext warm pulses palpable edema +2 L > R, blisters rt lle
Inc EVH left healing
Pertinent Results:
[**2183-6-30**] 08:03PM BLOOD WBC-12.6* RBC-3.27* Hgb-10.4* Hct-30.9*
MCV-94 MCH-31.9 MCHC-33.8 RDW-14.6 Plt Ct-286
[**2183-6-25**] 03:40AM BLOOD WBC-22.6* RBC-3.17*# Hgb-10.2*# Hct-29.3*
MCV-93 MCH-32.3* MCHC-34.9 RDW-15.6* Plt Ct-178
[**2183-6-11**] 07:50AM BLOOD WBC-13.8* RBC-4.21 Hgb-13.3 Hct-40.3
MCV-96 MCH-31.7 MCHC-33.1 RDW-14.3 Plt Ct-242
[**2183-6-19**] 04:56AM BLOOD Neuts-69.0 Lymphs-24.5 Monos-4.3 Eos-1.5
Baso-0.7
[**2183-6-30**] 08:03PM BLOOD Plt Ct-286
[**2183-6-28**] 04:50AM BLOOD PT-11.6 PTT-31.9 INR(PT)-1.0
[**2183-6-11**] 09:25AM BLOOD PT-12.5 PTT-37.4* INR(PT)-1.1
[**2183-6-11**] 07:50AM BLOOD Plt Ct-242
[**2183-6-30**] 08:03PM BLOOD Glucose-147* UreaN-16 Creat-0.9 Na-133
K-4.9 Cl-99 HCO3-25 AnGap-14
[**2183-6-11**] 09:25AM BLOOD Glucose-139* UreaN-18 Creat-0.8 Na-141
K-3.8 Cl-106 HCO3-26 AnGap-13
[**2183-6-25**] 09:13AM BLOOD ALT-61* AST-97* AlkPhos-97 Amylase-38
TotBili-0.6
[**2183-6-17**] 07:58AM BLOOD ALT-120* AST-122* LD(LDH)-375*
CK(CPK)-219* AlkPhos-205* Amylase-50 TotBili-0.4
[**2183-6-28**] 04:50AM BLOOD Calcium-7.7* Phos-3.6 Mg-2.2
[**2183-6-14**] 07:35AM BLOOD calTIBC-335 Ferritn-219* TRF-258
[**2183-6-11**] 09:25AM BLOOD %HbA1c-7.9*#
[**2183-6-11**] 09:25AM BLOOD Triglyc-94 HDL-58 CHOL/HD-2.5 LDLcalc-69
[**2183-6-14**] 07:35AM BLOOD Ammonia-111*
[**2183-6-11**] 09:25AM BLOOD TSH-6.0*
[**2183-6-14**] 07:35AM BLOOD AFP-5.6
RADIOLOGY Final Report
CHEST (PA & LAT) [**2183-6-30**] 8:53 AM
CHEST (PA & LAT)
Reason: evaluate effusion
[**Hospital 93**] MEDICAL CONDITION:
55 year old woman s/p cabg x3
REASON FOR THIS EXAMINATION:
evaluate effusion
HISTORY: 55-year-old woman status post CABG x3.
COMPARISON: [**2183-6-26**].
CHEST, PA AND LATERAL: Cardiac, mediastinal, and hilar contours
are stable status post median sternotomy and CABG. There is
stable enlargement of cardiac silhouette. Pulmonary vasculature
is unremarkable. The left hemidiaphragm appears elevated,
however, there is an increased distance between this contour and
the gastric bubble consistent with a subpulmonic effusion. This
is moderate in size. A small right pleural effusion is also
noted. There is associated left lower lobe atelectasis and right
mid lung linear atelectasis. Osseous and soft structures are
unchanged.
IMPRESSION: Moderate left and small right pleural effusions
which are larger than [**2183-6-26**]. Left effusion likely has
subpulmonic component.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 5004**] THAM
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**]
Approved: MON [**2183-6-30**] 4:37 PM
Cardiology Report ECG Study Date of [**2183-6-24**] 5:50:22 PM
Sinus rhythm
Delayed R wave progression - is nonspecific
Nonspecific T wave abnormalities - cannot exclude in part
ischemia - clinical
correlation is suggested
Since previous tracing of [**2183-6-20**], further ST-T wave changes
present
Read by: [**Last Name (LF) **],[**First Name3 (LF) 177**] W.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
77 154 76 [**Telephone/Fax (2) 98626**] 10 15
Cardiology Report ECHO Study Date of [**2183-6-24**]
PATIENT/TEST INFORMATION:
Indication: Abnormal ECG. Chest pain. Congestive heart failure.
Coronary artery disease. Shortness of breath.
Status: Inpatient
Date/Time: [**2183-6-24**] at 12:57
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007AW 1-:
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name (STitle) **] R. [**Doctor Last Name **]
MEASUREMENTS:
Left Ventricle - Ejection Fraction: 35% to 39% (nl >=55%)
Aorta - Valve Level: 2.4 cm (nl <= 3.6 cm)
INTERPRETATION:
Findings:
LEFT ATRIUM: Mild LA enlargement. No spontaneous echo contrast
in the body of
the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. Depressed LAA emptying velocity (<0.2m/s) Cannot
exclude LAA
thrombus.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No spontaneous
echo contrast
in the body of the RA. A catheter or pacing wire is seen in the
RA and
extending into the RV. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thicknesses and cavity size.
Moderate regional
LV systolic dysfunction. No LV mass/thrombus. Moderately
depressed LVEF.
Transmitral Doppler and TVI c/w Grade III/IV (severe) LV
diastolic
dysfunction.
LV WALL MOTION: Regional LV wall motion abnormalities include:
mid anterior -
hypo; mid anteroseptal - hypo; anterior apex - hypo; septal apex
- hypo; apex
- hypo;
RIGHT VENTRICLE: Mild global RV free wall hypokinesis. Focal
apical
hypokinesis of RV free wall.
AORTA: Simple atheroma in ascending aorta. Simple atheroma in
aortic arch.
Simple atheroma in descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Mildly thickened
aortic valve
leaflets (3). No AS. Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular
calcification. Trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. No TEE
related
complications. The patient received antibiotic prophylaxis. The
TEE probe was
passed with assistance from the anesthesioology staff using a
laryngoscope.
The patient was under general anesthesia throughout the
procedure.
Conclusions:
PRE-CPB: The left atrium is mildly dilated. No spontaneous echo
contrast is
seen in the body of the left atrium or left atrial appendage.
The left atrial
appendage emptying velocity is depressed (<0.2m/s). A left
atrial appendage
thrombus cannot be excluded. No spontaneous echo contrast is
seen in the body
of the right atrium. No atrial septal defect is seen by 2D or
color Doppler.
Left ventricular wall thicknesses and cavity size are normal.
There is
moderate regional left ventricular systolic dysfunction with
anteroapical and
antroseptal moderate hypokinesis.. There is mild hypokinesis of
the remaining
segments. No masses or thrombi are seen in the left ventricle.
Overall left
ventricular systolic function is moderately depressed.
Transmitral Doppler and
tissue velocity imaging are consistent with Grade III/IV
(severe) LV diastolic
dysfunction. There is mild global right ventricular free wall
hypokinesis.
There is focal hypokinesis of the apical free wall of the right
ventricle.
There are simple atheroma in the ascending aorta. There are
simple atheroma in
the aortic arch. There are simple atheroma in the descending
thoracic aorta.
There are three aortic valve leaflets. The aortic valve leaflets
(3) are
mildly thickened but aortic stenosis is not present. Trace
aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial
mitral regurgitation is seen.
POST-CPB: On infusions of epinephrine, milrinone, phenylephrine.
Improved
biventricular systolic function on inotropic support. LVEF now
45%.
Anteroapical and anteroseptal hypokinesis is improved. RV
systolic function is
normal with normal RV apical wall motion. MR is trace. AI is
trace. Post
decannulation contour of the aorta is preserved. LV diastolic
function is
improved post bypass on inotropes.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD on [**2183-6-24**] 16:05.
[**Location (un) **] PHYSICIAN:
Brief Hospital Course:
Ms. [**Known lastname 449**] was admitted to the [**Hospital1 18**] on [**2183-6-11**] for a cardiac
catheterization. This revealed left main and severe three vessel
coronary artery disease. Heparin was started given her ulcerated
left main disease. Given the severity of her disease, the
cardiac surgical service was consulted for surgical
revascularization. Ms. [**Known lastname 449**] was worked-up in the usual
preoperative manner. A carotid duplex ultrasound was obtained
which showed a 40-59% right internal carotid artery stenosis and
a less than 40% left internal carotid artery stenosis. Given her
history of hepatitis C, the hepatology service was consulted for
assistance in her care. A liver biopsy was obtained which showed
changes that were consistent with chronic viral hepatitis with
grade 2 inflammation/activity and stage 3-4 fibrosis. She was
classified as having Child's score A cirrhosis. Ms. [**Known lastname 449**]
developed blood in her stool on heparin and a gastroenterology
consult was obtained. An ultrasound of her abdomen was obtained
which showed a coarse liver with no change in a hyperechoic
lesion in the right lobe of liver which may represent a
granuloma or a scar from previous trauma. A CT scan was obtained
and showed no significant abnormalities or changes. A
colonoscopy and upper endoscopy were performed which showed
gastritis and diverticuli. A biopsy was obtained which showed an
adenoma which will need to be addressed following her heart
surgery. On [**2183-6-17**], Ms. [**Known lastname 449**] had an acute episode of pulmonary
edema requiring intubation and diuresis. She was successfully
extubated the following day. Haldol was used for aggitation and
the psychiatry service was consulted. Seroquel was added with
some improvement in her mood.
After her white blood cell count returned to [**Location 213**], she was
cleared for surgery. On [**2183-6-24**], Ms. [**Known lastname 449**] was taken to the
operating room where she underwent coronary artery bypass
grafting to three vessels. Postoperatively, she was taken to the
intensive care unit for monitoring. On postoperative day one,
Ms. [**Known lastname 449**] [**Last Name (Titles) 5058**] neurologically intact and was extubated. Beta
blockade, aspirin and a statin were resumed. Gentle diuresis was
initiated.Chest tubes on POD #2.pacing wires removed POD
#3.Transferred to the floor on POD #4 to begin increasing her
activity level. Cleared for discharge to rehab on POD #7. Pt. is
to make all follow-up appts. as per discharge instructions and
wear mammary support bra at all times.
Medications on Admission:
Medications on admission:
1. Aspirin 325mg daily every morning
2. Plavix 75mg daily every morning
3. Lipitor 40mg daily every morning
4. Atenolol 50mg daily every morning
5. Lisinopril 20mg, two tablets every morning
6. Furosemide 40mg daily every morning
7. Imdur 30mg daily every morning
8. Nitroglycerin SL 0.3mg as needed
9. Humulin N 60 units every morning, 30 units at 8pm
10. Humalog 20 units every morning
11. Sliding scale Humalog four times a day
12. Gabapentin 600mg two tablets three times a day
13. Glyburide 5mg daily every morning
14. Levoxyl 175mcg daily every morning
15. Bupropion SR 150mg daily every morning
16. Trileptal 300mg two tablets twice a day
17. Advair diskus 500-50 one puff twice a day
18. Albuterol nebulizer three to four times a day as needed
.
Medication on transfer to CCU:
ASA 325 po daily
Atorvastatin 40 mg po daily
Metoprolol 37.5 [**Hospital1 **] po daily
furosemide 40 mg po daily
Lisinopril 20 mg po daily
Isosorbide dinitrate 10 mg po tid
Gabapentin 1200 mg po tid
Oxcarbazine 600 mg po bid
Colace
Advair
Atrovent
Pantoprazole 40 mg po bid
Ativan prn
Supropion 150mg po qam
Levothyroxine 200 mcg po daily
SSI
NPH 60 qam 30 qpm
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
5. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
8. Levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
10. Bupropion 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO QAM (once a day (in the morning)).
11. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
13. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
14. Oxcarbazepine 600 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
15. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
16. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
17. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours).
18. insulin sliding scale
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Humalog Humalog Humalog Humalog
Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose
0-60 mg/dL 4 oz. Juice 4 oz. Juice 4 oz. Juice 4 oz. Juice
61-109 mg/dL 0 Units 0 Units 0 Units 0 Units
110-140 mg/dL 2 Units 2 Units 2 Units 2 Units
141-199 mg/dL 4 Units 4 Units 4 Units 4 Units
200-239 mg/dL 6 Units 6 Units 6 Units 6 Units
240-280 mg/dL 8 Units 8 Units 8 Units 8 Units
19. Insulin Glargine 100 unit/mL Solution Sig: Thirty Five (35)
35 units Subcutaneous once a day: QAM only.
20. Insulin Glargine 100 unit/mL Solution Sig: Thirty (30) 30
units Subcutaneous at bedtime: Q PM only.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] Rehabilitation & Nursing Center - [**Location (un) 538**]
Discharge Diagnosis:
CAD s/p CABGx3
Hyperlipidemia
HTN
Insulin dependent diabetes
Asthma
Prior alcohol and substance abuse
Hepatitis C
Hypothyroidism
Depression
Arthritis
obesity
diverticulosis
colon adenoma
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Please shower daily.
No bathing or swimming for 1 month. Use sunscreen on incision if
exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month.
7) Call with any questions or concerns.
8) WEAR MAMMARY SUPPORT BRA AT ALL TIMES.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] ([**Last Name (STitle) **]) in 1 month. Call ([**Telephone/Fax (1) 4044**]
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2183-7-14**]
11:50
Follow-up with cardiologist Dr. [**Last Name (STitle) **] in 2 weeks.
[**Telephone/Fax (1) 2934**]
Follow up in 4 weeks with GI Drs. [**Name5 (PTitle) 1940**]/Moss for colon adenoma
[**Telephone/Fax (1) 463**].
Completed by:[**2183-7-1**]
ICD9 Codes: 4280, 4111, 5715, 5849, 3572, 2449, 4019, 2724, 311, 412, 3051, 2930 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3872
} | Medical Text: Admission Date: [**2110-1-10**] Discharge Date: [**2110-1-12**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1899**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Cardiac Catheterization
History of Present Illness:
Mr. [**Known lastname 86602**] is a [**Age over 90 **] year old man with a PMHx s/f Afib, bladder
cancer, perioperative MI, glaucoma, and hypertension who
presented to BIDN with chest pain on the morning of [**2110-1-10**]. Mr.
[**Known lastname 86602**] noted "indigestion" for several hours, admitted this to
his daughter over the phone who called an ambulance. Upon
presentation to [**Hospital1 **] [**Location (un) 620**], he was initially found to be in
Vtach with HR to 200-210 and patient converted to NSR with 150mg
bolus of amiodarone. While patient was in Vtach, BP was stable
at 104/62. Once normal sinus rhythm was achieved, STE in the
inferior leads were apparent. Given ASA 325mg, and Heparin 5000
bolus. He was transferred to [**Hospital1 18**] for emergent catheterization.
.
Upon arrival to the cath lab, SBP was initially in the low 70's
following administration of nitro, but was fluid responsive to
SBP up to 120's now. Catheterization showed total occlusion of
the RCA with collaterals; there was minimal disease elsewhere.
.
Review of systems is positive for shortness of breath with stair
climbing, daily cough and rhinorrhea, as well as daily
palpitations.
.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema, or
presyncope. He denies any prior history of stroke, TIA, deep
venous thrombosis, pulmonary embolism, bleeding at the time of
surgery, myalgias, joint pains, hemoptysis, black stools or red
stools. He denies recent fevers, chills or rigors.
Past Medical History:
1. CARDIAC RISK FACTORS: Hypertension
2. CARDIAC HISTORY:
- MI in [**2106**]
- Afib
3. OTHER PAST MEDICAL HISTORY:
- Glaucoma
- Bladder Cancer
Social History:
Lives in [**Location **] with his wife, they are independent in
ADLS/IADLS. He is retired. He occasionally drinks alcohol
rarely. He smoked 30 pack years but quit 50 years ago. The rest
of review of system is negative.
Family History:
- Father died in 70s s/p CVA.
- Mother died in 40s of unknown cause
- No known early cardiac demise.
Physical Exam:
ADMISSION PHYSICAL EXAM:
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVD at mid-neck at 20 degrees.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
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+
.
DISCHARGE PHYSICAL EXAM: unchanged
Pertinent Results:
ADMISSION LABS:
[**2110-1-10**] 08:44PM BLOOD Hct-27.7* Plt Ct-193
[**2110-1-10**] 08:44PM BLOOD Glucose-134* UreaN-26* Creat-1.2 Na-139
K-3.7 Cl-106 HCO3-26 AnGap-11
[**2110-1-10**] 08:44PM BLOOD Albumin-3.2* Calcium-7.7* Phos-2.6*
Mg-1.8
[**2110-1-10**] 08:44PM BLOOD CK-MB-16*
.
DISCHARGE LABS:
[**2110-1-12**] 04:10AM BLOOD WBC-4.8 RBC-2.88* Hgb-8.1* Hct-25.1*
MCV-87 MCH-28.0 MCHC-32.1 RDW-15.4 Plt Ct-216
[**2110-1-12**] 04:10AM BLOOD PT-39.1* PTT-42.3* INR(PT)-3.8*
[**2110-1-12**] 04:10AM BLOOD Glucose-99 UreaN-24* Creat-1.2 Na-136
K-4.4 Cl-103 HCO3-27 AnGap-10
[**2110-1-12**] 04:10AM BLOOD ALT-22 AST-26 AlkPhos-40 TotBili-0.2
[**2110-1-12**] 04:10AM BLOOD TSH-1.5.
.
TTE [**1-11**]
The left atrium is elongated. Left ventricular wall thicknesses
and cavity size are normal. There is mild regional left
ventricular systolic dysfunction with distal inferior and apical
hypokinesis (distal LAD territory). The remaining segments
contract normally (LVEF = 55%). Right ventricular chamber size
and free wall motion are normal. The ascending aorta is mildly
dilated. The aortic arch 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
leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
There is an anterior space which most likely represents a
prominent fat pad.
IMPRESSION: Mild regional left ventricular systolic dysfunction,
c/w distal LAD disease. Aortic valve sclerosis without stenosis.
Mild pulmonary hypertension.
.
CXR [**1-11**]:
FINDINGS: There are no old films available for comparison. Heart
is upper
limits of normal in size. The aorta is minimally tortuous. There
are some
aortic calcifications. There is a small amount of volume loss at
both bases and minimal blunting of the CP angles. There are
degenerative changes of the spine with anterior osteophytes,
disc space narrowing, and sclerosis.
Brief Hospital Course:
Primary Reason for Hospitalization:
Mr. [**Known lastname 86602**] is a [**Age over 90 **] year old male with PMHx s/f CAD, AFib, and
prior bladder cancer who presents with VT following a STEMI.
Active Diagnoses:
# STEMI: Inferior STEMI likely [**1-9**] thrombosis. No intervenable
lesion on cath. No distal sites for re-anastomosis and patient's
age make him a poor candidate for CABG. TTE showed mild regional
LV systolic dysfunction, c/w distal LAD disease, aortic valve
sclerosis without stenosis and mild pulmonary HTN. Will start
medical management for MI. Patient was maintained on ASA 325mg
daily, plavix loaded and then 75mg daily, metoprolol 12.5 mg [**Hospital1 **]
titrated to HR 60, lisinopril 10mg, and atorvastatin 80mg. His
warfarin was held for supratherapeutic INR, and he was not put
on heparin as he was already anticoagulated.
# RHYTHM: Pt has history of CAD and prior perioperative NSTEMI
by report. Given that "indigestion" symptoms pre-dated his
palpitations, it is likely that his STEMI led to a focal area of
arrythmia. Also, the fact that his VT was quite regular is
somewhat indicative of a focal source as opposed to prior scar.
Given baseline symptoms of palpitations, chronic intermittent VT
caused by myocardial scarring from prior MI may have been
occurring. He was continued on metoprolol and his electrolytes
were repleted.
Chronic Diagnoses:
# HTN: He was continued on lisinopril and he remained
normotensive.
# HLD: He was started on atorvastatin in lieu of home dose of
simvastatin.
# Anemia: Ferrous sulfate was held in hospital to avoid
confusion with melena.
Transitional Issues:
He should receive cardiac rehab after f/u with primary
cardiologist.
Patient may benefit from echo in the future.
He will follow-up with PCP for INR check and re-starting
coumadin.
Medications on Admission:
- coumadin 6mg daily
- simvastatin 40mg daily
- lisinopril 10mg daily
- metoprolol succinate 25mg daily
- ferrous sulfate 650 mg daily
- [**Last Name (un) **] shell 500mg daily
- I-caps eye vitamins daily
Discharge Medications:
1. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. dorzolamide-timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
5. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H
(every 8 hours).
6. amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): 1 tablet twice daily for 2 weeks (last day [**1-26**]) then 1
tablet daily.
Disp:*60 Tablet(s)* Refills:*2*
7. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
9. Oyster Shell Calcium Oral
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: ST elevation myocardial infarction, Coronary artery
disease, ventricular tachycardia
Seconary: Hyperlipidemia, atrial fibrillation, glaucoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname 86602**],
It was a pleasure taking care of you during your
hospitalization. You were transferred to the [**Hospital1 18**] from our
[**Hospital 620**] campus after it was noted you were in an abnormal heart
rhythm known as ventricular tachycardia. This was secondary to
a heart attack you suffered. You were taken to the cath lab,
however there was no way to open up the blocked artery.
Therefore you were treated medically for your heart attack. You
were started on a medication called amiodarone to keep your
heart rhythm normal. You were also seen by our physical
therapists who felt you were safe to go home.
.
Your INR was elevated to 3.8 on your day of discharge. You
should hold your coumadin until you are able to get your INR
rechecked, which should be on Tuesday, [**2110-1-14**] at Dr.[**Name (NI) 86603**]
office.
.
We made the following changes to your medications:
STARTED
Atorvastatin 80mg by mouth daily
Aspirin 325mg by mouth daily
Amiodarone 200mg by mouth twice daily for 2 weeks (until
[**2110-1-26**]), then 200mg daily
Clopidogrel (Plavix) 75mg by mouth daily
.
DECREASED
lisinopril to 5mg daily
.
STOPPED
simvastatin - The atorvastatin replaces this
Coumadin - Stop taking this until told by Dr.[**Name (NI) 86603**] office
to restart it - this will be done by checking your INRs
.
Please continue your other medications as previously prescribed.
Followup Instructions:
You will need to follow up with Dr.[**Name (NI) 86603**] office on Tuesday
[**2110-1-14**] to have your INR checked. You will also need to schedule
an appointment with her to be seen in the next week. Please
call [**Telephone/Fax (1) 31529**] to schedule this appointment.
.
Please call Dr. [**First Name8 (NamePattern2) **] [**Last Name (STitle) 86604**] office at [**Telephone/Fax (1) 3342**] to schedule a
follow-up Cardiology appointment at [**Hospital1 18**] [**Location (un) 620**] in [**3-14**] weeks.
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 1905**]
Completed by:[**2110-1-13**]
ICD9 Codes: 4271, 412, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3873
} | Medical Text: Admission Date: [**2188-1-30**] Discharge Date: [**2188-2-13**]
Date of Birth: [**2112-8-23**] Sex: F
Service: MEDICINE
Allergies:
Ace Inhibitors / Neurontin
Attending:[**First Name3 (LF) 5037**]
Chief Complaint:
Ventral hernia, incisional hernia
Major Surgical or Invasive Procedure:
[**2188-1-30**] Laparoscopic Ventral hernia repair
History of Present Illness:
Ms [**Known lastname 106665**] is a 75 year-old female with ESRD s/p LRRT in [**2180**],
dCHF, and incisional hernia s/p previous repairs with
recurrence. She continues to have pain at the hernia site with
pressure or movement. She has also had some RLQ pain which
radiates to her groin. Otherwise she has been doing well with
just an occasional cough. Kidney function has been stable
Past Medical History:
ESRD s/p transplant ([**2180**])
CAD
Diastolic CHF
HTN
COPD
Chronic aortic dissection
GERD
moderate pulm HTN
PSH:
s/p TAH/BSO
s/p appy
s/p ventral hernia repair [**3-30**]
Social History:
Lives at home alone, but occasionally after hospitalizations has
stayed with her daughter/granddauthger. Currently has VNA s/p
recent hospitalization. Previously worked as a nurses aid.
-Tobacco history: +smokes [**2-29**] cigarettes a day
-ETOH: Endorses minimal EtoH use
-Illicit drugs: Denies
Family History:
monther with MI at 68, father with MI at 70
Physical Exam:
Gen: Elderly femle, minimal resp distress
Vitals: 150-160/70-80, RR 16-18, afebrile, 100% on face tent
HEENT: pallor present, no icterus
NEck: Supple, no LAD
Chest: Rales b/l bases
CVS: S1S2 rrr, no r/m/g
Abd: S, obese, mild to moderate tenderness with palpation, abd
banding present
Ext: 1 plus edema b/l LE
Pertinent Results:
Admission Labs:
[**2188-1-30**] 04:43PM BLOOD WBC-11.0 RBC-3.34* Hgb-10.1* Hct-30.3*
MCV-91 MCH-30.2 MCHC-33.3 RDW-16.9* Plt Ct-226
[**2188-1-30**] 04:43PM BLOOD Glucose-101* UreaN-54* Creat-2.3* Na-133
K-5.6* Cl-101 HCO3-22 AnGap-16
[**2188-1-30**] 04:43PM BLOOD Calcium-9.1 Phos-4.9* Mg-1.5*
Discharge Labs:
[**2188-2-11**] 05:20AM BLOOD WBC-12.5* RBC-3.51* Hgb-11.5* Hct-32.4*
MCV-92 MCH-32.7*# MCHC-35.4*# RDW-16.2* Plt Ct-385
[**2188-2-11**] 05:20AM BLOOD Glucose-127* UreaN-64* Creat-2.3* Na-132*
K-5.4* Cl-98 HCO3-25 AnGap-14
[**2188-2-11**] 05:20AM BLOOD Calcium-8.8 Phos-3.5 Mg-1.8
URINE STUDIES:
[**2188-2-8**] 07:55PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.011
[**2188-2-8**] 07:55PM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-LG
[**2188-2-8**] 07:55PM URINE RBC-3* WBC->182* Bacteri-MANY Yeast-NONE
Epi-3 RenalEp-<1
[**2188-2-8**] 07:55PM URINE WBC Clm-FEW Mucous-RARE
[**2188-2-8**] 07:55PM URINE Eos-POSITIVE
MICRO:
[**2188-2-4**] 2:06 am STOOL CONSISTENCY: SOFT Source: Stool.
**FINAL REPORT [**2188-2-4**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2188-2-4**]):
Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**2188-2-4**] 11:25AM.
CLOSTRIDIUM DIFFICILE.
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
(Reference Range-Negative).
A positive result in a recently treated patient is of
uncertain
significance unless the patient is currently
symptomatic
(relapse).
[**2188-2-8**] 7:55 pm URINE Source: CVS.
**FINAL REPORT [**2188-2-10**]**
URINE CULTURE (Final [**2188-2-10**]):
SERRATIA MARCESCENS. >100,000 ORGANISMS/ML..
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
SERRATIA MARCESCENS
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 128 R
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- <=1 S
IMAGING:
CT ABDOMEN/PELVIS [**2188-2-2**]:
The included portions of the lung bases demonstrate small
bilateral
pleural effusions, left greater than right with associated
atelectasis. There are dense calcifications of the aorta
extending throughout the intra-abdominal aorta to the iliac
arteries.
Within the abdomen and pelvis, the patient is status post repair
of an
anterior abdominal wall hernia. There is post-operative
subcutaneous
emphysema and fat stranding. A more focal 5.4 x 3.7 cm
collection with
air-fluid level is present in the anterior left lower
subcutaneous tissues
(2:40).
No focal liver lesion is seen. There may be some intrahepatic
biliary
dilation, though evaluation is limited on this non-contrast
examination.
Additionally, the CBD appears prominent measuring approximately
9 mm in
diameter. The gallbladder appears unremarkable. The spleen
appears unchanged with coarse calcification.
The native kidneys are atrophic with hypodensities consistent
with cysts.
Loops of small and large bowel are normal in size and caliber.
A trace amount of free fluid is present within the pelvis;
however, no large collection to explain hematocrit drop is seen.
No hematoma is identified.
There is a transplant kidney in the left lower quadrant. The
bladder contains a Foley catheter. Multiple foci of subcutaneous
emphysema are seen. A locule of air along the anterior abdominal
wall (2:51), could be within the abdomen, though would not be
unexpected given the recent surgery.
There is diffuse anasarca.
No concerning osseous lesion is seen.
IMPRESSION:
1. Postoperative changes (mesh placement) with subcutaneous
emphysema and
edema within the subcutaneous tissues of the anterior abdominal
wall,
bilaterally. A focal subcutaneous fluid collection with air
fluid level
measuring 5.4 x 3.7 cm may represent a postoperative seroma;
however, the
presence of infection cannot be excluded by CT.
2. No evidence of hematoma or collection to explain hematocrit
drop.
3. Mild intrahepatic biliary dilation. Mildly dilated CBD,
though not
significantly changed from prior examinations. If there is
clinical concern, a right upper quadrant ultrasound may be
performed.
4. Small bilateral pleural effusions, left greater than right.
5. Atrophy native kidneys with cysts; transplant kidney in left
iliac fossa.
TRANSPLANTED KIDNEY U/S [**2188-2-8**]:
The renal transplant is located in the left lower quadrant and
measures 10.7 cm. No hydronephrosis, stones, or masses are
observed. No perinephric fluid collection is seen. The urinary
bladder appearance is normal.
COLOR DOPPLER AND SPECTRAL WAVEFORM ANALYSIS: The MRV is patent
showing the normal flow direction.
The MRA is patent with normal peak systolic velocity.
The upper, mid, and lower pole of the renal arteries are patent,
showing RIs in the range of 0.78 to 0.83 that are minimally
higher in comparison to prior examination ( RI's in the range of
0.75-0.8).
IMPRESSION:
1. No evidence of hydronephrosis or perinephric fluid collection
in the
transplanted kidney.
2. Patent kidney vasculture.
3. Minimal interval increase in the RIs of the intrarenal
arteries.
Brief Hospital Course:
Primary Reason for Hospitalization:
75yoF admitted for elective laparoscopic ventral hernia repair
with mesh
Active Issues:
# Ventral Hernia Repair c/b acute on chronic diastolic heart
failure, c diff infection: Pt had laparoscopic ventral hernia
repair on [**2188-1-30**] by Dr. [**First Name (STitle) **]. She tolerated the procedure
well and was transferred to the PACU in stable condition. She
has had some abdominal pain since the procedure in the area of
her hernia repair. She had a repeat CT abdomen which showed no
evidence of abscess or other post-surgical complications. The
surgical service felt her pain did not warrant further surgical
intervention, and her pain was controlled with PO oxycodone. If
her pain is not well controlled on oxycodone at rehab hospital
would favor trial of PO dilaudid.
# Acute on chronic diastolic heart failure: She did well until
[**2-1**] when her urine output decreased to 10-15cc/hr. She received
IV fluids (total 3L NS), and the following morning was noted to
be in respiratory distress requiring O2 via NRB and hypertensive
to 200/100. CXR showed pulmonary edema, and ABG showed
metabolic and resp acidosis. She was transferred to TSICU for
respiratory support, was never intubated. She was diuresed with
IV lasix and started on nitro gtt for BP control, and she was
weaned to room air. TTE was consistent with moderate diastolic
dysfunction. She was called out to the floor on [**2-4**], breathing
comfortably on room air.
# Acute on chronic kidney disease: On POD#10 her creat increased
to 2.7 (baseline 2.2-2.4). She was transferred to the medical
service (transplant nephrology) for further evaluation. This
was felt most likely [**12-27**] diuresis since her urine output
decrease and urine lytes were consistent with pre-renal
etiology. Diuresis was held for a day and then resumed at her
home dose lasix 40mg PO daily. Her creat downtrended and was
2.0 on discharge. She was noted to have persistent mild
elevation in potassium (5.0-6.0), and was started on Kayexalate
15gm qMon and Thurs. She should have repeat potassium level
checked 2 days after discharge.
# Acute on chronic anemia: Pt sustained acute decrease in Hct
from 28.9 on [**2-1**] to 22.9 on [**2-2**]. CT abdomen/pelvis showed no
evidence of bleed. She received 2 units pRBCs and her Hct
responded appropriately and was stable for the remainder of her
hospitalization. Most likely the acute decrease was dilutional
in setting of receiving 3L fluid the previous night.
# C diff infection: Her course was complicated by c diff
infection, was initially treated with PO flagyl but this caused
nausea/vomiting and she was switched to PO vancomycin. She
should continue PO vancomycin until [**2188-3-3**] (2 weeks after her
course of cefpodoxime is completed).
# Serratia UTI: Pt developed dysuria and urine cultures from
[**2-8**] grew Serratia Marcescens which was sensitive to
cephalosporins. She was started on PO cefpodoxime, and she
should complete 10 day course (will be completed on [**2-18**]).
# HTN: Pt had hypertensive urgency on day of transfer to TSICU
with BP 200/100. Her BP improved on nitro gtt but remained
elevated after her home meds were resumed. Her labetolol was
increased to 200mg PO daily, and her amlodipine was switched to
Nifedipine CR 30mg daily. She was continued on her home Imdur
30mg daily. Her BP was well controlled on this regimen at time
of discharge.
Chronic Issues
# CAD: Continued home ASA.
# GERD: Continued home omeprazole.
Transitional Issues:
-Medication changes: STARTED cefpodoxime for UTI, PO vancomycin
for c diff infection, tylenol and oxycodone for pain, kayexolate
for high potassium, sodium bicarb tablets, CHANGED labetolol to
200mg PO BID, switched amlodipine to nifedipine CR.
-If abdominal pain not well controlled by oxycodone would
recommend trial of PO dilaudid for better pain control.
-She has f/u appts scheduled in transplant surgery and renal
transplant clinics.
-She should have repeat potassium level checked on [**2188-2-15**], and
repeat creatinine level checked within the next week.
-She maintained full code status throughout hospitalization.
Medications on Admission:
Albuterol
alendronate 35 mg qweek
amlodipine 2.5 mg po daily
azathioprine 50 mg po daily
calcitriol 0.25 mcg po daily
Sensipar 30 mg po daily
citalopram 10 mg po daily
Aranesp monthly injection
Lasix 40 mg po daily
Isordil 30 mg po daily
labetalol 100 mg po bid
nitroglycerin SL prn
omeprazole 20 mg po daily
Prograf 5 mg po bid
aspirin 81 mg po daily
multivitamins
iron
Discharge Medications:
1. citalopram 10 mg Tablet Sig: One (1) Tablet PO once a day.
2. cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
6. azathioprine 50 mg Tablet Sig: One (1) Tablet PO once a day.
7. labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. fluticasone 50 mcg/actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
9. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
10. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation every four (4) hours as needed for
shortness of breath or wheezing.
11. alendronate 35 mg Tablet Sig: One (1) Tablet PO once a week.
12. azathioprine 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Aranesp (polysorbate) 150 mcg/0.3 mL Syringe Sig: One (1)
injection Injection once a month.
14. Lasix 20 mg Tablet Sig: Two (2) Tablet PO once a day.
15. ipratropium bromide 17 mcg/actuation HFA Aerosol Inhaler
Sig: Two (2) puffs Inhalation four times a day.
16. Kayexalate Powder Sig: Fifteen (15) gm PO On Monday and
Thursday.
17. nifedipine 30 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO DAILY (Daily).
18. tacrolimus 5 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
19. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
20. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 19 days: Last day [**2188-3-3**].
21. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
22. cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO once a day
for 5 days: Take until [**2-18**].
23. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
24. sodium bicarbonate 650 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
25. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual q5min as needed for chest pain: Use q5min for 3 doses
prn chest pain.
26. multivitamin Tablet Sig: One (1) Tablet PO once a day.
27. ferrous gluconate 324 mg (37.5 mg iron) Tablet Sig: One (1)
Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
Roscommon on the Parkway - [**Location 1268**]
Discharge Diagnosis:
Ventral Hernia repair
C.diff infection
Acute on chronic diastolic heart failure
Urinary tract infection
S/p renal transplant
Acute on chronic kidney failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname 106665**],
You were admitted to [**Hospital1 18**] for elective hernia repair. While
here, you developed difficulty breathing due to fluid in your
lungs and required observation in the ICU for a short period of
time. You improved with IV lasix. You also developed an
infection in your colon and a urinary tract infection which are
being treated with antibiotics.
Please note the following changes to your medications:
-START cefpodoxime to treat urinary tract infection
-START oral vancomycin to treat the infection in your colon
-START nifedipine for blood pressure and STOP amlodipine
-START tylenol and oxycodone for pain
-START kayexalate for high potassium
-START sodium bicarb tablets
-INCREASE labetolol to 200mg twice daily
We made no other changes to your medications while you were in
the hospital. Please continue taking the rest of your
medications as prescribed by your outpatient providers.
Please call the transplant office [**Telephone/Fax (1) 673**] if you develop
any of the following: temperature of 101 or greater, chills,
nausea, vomiting, Increased abdominal pain, abdominal
distension, incision redness/bleeding/ drainage or worsening
diarrhea.
Please see below for your currently scheduled appointments at
[**Hospital1 18**].
It has been a pleasure taking care of you and we wish you a
speedy recovery.
Followup Instructions:
You are scheduled for the following appointments at [**Hospital1 18**]:
Department: TRANSPLANT CENTER
When: MONDAY [**2188-2-25**] at 8:45 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: TRANSPLANT CENTER
When: FRIDAY [**2188-2-29**] at 8:40 AM
With: [**Name6 (MD) 2105**] [**Name8 (MD) 2106**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**2188-3-31**] 10:00a BRAIN,[**First Name8 (NamePattern2) 1238**] [**Last Name (NamePattern1) 1239**]
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
[**Name8 (MD) 191**] [**Hospital **] CLINIC
[**Name6 (MD) 2105**] [**Name8 (MD) 2106**] MD [**MD Number(2) 5038**]
ICD9 Codes: 5990, 2761, 5849, 4280, 496, 4168, 3051, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3874
} | Medical Text: Admission Date: [**2104-1-30**] Discharge Date: [**2104-3-24**]
Date of Birth: [**2029-8-6**] Sex: F
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: The patient is a 74 year old
female transferred from [**Hospital 2523**] Hospital with complaint of
shortness of breath and chest pain. The patient was admitted
to [**Hospital 2523**] Hospital for right lower extremity cellulitis and
was started on Unasyn. During her admission there, she
developed shortness of breath and substernal chest pain and
desaturation on room air. The patient was then transferred
to [**Hospital6 256**] for further
evaluation and management. Upon admission, the patient
appeared to have an acute myocardial infarction and unstable
angina.
PAST MEDICAL HISTORY: The patient is a 74 year old woman
who, in [**2089**], underwent an aortic valve replacement and
coronary bypass grafting. She subsequently developed
unstable angina. Catheterization showed severe three vessel
disease. EF of approximately 45%. The aortic valve
prosthesis, which was a St. Jude's valve, was in good working
order on admission.
HOSPITAL COURSE: She was taken by Dr. [**Last Name (STitle) **] to the
Operating Room and underwent a redo coronary artery bypass
graft x 3; left internal mammary artery to left anterior
descending artery, saphenous vein to diagonal branch and
saphenous vein graft to posterior descending coronary artery.
The patient also was placed on an intra-aortic balloon pump
by her femoral artery on [**2104-2-5**], by Dr. [**Last Name (STitle) **].
Unfortunately, the patient has severe lower leg cellulitis
requiring treatment prior to bypass surgery. She has a
history of severe peripheral vascular disease and therefore,
intra-aortic pump was not placed.
The patient was taken to the Operating Room by Dr. [**Last Name (STitle) **] on
[**2104-2-5**], and underwent a redo coronary artery bypass
grafting x 3 for left internal mammary artery to the left
anterior descending, saphenous vein graft to diagonal branch
and saphenous vein graft to posterior descending coronary
artery.
Postoperatively, she was placed on Vanco and
levofloxacin for her cellulitis.
On postoperative day #1, the patient had an intra-aortic
balloon pump in place and was placed on pressor in the CSRU.
On postoperative day #2, the patient was reintubated for
ventilatory difficulties. Subsequently, the patient also
went into A fib and on postoperative day #4, the patient was
cardioverted to sinus for A fib, unresponsive to Amiodarone.
She was taken back to the cath lab where several grafts were
foun occluded. She underwent PTCA and stenting of the LIMA
graft and the LM artery..
Also, her postoperative course was complicated by renal
failure. On [**2-15**], she had a Quinton dialysis catheter
placed in the right groin. She tolerated the procedure well
but subsequent dialysis was not required.
Also, on [**2-12**], Infectious Disease recommended Flagyl
for her diarrhea.
Throughout her course, the patient was extubated on [**2-7**]. Subsequently, her course was
complicated by fluid overload,
PMVT arrest, bacteremia. The patient was extubated again on
[**2104-2-21**], and Dobbhoff that was placed became clogged
and was d/c'd. The patient failed speech and swallow study
because of aspiration within liquids. The study was done on
[**2104-1-30**]. Subsequently, the patient was recommended
for percutaneous endoscopic gastrostomy placement and
tracheostomy.
Due to her recurrent failure of extubation, Dr. [**Last Name (STitle) **] placed
a percutaneous tracheostomy tube and flexible bronchoscopy on
[**2104-3-3**]. The procedure went well. On the
following day, [**2104-3-4**], the patient underwent a
percutaneous gastrostomy tube placement in the Operating
Room. After the placement of a percutaneous endoscopic
gastrostomy, the patient was started on gastric feeds, and
the patient appeared to be tolerating gastric feeds well.
.
And also throughout her course, she was placed on
Plavix for her coronary artery stents and poor small vessels
The patient is status post coronary artery bypass graft
complicated by early graft closure and also had left main
percutaneous transluminal coronary angioplasty stents, left
internal mammary artery percutaneous transluminal coronary
angioplasty stents and diagonal percutaneous transluminal
coronary angioplasty stents postoperative. Her EF was less
than 20%.
Postoperative course was also complicated by arrhythmia and
over time her renal status appeared to be improving and
eventually her creatinine had come down to baseline of 1.5
and she began to make urine with Lasix.
On [**2104-2-20**], the patient is status post stenting.
Postoperative day #12, status post coronary artery bypass
graft x 3 and stenting. The patient developed a rectus
sheath hematoma and was required two units of transfusion.
General Surgery was consulted. Apparently the bleeding
appeared to be stable and it stopped on its own. The patient
did not require operation at that time.
Given the patient's frequent arrhythmia, the patient was
taken by EP to have an AICD placed on [**2104-2-22**]. On
the 27th, electrocardiogram showed she has a ventricular
paced rhythm with 100% capturing.
The patient developed VT arrest after trach. At the same
time, the patient was on vancomycin and Flagyl for
antibiotic coverage. The patient had a Portacath catheter
placed on the [**3-7**]. The patient was also started
on a Heparin drip for anticoagulation.
The patient had AICD placed on [**2104-3-12**], and
postoperative day #1 after AICD placement, the patient had an
V tach and continued to have irregular rhythm. An
echocardiogram was performed on the [**3-14**], which
showed a thrombus at her St. Jude's valve. The patient
underwent a TPA of thrombus. Post TPA echocardiogram showed
mild to moderate aortic regurgitation; mitral valve leaflets
are mildly thickened. There is no mitral valve prolapse.
Mild to moderate mitral regurgitation and no pericardial
effusion. The gradient across the aortic valve has appeared
to be decreased to approximately 28 with intravenous TPA.
At this time, the patient remained in the CSRU on trach and
tolerating the percutaneous endoscopic gastrostomy tube and
her AICD. She is being AV paced with AICD at heart rate of
approximately 105.
Post TPA, the patient course was complicated by hematoma at
her AICD site over her left subclavian site. The patient
underwent a hematoma evacuation on [**2104-3-18**].
Postoperatively, the patient did well.
The patient was deemed ready for discharge at this time.
Prior to her discharge, the patient was afebrile. Vital
signs were stable. Chest was clear. Abdomen was soft,
nontender, nondistended.
The patient was tolerating percutaneous endoscopic
gastrostomy feed and she is getting ProMod with fiber at full
strength at 55 cc an hour. The patient's AICD was turned
on by Cardiology of AV pacing to a rate of 90. The patient
tolerated that for about a week and appeared to be tolerating
that and stable on the current AICD settings.
The patient is pending rehabilitation bed at this time.
Please have the patient call the Electrophysiology Service,
attending, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 284**], for follow up appointments
with AICD and upon her discharge from rehabilitation, please
have her contact Dr. [**Last Name (STitle) **] for follow up appointments. The
patient had a tracheostomy #7 and per
Respiratory Therapy, please
always deflate cuff prior to placing the
valve and monitor O2 sats and respiration while valve in
place. Take the valve off while no one is supervising her.
Do not allow the patient to sleep with the valve in place.
PNB wean schedule is up to the discretion of the Nurse's and
the Respiratory Therapist at rehabilitation facility.
DISCHARGE DIAGNOSIS:
1. Status post coronary artery bypass graft x 3.
2. Status post percutaneous endoscopic gastrostomy.
3. Status post trach.
4. Status post AICD placement.
5. TPA of thrombosed aortic valve.
6. Status post hematoma evacuation.
7. Coronary artery disease.
8. Acute renal failure.
9. Diabetes mellitus.
10. Hypertension.
11. Chronic respiratory insufficiency.
12. Mechanical ventilation dependency.
DISCHARGE MEDICATIONS: The patient is to be discharged with:
1. Spironolactone 25 mg p.o. q d.
2. Lasix 80 mg intravenous t.i.d.
3. Amiodarone 400 mg p.o. q d.
4. Levothyroxine 25 mcg p.o. q d.
5. Ascorbic Acid 500 mg per nasogastric tube q d.
6. Multi-vitamin 5 mg per nasogastric tube q d.
7. Zinc Sulfate 220 mg per G tube q d.
8. Percocet Elixir 5 mg per G tube q 4 to 6 hours prn.
9. Glipizide 10 mg p.o. b.i.d.
10. Aspirin 325 mg per G tube q d.
11. Prevacid 30 mg per G tube q d.
12. Albuterol one to two puffs q 4 hours prn.
13. Coumadin 2 mg p.o. q hs.
14. Thyroxalin 5 mg p.o. q d.
15. The patient is to be discharged with ProMod with fiber at
full strength at 55 cc an hour.
DISCHARGE INSTRUCTIONS: Please check INR and adjust Coumadin
level for a target range of INR of 3 for her prosthetic
aortic valve. She had to finish a 30 day course of Plavix
and will no longer be requiring Plavix per Cardiology.
The patient is deemed ready for discharge.
Dictated By:[**Location (un) 31605**]
MEDQUIST36
D: [**2104-3-20**] 17:48
T: [**2104-3-20**] 19:00
JOB#: [**Job Number 31606**]
ICD9 Codes: 4271, 2762 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3875
} | Medical Text: Admission Date: [**2136-6-29**] Discharge Date: [**2136-7-4**]
Date of Birth: [**2087-9-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2136-6-29**] CABGx2 (SVG->LAD, SVG->OM)
History of Present Illness:
Mr. [**Name (NI) 39544**] is a 48-year-old, obese, diabetic male who suffers
from Hodgkin disease and had radiation therapy to his
mediastinum. Recently he complains of progressive dyspnea on
exertion.He underwent an abnormal exercise tolerance test in
[**Month (only) 956**] and subsequently underwent a cardiac catheterization
which revealed left main and two vessel disease. He was thus
referred to Dr. [**Last Name (STitle) **] for surgical revascularization.
Past Medical History:
Hodgkins lymphoma s/p radiation and chemotherapy
Left thoracotomy w/ division of left internal mammary artery
Diabetes
Hypercholesterolemia
Hypertension
Hypothyroid
Social History:
Married. Lives with wife and four children.
Family History:
Father with CABG at age 85
Physical Exam:
GEN: WD/WN in NAD
SKIN: Well healed left thoracotomy. No rash or lesions
HEENT: Benign
NECK: NO JVD
HEART: RRR, Normal S1-S2, no murmur
LUNGS: Clear
ABD: Benign
EXT: No varicosities, no edema.
NEURO: Nonfocal
Pertinent Results:
[**2136-7-3**] 06:10AM BLOOD WBC-8.3 RBC-3.12* Hgb-9.1* Hct-27.3*
MCV-88 MCH-29.3 MCHC-33.5 RDW-14.9 Plt Ct-296
[**2136-7-3**] 06:10AM BLOOD Plt Ct-296
[**2136-7-4**] 05:55AM BLOOD UreaN-21* Creat-1.0 K-4.1
[**2136-7-1**] 06:12PM BLOOD Glucose-184* K-3.8
[**2136-7-2**] CXR
1. Right internal jugular venous access catheter in stable
position.
2. Low lung volumes with slight increase in bibasilar
atelectasis.
3. Stable bilateral pleural effusions
[**2136-6-30**] EKG
Compared to the previous tracing the sinus rate is slightly
faster and there are subtle repolarization changes in leads I
and avL consistent with lateral ischemia. The P-R interval is
marginally shorter.
[**2136-6-29**] Pathology
Mediastinal lymph node - Pending
Brief Hospital Course:
Mr. [**Name (NI) 39544**] was admitted to the [**Hospital1 18**] on [**2136-6-29**] and taken directly
to the operating room where he underwent coronary artery bypass
grafting to two vessels. Postoperatively he was taken to the
cardiac surgical intensive care unit for monitoring. On
postoperative day one, Mr. [**Name (NI) 39544**] [**Last Name (Titles) 5058**] neurologically intact and
was extubated. He was then transferred to the cardiac surgical
step down unit for further recovery. Mr. [**Name (NI) 39544**] was gently
diuresed towards his preoperative weight. The physical therapy
was consulted for assistance with Mr. [**Name (NI) 39545**] postoperative
strength and mobility. His wires and drains were removed per
protocol. Beta blockade was titrated for optimal heart rate and
blood pressure control. As his diet improved, his preoperative
oral diabetes medications were resumed. Mr. [**Name (NI) 39544**] continued to
make steady progress and was discharged to his home on
postoperative day five. He will follow-up with Dr. [**Last Name (STitle) **], his
cardiologist and his primary care physician as an outpatient.
Medications on Admission:
Gemfibrozil 600mg [**Hospital1 **]
Metformin 500mg [**Hospital1 **]
Lipitor 40mg QD
Synthroid 150mcg QD
Folic acid 1mg QD
Amaryl 8mg QD
Avandia 8mg QD
Wellbutrin SR 150mg [**Hospital1 **]
Verapamil 240mg QD
HCTZ 12.5mg QD
Celexa 20mg QD
Atenolol 25mg QD
Discharge Medications:
1. 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:*4*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
3. Citalopram Hydrobromide 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Levothyroxine Sodium 150 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
7. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO BID (2 times a day).
Disp:*60 Tablet Sustained Release(s)* Refills:*2*
10. Avandia 4 mg Tablet Sig: Two (2) Tablet PO once a day: At
noon/Lunch time.
Disp:*60 Tablet(s)* Refills:*2*
11. Amaryl 4 mg Tablet Sig: Two (2) Tablet PO once a day: At
noon/lunchtime.
Disp:*60 Tablet(s)* Refills:*2*
12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day: In
evening.
Disp:*30 Tablet(s)* Refills:*2*
13. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 3 days: Take for three days then stop.
Disp:*6 Tablet(s)* Refills:*0*
14. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 3 days: Take for three days with lasix,
then stop.
Disp:*6 Packet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Coronary artery disease, s/p CABG x2 (SVG->LAD, SVG->OM)
PMH:^chol, HTN, Hodgkin's s/p XRT/chemo, DM2, Hypothyroid, s/p
Lft thoracotomy
Discharge Condition:
Good
Discharge Instructions:
1) Please monitor wounds for signs of infection. These include
redness, drainage or increased pain.
2) Monitor weights. Report any weight gain greater then 2 pounds
in 24 hours.
3) Report any fever greater then 100.5.
4) No lifting more then 10 pounds for one month. No driving for
one month.
5) Do not apply lotions, creams or powders to wound for 6 weeks.
Use sunscreen on wound when in sun thereafter.
6) Take lasix and potassium twice daily for three days then
stop.
7) Call with any questions or concerns.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] in 6 weeks. Call for appointment.
Follow-up with your cardiologist Dr. [**Last Name (STitle) 2912**] in 2 weeks.
Follow-up with your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in [**1-27**]
weeks.
Please call to schedule all appointments.
Completed by:[**2136-7-4**]
ICD9 Codes: 2720, 4019, 2449, 4111 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3876
} | Medical Text: Admission Date: [**2180-8-6**] Discharge Date: [**2180-8-24**]
Date of Birth: [**2100-5-15**] Sex: M
Service: MEDICINE
Allergies:
Iodine-Iodine Containing / Procainamide / Cephalosporins
Attending:[**First Name3 (LF) 2265**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
PICC line placement
History of Present Illness:
79-year-old male with ischemic CHF NYHA IV (EF 30%), BiV ICD,
pAFIB, CKD (Cr 1.6-1.8), hx of LGIB (angioectasia colonoscopy
[**2179**]), presenting with worsening fatigue and dyspnea, and a 20lb
weight gain over 2 months. Last discharge from [**Hospital1 18**] in early
[**Month (only) **] after a prolonged hospitalization for CHF exacerbation.
Closely monitored via home visits by [**First Name4 (NamePattern1) 2147**] [**Last Name (NamePattern1) 107826**], NP. Weight
has been steadily increasing, as diuretics were decreased due to
low blood pressures. Fatigue and dyspnea have also worsened
though he has remained ambulatory and independent. On morning of
admission, he was able to slowly get to the bathroom with walker
as well as dress himself, though complaining of significant
fatigue.
.
In the ED, initial vitals were 98.3 80 114/61 18 98% 2L Nasal
Cannula
and exam showed he was breathing comfortably when HOB >45
degrees (but not flat); no respiratory distress but
uncomfortable. Rales at bases.(+)LE edema to thighs. CXR was
unremarkable. Labs significant for K of 6.8 and a Cr of 2.0.
Patient given 40mg IV lasix and put out 200cc of urine. Also
given Ca gluconate, kayexalate, insulin/D50.
Vitals on transfer were T97.8, HR 84, BP 95/61, RR 15, POx
100%RA.
.
On arrival to the floor, patient was somnolent but arousable.
Complaining of dyspnea. No other complaints.
Past Medical History:
1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
--- CHF (NYHA class IV, ACC/AHA stage D) - LVEF 30%
--- Atrial Fibrillation
- CABG: Yes, [**2152**]
- PERCUTANEOUS CORONARY INTERVENTIONS: None.
- PACING/ICD: Bivalve pacemaker and ICD
3. OTHER PAST MEDICAL HISTORY:
- dysphagia with large C3 osteophyte
- G-tube
- Pulmonary fibrosis
- Chronic GI bleeds
- Peripheral vascular disease
- Anemia
- Obesity
- Sleep apnea
- Restless legs syndrome
- Colonic Polyp
- Gout
- Lumbar spinal stenosis
- Nephrolithiasis
Social History:
Occupation: Retired security guard, worked at a pharmaceutical
company with chemical exposure. Lives with wife in [**Name (NI) 1468**].
Ambulatory with a walker at home.
Family: Married
Tobacco history: Smoked from age 6-35; quit at 35.
ETOH: 1-2 drinks per month.
Illicit drugs: Denies.
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: 97.2 116/49 70 18 98%
GENERAL: fatigued and difficult to arouse. Oriented x3. NAD.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple, no JVP
CARDIAC: irregularly irregular, no murmurs rubs gallops
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Significant crackles
lower [**1-3**] bilaterally
ABDOMEN: Soft, NTND. No HSM or tenderness. G-tube in place,
erythematous with drainage of pus
EXTREMITIES: 2+ edema R>L
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
DISCHARGE
temp 96.7 HR 67 BP 85/41 O2 Sat 99% on 2L NC RR 12
GENERAL: alert and oriented x3 , fatigued, breathing comfortably
on RA
HEENT: Sclera anicteric. PERRL, EOMI. Conjunctiva were pink,
mild oral cyanosis.
NECK: Supple, JVP mildly elevated above clavicle
CARDIAC: tachy, irregular rhythm, 2/6 systolic murmur loudest in
the aortic band
LUNGS: Resp were unlabored, no accessory muscle use. No
wheezes/rhonchi/rales
ABDOMEN: Soft, mildly distended. No HSM or tenderness.
EXTREMITIES: warm, trace edema to the knees bilaterally
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas
Pertinent Results:
Admission Labs:
[**2180-8-6**] 12:38PM WBC-9.2 RBC-3.25* HGB-9.5* HCT-30.3* MCV-93
MCH-29.2 MCHC-31.3 RDW-22.2*
[**2180-8-6**] 12:38PM PLT COUNT-201
[**2180-8-6**] 12:38PM GLUCOSE-113* UREA N-78* CREAT-2.0* SODIUM-133
POTASSIUM-6.8* CHLORIDE-96 TOTAL CO2-25 ANION GAP-19
[**2180-8-6**] 03:51PM K+-5.3
[**2180-8-6**] 12:38PM PT-16.7* PTT-26.3 INR(PT)-1.5*
Pertinent Labs:
Cardiac Enzymes
[**2180-8-6**] 12:38PM BLOOD CK-MB-2 cTropnT-0.02* proBNP-2294*
[**2180-8-7**] 01:40AM BLOOD CK-MB-2 cTropnT-0.03*
[**2180-8-7**] 07:35AM BLOOD CK-MB-2 cTropnT-0.03*
Discharge Labs:
[**2180-8-18**] 02:31AM BLOOD WBC-7.5 RBC-2.87* Hgb-8.3* Hct-25.4*
MCV-89 MCH-29.0 MCHC-32.7 RDW-19.9* Plt Ct-307
[**2180-8-18**] 02:31AM BLOOD Glucose-156* UreaN-120* Creat-1.4* Na-143
K-5.3* Cl-93* HCO3-48* AnGap-7*
[**2180-8-18**] 02:31AM BLOOD Calcium-9.3 Phos-3.0 Mg-3.2*
[**2180-8-17**] 05:40AM BLOOD Type-[**Last Name (un) **] pO2-37* pCO2-68* pH-7.50*
calTCO2-55* Base XS-24
EKG [**2180-8-6**]: Probable atrial fibrillation with rightward axis.
Right bundle-branch block and intermittent demand ventricular
pacing. Compared to the previous tracing of [**2180-5-15**] no
significant change other than atrial fibrillation with a
moderately fast ventricular response.
Imaging:
CXR PA and LAT [**2180-8-6**]: PA and lateral radiographs demonstrate
unremarkable mediastinal and hilar contours. Cardiac silhouette
demonstrates stable enlargement. Biventricular pacemaker leads
are identified with leads positioned in the right atrium and
bilateral ventricles. Sternotomy sutures are midline and intact.
There is stable background of increased interstitial markings
consistent with the fibrotic lung changes identified on the [**5-14**], [**2180**] chest CT. There is a stable increased opacity at the
right lung base, which appears to correspond to more confluent
fibrotic changes identified on the prior CT. The bilateral
costophrenic angles are minimally blunted, which may reflect
scarring and chronic change, but trace pleural effusions may be
present. No pneumothorax is evident. Overall exam is relatively
unchanged compared to [**5-14**] and 28, [**2180**].
CT ABD & PELVIS [**2180-8-7**] W/O CONTRAST:
IMPRESSION:
1. Increased opacification in bilateral lower lobes including
ground-glass
opacification, consolidation and interlobular septal thickening
may represent pulmonary edema superimposed on background lung
disease; however, underlying infection cannot be completely
excluded in the correct clinical setting.
2. Foci of air in the subcutaneous fat likely represent
injection sites, but clinical correlation is recommended.
3. G-tube site is in normal position with no adjacent focal
fluid
collections.
4. Simple left renal cyst is noted.
5. Anasarca including a small quantity of ascites.
Brief Hospital Course:
Primary Reason for Hospitalization:
80 yo M with severe ischemic cardiomyopathy, atrial
fibrillation, and a biventricular pacemaker admitted for
worsening of his CHF, with a 20lb weight gain, dyspnea and
significant edema.
.
Active Issues:
# Goals of care: Palliative care was consulted to assist with
clarifying the patient and family's wishes regarding his goals
of care. He was often reluctant to participate in these
discussions and expressed that he would prefer his wife make
these decisions. His wife expressed understanding that his CHF
was endstage but did not want the focus to be on end-of-life but
rather on allowing him to live as well as possible. They agreed
that they would not want him to be intubated, and his code
status was changed to DNR/DNI. ICD was disabled, but continued
pacing because it may improve his symptoms. They also decided
that he would not be re-admitted to the hospital. On discharge,
it was decided that patient would go to inpatient hospice care
and prescriptions for PO morphine and lorazepam were given for
hospice care.
#Congestive Heart Failure with pulmonary edema- The patient was
not able to be diuresed on the floor due to hypotension, and was
transferred to the CCU for IV dopamine with lasix drip as
similar support was required for successful diuresis in the
past. It was determined his oral lasix regimen was no longer
effective and that his congestive heart failure was end stage.
Furthermore in order to keep the patient comfortable he would
likely require IV lasix at home. Palliative care was consulted
to facilitate definition of goals of care. The patient and his
wife expressed a desire for the patient to spend the remainder
of his life at home. Therefore arrangements were made for home
lasix therapy. He had a PICC line placed on [**2180-8-10**] and central
position confirmed. He continued diuresis with IV lasix, PO
metolazone, augmented with dopamine pressor support. He reached
his dry weight by [**8-16**], but was noted to have worsening
metabolic alkalosis (see below) and his diuretics were then
held. His weight at discharge was 84 kg. After discussion
with his wife, he was made DNR/DNI and his ICD was turned off,
with pacemaker still on given that it may increase patient
comfort (details below). He will be sent to inpatient hospice
care his end stage disease and has a prescription for home
oxygen (on 2L of nasal cannula on discharge). Patient was made
comfort measures only and lasix was not restarted. Lab tests
were discontinued. Patient was started on morphine as needed
for dyspnea and discomfort.
# Metabolic alkalosis: During his hospitalization his HCO3
steadily increased, and his VBG was c/w metabolic alkalosis with
pH 7.5. This was thought to be [**2-2**] volume contraction. He was
started on a trial of acetazolamide but this had no effect and
was discontinued. His diuretics were held and his potassium was
repleted with KCl. Lab tests were discontinued when patient was
made comfort measures only.
#Atrial fibrillation: Patient was in atrial fibrillation on
admission, not anticoagulated due to history of lower GI bleed.
Rates were initially in low 100s while on dopamine gtt. Home
metoprolol dose was increased from 6.25mg [**Hospital1 **] to 12.5mg [**Hospital1 **], and
his HR was stable in 70s-80s. When patient was made comfort
measures only, metoprolol was discontinued and patient was taken
off of telemetry monitoring.
#Anemia: Pt has known chronic GIB, and during hospitalization
had occasional BRBPR. His Hct steadily dropped during admission
and he received 3 units PRBC during this admission. Aspirin was
discontinued when patient was made comfort measures only.
#Nutrition- On physical exam, patient had e/o superficial
cellulitis with erythema and pus from insertion site of G-tube.
CT abdomen was negative for abscess or deeper infection. He
completed a 10 day course of clindamycin 300mg PO q8 hours. His
G-tube fell out on HD 13. IR was consulted for replacement
however given his allergy to dye, endoscopy was the only method
for replacing G-tube. After discussion with the family and
patient, the decision was made not to replace the tube.
Stable Issues:
.
# CAD: Pt has history of CAD status post CABG ([**2152**]: SVG-LAD,
SVG-rPDA, SVG-OM1-OM2), status post PCI ([**2171**]:SVG-LAD), ischemic
cardiomyopathy (LVEF 35-40%), status post inferior/inferolateral
myocardial infarction. He had no chest pain and r/o for MI on
admission. His ASA was discontinued due to decreasing Hct and
BRBPR (see above). His statin was discontinued.
.
# CKD: Creatinine improved to 1.4 with diuresis.
.
# Pulmonary Fibrosis: Stable. He was continued on his home
albuterol and atrovent nebs.
.
# Dysphagia: Attributed to a large osteophyte located at C3.
Initially hadG-tube and received bolus tube feeds with
isosource. However his G-tube fell out over the course of the
hospitalization. After discussion with the family it was
determined that replacement of the tube would not be in-line
with the goals of care. Therefore the patient was continued on
a full liquid diet PO with boost supplements.
.
# Transitional Issues:
- Patient maintained DNR/DNI code status throughout
hospitalization, confirmed with pt and family.
- Patient will be going to inpatient hospice hospice and should
not be readmitted to the hospital, based on the wishes of the
patient and his wife. IV lasix can be given at hospice to
improve patient symptoms. Hospice care will be followed by his
PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], and [**Doctor First Name **] [**Doctor First Name 107826**], [**Name6 (MD) 2287**] cardiology NP.
Medications on Admission:
Codeine-Guaifenesin 10-100 mg/5 mL two tspns q4hr
Lansoprazole 30 mg daily
Simvastatin 10 mg QHS
Potassium Chloride 10 % Liquid 75ml daily
Metoprolol Succinate 12.5mg daily
Pramipexole 0.5 mg daily
Ipratropium-Albuterol 0.5 mg-3 mg(2.5 mg base)/3 mL QID
Allopurinol 100 mg daily
Trazodone 25 mg QHS prn insomnia
Torsemide 60mg daily
Ipratropium Bromide 0.02 % neb TID
Betamethasone Dipropionate (DIPROSONE) 0.05 % Topical Cream [**Hospital1 **]
Ferumoxytol (FERAHEME) 510 mg/17 mL (30 mg/mL) IV
Ferrous Sulfate 325 mg (65 mg Iron) Oral Tablet 1 tablet qd
Fluocinolone 0.025 % TOPICAL CREAM [**Hospital1 **] to legs
Colase 100MG PO takes one [**Hospital1 **]
Metolazone 5mg daily
Discharge Medications:
1. hospice
please evaluate for hospice
2. Atropine-Care 1 % Drops [**Hospital1 **]: 1-4 drops Ophthalmic prn as
needed for increased secretions.
Disp:*QS * Refills:*2*
3. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution [**Hospital1 **]:
5-20 mg PO q2hrs:prn as needed for shortness of breath or
wheezing.
Disp:*30 mL* Refills:*0*
4. haloperidol lactate 2 mg/mL Concentrate [**Hospital1 **]: 2-4 mg PO Q2H as
needed for agitation.
Disp:*1 bottle* Refills:*0*
5. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
6. ipratropium bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) Inhalation
Q6H (every 6 hours) as needed for dyspnea.
7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Last Name (STitle) **]: One (1) Inhalation Q6H (every 6 hours) as
needed for dyspnea.
8. allopurinol 100 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
9. betamethasone dipropionate 0.05 % Cream [**Last Name (STitle) **]: One (1) Appl
Topical [**Hospital1 **] (2 times a day).
10. fluocinolone 0.025 % Cream [**Hospital1 **]: One (1) Appl Topical [**Hospital1 **] (2
times a day).
11. docusate sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1) PO BID (2
times a day).
12. metoprolol tartrate 25 mg Tablet [**Hospital1 **]: 6.25 mg PO twice a
day.
Disp:*12 tablets* Refills:*2*
13. pramipexole 0.25 mg Tablet [**Hospital1 **]: 1-2 Tablets PO TID (3 times
a day) as needed for restless legs.
14. acetaminophen 650 mg/20.3 mL Solution [**Hospital1 **]: Six [**Age over 90 1230**]y
(650) mg PO Q6H (every 6 hours) as needed for pain.
Disp:*1 bottle* Refills:*1*
15. trazodone 50 mg Tablet [**Age over 90 **]: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
16. ferrous sulfate 300 mg (60 mg iron)/5 mL Liquid [**Age over 90 **]: One (1)
PO DAILY (Daily).
17. heparin, porcine (PF) 10 unit/mL Syringe [**Age over 90 **]: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
Disp:*50 ML(s)* Refills:*2*
18. sodium chloride 0.9 % 0.9 % Solution [**Age over 90 **]: Three (3) mL
Injection every eight (8) hours: Q8H and PRN line flush.
Disp:*QS QS* Refills:*2*
19. home oxygen
home oxygen by nasal cannula
20. torsemide 20 mg Tablet [**Age over 90 **]: Three (3) Tablet PO once a day:
please start if weight increases by 3 lbs in one day, or if
increasing shortness of breath.
21. furosemide 10 mg/mL Solution [**Age over 90 **]: One [**Age over 90 **]y (120)
mg Injection PRN as needed for shortness of breath, weight gain.
Disp:*100 mL* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 656**] family hospice house
Discharge Diagnosis:
chronic systolic heart failure
anemia
chronic lower gastrointestinal bleed
chronic kidney disease, stage IV
atrial fibrillation
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were seen in the hospital for shortness of breath and weight
gain. This was most likely due to fluid overload from your
heart failure. While in the hospital, your symptoms improved
somewhat with fluid removal with IV lasix and dopamine. Hospice
was discussed with you and your wife and you will go to a
hospice facility with the goal of your care
WE have stopped giving you your diuretics and other cardiac
medicines but have started medicines that will keep you
comfortable. These include creams and benedryl for the itching,
morphine and lorazepam for pain and trouble breathing, bowel
medicines to prevent constipation, nebulizers to help your
breathing and allopurinol to prevent a gout flare.
Followup Instructions:
Please address any concerns with your hospice nurse.
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2273**]
ICD9 Codes: 4168, 4280, 2724, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3877
} | Medical Text: Admission Date: [**2145-12-9**] Discharge Date: [**2145-12-15**]
Date of Birth: [**2078-7-16**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
mitral valve mass
Major Surgical or Invasive Procedure:
Mitral valve replacement (29MM [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] mechanical) [**2145-12-10**]
left heart catheterization, coronary angiogram
History of Present Illness:
This 67 year old white male presented elsewhere with right arm
numbness and tingling which quickly resolved. A transient
ischemic attack was suspected, however, carotid ultrasonography
failed to reveal any significant plaque. Echocardiography
revealed a 1.25cm mass on the atrial side of the posterior
mitral leaflet and a 1.35cm mass on the ventricular side, with
mild regurgitation. He was urgently transferred for surgical
evaluation.
Past Medical History:
Noninsulin dependent diabetes mellitus
s/p coronary stent
coronary artery disease
s/p tonsillectomy
hyperlipidemia
Social History:
Lives with: wife
Occupation: sales- dairy products
Tobacco: none recently
ETOH: social
Family History:
father died at 88yo secondary to complications of valvular
surgery
mother living at [**Age over 90 **]yo
Race: caucasian
Last Dental Exam: 2 weeks ago
Physical Exam:
Admission:
Pulse: 74 Resp: 22 O2 sat: 94%RA
B/P Right: Left: 153/91
Height: Weight: 112kg
General: NAD, WGWN, appears stated age
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur-none
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact x
Pulses:
Femoral Right: 2+ Left:2+
DP Right: 2+ Left:2+
PT [**Name (NI) 167**]: 2+ Left:2+
Radial Right: 2+ Left:2+
Carotid Bruit Right: Left:
no bruits
Pertinent Results:
[**2145-12-13**] 04:20AM BLOOD WBC-12.8* RBC-3.16*# Hgb-9.7* Hct-27.3*
MCV-87 MCH-30.6 MCHC-35.4* RDW-14.2 Plt Ct-158
[**2145-12-9**] 07:15PM BLOOD WBC-9.2 RBC-4.62 Hgb-14.8 Hct-41.8 MCV-90
MCH-32.1* MCHC-35.5* RDW-12.2 Plt Ct-267
[**2145-12-14**] 04:20AM BLOOD PT-26.3* INR(PT)-2.6*
[**2145-12-13**] 04:20AM BLOOD PT-23.9* INR(PT)-2.3*
[**2145-12-12**] 02:44AM BLOOD PT-16.7* PTT-30.1 INR(PT)-1.5*
[**2145-12-11**] 03:08AM BLOOD PT-15.1* PTT-28.1 INR(PT)-1.3*
[**2145-12-14**] 04:20AM BLOOD Na-136 K-3.7 Cl-101
[**2145-12-9**] 07:15PM BLOOD Glucose-113* UreaN-17 Creat-1.1 Na-140
K-4.1 Cl-103 HCO3-27 AnGap-14
[**2145-12-9**] 07:15PM BLOOD ALT-33 AST-33 LD(LDH)-231 AlkPhos-80
Amylase-38 TotBili-0.5
[**2145-12-9**] 07:15PM BLOOD %HbA1c-5.7 eAG-117
[**2145-12-15**] 04:25AM BLOOD PT-25.8* INR(PT)-2.5*
[**2145-12-14**] 04:20AM BLOOD PT-26.3* INR(PT)-2.6*
Brief Hospital Course:
Following admission preoperative work up was undertaken. Cardiac
catheterization
demonstrated nonobstructive coronary disease. On [**12-10**] he was
taken to the Operating Room where mitral valve replacement was
performed. He weaned from bypass on Propofol and Neo Synephrine
in stable condition. See operative note for details.
He remained stable and was extubated easily and weaned from
pressors. He Remained stable and was transferred to the floor.
Coumadin was begun for the mechanical valve and Heparin was
transiently given until the INR was greater than 2.0.
Physical Therapy worked with him for mobility and beta blockade
was begun and he was diuresed towards his preoperative weight.
He experienced some visual hallucinations and narcotics and
Ultram were discontinued with resolution.
OR cultures were negative and final pathology was pending on the
speciman at discharge. He remained in sinus rhythm.
Arrangements were made for Coumadin management with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 48239**].
Medications, restrictions, precautions as well as follow up were
discussed in detail with him prior to discharge on [**12-15**].
Medications on Admission:
Lopressor 50mg daily
Plavix 75mg daily
metformin 500mg daily
simvastatin 40mg daily
pantoprazole 40mg daily
asa 81mg daily
Discharge Medications:
1. influenza vaccine tr-s 10 (PF) 45 mcg (15 mcg x 3)/0.5 mL
Syringe Sig: One (1) ML Intramuscular NOW X1 (Now Times One
Dose).
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO QHS
(once a day (at bedtime)) as needed for sleep.
5. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
Disp:*7 Tablet(s)* Refills:*0*
7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/temp.
9. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
10. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
11. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO once a day for 7
days.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
12. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Coumadin 2.5 mg Tablet Sig: as directed Tablet PO once a
day: take as directed according to INR results.
Disp:*100 Tablet(s)* Refills:*2*
14. Outpatient [**Name (NI) **] Work
PT/INR on [**2145-12-16**], than prn.
Please FAX results to Dr. [**Last Name (STitle) 48239**] (attention:[**Doctor First Name **]) [**Telephone/Fax (1) 88184**],
or phone [**Telephone/Fax (1) 26035**].
Discharge Disposition:
Home With Service
Facility:
southern [**Hospital **] homecare
Discharge Diagnosis:
mitral valve mass
s/p mitral valve replacement
noninsulin dependent diabetes mellitus
hyperlipidemia
coronary artery disease
s/p coronary stent
gastroesophageal reflux
s/p tonsillectomy
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with steady gait
Incisional pain managed with Tylenol
Incisions:
Sternal - healing well, no erythema or drainage
Edema: trace
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**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
Cardiologist: Dr.[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 48239**] ([**Telephone/Fax (1) 26035**]on [**2145-12-29**] at
1:30pm
Please call to schedule appointments with:
Primary Care: Dr. [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 58292**] ([**Telephone/Fax (1) 58293**]) in [**5-17**]
weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication mechanical mitral valve
Goal INR 2.5-3.5
First draw [**12-16**]
Results to Dr. [**Last Name (STitle) 48239**] att:[**Doctor First Name **]
phone:[**Telephone/Fax (1) 26035**] fax:[**Telephone/Fax (1) 88184**]
Completed by:[**2145-12-15**]
ICD9 Codes: 5185, 4240, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3878
} | Medical Text: Admission Date: [**2168-11-13**] Discharge Date: [**2168-11-18**]
Service: MEDICINE
Allergies:
Penicillins / Levofloxacin
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
History obtained from son and from [**Name (NI) **] notes and signout as pt.
somnolent and on BIPAP on arrival to ICU. In brief, Mr. [**Known lastname 5749**] is
an 89 year old [**Hospital 100**] Rehab resident with history of coronary
artery disease, congestive heart failure, OSA, multiple previous
pneumonias/bronchitis presents with 1 day of shortness of breath
and non-productive cough at [**Hospital 100**] rehab, and started on
ciprofloxacin (per ED resident) 1d prior to admission. This AM,
he became increasingly tachypneic and hypoxic to 80s on baseline
oxygen, given abx. and lasix 40mg IM.
Recent admission in may with similar presentation, given abx.,
nebs, lasix, and improved without need for intubation or NIPPV.
Per son, also recently treated for PNA 1 month ago. Today, also
became more lethargic, so decision made to send patient to [**Hospital1 18**]
ER. At baseline, most vigorous activity involves transfers to
powerized wheelchair, but is cognitively clear.
.
In [**Name (NI) **], pt. 99.6, HR 93, 128/68, 35 91% on NRB, somnolent on NRB
with initial gas of 7.23/106/133/47 on NRB. Repeat gas
7.30/90/62/46 on 30%FiO2 on BIPAP. CXR showed increased
inflitrates bilaterally, so given 1 dose of vancomycin. Given
poor gas, ED had discussion of possible temporary intubation
(pt. has signed DNR/DNI) with pt. who refused, but was thought
to be too somnolent to have capacity.
.
I spoke with son and both of his most recent PCPs Drs. [**Last Name (STitle) 14936**]
and [**Name5 (PTitle) **] about his code status, and pt. was clear that he did
not want prolonged or permanent time on ventilator but had not
had discussion re: temporary intubation for reversible causes,
and both PCPs felt that it was appropriate for that decision to
be made by his son who was HCP. When I spoke to his son, he
reiterated above, but agreed that a trial intubation would be
what his father would want.
Past Medical History:
DDD Pacemaker placed [**7-8**] for second degree AV block
Coronary Artery Disease
Congestive Heart Failure. Echo: LVEF>55% [**2168-5-25**]
Obstructive Sleep Apnea
Hypertension
gout
Lichen Simplex Chronicus, on zyrtec
Incisional hernia
chronic skin ulcers
iron-deficiency anemia
h/o DVT
s/p prostatectomy
s/p appy
Ventral hernia
Obesity
H/o DVT, on coumadin completed 6m course [**2166**]
Hypothyroidism
Chronic bilateral bronchiectasis and bronchomalecia
CRF with BL Cr in 1.1-1.4
Social History:
Lives at [**Hospital 100**] Rehab, denies ever smoking
Family History:
NC
Physical Exam:
Vitals: T 96 axillary HR 74, BP 118/60 RR 15 O2 sat 93% on CPAP
Fio2 35% on 15/8.
Gen: somnolent, arousable to voice for a few seconds before
falling back asleep, A&Ox2, answers intermittently coherent
HEENT: PERRL, EOMI, OP exam deferred as on BIPAP
CV: RRR, nl S1/S2
Chest: Coarse rhonchi diffusely, decreased BS throughout, worst
at apices, no wheezes
Abd: Soft, NDNT, ventral hernia
Ext: No edema
Neuro: moving all 4 ext. against gravity. EOMI, + cough, Hearing
intact.
Pertinent Results:
Admit labs:
[**2168-11-13**] 12:28PM LACTATE-0.8 K+-4.7
[**2168-11-13**] 12:28PM TYPE-ART PO2-133* PCO2-106* PH-7.23* TOTAL
CO2-47* BASE XS-12 INTUBATED-NOT INTUBA COMMENTS-NON-REBREA
[**2168-11-13**] 12:40PM PT-30.6* PTT-35.0 INR(PT)-3.2*
[**2168-11-13**] 12:40PM PLT COUNT-280
[**2168-11-13**] 12:40PM NEUTS-74.8* LYMPHS-18.5 MONOS-4.6 EOS-1.8
BASOS-0.3
[**2168-11-13**] 12:40PM WBC-6.1 RBC-4.46* HGB-13.2* HCT-43.6 MCV-98
MCH-29.5 MCHC-30.1* RDW-15.8*
[**2168-11-13**] 12:40PM DIGOXIN-0.9
[**2168-11-13**] 12:40PM CALCIUM-9.5 PHOSPHATE-4.1# MAGNESIUM-2.4
[**2168-11-13**] 12:40PM CK-MB-NotDone
[**2168-11-13**] 12:40PM cTropnT-0.03*
[**2168-11-13**] 12:40PM CK(CPK)-39
[**2168-11-13**] 12:40PM estGFR-Using this
[**2168-11-13**] 12:40PM GLUCOSE-123* UREA N-22* CREAT-1.5* SODIUM-143
POTASSIUM-5.0 CHLORIDE-97 TOTAL CO2-46* ANION GAP-5*
[**2168-11-13**] 12:46PM LACTATE-1.2 K+-4.9
[**2168-11-13**] 12:46PM COMMENTS-GREEN TOP
[**2168-11-13**] 01:20PM TYPE-ART O2-31 PO2-62* PCO2-90* PH-7.30*
TOTAL CO2-46* BASE XS-13 INTUBATED-NOT INTUBA
[**2168-11-13**] 02:22PM TYPE-ART TEMP-37.6 RATES-/14 PEEP-8 O2-33
PO2-64* PCO2-92* PH-7.29* TOTAL CO2-46* BASE XS-13 INTUBATED-NOT
INTUBA COMMENTS-CPAP
[**2168-11-13**] 05:20PM TYPE-ART TEMP-36.7 PO2-65* PCO2-64* PH-7.44
TOTAL CO2-45* BASE XS-15
[**2168-11-13**] 07:46PM PT-33.3* PTT-35.2* INR(PT)-3.6*
[**2168-11-13**] 07:46PM PLT COUNT-274
[**2168-11-13**] 07:46PM WBC-6.0 RBC-4.10* HGB-12.3* HCT-40.1 MCV-98
MCH-30.0 MCHC-30.6* RDW-15.9*
[**2168-11-13**] 07:46PM CALCIUM-9.2 PHOSPHATE-2.6* MAGNESIUM-2.2
[**2168-11-13**] 07:46PM GLUCOSE-119* UREA N-26* CREAT-1.4* SODIUM-143
POTASSIUM-4.1 CHLORIDE-96 TOTAL CO2-44* ANION GAP-7*
[**2168-11-13**] 09:44PM O2 SAT-92
[**2168-11-13**] 09:44PM LACTATE-2.0
[**2168-11-13**] 09:44PM TYPE-[**Last Name (un) **] PO2-65* PCO2-76* PH-7.35 TOTAL
CO2-44* BASE XS-11
CHEST (PORTABLE AP) [**2168-11-13**] 12:27 PM
IMPRESSION: Persistent, patchy, right-sided multifocal airspace
process unchanged in appearance compared to [**2168-5-24**] and [**2165-8-23**]
probably related to chronic findings secondary to
bronchiectasis. Question new left perihilar opacities. Probable
small pleural effusions. Clinically correlate.
.
CHEST (PORTABLE AP) [**2168-11-17**] 10:45 AM
FINDINGS: In comparison with the study of [**11-16**], there is little
change. Again, there are bilateral lower lobe and right middle
lobe opacifications consistent with pneumonia. Pacemaker device
remains in place.
.
MICROBIOLOGY: Blood Cx ([**11-13**]): NGTD x2
.
Discharge labs:
[**2168-11-18**] 03:43AM BLOOD WBC-5.9 RBC-4.07* Hgb-12.0* Hct-39.0*
MCV-96 MCH-29.4 MCHC-30.7* RDW-16.5* Plt Ct-340
[**2168-11-17**] 06:05AM BLOOD Neuts-62.6 Lymphs-22.8 Monos-5.9 Eos-8.3*
Baso-0.3
[**2168-11-18**] 03:43AM BLOOD PT-19.3* PTT-28.0 INR(PT)-1.8*
[**2168-11-18**] 03:43AM BLOOD Glucose-101 UreaN-40* Creat-1.5* Na-140
K-4.3 Cl-100 HCO3-37* AnGap-7*
[**2168-11-18**] 03:43AM BLOOD Calcium-9.0 Phos-3.2 Mg-2.5
[**2168-11-17**] 10:55AM BLOOD pO2-67* pCO2-65* pH-7.37 calTCO2-39* Base
XS-8
Brief Hospital Course:
He was admitted to the MICU [**Location (un) **] team, where he was treated on
BiPAP with good success, along with vancomycin and cefepime from
presumed nosocomial pneumonia.
.
He was transferred to the floor on evening of [**2168-11-16**], but was
noted to be hypoxic with oxygen saturation of 85% on 4L. He had
been stable overnight while on BiPAP, however he had increased
respiratory rate and was hypoxic on 50% face [**Last Name (LF) **], [**First Name3 (LF) **] he
transferred back to MICU due to need for more frequent BiPAP and
for closer monitoring.
.
# Hypercarbic respiratory distress/PNA: As previously related,
at baseline patient requires 2 L NC O2 prn and is unable to do
most physical activity, including walking. He presented with
with worsening chronic respiratory acidosis with likely
additional metabolic alkalosis, this was felt to be secondary to
a nosocomial pneumonia in conjunction with his baseline lung
disease and sleep apnea. He continues to have stable blood
gases, however was noted to be more somnolent. The
differential, as previously discussed, included PNA, CHF
exacerbation, bronchiectasis/bronchomalacia causing worsening
ventillation. Admission CXR showed question new left perihilar
opacities and probable small pleural effusions. WBC 6.1 on
admission. Blood cx on admission with NGTD x2.
Vancomycin/cefepime (7 days total) to cover nosocomial,
post-obstructive PNA, and possible aspiration PNA as well, given
allergy to penicillins and levofloxacin. Has tolerated
cephalosporins well in past. Antibiotics were started on [**11-13**],
so will complete course on [**11-19**]. Patient was put on BIPAP at
night and as needed during day for somnolence, FaceT and Venturi
otherwise. He received Chest PT and incentive spirometry as
possible. Aimed for o2 sats 88-92 given likely a co2 retainer.
Given Lasix [**11-15**] with good UOP, and will continue diuresis as
tolerated as patient may have element of failure which is
worsening his respiratory status. He was also given albuterol
ATC, but stopped Atrovent as it may have made his secretions
thicker. Given Guaifenesin ATC to thin secretions.
.
# Afib: Patient started on coumadin in [**5-9**] per Dr. [**Last Name (STitle) **]. INR
3.2 on admission, so Coumadin was initially held. Coumadin was
re-started on [**11-6**] at 5mg. On discharge his INR was 1.8, so
coumadin was increased to his original home dose of 7.5mg qhs.
Coumadin to be titrated per rehab facility. Continued digoxin
at admission dosing.
.
# CHF: Patient has preserved EF, not currently on ACE-I, BB, or
statin. Does not appear grossly overloaded on exam. Lasix to
mantain negative fluid balance (started [**11-15**]). Continued
digoxin at home dosing.
.
# Gout: Continued allopurinol at 100mg qdaily, dosed per renal
function, though on 250qdaily at prior to admit.
.
# Hypothyroidism: continued levothyroxine 75mg po
.
# Allergies: Continued fexofenadine.
.
# [**Hospital 97291**] health care maintenance: Continued ASA for
cardiac health. Continued Vitamin D/Calcium for bone health.
.
# FEN: Speech and swallow evaluation completed, recommendations
were for PO diet of nectar thick liquids and regular consistency
solids, assistance with meals, and pills whole with purees.
.
# Code: DNR/DNI: Confirmed with pt., that given unlikelihood of
being able to wean off ventilator if intubated, he is DNR/DNI.
Medications on Admission:
- Allopurinol 250 mg qdaily
- Calcium Carbonate 650bid
- Vit D 1000U daily
- Digoxin .0625 mg QMOWEDFRI
- Digoxin 0.125 mg QSUNTUESTHURSSAT
- Fexofenadine 60 mg [**Hospital1 **]
- Furosemide 20mg po daily
- Synthroid 75 mcg qd
- senna 1 tab qd
- tylenol 650 mg q4 hours prn
- guaifenesin/dextromethorphan prn
- hydrocortisone 1% cream to buttock area
- coumadin, doses not clear
- albuterol/atrovent 2 puffs q8h
- Fluticasone (2) Inhalation [**Hospital1 **]
- albuterol nebs q4h
- atrovent nebs
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
2. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours).
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. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day).
7. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
10. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q4H (every 4 hours) as needed for wheezing.
12. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY16
(Once Daily at 16).
13. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO QSU, TU, TH,
SA ().
14. Digoxin 125 mcg Tablet Sig: [**1-5**] tab Tablet PO QMO, WE, FR
().
15. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
16. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
gram Intravenous Q 24H (Every 24 Hours) for 1 days: last day
[**11-19**].
17. Cefepime 2 gram Recon Soln Sig: Two (2) grams Injection Q24H
(every 24 hours) for 1 days: last day [**11-19**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary:
Health care associated-Pneumonia
Bronchomalacia
____________________
Secondary:
Atrial Fibrillation
CHF
Gout
Hypothyroid
Discharge Condition:
good, satting well on BIPAP, tolerating pos, unable to walk
Discharge Instructions:
Please seek medical attention ahould you develop chest pain,
increased shortness of breath, fever, or any other concerning
symptoms. You have been diagnosed with pneumonia which
increases respiratory secretions and bronchomalacia, which makes
it more difficult to clear these secretions resulting in your
shortness of breath.
You will have one more day of vancomycin and cefepime
antibiotics. You should continue on your BIPAP at night and
during the day whenever you are sleeping or short of breath.
We have decreased your allopurinol dose to account for your
impaired renal function.
Followup Instructions:
follow up with Dr. [**Last Name (STitle) **] as previously scheduled
ICD9 Codes: 486, 4280, 5859, 2749, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3879
} | Medical Text: Admission Date: [**2199-11-4**] Discharge Date: [**2199-11-9**]
Service: MEDICINE
Allergies:
Morphine
Attending:[**Doctor First Name 2080**]
Chief Complaint:
Biliary obstuction.
Major Surgical or Invasive Procedure:
ERCP
IR guided biliary drain
History of Present Illness:
This is an 88 yo man transferred from OSH [**11-4**] for ERCP for
biliary obstruction with obstructive hepatopathy. presented to
[**Hospital 1562**] Hospital on [**11-3**] with increasing shortness of breath,
dizziness, and jaundice. Per OSH also reported fevers, chills,
and nausea. Had gveen given bactrim for a UTI one week prior. He
underwent an abdomen CT which showed intrahepatic and
extrahepatic obstruction likely secondary to metastatic cancer
to the pancreatic head. He was started on flagyl, zosyn, and
vanc and transferred to [**Hospital1 18**] for ERCP.
While being prepped for ERCP (while under MAC) and turned prone
he regurgitated coffee-brown material so he was electively
intubated due to concern for his risk of aspiration. They
proceded with ERCP, but were unable to cannulate the biliary
tree. A dudodenal stent was placed due to external compression
of the duodenum. He was placed on propofol for sedation and his
SBP's dropped to the 80's in the PACU. He was started on neo
through a PIV for pressure support.
In the ICU the neo was rapidly weaned and he was extubated
easily [**11-5**]. It was thought that his inability to extubate
post-procedure and hypotension were due to sedation rather than
aspiration given his rapid improvement.
ROS: 10 point review of systems negative except as noted above.
Past Medical History:
1. Colon cancer with mets s/p colectomy complicated with small
and large bowel obstruction with a colostomy. Oncologist
identified in OSH records as Dr. [**Last Name (STitle) 25802**].
2. Prostate enlargement s/p TURP, ? in OSH of prostatic mets
3. Hypertension
4. Hypercholesterolemia
5. GERD
6. S/p tonsillectomy
Social History:
Lives alone. Per OSH records is a nonsmoker, and no alcohol use.
Known family is sister in [**Name (NI) 9012**].
Family History:
noncontributory
Physical Exam:
Vitals:
Gen: well appearing, pleasant male
HEENT: sclera icteric, PERRLA, EOMI, OP clear
CV: +s1s2, rrr, no mrg appreciated
Lungs: ctab
Abd: + ostomy bag in place, + biliary drain in place, +bs, soft,
nt, nd
Ext: no c/c/e
Pertinent Results:
Admission labs:
CBC:11.4 (n 89, no bands)->9.3, hct 25.1->28, plt 388
BMP: 135, 4.2, 102, 23, 19, 1.0, 94
alt 236->218, ast 300->268, ap 856->816, bili 11.8->11.2, lipase
184->120
ptt 28.4, inr 1.3
lactate 0.8
.
Discharge Labs:
[**2199-11-9**] 05:32AM BLOOD WBC-8.2 RBC-2.57* Hgb-8.3* Hct-25.8*
MCV-101* MCH-32.3* MCHC-32.1 RDW-17.5* Plt Ct-383
[**2199-11-9**] 05:32AM BLOOD Glucose-102 UreaN-19 Creat-0.9 Na-139
K-3.5 Cl-106 HCO3-25 AnGap-12
[**2199-11-9**] 05:32AM BLOOD ALT-97* AST-58* AlkPhos-662* TotBili-5.4*
.
UA: BLOOD-SM NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG
BILIRUBIN-MOD UROBILNGN-NEG PH-5.5 LEUK-MOD RBC-4* WBC-13*
BACTERIA-FEW YEAST-NONE EPI-0
.
Urine Cx [**11-4**]: no growth.
Blood Cx [**11-4**]: pending.
MRSA screen [**11-4**]: pending.
.
CXR port [**11-4**]: Lung volumes are quite low. With the chin down,
the tip of the ET tube at the upper margin of the clavicles is 3
cm above optimal placement. [**Month (only) 116**] be left hilar enlargement and
one or more nodules in the left lung. A band of atelectasis is
present at the base of the right lung which is otherwise clear.
Heart is mildly enlarged. No pneumothorax. Small bilateral
pleural effusions, left greater than right, are likely present.
An apparent bulge in the right mediastinal contour could be a
skin fold instead. Repeat radiographs, conventional if possible,
recommended when feasible.
.
ERCP [**11-4**]: A large amount of gastric fluid was found when the
endoscope was passed into the stomach, suggestive of outflow
tract obstruction.
Unable to pass the scope to the second part of the duodenum due
to obstruction, most likely extrinsic compression from colon
cancer metastases. A duodenal stent ( 9cm x22mm Wallflex enteral
duodenal stent) was placed successfully under fluoroscopic
guidance to alleviate the gastric outlet obstruction. Ref 6502.
Lot [**Numeric Identifier 25803**](stent placement)
.
Fluoro [**11-6**]:
IMPRESSION: Percutaneous transhepatic cholangiogram
demonstrating moderate
intra- and extra-hepatic biliary ductal dilatation with
obstruction of the
common bile duct at the level of the ampulla. Successful
placement of a right transhepatic internal-external biliary
draining catheter with the catheter connected to a bag for
external drainage
Brief Hospital Course:
Assessment and Plan: 88 yo male with pmh of metastatic colon
cancer and hypertension who is being admitted to the [**Hospital Unit Name 153**] due to
hypotension and need for continued intubation s/p ERCP attempt
for biliary obstruction.
.
# Hypotension: Patient became hypotensive after intubation on
propofol. Likely secondary to propofol, however also in the
differential is hypotension from sepsis. He has two potential
sources for sepsis: biliary obstruction and recent apsiration.
Also could have volume depletion. Since coming to the floor his
pressures had recovered and phenylephrine weaned off. Given the
possibility of sepsis, he was started on vancomycin, flagyl and
cefepime, but then changed to ceftriaxone and flagyl. The
vancomycin was discontinued after the cultures were negative x
48 horus. On the day before discharge he was transitioned to PO
levofloxacin to complete a full course through [**11-11**], cultures no
growth to date at discharge.
.
# Biliary obstruction/obstructive jaundice: The patient
underwent a CT at the OSH which showed intrahepatic and
extrahepatic bile duct dilatation likely due to a metastasis to
the pancreatic head from his colon cancer. He failed ERCP due to
external compression of the duodenum limiting their ability to
pass the scope. A duodenal stent was placed by the ERCP team to
help to decompress the gastric outlet obstruction. Given the
failed ERCP attempt, IR was consulted and performed an IR guided
biliary drain on [**2199-11-6**]. He was transferred to the floor and
his LFTs trended down after the stent was placed. His drain was
clamped on [**11-8**] and with continued improvement of his liver
tests and symptoms. He was discharged with a clamped biliary
drain to follow up with interventional radiology. If symptoms
return, the drain can be unclamped to a bag.
.
# Respiratory distress: The patient presented to the ICU
intubated since the ERCP. On the following morning he was
successfully extubated and breathing appropriately on room air.
.
# Anemia, chronic disease: The patient was noted to have
coffe-ground regurgitation during the ERCP procdure. He was
anemic with a Hct of 26 at the OSH and 25 on admission labs
here. Vit B12 and folate normal at the OSH. Fe low, but other Fe
studies not sent. Haptoglobin high makes hemolysis unlikely.
Most likely due to anemia of chronic disease and possibly due to
oncologic treatment. Started an IV PPI due to concern for coffee
ground regurgitant. His hematocrits were stable and did not
need transfusions.
.
# Metastatic colon cancer: Patient has multiple mets seen on OSH
imaging. He will follow up with his outpatient surgeon after
discharge.
.
# Hypertension, benign: stable
Medications on Admission:
Home medications:
Prevacid 10 mg po daily
Lipitor 10 mg po qhs
Discharge Medications:
1. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 2 days.
Disp:*2 Tablet(s)* Refills:*0*
2. Prevacid 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Discharge Disposition:
Home With Service
Facility:
VNA of Upper [**Hospital3 **]
Discharge Diagnosis:
Metatstatic colon cancer
Gastric outlet obstruction s/p duodenal stent placement
Biliary obstruction s/p IR placed drain
Prostate enlargement s/p TURP
Hypertension, benign
Hypercholesterolemia
gastroesophageal reflux
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the hospital becuase you had an obstruction
in the small bowel and also in your biliary tract. You went for
a procedure that stented open your small bowel allowing you to
eat liquids and solids. You then went to the have a drain
placed in your biliary duct in order to the relieve the
obstruction.
Resume all of your home medications except Lipitor, until follow
up with your doctors.
You will need to continue the levofloxacin for 7 days until
[**2199-11-11**]. You will need to follow up with your primary surgeon
and your primary care doctor. Additionally, interventional
radiology will contact you to follow up with your drain
management.
Return to the hospital if you experience fevers/chills,
abdominal pain, recurring jaundice, or any other concerning
symptoms.
Followup Instructions:
As above, you will need to follow up with your primary surgeon,
Dr. [**Last Name (STitle) 25804**] when you return home, as well as with your PCP [**Last Name (NamePattern4) **].
[**Last Name (STitle) 25237**] as soon as possible.
You will also need to follow up with the interventional
radiology department in order to change the drain in 3 months.
They will contact you to schedule this.
ICD9 Codes: 5070, 5789, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3880
} | Medical Text: Admission Date: [**2190-5-3**] Discharge Date: [**2190-5-4**]
Date of Birth: [**2110-1-21**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
carotid stenosis s/p carotid stenting
Major Surgical or Invasive Procedure:
Percutaneous Carotid Angiography and stenting of Left Internal
Carotid Artery with 10x24mm self expanding Carotid Wall stent.
History of Present Illness:
The patient is an 80yoM w/ a h/o AAA (4.2x3.9 by ultrasound
[**7-2**]), COPD, CAD s/p IMI, hyperlipidemia, R common iliac artery
aneurysm (1.9cm [**11-30**]) presents for elective carotid stenting.
The patient had an episode of syncope 2 months prior to
admission, during a syncope workup he was found to have a L ICA
stenosis of 70-90% and < 50% on the R. Since that episode of
syncope the patient did not have any further episodes.
.
He states that his episode of syncope was as follows: he was
sitting down, eating, felt food getting stuck in his
epigastrium, drank a sip of room temperature water and then his
wife noted him to fall back in his chair and hit the ground, per
the patient the next thing he remembers if being on the ground,
he regained consciousness after 1-2 minutes. He states prior to
this episode he had an identical episode 4 months prior to
admission.
.
He denies any CP, has stable DOE (3 flights of stairs), has no
pedal edema, denies any stroke or TIA symptoms.
Past Medical History:
Hyperlipidemia
COPD
Possible CAD based on nuclear imaging stress test (2 months
prior to admission, small mild fixed perfusion abnormality of
the inferior wall with hypokinesis and an EF of 53%)
Left internal carotid stenosis 70-90%
Dysphagia
Aortic aneurysm -measured at 4.2 x 3.9cm by U/S dated [**2189-7-7**]
Right common iliac artery aneurysm measuring 1.9cm from study
dated [**11-30**]
cataract surgery bilaterally [**11-2**]
Skin cancer removed left ear
Left hand growth removed
Eczema
Social History:
-Tobacco history: 62 pack year history of smoking, quit 3
months ago
-ETOH: on wednesdays
Family History:
father died at 87, mother died of 89. 1 of 14 siblings.
Brother with MI in 40s.
Physical Exam:
VS: T 97.7 HR 80 BP 138/80 RR 17 O2 96% on RA.
GENERAL: NAD, AOX3
HEENT: MMM, OP clear, no carotid bruits, JVP not elevated
CARDIAC: RRR, no m/r/g
LUNGS: CTAB anteriorly
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. WWP, R femoral site without hematoma or
bruit.
NEURO: normal mentation, appropriate, no significant memory
deficits, AOx3, CN2-12 intact, EOMI, PERRL, [**4-28**] stregnth in UE
(grip, bicep, tricep, deltoid), [**4-28**] Stregnth in LE (Quad,
hamstring, plantarflex / dorsiflex), normal sensation to light
touch bilaterally symmetric.
Pertinent Results:
Admission Labs:
[**2190-5-3**] 04:48PM BLOOD Plt Ct-223
[**2190-5-3**] 04:48PM BLOOD K-4.2
Carotid Angiogram and Left ICA stent [**2190-5-3**]:
1. Access was obtained in retrograde fashion through the right
CFA
artery under USS guidance. A copy of the right CFA USS image was
printed
and attached to patient's note.
2. A 4F Pigtail catheter was advanced into the right ascending
aorta.
Arch angiography revealed a type III arch with 90% left internal
carotid
artery stenosis.
3. Successful PTCA and stenting of the left internal carotid
artery with
a 10x24mm self expanding Carotid Wall stent that was postdilated
to
4.5mm. Final angiography revealed 10% residual stenosis, no
angiographically apparent dissection and good distal flow (see
PTA
comments).
4. Cerebral angiography revealed left ACA stenosis, patent left
MCA.
5. Lower abdominal arotography revealed:
- abdominal aortic aneurysm
- right CIA aneurysm
6. Successful deployment of angioseal closure device.
Brief Hospital Course:
# Carotid stenting: The patient had a type III aortic arch with
90% L carotid stenosis. There were both an abdominal and iliac
aneurysm (known from previous imaging obtained from OSH).
Difficulty cannulating L carotid, it was eventually stented with
distal protection and 10% residual stenosis. He had a L ACA
defect (likely stenosis) on angio post procedure. He was
admitted to the Cardiac ICU for monitoring overnight. Aspirin
and clopidogrel were conitnued. Statin was continued. Serial
neuro exams were normal with no deficits noted. Blood pressure
was monitored to maintain systolic pressures between 100 and
120; he did not require additional medications to maintain
systolic pressures within this range. Pain at catheter
insertion site was minimal. On hospital day 1, he was noted to
be hemodynamically stable with no evidence of complication from
the left internal carotid stent procedure. He was discharged
home from the ICU to follow-up with his outpatient cardiologist
and primary care physician.
# Hyperlipidemia: Continued Simvastatin
# COPD: On admission, there were no wheezes on exam or other
evidence of COPD exacerbation. Advair and Spiriva were
continued.
Medications on Admission:
CLOPIDOGREL 75mg daily (rec'd 300mg x 1 on [**4-30**], started 75mg
daily on [**5-1**])
ADVAIR 250 mcg-50 mcg 2 puffs [**Hospital1 **]
SIMVASTATIN 20mg daily
SPIRIVA 1 puff daily
ASPIRIN 81mg daily
CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 500 + D]
MULTIVITAMIN daily
OMEGA-3 FATTY ACIDS-VITAMIN E [OMEGA-3 FISH OIL] daily
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. Calcium 500 + D 500 mg(1,250mg) -200 unit Tablet Sig: One (1)
Tablet PO once a day: Take as previously prescribed.
7. Omega-3 Fatty Acids-Vitamin E 1,000 mg Capsule Sig: One (1)
Capsule PO once a day: Take as previously prescribed.
8. Multivitamin Capsule Sig: One (1) Capsule PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Left Carotid Artery Stenosis s/p percutaneous
stenting
Secondary Diagnosis: COPD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital after you had a stent placed
in the occlusion in your left internal carotid artery. You were
admitted to the Cardiac Intensive Care Unit for close
monitoring. Your tolerated the procedure well and you had no
complications after the surgery. You are being discharged home
to follow-up with your cardiologist.
You will need to continue Plavix (Clopidogrel) until instructed
to stop by your physician.
Changes in Medication:
Increase Aspirin to 325 mg by mouth daily
Continue Plavix (Clopidogrel) 75 mg by mouth daily
Please continue all other medications as previously prescribed
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 62**] on [**5-20**] at 2:20
pm [**Hospital Ward Name 23**] buliding [**Location (un) **] (Cardiology).
It is highly encouraged that you follow-up with your primary
care physician after discharge from the hospital. Please call
to arrange an appointment in the next 2 weeks to review your
general health and medications.
Completed by:[**2190-5-4**]
ICD9 Codes: 496, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3881
} | Medical Text: Admission Date: [**2195-10-28**] Discharge Date: [**2195-11-14**]
Date of Birth: [**2141-6-26**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (un) 2888**]
Chief Complaint:
Elevated creatinine
Major Surgical or Invasive Procedure:
[**2195-11-2**]: Right heart catheterization
Dual chamber ICD placement
History of Present Illness:
Mr. [**Known lastname 49249**] is a 54 year old gentleman with HTN, DM2, CKD
(baseline Cr 2.0-2.2), CAD s/p CABG [**2186**], as well as systolic
and diastolic heart failure (EF had been as low as 20% but last
known to be 40%), who was recently admitted to the [**Hospital1 18**]
Cardiology service from clinic on [**2195-10-16**] for worsening dyspnea
over 2 weeks. CHF exacerbation was in the setting of new
inferior HK and he was diuresed with hopes of pursuing RHC/LHC.
Hospital course was complicated by [**Last Name (un) **] (Cr>3.0), PIV-associated
MSSA bacteremia (did not want [**Last Name (LF) **], [**First Name3 (LF) **] dc'ed on IV nafcillin x4
weeks). RHC was done and showed elevated filling pressures, so
he was transferred to the CCU for Milrinone to assist with Lasix
gtt. Due to infection, he was only on milrinone for a few hours.
He was transferred back to the floor and was diuresed well prior
to discharge. He followed up in clinic on [**2195-10-27**] and was found
to have creatinine elevated to 5.4 despite holding torsemide on
[**10-22**] (took it [**10-27**]). He was admitted to [**Hospital1 1516**] for
management of his [**Last Name (un) **].
On interview this afternoon, he denies SOB at rest. He hasn't
been walking much, but doesn't feel "crushing fatigue" now like
he did before. He has been sitting to sleep, which he does think
is worse than when he was admitted. His itchiness continues, but
isn't worse than when in the hospital. He does endorse nausea,
diarrhea (8 loose stools a day) which he reports started with
the nafcillin. Denies fever, chills, abd pain. He reports "I
don't do well with IVs. They always increase my creatinine
regardless of what it is." He has been following the same diet
and eating light. He reports poor intake of fluid as he's trying
to avoid drinking a lot, "much less than 1L a day." His right
eye seems like it has a swollen eyelid today, but he hasn't
noticed. His wife reports that it always looks like this. No
headache.
Reports we weighed 219 today (recorded as 219.2), 215 yesterday,
211 on discharge.
On review of systems, he denies any prior history of stroke,
TIA, pulmonary embolism, bleeding at the time of surgery,
myalgias, joint pains, cough, hemoptysis, black stools or red
stools. He denies recent fevers, chills or rigors. He denies
exertional buttock or calf pain. All of the other review of
systems were negative.
Cardiac review of systems is notable for absence of chest pain,
palpitations, syncope or presyncope. +Orthopnea, +PND
Past Medical History:
Hypertension
Dyslipidemia
Diabetes mellitus
-retinopathy s/p laser surgery
-peripheral neuropathy with ulcers
Chronic kidney disease (baseline Cr 2.0-2.2)
Coronary artery disease
-s/p CABG in [**2186**] (LIMA-LAD, SVG-PDA, and radial-OM1-OM2)
Congestive heart failure
-[**4-/2195**]: B&WH admission with EF of 20% in CHF, improved to 40%
on discharge
Deep vein thrombosis x1 (s/p Warfarin in the past)
s/p Right knee arthroscopy
Iron deficiency anemia
Gout
Social History:
-Home: Lives in [**Location **] with his wife. Married 20 years.
-Occupation: Works as a financial planner, lawyer, runs a
property company.
-Tobacco: used to smoke one cigar daily since high school until
stopping after CABG. No cigaretters.
-EtOH: None
-Illicits: None
Family History:
Mom had CABG in 60s.
3 brothers all without heart disease or diabetes.
Father with ?lymph cancer.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: 97.6 - 144/77 - 74 - 20 - 95RA - BS304
weight: 219.2 (on discharge [**2195-10-25**], 96kg (211 lbs)
GENERAL: Alert, oriented x3. Sitting in bed with wife at
bedside. No respiratory direstress.
HEENT: MMM, R eye seems ptotic
NECK: Supple with JVP 8-9 cm
CARDIAC: PMI closer to midline w/ RV lift. RR, S1, S2 w/
paradoxical splitting, S3. No murmur or rub.
LUNGS: Mild crackled bilateral bases, no wheeze
ABDOMEN: Softly distended. Abd aorta not enlarged by palpation.
No abdominal bruits. BS present. +hepatojugular reflex
EXTREMITIES/SKIN: severe stasis dermatitis with anterior
weeping ulcers on lower extremities. also continues to have scab
on
lateral R thigh. Not grossly edematous (trace)
NEURO: CN 2-12 intact, bilateral ue's and le's [**6-13**], finger
extensors [**6-13**], no sensation to light touch from mid calf
downwards (stable from last exam), no decreased sensation to
touch in UEs.
.
DISCHARGE
Afebrile, normotensive (SBP 130s-140s), non-tachycardic,
non-tachypneic, saturating well on RA
Exam same as above except:
Chest: L upper chest- well-appearing, no mass palpated,
appropriately tender
Pulm: mild bibasilar crackles
Ext: LE edema much improved, ulcers healing well
Pertinent Results:
ADMISSION LABS
[**2195-10-28**] 05:35PM BLOOD WBC-6.8 RBC-3.80* Hgb-9.1* Hct-29.4*
MCV-77* MCH-23.9* MCHC-30.9* RDW-18.8* Plt Ct-296
[**2195-10-27**] 02:54PM BLOOD UreaN-105* Creat-5.4*# Na-128* K-4.7
Cl-85* HCO3-27 AnGap-21
[**2195-10-28**] 05:35PM BLOOD Glucose-261* UreaN-91* Creat-4.9* Na-132*
K-3.7 Cl-88* HCO3-29 AnGap-19
[**2195-10-28**] 05:35PM BLOOD Calcium-8.8 Phos-7.0*# Mg-3.0*
.
Imaging:
[**11-11**] Echo
Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is severely depressed (LVEF= 30 %). Right
ventricular chamber size is normal. with borderline normal free
wall function. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of [**2195-11-9**],
left ventricular cavity size is smaller and overall ejection
fraction has increased.
[**2195-11-9**] Echo
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity is
moderately dilated. There is severe global left ventricular
hypokinesis (LVEF = 20 %). No masses or thrombi are seen in the
left ventricle. There is no ventricular septal defect. The right
ventricular cavity is mildly dilated with depressed free wall
contractility. The diameters of aorta at the sinus, ascending
and arch levels are normal. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The left ventricular inflow pattern
suggests a restrictive filling abnormality, with elevated left
atrial pressure. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2195-10-29**],
biventricular systolic function has decreased.
[**2195-11-2**] Cath
COMMENTS:
1. Right heart catheterization revealed severely elevated right
and left
sided filling pressures. The mean RA pressure was severely
elevated at
18 mmHg, and the RVEDP was severely elevated at 22 mmHg. There
was
severe pulmonary arterial hypertension with a PA pressure of
80/33 mmHg
and a mean PA pressure of 49 mmHg. The mean wedge pressure was
severely
elevated at 32 mmHg. The cardiac output and index were reduced
at 4.3
L/min and 2.0 L/min/m2. The pulmonary vascular resistance was
moderately elevated at 316 dyne-sec/cm5.
2. Ultrasound of the right internal juggular vein suggested
thrombus
which is possibly related to the patient's right sided PICC
line,
however subsequent imaging indicated no thrombus but RIJ very
medially
displaced.
FINAL DIAGNOSIS:
1. Severely elevated right and left sided filling pressures.
2. Severe pulmonary arterial hypertension.
3. Reduced cardiac output/index.
4. Moderately elevated PVR.
5. Possible thrombus in the right internal jugular vein which
was not
confirmed by subsequent studies which showed RIJ very medially
displaced.
[**2195-11-13**] CXR
Transvenous right atrial pacer and right ventricular pacer
defibrillator leads
are in standard positions. Yesterday's mild pulmonary edema has
resolved.
There is no pneumothorax, pleural effusion or mediastinal
widening. Heart is
top normal size, unchanged over the long term. Also unchanged
since at least
[**10-19**] are fractures of the two uppermost sternal wires,
which
developed sometime after [**2186-4-26**] when non-fusion of the
manubrium was
already evident radiographically.
[**11-12**] CXR
FINDINGS: In comparison with study of [**11-5**], there has been
placement of an
ICD device with the leads in the region of the right atrium and
apex of the
right ventricle. Specifically, there is no evidence of
pneumothorax. Little
change in the appearance of the heart and lungs.
Persistent separation of the upper sternal fragments therefore
does not
suggest infection, but it is an explanation for fracture of the
wires
[**10-28**] CXR
REASON FOR EXAMINATION: Evaluation of the patient with systolic
and diastolic
heart failure.
PA and lateral upright chest radiographs were reviewed in
comparison to
[**2195-10-23**].
Heart size is enlarged in a globular manner, unchanged.
Mediastinum is
stable. Multiple broken sternal wires are redemonstrated.
As compared to the prior study, there is interval improvement in
interstitial
pulmonary edema, currently mild. There is also improvement in
more focal
right upper lobe opacity. Prominence of pulmonary arteries is
demonstrated,
most likely consistent with pulmonary hypertension. No
appreciable pleural
effusion is seen.
[**2195-10-28**] RENAL U/S
IMPRESSION: No hydronephrosis seen in either kidney. Small
right renal
nonobstructing stone.
.
Discharge
[**2195-11-13**] 04:00AM BLOOD WBC-7.1 RBC-3.28* Hgb-8.4* Hct-28.1*
MCV-86 MCH-25.7* MCHC-30.0* RDW-23.2* Plt Ct-234
[**2195-11-13**] 04:00AM BLOOD PT-15.2* PTT-37.4* INR(PT)-1.4*
[**2195-11-14**] 05:00AM BLOOD Glucose-220* UreaN-74* Creat-3.3* Na-133
K-3.5 Cl-91* HCO3-31 AnGap-15
[**2195-11-14**] 05:00AM BLOOD Calcium-9.3 Phos-3.8 Mg-2.1
Brief Hospital Course:
BRIEF HOSPITAL COURSE
Mr. [**Known lastname 49249**] is a 54y/o gentleman with HTN, HLD, DM2, CKD
(baseline Cr 2.0-2.2), CAD s/p CABG [**2186**] (LIMA-LAD, SVG-PDA, and
radial-OM1-OM2) with systolic and diastolic heart failure, who
was re-admitted from clinic for management of [**Last Name (un) **].
#. Acute on chronic renal failure: Baseline Cr 2.1, presented
last admission at 2.5, and presented at this admission with
creatinine 5.4 in clinic. His renal function fluctuated, and he
was initially managed with 40mg [**Hospital1 **] torsemide. However, he did
not respond well and had worsening renal function. Accordingly,
he underwent R heart cath, which showed severely elevated right
and left sided filling pressures, severe pulmonary hypertension
and depressed CO/CI. He was admitted to the CCU for milrinone
drip and more aggressive diuresis.
On admission, urine studies suggested pre-renal cause of [**Last Name (un) **]
(FEurea 44% is indeterminate, FENa 0.86%). Torsemide had been
held between hospital admissions. Nephrology was consulted and
recommended cefazolin to substitute for Nafcillin (though due to
the short time period, they did not believe [**Last Name (un) **] was consistent
with nafcillin-associated acute interstitial nephritis and urine
eosinophils were positive. Sarna lotion and hydroxyzine were
given for symptomatic relief of uremia-related pruritus. Pt's Cr
trended down to mid 3s, plateaued and then steadily rised. After
pt was switched from milrinone drip to dobutamine drip as well
as optimized afterload reduction with hydralazine and Isordil,
Cr consistently trended down. Upon discharge, Cr was 3.3.
.
#. Acute on chronic CHF: Due to continued weight gain and poor
response, he underwent a R heart cath [see above]. Pt's beta
blocker was restarted at a low dose and then later on
discontinued as pt was in decompensated HF and later on put on
dobutamine drip. Afterload reduction was successful while up
titrating hydralazine and Isordil. Upon discharge, pt's BP was
ranging 130-140. Heart failure team believed CHF is both related
to significant dyssynchrony and contractility issues, both most
likely related to ischemia. Pt was diuresed aggressively
throughout course initially with Lasix drip and then
transitioned to IV Lasix boluses with goal of [**3-12**].5L negative in
24h using 120mg boluses. Pt was transitioned to 100mg Torsemide
at discharge. Dyssynchrony component of HF was addressed with
attempting to place CRT-D. Unfortunately, coronary sinus could
not be accessed successfully and thus LV lead was not placed.
Contractility was addressed with dobutamine drip which pt was
discharged with. After starting dobutamine infusion, EF improved
from 20 to 30% on TTE. Pt will need to followup with EP in order
to access LV for appropriate resynchronization and will probably
have a cardiac catheterization to assess coronaries.
.
#. Peripheral IV-associated MSSA bacteremia:
- Changed nafcillin to cefazolin per ID recs; he underwent a [**Date Range **]
this admission, which did not show any valvular vegetations. As
a result, he underwent a shortened course of IV antibiotics (2
weeks), which ended on [**2195-11-2**]. Pt remained afebrile and stable
thereafter.
.
#. Loose stools
- Recent hospital stay could raise concern for C. diff (pt
nauseous, but no f/c). Per patient, he feels that loose stools
began w/ nafcillin. Either way, may contribute to pre-renal
cause of [**Last Name (un) **] (along with recent poor intake). Loose stools
resolved after stopping nafcillin. In addition, he was c. diff
negative.
.
.
#. CAD s/p CABG
Last cath in [**2191**] noted severe native 3VD with patent LIMA-LAD,
SVG-PDA, and Radial-OM1-OM2. TTE on prior showed new inferior
HK. He was continued on ASA, Pravastatin, and beta blocker
(Metoprolol changed to Carvedilol). In the future he needs L
heart catheterization in order to assess grafts/native vessels.
Pt was continued on ASA and statin. Carvedilol was ultimately
held given decompensated heart failure and pt put on dobutamine
infusion.
.
#. Neuropathic & venous stasis ulcers: Pt was seen by wound care
specialist during hospitalization. Ulcers appeared to heal more
optimally when LE edema decreased with aggressive diuresis. Pt
is to followup with PCP to continue DM management and may need
referral to vascular surgery if ulcers persist or worsen.
.
#. Diabetes mellitus: Stable on ISS, and discharged with Lantus
44u at bedtime with ISS.
.
# Iron deficiency anemia: Hct stable during last admission
30-33. Iron studies showed low level of iron and pt was given 5
days of ferric gluconate IV 125mg to replete iron deficit. Pt's
anemia was stable thereafter and discharged with hct of 28.1.
#Elevated INR: Pt's INR was elevated over 2 during hospital
course without anticoagulation. This was attributed to Vitamin K
deficiency secondary to antibiotic use, malnutrition and
malabsorption from congested bowels related to decompensated
CHF. DIC labs were not remarkable. Pt's elevated INR was
refractory to PO Vit K which supported hypothesis of congestion
in GI tract causing malabsorption issues. As pt's nutrition
improved and preload reduction, INR trended down to 1.4 at time
of discharge. Pt was followed by nutrition during stay and would
benefit from outpt nutrition management.
.
>> TRANSITIONAL ISSUES
- follow up with EP regarding CRT lead placement into LV
- could benefit from ACEI once kidney function improves
- readdress restarting carvedilol when HF better controlled off
of dobutamine
- f/u with PCP regarding lower extremity wounds, medication
reconciliation and diabetes management
- would benefit from outpt nutritional support (fluid
restriction, diabetes)
- would benefit from cardiac cath once kidney function stable
and adequate to assess coronaries/ischemic disease related to
heart failure
- f/u with cardiology
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Nafcillin 2 g IV Q4H
Four week course [**Date range (1) 49250**]
2. Aspirin 81 mg PO DAILY
3. Glargine 44 Units Bedtime
aspart 22 Units Breakfast
aspart 22 Units Lunch
aspart 22 Units Dinner
4. Pravastatin 80 mg PO DAILY
5. Carvedilol 12.5 mg PO BID
6. HydrALAzine 50 mg PO Q8H
7. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
8. Torsemide 60 mg PO BID
held Torsemide on last discharge, from [**10-25**] onwards
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
3. Pravastatin 80 mg PO DAILY
4. HydrALAzine 75 mg PO Q8H
please hold for SBP <100
RX *hydralazine 50 mg 1.5 tablet(s) by mouth three times per day
Disp #*45 Tablet Refills:*0
5. Outpatient Lab Work
For VNA to draw: On Tuesday [**2195-11-17**], please draw Na, K, BUN/Cre,
Bicarb, Cl, glucose, Mg. Please fax results to: Dr. [**Last Name (STitle) **] at
[**Telephone/Fax (1) 9825**]. Diagnosis: chronic systolic heart failure.
6. DOBUTamine 5 mcg/kg/min IV DRIP INFUSION
Please double concentrate if possible
RX *dobutamine 500 mg/40 mL (12.5 mg/mL) IV DOBUTamine 5
mcg/kg/min continous infusion Disp #*30 Bag Refills:*0
7. Torsemide 100 mg PO DAILY
Hold for SBP <90
RX *torsemide 100 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
8. HydrOXYzine 25 mg PO Q6H pruritus
pt may refuse
RX *hydroxyzine HCl 25 mg 1 tablet by mouth Every 6 hours Disp
#*120 Tablet Refills:*0
9. Potassium Chloride 40 mEq PO DAILY
RX *potassium chloride 20 mEq 2 tablets by mouth Daily Disp #*60
Tablet Refills:*0
10. Glargine 44 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
11. Heparin Flush (10 units/ml) 2 mL IV PRN Flush daily and as
needed
RX *heparin lock flush (porcine) [heparin lock flush] 10 unit/mL
2mL to PICC line Flush daily and as needed Disp #*100 Milliliter
Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Last Name (un) 6438**]
Discharge Diagnosis:
PRIMARY
Acute on chronic kidney injury
Acute on chronic systolic heart failure
SECONDARY
MSSA bacteremia
Type 2 diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 49249**],
You were first readmitted to [**Hospital1 1170**] for worsened kidney function as well as worsening
symptoms of heart failure.
You were then tranferred to the CCU because you required
medications to help your heart pump. You were first started on
milrinone with minimal improvement and were then started on
dobutamine. You will go home on a continuous infusion of
dobutamine. It is very important for you to follow up closely
with your doctors and to take your medications as prescribed.
While you were here we tried to place a CRT device, however
there was difficulty placing one of the leads. You now have an
ICD. You will need a different procedure in the future to place
an additional lead on your heart for cardiac resynchronization.
You will also need a cardiac catheterization as an outpatient.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
It was a pleasure caring for you,
Your [**Hospital1 18**] doctors
Followup Instructions:
Department: CARDIAC SERVICES
When: WEDNESDAY [**2195-11-18**] at 10:40 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Please call and schedule the following appointments:
1) With Dr. [**Last Name (STitle) **] in the next week: [**Telephone/Fax (1) 62**]
2) With your primary care doctor in the next week: JAKHRO,[**Telephone/Fax (1) **]
A at [**Telephone/Fax (1) 49260**]
ICD9 Codes: 5849, 2761, 4280, 3572, 4168, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3882
} | Medical Text: Admission Date: [**2114-9-12**] Discharge Date: [**2114-10-4**]
Date of Birth: [**2050-8-10**] Sex: F
Service: GENERAL MEDICINE
ADMISSION DIAGNOSIS:
Profound acidosis and mental status changes.
HISTORY OF PRESENT ILLNESS: This is a 64 year-old African
American female with a complicated medical history, which
renal disease on hemodialysis. The patient was transferred
to the [**Hospital1 18**] from the [**Hospital3 417**] Hospital where she was
admitted on [**2114-9-9**] for evaluation of abdominal pain. By
report the abdominal pain began the Sunday prior with no
associated nausea, vomiting, melena or hematochezia.
Reportedly the patient had some complaints of urinary
retention the day before, but no frank dysuria. Of note, the
hemodialysis.
At the [**Hospital3 417**] Hospital her workup was essentially
negative and only notable for a urinary tract infection, for
which she was treated with Levaquin. There was a question of
pelvic ramus fracture, which was thought to be possibly old
by orthopedics and constipation, which was successfully
treated with enemas at the [**Hospital3 417**] Hospital.
The patient was sent to the [**Hospital1 18**] for further workup of her
questionable pelvic ramus fracture. On arrival she was found
to be febrile, but responsive, although with questionable
clarity of mind. Over the preceding hours the patient became
increasingly unresponsive and hypotensive. The MICU team was
called and examination at the time revealed a temperature of
101, heart rate 115, blood pressure 74/palp. An arterial
blood gases done at the time showed a pH of 7.14, PCO2 20,
and PO2 144 on 4 liters of supplemented oxygen.
PAST MEDICAL HISTORY: From the record, 1. Status post open
reduction and internal fixation of the right hip fracture
complicated by right femoral fracture in [**2113-10-6**],
status post total hip replacement in [**2106**] and [**2109**] due to
osteoarthritis with infected hardware, which was removed in
[**2113-5-6**].
2. Type 2 diabetes mellitus with retinopathy and
nephropathy. 3. Hypertension. 4. End stage renal disease
on hemodialysis secondary to diabetes and hypertension. 5.
History of hypertensive episode in [**2114-1-5**]. 6.
Anemia. 7. Status post Methacillin resistance
staphylococcus aureus bacteremia [**2113-11-5**]. 8. History
of deep venous thrombosis [**2113-11-5**]. 9. Coronary artery
disease. 10. Gastrotomy tube placement in [**2113-11-5**].
11. Congestive heart failure, but with a preserved EF of
55%, mild mitral regurgitation and delayed relaxation. 12.
Status post respiratory failure and tracheostomy in [**2113-11-5**]. 13. History of aspiration pneumonia. 14. History of
Pseudomonas pneumonia. 15. History of previous stroke. 16.
History of C-diff colitis. 17. History of bipolar disorder
with paranoid hallucinations for about twenty years with a
question of schizophrenia. 18. Status post total abdominal
hysterectomy and bilateral salpingo-oophorectomy. 19.
Osteoporosis. 20. Recurrent chronic atrial
fibrillation/atrial flutter. 21. History of myoclonic
jerking.
ALLERGIES: No known drug allergies, but allergic to
strawberries.
MEDICATIONS: 1. NPH insulin 14 units q.a.m. and 12 units
q.p.m., regular insulin sliding scale. 2. Folate 1 mg po
q.d. 3. Nephrocaps one tablet po q.d. 4. Vitamin C 500 mg
po b.i.d. 5. Clonazepam 0.25 mg po q.d. 6. Zantac 150 mg
po q.d. 7. Coumadin 4 mg po q.d. 8. Lopressor 50 mg po
b.i.d. 9. Cardizem 180 mg po q.i.d. 10. Tylenol as
needed. 11. Lomotil as needed. 12. Colace 100 mg po
b.i.d. 13. Vicodin ES 7.5/750 q 6 hours prn. 14. Dulcolax
10 mg po pr prn. 15. Ativan 1 mg intravenous q.h.s. prn.
16. Klonopin 0.125 q.h.s. 17. Premarin 0.625 q.d. 18.
Pravachol 10 mg po q.d. 19. Renagel 800 mg b.i.d. 20.
Bromfed two tablets b.i.d.
SOCIAL HISTORY: The patient lives at home with daughter.
She has lived in nursing homes in the past. No history of
alcohol use or cigarette use. She has been retired for seven
years before which she was a school teacher.
FAMILY HISTORY: No history of epilepsy, schizophrenia,
dementia or bipolar disease.
PHYSICAL EXAMINATION: Vital signs, temperature 101. Heart
rate 115. Blood pressure 74/palp.
In general, this was an unresponsive African American woman
who is not intubated. Head and neck, myoclonic facial jerks.
Pupils are equal, round and reactive to light minimally.
Anicteric. No JVD. Pulmonary, clear to auscultation
bilaterally. No wheezes. Cardiovascular, irregularly
irregular with a rapid rate, but no murmurs, rubs or gallops.
Abdomen, nontender, nondistended. No hepatosplenomegaly. No
rebound or guarding. Extremities no edema and no clubbing.
Neurological, could not assess.
LABORATORY: Hematocrit 41.7, white count 8.7, platelet 299,
INR 9.4, PT 37.8, PTT 59.3. Repeat blood gas pH 7.15, CO2
54, PO2 405 on 100% oxygen. Large acetone. Cerebral spinal
fluid analysis, 1 white cell, 0 red cells, 80 polys and 20
lymphocytes, 53 proteins, 226 glucose, LDH 22.
HOSPITAL COURSE: The patient had a complicated hospital
course. The initial treatment in the MICU included Levophed,
bicarbonate, Vancomycin, Gentamycin and cardiopulmonary
support was continued. The patient was subsequently found to
be in diabetic ketoacidosis and treated with an insulin drip
and responded well. Cardiovascularly, the patient has a
history of chronic atrial fibrillation and in the ICU had a
heart rate of 100 to 130 with no ectopy noted. She had
cardiac enzymes consistent with an acute myocardial
infarction. This is likely secondary to rate. Given the
patient's unstable condition she was not a candidate for a
catheterization while in the Intensive Care Unit.
From an infectious disease stand point she had a T max of
102.4 and received one dose of Vancomycin and Gentamycin as
previously mentioned. She also received one dose of
Ceftriaxone and was started on Flagyl. Urinalysis was
consistent with a urinary tract infection. The patient was
put on contact precautions secondary to history of C-diff and
MRSA.
Respiratory wise, the patient improved while in the Intensive
Care Unit and weaned down to 3 liters of nasal cannula oxygen
with an arterial blood gas of 7.34 pH, 45 CO2. The patient
continued to improve over the next couple of days in the unit
and was transferred to the floor under the service of Dr.
[**First Name8 (NamePattern2) **] [**Name (STitle) 805**].
Hospital history while on the medical service is as follows:
1. Endocrine. The patient has a history of type 2 diabetes
complicated by diabetic ketoacidosis. During her stay in the
hospital NPH insulin was adjusted to keep blood sugars under
200 with supplemental insulin sliding scale. At the time of
discharge the patient had adequate glucose control with NPH
insulin 8 units q.a.m. and 7 units q.p.m. The last
hemoglobin A1C done at this admission was 6.8.
2. Infectious disease. The patient was found to have a
urinary tract infection, which was treated initially with
Ceftriaxone, but later found to be Klebsiella species, which
expended spectrum beta lactamase resistance. The ID Service
was consulted and Zosyn was begun. However, the patient
continued to spike fevers for several days despite being on
Zosyn and ID was reconsulted and the patient was started on
renally dosed Meropenem. Despite our best efforts she
continued to spike fevers on Meropenem. All blood cultures
from peripheral and central lines had been negative to date.
Of note, the patient's clinical picture continued to improve
with improving mental status despite elevated temperatures
primarily at night. Given the patient's clinical
improvement, the issue of bacteremia was readdressed and
infectious disease was reconsulted. The patient was
discontinued on Meropenem as it was felt Meropenem may be
causing a drug fever. The patient became afebrile off
Meropenem for four days and at the time of discharge was
afebrile.
3. Renal. The patient continued to have hemodialysis during
her hospital stay without issue.
4. Fluid and electrolytes. The patient initially had poor
po intake and a swallow study was performed. It was not
significantly different from the one in [**2113-6-5**], which
showed no aspiration, but an increase risk for aspiration
secondary to residual. The patient continued to increase her
po intake during the hospital course as her mental status
improved. She was tolerating loose and a soft diet with
assistance. The concern remains that she will not take in
enough po to sustain her nutritional needs, however, given
her continued improvement, the decision was made to hold off
on enteral feedings.
5. Cardiovascular. Her cardiac status was complicated by
one episode of cardiac arrest while on the floor. The
patient was sitting up in her bed after dialysis and the
nurse noted that she became increasingly unresponsive.
Assessment revealed that she was in cardiac arrest for about
one minute and a code was called and the patient successfully
resuscitated. The etiology of this event remains unclear.
However, this is likely secondary to a mucous plug leading to
decreased respirations and bradycardia secondary to decreased
oxygenation. Otherwise the patient's cardiovascular status
has been improving. Her beta blocker was increased to better
rate control. At the time of discharge her heart rate was in
the 60s to 70s and in sinus rhythm. The patient continues to
be on Coumadin for anticoagulation with a history of
paroxysmal atrial fibrillation.
6. Pulmonary. The patient's pulmonary status has improved
markedly since her admission and currently is breathing room
air with SPO2s in the high 90s.
7. Rheumatology and rehabilitation. The patient has had a
history of hip replacement in the past with osteoporosis and
osteoarthritis. She was started on scheduled Ultram with
good response. Physical therapy has been working with the
patient for increased mobility and ambulation. The patient
has received her leg brace fitting to help her with
ambulation. Radiologic studies indicate no evidence of acute
pubic ramus fracture, but there did reveal extensive
heterotopic bone formation surrounding the right total hip
replacement.
8. Neurologic. The patient has a history of myoclonic
jerking, which was seen by neurology and started on Dilantin.
The patient had an abnormal electroencephalogram with
background slowing with bursts of generalized slowing. This
pattern is suggestive of deep subcortical bilateral
dysfunction or may be seen in the setting of moderate to
severe encephalopathy of toxic metabolic or anoxic etiology.
The [**Hospital 228**] hospital course showed a steady improvement.
Multiple laboratory and radiologic studies were performed
during the hospitalization to further characterize the
problems indicated above. Head CT during this admission
revealed extensive chronic microvascular infarctions. A
video swallow test was done to evaluate swallowing as
indicted above with diffuse pharyngeal residue without
evidence of aspiration. A CT of the pelvis and abdomen was
done to help localize a source of fevers. There was no
evidence of intra-abdominal or intrapelvic abscess. There
was a small area of hypodensity on CT consistent with a small
left adrenal adenoma. The patient had a small left pleural
effusion with some basal atelectasis and consolidation. This
was felt to be adequately treated by the ID staff with her
multiple courses of antibiotics, which include Vancomycin,
Gentamycin, Ceftriaxone, Zosyn and Meropenem.
At the time of discharge the patient was medically stable.
Of note, the patient is highly sensitive to morphine and
becomes disoriented when even low doses of morphine are used.
We would recommend that the patient be given .5 mg of Ativan
if she becomes agitated at night, but would caution the use
of narcotics.
DISCHARGE STATUS: Discharged to rehab facility.
CONDITION AT DISCHARGE: Improved.
DISCHARGE DIAGNOSES:
As in past medical history indicated above and:
1. Diabetic ketoacidosis.
2. Status post cardiac arrest.
3. Klebsiella UTI
DISCHARGE MEDICATIONS: 1. Dilantin 100 mg po t.i.d. 2.
Diovan 80 mg po q.d. 3. Pravachol 10 mg po q.d. 4.
Lopressor 125 mg po b.i.d. 5. Nephrocaps one capsule po
t.i.d. 6. Klonopin 0.25 mg po q.h.s. 7. Enteric coated
aspirin 325 mg po q.d. 8. Colace 100 mg po b.i.d. 9.
Renagel two capsules po t.i.d. with meals. 10. Coumadin 2
mg po q.d. 11. NPH insulin 8 units subcutaneous q.a.m. and
7 units subcutaneous q.p.m. 12. Ultram 50 mg po t.i.d. 13.
Protonix 40 mg po b.i.d. 14. Motrin 400 mg as needed. 15.
Dulcolax 10 mg po pr q.d. prn. 16. Boost vanilla one can po
t.i.d.
[**Name6 (MD) 7853**] [**Last Name (NamePattern4) 7854**], M.D.
[**MD Number(1) 7855**]
Dictated By:[**Last Name (NamePattern4) 26426**]
MEDQUIST36
D: [**2114-10-4**] 10:01
T: [**2114-10-4**] 11:07
JOB#: [**Job Number 26427**]
ICD9 Codes: 5990, 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3883
} | Medical Text: Admission Date: [**2140-1-31**] Discharge Date: [**2140-2-2**]
Date of Birth: [**2095-6-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1936**]
Chief Complaint:
Etoh withdrawal
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
This is a 44 year old male with a history of hypertension,
chronic knee pain, and alcohol abuse with history of DTs who was
found down in the snow with hypothermia, now in alcohol
withdrawal.
Per report, patient was found down outside by EMS, initially
temperature around 92.2, 94.5 oral on arrival to the ED. The
patient does not recall being found or where he was at that
time. He was found shivering with slurred speech and
incontinent of urine. FS was 144. On arrival to the ED, he was
following commands and speaking in full sententences.
In the ED, he received a banana bag and 1 L NS. He was placed on
a bearhugger and warmed up to T max of 99.4. Once he awoke and
was warmed, he was agitated, tachycardic, diaphoretic, &
tremulous, c/w EtOH withdrawal. He also expressed suicidal
ideation; seen by psychiatry in ED who did not think he was an
immediate danger to himself.
On arrival to [**Hospital Unit Name 153**], belligerent, but after speaking with
admitting resident, calmed down, apologized for his behavior and
accepted plan for EtOH detox.
ROS: The patient states he just feels like he was "run over by a
truck." Denies any fevers, chills, weight change, nausea,
vomiting, abdominal pain, diarrhea, constipation. He reports
occasional hematemesis, none recently, and occasional BRBPR,
none recently. never had any endoscopy. Also complains of a
headache now. Denies CP, shortness of breath, orthopnea, PND,
lower extremity oedema, cough, urinary frequency, urgency,
dysuria, lightheadedness, gait unsteadiness, focal weakness,
vision changes, rash or skin changes.
Past Medical History:
Hypertension
Chronic knee pain from MVA in [**2111**] s/p multiple surgeries (? in
[**Hospital1 8**])
Hepatitis C from blood transfusion in the [**2111**], never treated
(couldn't stay sober long enough), history of biopsy many years
ago
Alcohol abuse
Type 2 DM
Anxiety/depression
s/p umbilical hernia repair
Social History:
Homeless for the last 4 months. Was kicked out of [**Hospital1 **]
Shelter for 60 days approximately one week ago for beating up
another resident. Has been on the street since that time.
Smokes as much as possible. Drinks at least 2 pints of Schnapps
and 1.5 gallons of vodka daily. Has no family. Adamantly
denies any history of past or present IVDU.
Family History:
Breast cancer, hepatocellular cancer in his grandmother.
Physical Exam:
Vitals: 97.4 143/80 88 18 98%RA
Pain: [**2141-3-29**] L chest/rib cage, R knee
Access: PIV
Gen: desheveled, belching
HEENT: anicteric, mmm
CV: RRR, no m
Resp: CTAB, no crackles or wheezing
Abd; soft, obese, +tenderness over R ribcage, otw nontender, +BS
Ext; no edema, no R knee swelling
Neuro: A&OX3, grossly nonfocal, mild tremors
Skin: no changes
psych: more sedated today, but easily angry/agitated when awake
gross dermatitis. No ecchymoses.
Pertinent Results:
wbc 5.5
hgb 15.8-->13.3-->12.1 MCV 88
LFTs wnl [**2-1**]
Chem panel unremarkable, K/phos/Mag okay
Serum tox: etoh 277, +benzo
.
.
Imaging/results:
CXR: [**1-31**] and [**2-1**]: no acute abnormality
Brief Hospital Course:
44year old male with longstanding ETOH dependence c/b DTs,
tobacco abuse, narcotic abuse, Hep C, Depression/anxiety,
chronic R knee pain, DM, homelessness brought to [**Hospital1 18**] with
environmental hypothermia when found down in ice on [**1-31**]. Was
externally warmed up but then actively withdrawing, so t/f to
MICU. Loaded with valium, given IVFs, bannana bag, stabilized
overnight. Then transfered to Gen Med for social work and
placement. Was continued on CIWA scale/valium through the night.
Was also started on seroquel 300mg qhs (on this as outpt).
Kicked out of [**Hospital1 **] several weeks ago for fighting, cannot
return till [**2139-3-18**], so now homeless. Initially was agreeable
for inpatient detox but on HD#2, refused detox. Stated that his
plan was to keep drinking and pass out every day and he does not
care if he doesnt wake up. He denied active SI or plan
(passive). Seen by psych who felt that he understood his risks
and was capable of making his own decisions. Signed out AMA so
that he can "go to liquor store and continue drinking". Was not
given any Rx on discharge for valium/seroquel/cymbalta/klonopin
per psych recs since his plan was to continue drinking and he
openly admitted that he was abusing seroquel and cymbalta and he
still has active scripts at his pharmacy in [**Hospital1 3494**]. Attempts
by psych at contacting his outpt psych were unsuccesful. Of
note, reported that he fell on L side so c/o a lot L chest/rib
pain (CXR neg for fracture, no rib films done prior to him
signing out AMA) and chronic R knee pain. Has h/o chronic
narcotic abuse (percocet-30mg), here was getting oxycodone 15mg
q4hrs prn. He states that he gets this off the street and
through his MD [**First Name (Titles) **] [**Last Name (Titles) **] was not given for this. He was stated on
clonidine here for HTN but stated he would not take this on
discharge (was previously on this and still has Rx at pharmacy).
Refuse to comply with diabetic diet (and seroquel not helping).
Social work tried to talk with patient about finding a homeless
shelter but pt did not want to wait for this. Signed out AMA on
[**2-2**], got cab voucher so he can go to homeless shelter.
.
progress note
.
Etoh withdrawal: +++longstanding ETOH abuse, History of DTs, not
clear about seizures. Also on chronic klonipine (benzo)
contributing to withdrawal
-Cont Valium per CIWA scale->decrease frequency as tolerated
(also given that patient is on chronic Klonipin). monitor for
benzo intoxication
-pt states very clearly that he intends to drink upon discharge
(is variable about wanting detox) so will NOT given Valium on
discharge since high risk of abuse
- cont MVI, folate, thiamine
- Psych and SW consult saw pt, he is NOT interested in inpatient
detox, wants to sign out AMA despite multiple discussions
emphasizing risk (weather, continued drinking)
.
.
Pain: Complaining of chronic R knee pain, also with some left
sided rib pain, appears musculoskeletal, reproducible. CXR done
in ED no obvious rib fracture and pt appears to be comfortable
w/o any splinting and able to ambulate. Chronic narcotic user.
- Valium as above, oxycodone 15mg ([**Month (only) **] from 20mg) q4 prn for
pain (patient reports getting percocet-30 from PCP and off the
street for 20years) and continue tylenol q6prn. No Rx on
discharge
.
.
Hepatitis C: Reports infection during the [**2111**] from blood
transfusion. Denies any IVDU, no tatoos. Has had biopsy in the
past, no treatment. Appears he has history of upper GI bleed
but has never had endoscopy. LFTs wnl, coags normal, albumin 4.1
all of which go against chronic hepatitis.
.
.
Anemia, acute drop: HCT drop 42.9-->36.9 but has recieved IVFs
and HCT now stable and likely his baseline. No active bleeding
noted but he is certainly high risk
.
.
Hypertension: supposed to be on nifedipine and clonidine at
home, not sure if taking. Also component of acute etoh
withdrawal.
-well controlled now with valium and clonidine 0.2mg [**Hospital1 **]. hold
nifedipine. Pt states he will not take this meds on discharge
though he has clonidine that he uses for w/drawal symptoms.
.
.
Type 2 DM: On glipizide 10mg [**Hospital1 **] at home, has not been taking
it. Sugars now in 300s since he is taking good PO. Seroquel
making DM worse.
- resumed glipizide while here with SSI, refused to follow
diabetic diet
.
.
Depression/anxiety: psych following, they do not feel he is
actively suicidal despite his occ comments about wanting to lie
in snow and die. They feel he has capacity to leave AMA if he
wants.
-never recieved OSH records from OP Psych re: prior hx and meds
-for now, on seroquel 300mg qhs (pt admits that he abuses
seroquel as outpt). holding cymbalta and klonipin (on valium as
above)
-spoke with psych resident, pt has refills on ALL his meds at
pharmacy and given that he openly admits that he abuses ALL his
meds, will no provide any additional Rx on discharge
.
.
Tobacco abuse: nicotine patch 21mg/24hr while here
.
Left AMA
.
Medications on Admission:
Glucotrol 10 mg [**Hospital1 **]
Cymbalta 60 mg [**Hospital1 **]
Nifedipine CR 30 mg
Seroquel 300 mg HS
Clonidine 0.2 mg [**Hospital1 **]
Klonipin 2 mg TID
percocet-30, 6 pills daily, prescribed, plus what patient buys
illicitly
Discharge Medications:
1. Quetiapine 200 mg Tablet Sig: 1.5 Tablets PO QHS (once a day
(at bedtime)).
2. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Glipizide 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day.
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Environmental hypothermia
Etoh dependence and withdrawal
Discharge Condition:
At risk for further ETOH withdrawal and hypothermia
Discharge Instructions:
You were admitted to the intensive care unit after you were
found down in the snow and hypothermic. While here, you
developed alcohol withdrawal and were treated with valium. You
were seen by psychiatry who said you were capable of making your
own decisions since you understool all the risks associated with
your behaviour. You decided to leave Against Medical Advice
despite being requested to stay for inpatient detox, especially
since it is very cold outside and you are homeless now that you
have been kicked out of [**Hospital1 **] until [**2139-3-18**].
You left despite this. You were not given any prescriptions as
your pharmacy still has Rx for you.
Followup Instructions:
Please see you psychiatrist
ICD9 Codes: 4019, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3884
} | Medical Text: Admission Date: [**2166-8-22**] Discharge Date: [**2166-9-2**]
Date of Birth: [**2096-11-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
69M with chest pain
Major Surgical or Invasive Procedure:
[**2166-8-25**] CABG x 2 (LIMA->LAD, SVG->OM)
History of Present Illness:
69 y.o. man with hx of ectopy and left leg DVT/PE in [**5-15**]
presented to outside hospital with right-sided chest pain
lasting 5-10 seconds x 3 days and increased fatigue while
playing golf. Chest pain not accompanied by nausea, vomiting,
or diaphoresis. Patient presented to outside hospital where he
was ruled out for acute coronary syndrome. He had a scheduled
stress test yesterday and was noted to have 1-[**Street Address(2) 35144**]
depressions with a normal perfusion study. Patient was
transferred to [**Hospital1 18**] for cardiac catheterization which showed
70% occlusion of the distal LCMA.
Past Medical History:
DVT/Pulmonary Embolism [**5-15**]
Hyperlipidemia
remote hx ulcer disease
Social History:
smoked 1 PPD, cigars, pipe x 15 years, quit 20 years ago
Family History:
Father died of MI at age 58; brother had MI
Physical Exam:
VS: 119/59 51 18 98% RA weight: 222
GEN: elderly man lying in bed in NAD
HEENT: AT, NC, PERRL, EOMI, neck supple,
CV: Irregular, regular rate, no murmur
PULM: CTAB on anterior exam
ABD: soft, obese, non-tender, non-distended, no HSM, + BS
EXT: cool to touch BL, + 2 DP and radial pulses
NEURO: alert, oriented, CN II-XII grossly intact, sensation
intact in LE bilaterally
Pertinent Results:
[**2166-8-31**] 12:30PM BLOOD WBC-7.1 RBC-3.52* Hgb-9.9* Hct-29.2*
MCV-83 MCH-28.2 MCHC-33.9 RDW-17.1* Plt Ct-220
[**2166-9-2**] 07:05AM BLOOD PT-16.4* PTT-76.2* INR(PT)-1.8
[**2166-8-31**] 12:30PM BLOOD Glucose-114* UreaN-18 Creat-1.0 Na-139
K-4.5 Cl-104 HCO3-24 AnGap-16
Brief Hospital Course:
Mr. [**Known lastname 35145**] was admitted and went straight to the cardiac
catheterization lab where he was discovered to have 70% distal
LCMA occlusion. Cardiac surgery was consulted and patient was
scheduled for coronary artery bypass graft. In light of the
patient's known history of deep venous thrombosis and pulmonary
embolism patient was anticoagulated with heparin and he received
one dose of vitamin K to normalize his INR in preparation for
surgery. Discussed possibility of working patient up for
hypercoagulable disorder with Factor V Leiden, Homocysteine,
Antithrombin III tests but these tests are not available as
inpatient per lab. Iron studies to evaluate anemia were all
within normal limits. Urinalysis and chest x-ray were negative.
Room air ABG was performed and was notable for decreased PaO2.
Patient was maintained on his outpatient medications, including
sotalol for his ectopy. Patient went for his scheduled surgery
on [**8-25**].
On [**8-25**] he underwent a CABGx2 with LIMA->LAD, SVG->OM. He was
transferred to the CSRU in stable condition and was extubated on
his postop night. He had frequent ventricular ectopy and was on
Lido which was d/c'd on POD#1. He was restarted on Sotolol with
good effect. He was restarted on coumadin on the post op night
and was tx'd 1UPRBC. His chest tubes were d/c'd on POD#1 and
POD#2 he was transferred to the floor. His epicardial pacing
wires were d/c'd on POD#3 and he continued to progress. He was
seen by Dr. [**Last Name (STitle) **] of EP and he has followed the pt. for a
long time. He will continue to follow the pt. and may continue
ablation in the future. He was anticoagulated with heparin and
coumadin and was discharged to home on POD#8 in stable
condition.
Medications on Admission:
Coumadin
Sotolol
MVI
lipitor
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:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
4. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 1 weeks.
Disp:*14 Tablet(s)* Refills:*0*
6. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 1
weeks.
Disp:*28 Capsule, Sustained Release(s)* Refills:*0*
7. Sotalol 80 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day).
Disp:*90 Tablet(s)* Refills:*0*
8. Coumadin 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
CAD
s/p DVT/PE [**5-15**]
Frequent PVCs
hyperlipidemia
remote PUD
Discharge Condition:
Good.
Discharge Instructions:
Call with temperature more than 101, redness or drainage from
incision, or weight gain more than 2 pounds in one day or five
in one week.
No Heavy lifting or driving until followup with surgeon.
[**Month (only) 116**] shower,no baths or swimming, wash incision with mild soap
and water, no lotions creams or powders.
Followup Instructions:
Dr. [**Last Name (STitle) **] 4 weeks
Dr. [**Last Name (STitle) 1911**] 2 weeks
Dr. [**Last Name (STitle) 12816**] 2 weeks
Completed by:[**2166-9-2**]
ICD9 Codes: 9971, 4271 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3885
} | Medical Text: Admission Date: [**2106-6-17**] Discharge Date: [**2106-6-24**]
Date of Birth: [**2025-12-3**] Sex: M
Service: MEDICINE
Allergies:
Succinylcholine / Aspirin
Attending:[**First Name3 (LF) 465**]
Chief Complaint:
Sepsis, respiratory failure
Major Surgical or Invasive Procedure:
Intubation, extubation, central line/PICC placement
History of Present Illness:
80y M, NH resident s/p recent subdural hematoma evacuation who
was in his USOH until 3.30am today when (per NH records) he
suddenly became hypotensive and hypoxic. A STAT ABG at the time
was 7.48/25/66/18.7, his SBP was in 70s and was treated with IV
NS, x2 bld cx were drawn and the pt was started on empiric Vanc
for presumed UTI. His labs were significant for: WBC 25.7 and Na
133. The pt was transferred to [**Hospital1 18**] to r/o sepsis and PE.
.
Per ED notes, this morning pt was also noted to have increasing
confusion, decreased urine output, fever and elevated white cell
count. He was tachycardiac, and had fever to 103, lactate 5 and
SBP to 80s. He was treated w/ IVF w/ inc in BP to 111/49, 1 dose
Vanc/levo/flagyl.
.
Recent admission ([**Date range (1) 61538**]) to ED for mental status changes and
hypotension in setting of UTI (pan-sensitive P.aeruginosa)
treated w/ 7d course PO Cipro.
.
On arrival to the [**Hospital Unit Name 153**], the pt was deep suctioned by the
Respiratory therapist and his secretions were significant for
food particles and bloody secretions.
Past Medical History:
DM- not on meds on diet control
Paget's disease
subdural hematoma s/p L craniotomy w/ hematoma evacuation ([**5-18**]
and [**5-21**]. Has some residual right sided weakness, aphasic,
cognitive impairment)
recent admission for UTI
h/o MSSA
acute infarct noted on MRI [**5-15**] (left posterior frontal region
indicative of an acute infarct).
Social History:
Lives alone in an apartment in [**Hospital1 392**], MA. Divorced, has nephew
and brother in local area, children in other states.
Former smoker
NO alcohol
Family History:
Non contributory
Physical Exam:
VS: T: 98.4, HR: 115, BP: 109/82, RR:30, O2 sats: 88% on 15L
high-flow
GEN: Elderly male, awake, sitting up in bed, in obvious
respiratory distress, audible wheezing.
HEENT: OP clear but very dry, no LAD, PERRLA
CV: (difficult to auscultate [**2-11**] diffuse, loud ronchi) RRR,
S1+S2, no obvious m/r/g
PULM: Diffuse rhonchi and wheezing throughout both lung fields.
ABD: soft, NT, ND, +BS, no HSM
EXTREM: no c/c/e. Warm periphery.
Neuro: Pt thinks he is in [**Hospital1 392**]. Once oriented to place, he can
recall it after 10 minutes, recalls DOB. Not oriented to time or
date. Tone LUE>RUE. Downgoing left plantar, equivocal right
plantar. Decreased bulk throughout.
Pertinent Results:
lactate 5->3
Phenytoin: 9.0
CHEM7: (83% N with 1 Band), Occ bacteria, occ yeast
CBC: WBC 52, HCT 31.7->29.8
UA: WBC [**10-29**]
.
Radiology:
CXR: RLL opacity-> PNA vs aspiration, extensive Paget's disease
of the right humerus, scapula and clavicle
.
ETT placement: 6cm above carina. It's below the clavicles.
.
[**2106-6-17**] 5:30 pm URINE Site: CATHETER
**FINAL REPORT [**2106-6-20**]**
URINE CULTURE (Final [**2106-6-20**]):
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
YEAST. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
LINEZOLID------------- 2 S
NITROFURANTOIN-------- 64 I
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ =>32 R
.
[**2106-6-17**] 11:05 pm BRONCHOALVEOLAR LAVAGE
SPECIMEN COLLECTED VIA LAVAGE WITH STERILE WATER.
**FINAL REPORT [**2106-6-20**]**
GRAM STAIN (Final [**2106-6-18**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND SINGLY.
RESPIRATORY CULTURE (Final [**2106-6-20**]):
10,000-100,000 ORGANISMS/ML. OROPHARYNGEAL FLORA.
STAPH AUREUS COAG +. >100,000 ORGANISMS/ML..
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
Please contact the Microbiology Laboratory ([**7-/2406**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ <=1 S
.
[**2106-6-18**] 12:00 pm BRONCHIAL WASHINGS
GRAM STAIN (Final [**2106-6-19**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2106-6-20**]): NO GROWTH.
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
Brief Hospital Course:
80 year old male with DM, recurrent UTI, Paget's, s/p recent
subdural hematoma evacuation admitted to [**Hospital Unit Name 153**] w/ respiratory
failure found to have MRSA pna VRE urosepsis, now improved,
called out of [**Hospital Unit Name 153**] to medicine.
.
# Respiratory distress: Patient was in acute respiratory
distress on admission to the [**Hospital Unit Name 153**]. He was noted to have thick
bloody secretions on deep suctioning with visible food
particles. He was intubated and a bronchoscopy was performed on
[**6-18**] which showed inflamed friable mucosa with moderately thick
mucous in the LLL bronchus. No foreign body was visualized and
a BAL was sent for culture.
His acute respiratory distress was attributed to aspiration PNA
and urosepsis, however, his CXR on [**6-19**] was concerning for
possible ARDS. He was started on protective ARDS vent settings.
He was extubated successfully on [**6-20**]. His sputum culture
eventually grew MRSA and patient was continued on Linezolid for
coverage of MRSA PNA and VRE UTI. Pt also developed pulmonary
edema from fluids that were received, and received lasix for
diuresis with good effects. Pt's O2 was weaned as tolerated. At
the time of dicharge, pt was satting at 95% on RA.
.
# VRE urosepsis/aspiration, MRSA pneumonia: Patient was admitted
to the [**Hospital Unit Name 153**] for sepsis given hypotension, hypoxia, tachycardia,
fever and leukocytosis. The pt was noted to have a UTI. A
culture sent from the ED grew out enterococcus and patient was
noted to have bibasilar consolidations R > L accompanied by
small-to-moderate pleural effusions concerning for PNA. Patient
was started on Vancomycin, Levofloxacin, and Zosyn.
Blood cultures were sent from the ED remained NGTD. However,
urine cx returned positive for VRE, and patient was started on
Linezolid IV for coverage of his MRSA PNA and VRE UTI. The BAL
also came back + for MRSA which is covered by linezolid.
Attempted to d/c foley and pt unable to void after trial and
foley was replaced. Will need another voiding trial after
treatment of UTI.
.
# Hypotension: Patient arrived from the ED on Levophed. He was
aggressively fluid resuscitated and he was weaned off the
levophed on [**6-19**]. It was noted that the patient was developing
a non-gap hyperchloremic acidosis from the normal saline which
had been used for volume resusciation so his IVF was changed to
lactated ringers with good resolution. On [**6-18**] he failed his
[**Last Name (un) 104**] stim test and was started on stress-dose steroids. His
blood pressure stablized and his steroids were continued. IV
steroid was switched to po and po steroids tapered to off on
[**6-24**].
.
# Mental status changes: Patient is s/p subdural hematoma
evacuation. It is unclear what his baseline mental status is
although per report, he is able to follow commands, and there
was a notable decline which in part tiggered this admission.
Likely etiology of new decline in mental status is infection.
Given his past history of CVA, heparin SC was withheld. Patient
was continued on his seizure prophylaxis with Phenytoin
(currently 9.0; goal [**10-29**]) for his history of subdural
hematoma. He should be continued on this for an additional 2
weeks.
.
# DM: Patient was maintained on an ISS.
.
FEN: Patient was NPO while intubated. Nutrition was consulted
and tube feeding was initiated on [**6-18**]. Pt self discontinued his
NGT and a swallow study was performed. The video swallow showed
no aspiration but pt should have pills crushed for pocketing. In
addition, he does not have teeth and therefore should cont on
pureed solids. Pt was taking poor PO and had another family
discussion about PEG tube placement. Family does not want a PEG
tube but this should be readdressed with family if pt continues
to take poor PO. Daughter will address with her family. Pt was
started on Megace on [**6-24**].
*
PPx: Hepain SC, PPI, bowel regimen
*
Access: PICC
*
Code status: Full code (discussed with son, [**Name (NI) **], who lives in
[**Name (NI) 33977**])
*
Communication: son (W:[**Telephone/Fax (1) 66904**], C:[**Telephone/Fax (1) 66905**])
Medications on Admission:
Phenytoin for sz ppx
SC Heparin 5000U TID
Pantoprazole 40mg QD
Thiamine 100mg QD
MVI
Folic acid 1mg QD
Phenytoin 500mg QD (200mg [**Hospital1 **] and 100mg at noon)
Senna 1 Tab [**Hospital1 **] PRN
Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Lopressor 25 mg [**Hospital1 **]
ISS
recently completed course Ciprofloxacin 500 mg Tablet Q12H on
[**2106-6-6**]
Discharge Medications:
1. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty
(30) mg PO DAILY (Daily).
2. Phenytoin 100 mg/4 mL Suspension Sig: Two Hundred (200) mg PO
QAM AND QPM () for 2 weeks.
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): until ambulatory then stop.
4. Therapeutic Multivitamin Liquid Sig: One (1) Cap PO DAILY
(Daily).
5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Phenytoin 100 mg/4 mL Suspension Sig: One Hundred (100) mg PO
AT NOON ().
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. Senna 8.8 mg/5 mL Syrup Sig: Five (5) ML PO BID (2 times a
day) as needed for constipation.
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
12. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
13. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
injection Injection ASDIR (AS DIRECTED): Please see sliding
scale. .
14. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 6 days.
15. Megestrol 40 mg/mL Suspension Sig: One (1) PO DAILY
(Daily).
16. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) Flush Intravenous DAILY (Daily) as needed: 10 ml NS
followed by 2 ml of 100 Units/ml heparin (200 units heparin)
each lumen Daily and PRN. Inspect site every shift.
Order was filled by pharmacy with a dosage form of Syringe and a
strength of 100 U/ML.
17. Piperacillin-Tazobactam 2.25 g Recon Soln Sig: One (1) Recon
Soln Intravenous Q6H (every 6 hours) for 3 days.
18. Bisacodyl 5 mg Tablet Sig: Two (2) Tablet, Delayed Release
(E.C.) PO DAILY (Daily) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary diagnoses:
Aspiration/MRSA pneumonia
Sepsis
VRE urosepsis
.
Secondary diagnoses:
Hypertension
Discharge Condition:
Stable, afebrile
Discharge Instructions:
Call your doctor or come to emergency department if you develop
fevers, chills, nausea, vomiting, worsening cough, shortness of
breath, or any other worrisome symptoms.
Please call your PCP to make an appointment in [**1-11**] weeks after
you leave the rehab facility.
Followup Instructions:
Please follow-up with your PCP [**Last Name (NamePattern4) **] [**1-11**] weeks.
Follow up with Dr. [**Last Name (STitle) 739**] with head CT on [**2106-7-1**].
PROVIDER: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2106-7-1**] 2:00
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]
ICD9 Codes: 2768, 4019, 2859, 0389, 5070, 5990, 4280, 2762 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3886
} | Medical Text: Admission Date: [**2131-4-16**] Discharge Date: [**2131-4-20**]
Date of Birth: [**2070-1-22**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1561**]
Chief Complaint:
tracheobronchial malacia
Major Surgical or Invasive Procedure:
bronch
tracheobronchial malacia
History of Present Illness:
Ms. [**Known lastname **] is a 61-year-old woman
with severe tracheobronchomalacia. She has had improvement
after a stent trial.
Past Medical History:
100pkyr hx, s/p Nissen [**2-7**], Y-stent placed [**2-6**] removed [**3-9**],
COPD, hypertension, osteoporosis, depression, gout,
hyperlipidemia
TBM w/ stent trial
Social History:
100 pk year smoker
Family History:
non-contributory
Pertinent Results:
[**2131-4-19**] CXR : ONE VIEW. Comparison with [**2131-4-18**]. A right chest
tube has been removed. No pneumothorax is identified. Streaky
density consistent with subsegmental atelectasis or scarring
persist. Mediastinal structures are unchanged. Right rib
fractures and underlying pleural thickening, loculated pleural
fluid or extrapleural hematoma are again demonstrated.
IMPRESSION: No significant change post-removal of right chest
tube.
Brief Hospital Course:
pt was admitted and taken to the OR on [**2131-4-16**] for Tracheoplasty
with mesh, right main-stem bronchoplasty with mesh, left
mainstem bronchoplasty with
mesh, flexible bronchoscopy. an epsiural was placed pre-op for
pain control w/ good effect. Two right chest tubes were placed
in the OR and placed to sxn w/o no evidence of air leak. Post-op
-extubated and admitted to the ICU for post-op management. On
POD#0 -required IVB for low BP and low u/o-responded approp'ly.
O2 sats 94% on 4LNP. Bronch'd on POD#2 pt was bronched - edema
was seen in the upper airway and at right mainstem; secretions
were aspirated from the left lower lobe.
POD#3 chest tube removed and [**Doctor Last Name **] placed to bulb sxn.
Ambulating, [**Last Name (un) 1815**] po's and po pain med.
d/'d to home on POD#4 w/ home oxygen as PTA.
Medications on Admission:
Advair 50/500'', combivent 4'''', prevacid 30', prozac 40', HCTZ
25', trazadone 50 qhs, zocor 40', zantac 150', MVI'
.
Discharge Medications:
1. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-5**]
Puffs Inhalation Q6H (every 6 hours).
2. Fluoxetine 10 mg Capsule Sig: Four (4) Capsule PO DAILY
(Daily).
3. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] ().
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*75 Tablet(s)* Refills:*0*
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
7. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
9. Prevacid 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 **] of saco me
Discharge Diagnosis:
tracheobronchial malacia s/p tracheoplasty
Discharge Condition:
good-oxygen dependent at baseline
Discharge Instructions:
call Dr.[**Name (NI) 1816**] office [**Telephone/Fax (1) 170**] if you develop chest pain,
shortness of breath, fever, chills, redness or drainage from
your surgical incision.The steri-strips on the incisison will
fall off in time.
You may shower on saturday. After showering, remove the chest
tube site dressings and cover the site w/ a clean bandaid or
gauze daily until healed.
Do not drive while taking pain medication. Take a mild laxative
to prevent constipation while taking pain medication.
Followup Instructions:
Call Dr.[**Name (NI) 1816**] office [**Telephone/Fax (1) 170**] for a follow up
appointment
Completed by:[**2131-4-23**]
ICD9 Codes: 496, 5185, 3051, 4019, 311, 2749, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3887
} | Medical Text: Admission Date: [**2127-4-1**] Discharge Date: [**2127-4-7**]
Date of Birth: [**2045-1-4**] Sex: F
Service: MEDICINE
Allergies:
Sulfamethoxazole/Trimethoprim / Codeine / Antihistamines
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
Weakness, diarrhea
Major Surgical or Invasive Procedure:
left subclavien central line placement
right arm picc line placement
History of Present Illness:
PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 4844**] and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2425**], [**Company 94804**]
.
.
HPI: Ms. [**Known lastname 68181**] is an 82yo woman with h/o afib, COPD, recent
hospitalization [**Date range (1) 61523**] with shortness of breath, (treated for
pneumonia with levofloxacin for 10d (ended 3d ago) and COPD
flare with prednisone 5d course), and chronic low back pain on
oxycontin who presented to the ER today feeling drowsy and with
diarrhea. very poor historian. She has not had fever at home.
There are several calls to [**Date range (1) **] by her son, after which [**Name (NI) **]
[**Last Name (NamePattern1) 2425**], NP called an ambulance to bring her in today.
.
Per [**Last Name (NamePattern1) **] notes and ER staff there are questions of whether her
son has been giving her more than her prescribed oxycotnin
versus taking it himself (or selling). Per [**Last Name (NamePattern1) **] notes the
patient has been refusing all of her meds except oxycontin all
week, and her son has been giving her extra doses. She has also
been quite sleepy all week. Denies dysuria, cough, sob, abd
pain.
.
In the ER the patient was noted to be afebrile and in afib with
RVR at 160. Cards was called and recommended dilt drip. She
received 3LNS and was given potassium repletion and was started
on a dilt drip, which was able to bring her heart rate to
100-120s with an SBP of 100s. O2 sat 97-100% on 2LNC. She had a
WBC of 28. CXR was performed and revealed her prior pna seen on
CXR 3w ago. UA was negative for infection. Stool was not sent.
Blood cultures were drawn and she was given a dose of ctx and
azithro to cover for possible CAP before it was noted that her
infiltrate was unchanged from prior.
.
ROS: denies HA, states diplopia lasting a few seconds at a time
for last "month or so", lower back pain which is worse since
they lowered her oxycontin dose, not wearing bottom dentures
because gums are swollen and sore. no dysuria.
.
Past Medical History:
- chronic low back pain on oxycontin with oxycodone for
breakthrough
- HTN
- CAD with RCA stent: Pmibi in [**1-29**] showed Mild, reversible
perfusion defects of the apical portions of the inferior and
inferolateral walls. Normal left ventricular cavity size and
systolic function.
- CHF due to valvular disease: mod AR and AS with severely
thickened AV, mild MR [**First Name (Titles) **] [**Last Name (Titles) **] [**First Name (Titles) 151**] [**Last Name (Titles) 20440**] deformity and
annular calcification.
.
- rheumatic heart disease followed by Dr. [**Last Name (STitle) **]: echo [**9-28**]:
left atrium mildly dilated. [**Month/Year (2) 1192**] symmetric left ventricular
hypertrophy. Regional left ventricular wall motion is normal.
Overall left ventricular systolic function is normal (LVEF>55%).
aortic valve leaflets are severely thickened/deformed. [**Month/Year (2) 1192**]
aortic valve stenosis. [**Month/Year (2) **] (2+) aortic regurgitation.
mitral valve leaflets are moderately thickened. The mitral valve
shows characteristic rheumatic deformity. There is severe mitral
annular calcification. There is [**Month/Year (2) 1192**] thickening of the
mitral valve chordae. There is mild mitral stenosis. Mild (1+)
mitral regurgitation is seen. [Due to acoustic shadowing, the
severity of mitral regurgitation may be significantly
UNDERestimated.] [**Month/Year (2) 1192**] pulmonary artery systolic
hypertension. Compared with the findings of the prior report
(tape unavailable for review) of [**2124-8-29**], the pulmonary
hypertension is worse, and the mitral regurgitation may be
better.
.
- tachy-brady syndrome s/p dual chamber pacer
- panic disorder
- COPD: last PFTs [**9-28**] showed TLC 2.76 (72%), DLCO 39%pred, FVC
1.61 (75%) with FEV1 1.18 (83%) and FEV1/FVC 111% pred.
- restrictive lung disease with scoliosis
- s/p TAH/BSO
- multinodular goiter
- hyperlipidemia
- chronic leg edema with venous stasis
Social History:
lives with son. his [**Name2 (NI) 802**] [**Name (NI) 41215**] lives upstairs. smokes 1ppd for
about 65yrs. no etoh.
Family History:
siblings with "heart conditions" and "cancer"
Physical Exam:
T 96.0 HR 95, BP 96/33, RR 18, O2 100% on 2LNC
Gen: confused but answers questions
HEENT: NCAT, PERRL, R side of mouth with droop (no photos to
compare), MM dry
Neck: no LAD
Cor: irreg irreg, ii/vi systolic and diastolic murmurs heard
throughout precordium
Pulm: CTA L lung, R base with crackles
Abd: soft, NTND, no HSM, hyperactive BS
Ext: 2+ pitting edema BLE (per pt at baseline), DPs faintly palp
bilat
Neuro: able to move eyebrows bilat, able to puff out cheeks
bilat, pt will not smile for me. [**4-28**] bilat dorsi/plantarflexion,
[**2-26**] bilat hip flexor (cannot raise leg off of bed but can with
bent knee and foot on bed)
GU: foley catheter in place with concentrated brown urine in bag
Pertinent Results:
WBC-28.1*# RBC-4.56 HGB-11.9* HCT-36.1 MCV-79* MCH-26.1*
MCHC-32.9 RDW-15.7* PLT COUNT-380
- NEUTS-93.6* BANDS-0 LYMPHS-2.4* MONOS-3.4 EOS-0.4 BASOS-0.1
PT-29.4* PTT-36.2* INR(PT)-3.0*
GLUCOSE-100 UREA N-61* CREAT-1.3* SODIUM-131* POTASSIUM-3.8
CHLORIDE-94* TOTAL CO2-21*
CALCIUM-8.8 PHOSPHATE-3.9 MAGNESIUM-2.2
CK(CPK)-1431* ->799
CK-MB-29* -> 20
cTropnT-0.04* ->0.03
LACTATE-1.9 -> 1.1
URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-TR
BILIRUBIN-SM UROBILNGN-1 PH-6.5 LEUK-NEG
Markedly limited study. There is still persistent opacity at the
medial right lung base which may be the residual of prior
infection or recurrent disease. No significant edema.
.
EKG: afib at 150, nl axis, ST depression in II, III, F,
downsloping ST depression in V5-6. ST depressions decreased in
size on repeat at rate 123 .
.
Brief Hospital Course:
82yo woman with CAD, rheumatic valve disease, COPD, afib,
tachy-brady syndrome s/p pacer, recent hospitalization [**Date range (1) 61523**]
where she was treated for pneumonia with levo and COPD flare
with prednisone.
.
MICU course:
# SIRS/diarrhea: The patient was admitted overnight to the MICU,
where she was found to be afebrile, in atrial fibrillation with
RVR, hypotensive with systolic BP in the 80s-90s, confused and
clearly dehydrated. She was hydrated with normal saline
aggressively overnight, including 250cc boluses x 3 and a
continuous NS IV drip at 250cc per hour. CXR showed only
persistence of her known prior pneumonia. Blood cultures were
drawn and were pending. Stool cultures were sent for general
bacterial infection as well as C diff toxin and she was started
on Flagyl empirically and placed on contact precautions for
presumed C diff given her recent antibiotic exposure. On the
morning after admission, the patient was much improved
hemodynamically. Her urine output and blood pressure had
recovered to normal values and her acute renal failure as well
as hyponatremia both resolved after overnight hydration with NS.
# afib with RVR: She was continued on her sotalol and was
initially on a diltiazem drip for her atrial fibrillation,
however given her hypotensionand the fact that this was not
adequately controlling her HR this was stopped. Her heart rate
improved somewhat with hydration, dropping from the 140s to the
100-120s. At approximately 4am, the patient spontaneously
converted to NSR and was atrial paced at a rate of 70. After
this time, her SBP remained in the 100-120s.
# CAD: Her initial EKG at rate 150s showed marked ST depression
in II, III, F and V5-6. On repeat EKG at rate of 120s, ST
depressions were still present but smaller. After the patient
converted to NSR and was atrial paced at 70 ST depressions
resolved in II, III, and F but remained (although only 1-2mm) in
v5-v6. Notably the patient has known reversible inferior and
inferolateral defects seen on Pmibi in [**2124**] which were not
intervened upon. She ruled out for MI with cardiac enzymes and
was started on full dose aspirin. Her statin was continued, but
Ace was held and no BB was started given hypotension.
# social: Repeated conversations were had with the patient's
son, [**Name (NI) 4036**], who called the MICU 6 times in 20 minutes from the
time his mother was assigned a bed and the time she was settled
in with nursing staff. He appeared angry and paranoid by phone,
stating that the pt would say he was abusing her, that he
believed his [**Name (NI) 802**] [**Name (NI) 41215**] was overdosing the patient on her
oxycontin and that the two of them were whispering about him and
plotting against him. He also said he had to tell the patient
right away that he was moving out and not paying her rent. The
patient's [**Name (NI) 802**] [**Name (NI) 41215**] also phoned, saying that [**Doctor First Name 4036**] is
mentally ill and becomes more unstable when the patient is
in-house. Social work was called. Plan was to call [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 2425**], [**Company 94804**] who is very familiar with the pt and per her
recommendation to contact elder services, as it is likely the
patient is either being given too much oxycontin or that this is
being taken from her. [**Doctor First Name 4036**] called patient relations on the
morning following admission, and [**Doctor First Name **] from our patient
relations office also suggested we involve elder services.
# confusion: The patient was oriented x 1 on arrival ot MICU.
She has an unclear baseline. Possible that pt has MS change in
setting of infection, versus use of oxycontin/oxycodone as well
as valium. Her oxycontin dose was halved and on the day
following admission she was still somnolent. We switched to low
dose immediate release oxycodone only. This raises suspicion of
possible theft of her medications at home. Her valuim was held,
and she displayed no signs of withdrawal while in the MICU.
Mental status was somewhat improved after overnight hydration
and Flagyl, however she remained oriented x 1 only on call-out
to the floor.
# valvular CHF: Due to history of rheumatic heart disease. We
held her home lasix while in MICU due to dehydration and
aggressively hydrated her. On the morning following admission
she was still satting 100% on 2LNC and had developed only mild
crackles at her bilateral bases. Her JVP had increased to about
8 and further hydration was held, as she was felt to be replete
by exam, blood pressure and urine output.
.
MEDICAL FLOOR COURSE
.
# Atrial Fibrillation
The patient converted to NSR in the MICU. She was continued on
sotalol and electrolytes were repleted. She remained in NSR
until her cardiorespiratory arrest and death.
.
# C Diff colitis
She was started on PO Flagyl for presumed c diff colitis in the
MICU. Her C diff toxin was positive. She continued with
profuse watery diarrhea for the first several days while on the
medical floor. Given the fluid losses, she was given volume
resuscitation with normal saline. After 4 days of PO flagyl,
the patient's overall condition was somewhat improved. Though
still with profuse watery diarrhea and diffuse abdominal pain,
her mental status was improved such that she was oriented x 2
(name and location) and her white blood cell count was declining
as well. She was switched to PO vancomycin given her risk for
serious complications and recurrence of c diff per her age, MICU
admission, and co-morbidities. Over the next several days the
patient's white blood cell count increased and her abdomen was
increasingly painful and tender to palpation. She was also
increasingly somnolent. Her stools did decrease as well. On
[**4-7**] her white blood cell count increased dramatically despite
treatment with PO vancomycin. Given further worsening of her
abdominal examination, general surgery was consulted. She was
started also on IV flagyl (in case PO meds were not reaching the
colon). A CT scan was ordered with PO contrast to evaluate for
possible perforation and or pancolitis / megacolon. IV fluids
were also bolused as well given clinically hypovolemic state and
worsening acute renal failure on laboratory studies. The CT
scan was delayed by attempts to have the PO barium contrast for
the study ingested (concerns re: aspiration and risks to place a
NGT in her hypercoaguable state). As the day progressed on
[**4-7**], the medical team was notified by nursing that the
patient's RR was increasing to 30-40s.
.
# CODE BLUE [**2127-4-7**]
When the medical team arrived the patient was confused,
tachypneic, with cool distal extremeties and feet, and weak,
thready pulses. Her blood pressure was systolic 70s / doppler
(despite cuff measurement of systolic 110s). An ABG was
obtained which showed a severe metabolic acidosis. As the team
was preparing for enhanced intravenous access, the patient's
breathing shallowed and then she stopped breathing. A CODE BLUE
was called. The patient's airway was secured open and
venitlated with the Ambu-Bag. After several breaths the patient
vomited and aspirated a large volume of dark brown liquid. This
was suctioned and resuscitation was continued. Soon therafter
the patient lost a pulse and she entered into a PEA arrest. CPR
was initiated, and epinphrine, atropine, bicorbonate,
amiodarone, vasopressin were administered. An ET tube was
placed via anesthesia. The patient was shocked 3 times. Fluids
were being infused as rapidly as possible and dopamine was also
infused. Surgery placed a left subclavien central line for
access. After 25 minutes approximately, the patient's pulse did
not restart and the code was terminated. The time of death was
1:45pm. The chief cause of death was considered cardiopulmonary
arrest from progressive metabolic acidosis, likely from toxic
megacolon and/or bowel perforation. The son [**First Name8 (NamePattern2) **] [**Name (NI) 94805**]) was
present at the beginning of the resuscitation, and left soon
thereafter. He was contact[**Name (NI) **] via telephone approximately 1 hour
after the code was terminated. The patient's grandson [**Name (NI) **]
[**Name (NI) 94805**] also was contact[**Name (NI) **]; he and his wife arrived at the
hospital for viewing. [**Doctor First Name **] could not be contact[**Name (NI) **] again to
obtain permission for the post-mortem examination.
.
# Neglect
Concern regarding neglect was raised during the patient's
initial presentation. Per [**Name (NI) **] records, the [**Name8 (MD) 228**] NP had
several conversations with the son [**Name (NI) **] [**Name (NI) 94805**] about her
deteriorating clinical state. Despite the NP's recommendations,
the son refused to bring her to the hospital. After several
days and no improvement, the NP called EMS herself. Social work
was consulted and eldery services became alerted to the case.
Investigations were ongoing at the time of death regarding
elderly neglect / abuse.
.
# Coagulopathy
The patient presented to the medical floor with an elevated INR.
She takes coumadin at home for atrial fibrillation; it is
possible that the levofloxacin increased her INR. The INR did
not trend down over several days. This was considered secondary
to c diff colitis (overtaking normal bowel flora). It is also
possible that hypotension on the day of death contributed to
hepatic dysfunction. Haptoglobin and fibrinogen were checked to
evaluate for DIC, but were found to be WNL.
Medications on Admission:
- ASA 81 mg po qday
- atorvastatin 20mg po qday
- bisacodyl 10mg po qday prn (per d/c sum bottle not with her)
- citalopram 30mg po qday (per dc summ from 1week ago however
pt's med bottle says 20mg)
- diazepam 2-4mg po q8hrs prn
- colace 100mg po bid
- advair 250-50 1 inhalation [**Hospital1 **] (per d/c sum, not with her)
- furosemide 20 mg po qday
- lactulose 30mL po q8hrs prn (per d/c sum)
- lisinopril 10mg po qday
- oxycontin 20mg po qam, 10mg po qnoon prn, 10mg po qhs (bottle
not with her)
- oxycodone 5mg po q8hrs prn (bottle not with her)
- ranitidine 150mg po bid
- sotalol 120mg po bid
- warfarin 2.5mg po qhs
- ferrous sulfate 325mgpo qday (not on d/c summary but pt has
bottle with her)
Discharge Medications:
NONE
Discharge Disposition:
Expired
Discharge Diagnosis:
c diff colitis
copd
s/p pneumonia
atrial fibrillation
Discharge Condition:
deceased
Discharge Instructions:
expired
Followup Instructions:
none
ICD9 Codes: 0389, 486, 2762, 5849, 2761, 496, 4280, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3888
} | Medical Text: Admission Date: [**2117-5-25**] Discharge Date: [**2117-6-4**]
Date of Birth: [**2045-3-27**] Sex: M
Service:
CHIEF COMPLAINT: Syncope.
HISTORY OF PRESENT ILLNESS: The patient is a 72-year-old
male with a past medical history significant for
hypertension, hypercholesterolemia, coronary artery disease,
status post myocardial infarction, status post coronary
artery bypass graft in [**2101**], status post percutaneous
transluminal coronary angioplasty of the right coronary
artery in [**2113**]. Admitted to [**Hospital **] Hospital with syncope.
While in the hospital the patient's syncope occurred again in
the Intensive Care Unit with a polymorphic Ventricle run. At
that time the patient was unresponsive and was defibrillated
times two. At that time the patient was loaded with
intravenous Amiodarone and stabilized. At that time the
cardiac enzymes were negative for an myocardial infarction.
An echo at the outside hospital showed an ejection fraction
of 45 to 50% and inferior wall akinesia. The patient was
then transferred to the [**Hospital1 69**]
for cardiac catheterization to rule out ischemia.
PAST MEDICAL HISTORY: Hypertension, hyperlipidemia, coronary
artery disease, status post coronary artery bypass graft in
[**2100**], status post tonsillectomy, status post vasectomy.
MEDICATIONS:
1. Prilosec 10 mg q day.
2. Lisinopril 20 mg q day.
3. Isosorbide 60 mg p.o. q day.
4. Lopressor 50 mg twice a day.
5. Aspirin.
6. Lipitor 10 mg p.o. q day.
7. Benadryl p.r.n.
SOCIAL HISTORY: The patient lives with his wife, has five
children and is a retired school teacher.
ALLERGIES: No known drug allergies.
HOSPITAL COURSE: The patient was admitted to this service
with an initial diagnosis of possible acute coronary
syndrome. The patient had a cardiac catheterization which
showed severe three vessel coronary artery disease and a
nearly normal left ventricular systolic function.
Cardiothoracic surgery was consulted at that time and it was
decided the patient would benefit from a coronary artery
bypass graft.
On the [**9-26**] the patient was brought to the operating
room with initial diagnosis of recurrent coronary artery
disease, status post coronary artery bypass graft in [**2100**].
The patient had a re-do coronary artery bypass graft times
three with a RIMA to the left anterior descending, saphenous
vein graft to the PD and a left radial to the OM. The
procedure was performed by Dr. [**Last Name (STitle) 1537**] and Scarzgard. The
patient tolerated the procedure well and was transported to
the Coronary Intensive Care Unit in stable condition.
On postop day one, the patient had a rash in the distribution
of the iodine scrub after several doses of Benadryl the rash
dissipated. Also during postop day one the patient was
extubated, weaned from the Neo but continued on atrial pacing
to help with cardiac output. Prior to extubation the patient
had a bronchoscopy performed by Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **]. The
procedure was performed due to increased respiratory
secretions and a temperature in the 101.5 range. The
bronchoscopy was normal with no signs of pus or higher than
normal secretions. Later in the day the patient was
extubated without difficulty.
Postop day two the patient continued to do well with no major
events. Postop day three the dressings, wires and chest
tubes were discontinued. The patient was transferred to the
floor in stable condition. Postop day six, the patient
continued to do well, had an EP consult to evaluate the V-fib
arrest. EP noted that an ICD was not indicated secondary to
a negative EP study. It was decided that the patient would
follow-up with Dr. [**Last Name (STitle) 25775**] at the [**Hospital **] Hospital, would
have an ETP with Q-wave alteration study and a Holter Monitor
in roughly one month.
On postop day seven, a small amount of drainage was noted
from the patient's inferior chest wall and a click was noted
on exam. Due to the concerns of wound dehiscence the patient
was continued in the hospital until the [**10-4**]. On
the 24th and 25th there was no drainage from the wound and
there is no signs of cellulitis. On the 25th it was decided
that the patient could be discharged home in stable
condition.
DISCHARGE PHYSICAL EXAMINATION: Temperature 98.5, 74 and
sinus, 128/68, 20, 94% on room air. The patient's discharge
weight was roughly 3 kg below preoperative levels. Crit was
28.3. BUN 19, creatinine 1.1.
The patient was regular rate and rhythm. Abdomen soft,
nontender, nondistended. Incision was clean, dry and intact
with no signs of drainage. No click was heard on exam with
gentle pressure and patient coughing.
DISCHARGE DIAGNOSIS:
1. Status post re-do coronary artery bypass graft times
three with RIMA to the left anterior descending, SVG
to the PD and left radial artery to the OM.
SECONDARY DIAGNOSIS:
1. Hypertension.
2. Coronary artery disease.
3. Status post coronary artery bypass graft in [**2100**].
4. Status post tonsillectomy.
5. Status post vasectomy.
COMPLICATIONS: Wound drainage requiring several days of
hospitalization.
DISCHARGE MEDICATIONS:
1. Lopressor 37.5 mg p.o. twice a day.
2. Lisinopril 20 mg p.o. q day.
3. Torvostatin 10 mg p.o. q day.
4. Imdur 60 mg p.o. q day times three months.
5. Aspirin 325 mg p.o. q day.
6. Protonix 40 mg p.o. q day.
7. Colace 100 mg p.o. twice a day.
8. Lasix 20 mg p.o. twice a day.
DISCHARGE CONDITION: Good stable to home with VNA.
FOLLOW-UP: The patient will follow-up with Dr. [**Last Name (STitle) 25775**] in
two to four weeks. At that time the patient will have an ETT
with T-wave alteration studies. The patient will also have a
Holter monitor at that time. The patient will follow-up with
Dr. [**Last Name (STitle) 1537**] in four weeks, the patient is to call Dr.[**Name (NI) 18056**]
office with any concerns.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern4) 959**]
MEDQUIST36
D: [**2117-6-7**] 21:27
T: [**2117-6-7**] 22:52
JOB#: [**Job Number 25776**]
ICD9 Codes: 4271, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3889
} | Medical Text: Admission Date: [**2141-7-21**] Discharge Date: [**2141-7-29**]
Service: CARDIOTHORACIC
Allergies:
Amoxicillin / Oxycodone / Penicillins
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
s/p Mitral Valve Repair/Atrial Septal Defect Closur/MAZE
procedure & Left Atrial Appendage Ligation on[**2141-7-24**]
History of Present Illness:
87 y/o female w/ known Mitral Valve disease who has had multiple
episodes of CHF, most recently on evening of [**7-17**] requiring
admission to OSH. Her episodes of CHF are associated w/ AF and
has had several cardioversion. She reports he last episode was
about 1 year ago, but has had worsening DOE. She underwent
cardiac cath which showed -CAD and was transferred here for
surgical evalutaion.
Past Medical History:
Mitral Regurgitation/Mitral Valve Prolapse
Paroxysmal Atrial Fibrillation
Congestive Heart Failure
Hypertension
Hypothyroidism
h/o Pulmonary Embolism/Pulm. Infarct [**7-17**]
h/o Pneumonia [**7-17**]
h/o CVA [**19**]
h/o Vertigo
h/o GI Bleed
Bell's Palsey [**3-18**] w/ Left Eye/Face Droop
Myleodysplastic disease
Essential Left Hand Tremor
s/p Pelvic Fracture [**3-18**] d/t fall
s/p cataract surgery
s/p Total Abdominal Hysterectomy
Social History:
Lives alone. Daughter lives next door.
Denies ETOH/Tobacco
Family History:
Unknown
Physical Exam:
VS: 98.9 85AF 91/50 18 95% 2L
General: Very thin, frail, appearing stated age
Neuro: A&O x 3
HEENT: L pupil 2mm sluggish, R 3-4mm reactive to L & A,
irregular shape
Heart: Irreg/Irreg, 5/6 SEM loudest @ LSB
Lungs: Rales 1/2 up B
Abd: Well healed mid-line lower abdomen +BS, Soft NT/ND -r/r/g
Ext: Trace-1+ Edema, Warm
Pulses: BFA [**1-15**]+ (R hematoma), DP/PT 1+, BRA [**1-15**]+, -Carotid
bruits
Pertinent Results:
[**2141-7-21**] 01:45PM BLOOD WBC-11.5* RBC-2.93* Hgb-8.9* Hct-27.9*
MCV-95 MCH-30.3 MCHC-31.9 RDW-14.0 Plt Ct-406
[**2141-7-24**] 10:46AM BLOOD WBC-6.7 RBC-2.59* Hgb-7.9* Hct-23.9*
MCV-92 MCH-30.6 MCHC-33.3 RDW-14.4 Plt Ct-183#
[**2141-7-25**] 02:41AM BLOOD WBC-17.5*# RBC-3.71*# Hgb-10.9*#
Hct-33.5* MCV-90 MCH-29.5 MCHC-32.7 RDW-15.1 Plt Ct-263
[**2141-7-28**] 05:58AM BLOOD WBC-12.9* RBC-3.34* Hgb-10.1* Hct-30.6*
MCV-92 MCH-30.1 MCHC-32.9 RDW-14.2 Plt Ct-295
[**2141-7-21**] 01:45PM BLOOD PT-14.0* PTT-33.0 INR(PT)-1.3
[**2141-7-28**] 05:58AM BLOOD PT-12.3 INR(PT)-1.0
[**2141-7-21**] 01:45PM BLOOD Glucose-94 UreaN-15 Creat-1.0 Na-139
K-4.6 Cl-101 HCO3-31 AnGap-12
[**2141-7-28**] 05:58AM BLOOD Glucose-74 UreaN-14 Creat-0.7 Na-137
K-3.8 Cl-98 HCO3-31 AnGap-12
[**2141-7-28**] 05:58AM BLOOD Calcium-7.9* Phos-3.4 Mg-2.1
[**2141-7-21**] 01:45PM BLOOD %HbA1c-5.9 [Hgb]-DONE [A1c]-DONE
[**2141-7-21**] 01:45PM BLOOD TSH-11*
[**2141-7-21**] 12:09PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.014
[**2141-7-21**] 12:09PM URINE RBC-0 WBC-0-2 Bacteri-FEW Yeast-NONE
Epi-0
[**2141-7-21**] 12:09PM URINE 3PhosX-MOD
[**2141-7-21**] 12:09PM URINE Blood-MOD Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG
Brief Hospital Course:
Pt was transferred from OSH to [**Hospital1 18**] and underwent an Echo &
Carotid U/S before surgery. HD #2 pt was transfused 1 unit or
PRBCs. On [**7-24**], pt was brought to operating room and underwent a
MV repair, MAZE, ASD closure, and ligation of [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 1916**].
Please see op note for surgical details. Pt. tolerated the
procedure well. Total bypass tome was 90 min. and XCT was 75
min. Pt was transferred to CSRU in stable condition being
titrated on Neo, Propofol and receiving Amoidarone. Pt was
weaned from sedation and extubated later on op day without
incident. Pt. was MAE and following commands. Swan Ganz catheter
was d/c'd on POD #1. Chest tubes and pacing wires were both
removed by POD #2. Neo was weaned off and pt was transferred to
telemetry floor on POD #3. Pt. cont. to have A. Fib.
post-operatively. Coumadin dosing was being titrated for a goal
of [**2-15**].5. And would be followed by Rehab facility. Levofloxacin
was started (for 7 days) on POD #3 for UTI. The final urine
culture revealed E.Coli which was resistant to Levofloxacin, so
Bactrim was started instead on the day of discharge. This
should continue for 7 days. Pt. slowly improved without any
post-op complications and was transferred to rehab facility on
POD #5.
Medications on Admission:
1. Coumadin 3mg qd
2. Amiodarone 200mg [**Hospital1 **]
3. Lasix 20mg AM, 40mg PM
4. Kdur 40mg qd
5. Tporol XL 50mg qd
6. Synthroid 50mcg qd
7. MVI qd
Discharge Medications:
1. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 10 days. Packet(s)
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Levothyroxine Sodium 50 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. Bactrim DS 1 PO QD X 7 days
7. Warfarin Sodium 1 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily): Titrate dose for a goal INR of [**2-15**].5.
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day
for 10 days.
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO once a
day: 12.5mg.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Mitral Regurgitation/Mitral Valve Prolapse s/p Mitral Valve
Repair
Atrial Septal Defect s/p Atrial Septal Defect Closure
Paroxysmal Atrial Fibrillation s/p MAZE procedure & Left Atrial
Appendage Ligation
Urinary Tract Infection
Congestive Heart Failure
Discharge Condition:
Good
Discharge Instructions:
Can take shower. Wash insicions with warm water and gentle soap.
Do not bath or swim.
Do not apply any lotions, creams, ointmenets or powders to
incision.
Do not drive for 1 month.
Do not lift greater than 10 pounds for 2 months.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] in 4 weeks
Follow-up with Dr. [**Last Name (STitle) 5017**] in 2 weeks
Follow-up with Cardiologist in 2 weeks
Completed by:[**2141-7-29**]
ICD9 Codes: 4240, 5990, 4280, 4019, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3890
} | Medical Text: Admission Date: [**2193-4-26**] Discharge Date: [**2193-5-8**]
Service: Medicine
HISTORY OF PRESENT ILLNESS: The patient is an 82 year old
white female with a history of severe scoliosis,
osteoporosis, hypertension, status post T3-T12 fusion on
[**2193-4-26**], status post compression fracture one to two
years ago. The patient was doing well after her operation on
the orthopedic service, apart from self-extubating herself on
[**2193-4-27**], requiring increasing amounts of oxygen on the
floor.
On [**2193-5-1**], the patient had a fever of 101.4 and chest
x-ray showed left lower lobe collapse with a right greater
than left effusion. Blood cultures, one out of four, were
positive for gram positive rods, thought to be a contaminant,
and gram positive cocci. On [**2193-5-3**], overnight, the
patient had acute onset shortness of breath with an increase
in oxygen requirement with an oxygen saturation of 93% on a
40% face mask. Arterial blood gases at that point were 7.45,
50 and 65 at 1:00 a.m. and then later, at 5:00 a.m., 7.41, 57
and 128 on 40% to 50% face mask. Electrocardiogram was read
as stable. A chest x-ray showed no congestive heart failure,
with right sided effusion and left lower lobe collapse,
unchanged from prior. CT was negative for pulmonary embolus
but also saw bilateral effusions. The patient's mental
status was deemed stable, as she was alert and oriented times
three, with some inappropriateness.
A medicine consult was called for this desaturation at 1:00
a.m. on [**2193-5-2**] and then on [**2193-5-2**] for falling.
For the fall, she possibly hit her head and fell on her right
side and also had a transient desaturation, for which were
arterial blood gases were 7.41, 57 and 124. She had a CT of
her chest and head which showed no bleed and no fracture.
She was put in a collar until she was cleared and, at that
point, because a urinalysis was found to be positive for 46
white blood cells and greater than 1,000 red blood cells on
[**2193-5-2**] at 9:00 a.m. The patient was started on
ciprofloxacin and then transferred to the medical service.
PAST MEDICAL HISTORY: 1. Osteoporosis, status post
compression fracture in last one to two years, here with
T3-T12 fusion done on [**2193-4-26**]. 2. Severe scoliosis.
3. [**2193-4-22**] echocardiogram, concentric left
ventricular hypertrophy, left atrial enlargement, 1+ mitral
regurgitation, no wall motion abnormalities, normal left
ventricular ejection fraction. 4. Hypertension times two
years. 5. Hiatal hernia/gastroesophageal reflux disease.
6. Question of mitral valve prolapse but negative on
echocardiogram.
ALLERGIES: The patient has no known drug allergies except
for morphine, which causes her to get very sick, nausea
apparently.
MEDICATIONS ON ADMISSION: Iron supplements, Zantac 150 mg
p.o.q.d., Tenormin 25 mg p.o.q.d., Os-Cal 500 mg p.o.b.i.d.;
on transfer, albuterol and Atrovent nebulizers, Zantac 150 mg
p.o.b.i.d., Lopressor 12.5 mg p.o.t.i.d., Colace 100 mg
p.o.t.i.d., and p.r.n. Lasix, Zofran, codeine, Haldol and
Tylenol.
PHYSICAL EXAMINATION: On physical examination on transfer,
the patient's vital signs were 96.1, 66 to 80, 160 to 174/63
to 72 and 96% on 50% shovel mask, 84% in room air. Overnight
ins and outs were 760 and 1,553, and urine output was 300 cc
over the last eight hours. General: In no acute distress.
Head, eyes, ears, nose and throat: Moist mucous membranes,
oropharynx clear, no jugular venous distention, no point
tenderness. Chest: Clear to auscultation bilaterally,
slight crackles at right base, scattered. Cardiovascular:
Regular rate, S1 and S2 normal, II/VI systolic murmur at left
upper sternal border, no gallops or rubs. Abdomen: Soft,
nontender, nondistended, positive bowel sounds, no masses.
Extremities: No cyanosis, clubbing or edema. Neurologic
examination: Alert and oriented times three, recall [**5-1**]
immediately and [**1-31**] in five minutes, strength 5/5 throughout,
sensation to light touch intact throughout, finger-to-nose
bilaterally intact, gait not tested, reflexes 1+ throughout
bilaterally.
LABORATORY DATA: White blood cell count was 11.7, hematocrit
37.7, down from 39.6, platelet count 256,000, and coagulation
profile normal. Urinalysis showed specific gravity of 1.040,
large blood, positive nitrite, greater than 300 protein,
greater than 1,000 red blood cells, 46 white blood cells,
many bacterial and no epithelial cells. Chem-7: Sodium 144,
potassium 3.8, chloride 101, bicarbonate 32, BUN 22,
creatinine 0.4 and glucose 127. The patient was ruled out
with CKs of 252, 262 and 213 with negative MB, troponin less
than 0.3. Arterial blood gases: As above. CT scan of head
and chest: Negative for bleed and fracture respectively.
CTA: Negative for pulmonary embolus and bilateral pleural
effusions with question of left lower lobe loculation. Chest
x-ray: Bilateral effusions as on [**2193-4-28**].
HOSPITAL COURSE: 1. The patient was thought to have had
flash pulmonary edema, possibly due to arrhythmia given her
diastolic dysfunction by echocardiogram. The patient was
given 20 mg of Lasix. Lopressor was increased, eventually to
50 mg twice a day. Aspirin was given. The patient was put
on telemetry.
2. Pulmonary: The patient's effusions were thought likely
due to her flash pulmonary edema and were considered stable.
Left lobe loculation was not considered accessible by
ultrasound guided tap with risk of pneumothorax significant
enough to cause her significant clinical deterioration.
3. Infectious disease: The patient's urinary tract
infection was treated with five days of ciprofloxacin. Blood
cultures were negative and urine culture was pending at this
time.
4. Hematology: The patient's hematocrit remained stable
during her hospitalization, ranging from 33 to 39 and, on
discharge, was 37.2. Her white blood cell count continued to
climb during her hospitalization, although she remained
afebrile after transfer to medicine. It was thought possible
that she could have a pneumonia given her effusions and
difficult chest x-ray assessment based on her skeletal
changes. Ceftriaxone was started upon discharge for seven
days, 1 gram daily. Her wounds did not look infected.
5. Fluids, electrolytes and nutrition: The patient
initially had a BUN to creatinine ratio that was elevated
but, during her hospitalization, her creatinine remained
stable at 0.4 to 0.5 and her BUN fell from a peak of 23 on
[**2193-5-2**] to 15 on discharge. The patient was
intermittent getting intravenous fluids but mostly taking
orals and, by the end of her hospitalization, the patient was
taking adequate oral intake.
6. Neurology: The patient's mental status fluctuated day to
day and, as a result, she had a CT scan of her head initially
on transfer that was negative, and then another one on [**2193-5-7**] that was also negative for a subdural hematoma. Her
mental status changes were thought possibly due to
ciprofloxacin but, also, her family said that this was her
baseline. She was off codeine and only on Tylenol for her
pain.
7. Renal: As above, the patient's BUN to creatinine ratio
reduced over time. Orthopedic surgery followed her after her
transfer to the medicine service and after her fall. The
patient had a thoracic spine film, read by orthopedic surgery
who said that the alignment of the rods had shifted status
post the fall and still was adequate in terms of
stabilization of her spine. Another read on the thoracic
spine was a left eighth rib fracture, unclear when that
occurred based on this one film. There were no management
issues for that other than to heal spontaneously.
DISCHARGE STATUS: The patient was discharged to
rehabilitation in stable condition.
DISCHARGE DIAGNOSES:
Thoracic compression fracture, status post T3 to T12 spinal
fusion.
Acute desaturations secondary to possible congestive heart
failure with diastolic dysfunction.
Hypertension.
Gastroesophageal reflux disease.
Scoliosis.
Concentric left ventricular hypertrophy.
Osteoporosis.
DISCHARGE MEDICATIONS:
Ceftriaxone 1 gm i.v.q.24h. times seven days, until [**2193-5-16**].
Lactulose 15 cc p.o.b.i.d.p.r.n.
Lopressor 50 mg p.o.b.i.d.
Multivitamins one p.o.q.d.
Zantac 150 mg p.o.b.i.d.
Tylenol p.r.n.
Colace 100 mg p.o.b.i.d.
Aspirin 81 mg p.o.q.d.
Dulcolax 10 mg p.r.n.
Haldol p.r.n.
Heparin 5,000 units s.c.b.i.d.
FOLLOW-UP: The patient is to follow up with orthopedic
surgery as an outpatient and is to have her white blood cell
count checked at [**Hospital **] Rehabilitation to see if it
resolves with the ceftriaxone.
[**Doctor Last Name **] [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5712**]
Dictated By:[**Last Name (NamePattern1) 102750**]
MEDQUIST36
D: [**2193-5-8**] 10:19
T: [**2193-5-8**] 11:14
JOB#: [**Job Number 27840**]
ICD9 Codes: 4280, 4240, 5990, 486, 5180, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3891
} | Medical Text: Admission Date: [**2111-5-7**] Discharge Date: [**2111-5-17**]
Date of Birth: [**2048-6-17**] Sex: M
Service: MICU
HISTORY OF PRESENT ILLNESS: This is a 62 year old Caucasian
male initially admitted to the [**Hospital3 **] with
complaints of progressive abdominal distention and pain and
shortness of breath who was transferred to [**Hospital1 346**] for further evaluation. The patient
stated upon admission to [**Hospital3 **] that he had
developed increasing abdominal girth over the past four weeks
with a weight gain of approximately four pounds during the
week prior to admission. In addition, the patient also
endorsed generalized weakness and feeling faint in addition
to increasing lower extremity edema. The patient notes that
he has not been taking Lasix as he was switched to a
"different water pill".
The patient denied fevers, chills, night sweats, nausea,
vomiting, chest pain, dyspnea on exertion.
At the outside hospital, the patient was evaluated by the
Gastroenterology Service and had a diagnostic paracentesis
that was negative for SBP and malignant cells. A
paracentesis fluid cell block showed benign mesothelial and
inflammatory cells. The patient also had hepatitis B and C
antigens which were negative and [**First Name8 (NamePattern2) **] [**Doctor First Name **] titer which was less
than 1:40. The patient family requested that the patient be
transferred to [**Hospital1 69**] for
further evaluation.
PAST MEDICAL HISTORY:
1. Aortic valve replacement status post endocarditis of a
bicuspid aortic valve, ST. Jude's Valve in [**2100**].
2. DDD pacer / AICD for atrial fibrillation and history of
ventricular fibrillation.
3. Prostate cancer status post seed implants.
4. Diabetes mellitus.
5. Hypercholesterolemia.
6. Anxiety.
7. Cardiomyopathy with an ejection fraction of 29% in [**2105**]
and severely depressed ejection fraction in [**2107**].
MEDICATIONS:
1. Ativan 1 mg p.o. three times a day.
2. Prevacid 30 mg p.o. q. day.
3. Aldactone 75 mg p.o. twice a day.
4. Lasix 20 mg p.o. q. day.
5. Albuterol MDI p.r.n.
6. Digoxin 0.25 mg p.o. q. day.
7. Prozac 20 mg p.o. q. day.
8. Coumadin currently held.
9. Amiodarone 200 mg p.o. q. day.
10. Potassium chloride 10 mg p.o. q. day.
11. Lactulose three times a day p.r.n.
ALLERGIES: Vancomycin, Afrin and Ancef.
SOCIAL HISTORY: The patient currently lives with his wife
in the [**Name (NI) 86**] area. He denies tobacco or drug use. He
states that he had not drank alcohol in over 14 years.
PHYSICAL EXAMINATION: Temperature 97.6 F.; heart rate 82;
blood pressure 112/54; respiratory rate 22; 88% on room air.
In general, an elderly male sitting up in bed, in no acute
distress. HEENT: Pupils are equal, round and reactive to
light. Sclerae icteric. Extraocular muscles are intact.
Dry mucous membranes. Neck with no evidence of jugular
venous distention; no lymphadenopathy. Lungs: Clear to
auscultation bilaterally. Cardiac: Regular rate and rhythm,
mechanical S2, II/VI systolic ejection murmur heard loudest
the right upper sternal border. Abdomen: Distended,
normoactive bowel sounds. Positive fluid wave, nontender.
Extremities with two plus lower extremity edema to the
patient's buttocks. Neurological: Oriented times two,
somewhat confused, can follow commands, mild asterixis.
LABORATORY: White blood cell count 15.5, hematocrit 45.2,
platelets 263, INR 4.6, sodium 134, potassium 4.0, chloride
93, bicarbonate 26, BUN 24, creatinine 1.0, glucose 128,
calcium 8.8, magnesium 1.7, phosphorus 2.9. ALT 51, AST 123,
LDH 576, CK 242, alkaline phosphatase 146, bilirubin 5.5,
albumin 3.2. Troponin less than 0.01.
HOSPITAL COURSE:
1. CARDIOVASCULAR: The patient was admitted to the [**Hospital Unit Name 196**]
Service given his recent history of an AICD placement and
aortic valve replacement. The patient was ruled out for
myocardial infarction with cardiac enzymes and had an
echocardiogram on [**5-12**], that was consistent with his
previous echocardiogram and showed an ejection fraction of
20%, E:A ratio of 0.43 and left ventricular and right
ventricular function severely depressed with global
hypokinesis.
The patient was hemodynamically stable on the Medicine Floor
until [**5-13**], when he became hypotensive in the 80s over
50s. For this reason and his worsening renal function, the
patient was transferred to the Medical Intensive Care Unit
Service.
The etiology of the patient's shock was not entirely clear on
transfer given his history of severe congestive heart
failure, evidence of hypovolemia on examination, as well as a
concern for sepsis. Therefore, a right IJ cordis was placed
and a Swan-Ganz catheter was floated under fluoroscopy. The
patient's cardiac profile revealed normal filling pressures,
a high cardiac output and a low systemic vascular resistance
which suggested a distributive shock likely related to the
patient's liver disease but also possibly related to sepsis.
The patient was started empirically on Levofloxacin and
Flagyl given the concern for an SBP source. The patient was
given aggressive fluids with fresh frozen plasma and albumin
as well as boluses of normal saline. Given the continuing
low blood pressure, the patient was started on Levophed.
Over the remainder of his Medical Intensive Care Unit stay,
the patient was hemodynamically stable and normotensive and
his Levophed drip was titrated down and eventually
discontinued.
2. ACUTE RENAL FAILURE: Over to patient's stay on the
Medicine [**Hospital1 **], his creatinine gradually increased to 2.9.
The etiology of the patient's acute renal failure was not
entirely clear to the team, and a concern for hepatorenal
syndrome was raised. The Renal Consultation Service was
contact[**Name (NI) **] and thought that the patient's acute renal failure
was likely secondary to poor renal perfusion in the setting
of aggressive diuresis for ascites and the use of an ACE
inhibitor for hypertension.
The patient was transferred to the Medical Intensive Care
Unit as noted above and given the cardiac profile that
suggested distributive shock. The etiology of the patient's
acute renal failure was considered to be more consistent with
hypoperfusion / prerenal etiology. The patient's renal
function was noted to improve with the fresh frozen plasma,
albumin and normal saline he received on transfer to the
Medical Intensive Care Unit. A FeNa was calculated at 0.2%,
further suggesting a prerenal etiology. A renal ultrasound
was obtained which showed no evidence of hydronephrosis. The
patient's diuretics and ACE inhibitor were held and the
patient's urine output and creatinine were followed
throughout his stay in the Medical Intensive Care Unit.
3. CIRRHOSIS: The patient was transferred to [**Hospital1 346**] from an outside hospital with a
history of cirrhosis, unclear in etiology, but with a work-up
negative for malignancy, viral hepatitis and [**Doctor First Name **]. The
Hepatology consultation service was contact[**Name (NI) **] and followed
the patient throughout his stay in the hospital.
A right upper quadrant ultrasound was obtained and was
consistent with a nodular small liver consistent with
cirrhosis as well as portal vein thrombosis, both extra and
intra-hepatic. Based on his pattern of liver function tests
abnormalities, negative serologies and iron studies at the
outside hospital as well as portal vein thrombosis noted on
right upper quadrant ultrasound, the etiology of the
patient's cirrhosis was considered likely secondary to right
heart failure.
The Hepatology Consultation Service recommended continuing a
beta blocker, continuing anti-coagulation and considering an
esophagogastroduodenoscopy as an outpatient for evaluation
for varices. The patient had a diagnostic and therapeutic
six liter paracentesis on [**5-8**], which was significant for
a transudate with 200 white blood cells.
On transfer to the Medical Intensive Care Unit for
hypotension and worsening renal failure, the patient was
evaluated with a diagnostic paracentesis that was significant
for 270 white blood cells and which eventually grew Gram
positive cocci.
Given the concern for septic shock and the patient's ascites
being a source of infection, the patient was continued on
Levofloxacin and Flagyl and Linezolid was added for concern
of Methicillin resistant Staphylococcus aureus and given the
patient's history of anaphylaxis to Vancomycin. The final
results of this culture are pending at the time of dictation.
4. COAGULOPATHY: The patient was admitted with an elevated
INR that was considered likely to malnutrition and severe
liver disease. The patient's INR was reversed with fresh
frozen plasma Swan-Ganz catheter placement and paracentesis
in the Medical Intensive Care Unit and the patient was
started on a heparin drip for adequate anti-coagulation given
his history of aortic valve replacement.
The patient was continued on the heparin drip throughout his
stay on the Medical Intensive Care Unit Service and his INR
and coagulation studies were monitored.
5. RESPIRATORY DISTRESS: On transfer to the Medical
Intensive Care Unit, the patient appeared to be somewhat
tachypneic with oxygen saturations around 95% on two liters
by nasal cannula. The etiology of the patient's respiratory
distress was considered likely to VQ mismatch secondary to
his abdominal fullness and ascites, but given that the
patient appeared more dyspneic while sitting up, a possible
contribution by portal pulmonary hypertension versus a AVM
was entertained.
As the patient remained stable from a respiratory standpoint
with adequate oxygen saturations on two liters by nasal
cannula and no evidence of worsening respiratory distress, a
further work-up with a VQ scan to rule out hepatopulmonary
syndrome was not necessary.
6. PSYCHIATRIC: On admission to the Medical Floor, a
Psychiatry consultation was obtained for confusion and
agitation. The patient Psychiatry consultation service felt
that the [**Hospital 228**] medical presentation was most consistent
with delirium as the patient showed impaired attention with
impairment to memory, affective regulation as well as
hallucinations. The etiology of the patient's delirium was
considered possibly related to hepatic encephalopathy, drug
toxicity, infection or hypoxia.
The patient was maintained on Haldol three times a day and
had a 1:1 sitter on the floor. After transfer to the Medical
Intensive Care Unit, the patient's mental status improved
somewhat and he was continued on Haldol and Ativan p.r.n. for
anxiety.
The remainder of the [**Hospital 228**] hospital course as well as his
discharge medications and follow-up will be dictated upon
discharge from the hospital.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7585**]
Dictated By:[**Last Name (NamePattern1) 4950**]
MEDQUIST36
D: [**2111-5-17**] 18:35
T: [**2111-5-17**] 21:10
JOB#: [**Job Number 22356**]
ICD9 Codes: 5715, 5849, 4254 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3892
} | Medical Text: Admission Date: [**2199-1-14**] Discharge Date: [**2199-2-11**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
84 yo M c significant h/o CAD, atrial fibrillation, s/p
pacemaker placement for Sick Sinus Syndrome with recent
admission in [**Month (only) **] for STEMI found to have increasing SOB and
tachypnea at Rehab hospital. He was admitted in [**Month (only) **] for
STEMI after bilateral knee replacement. Catherization at that
time showed 100% proximal stent restenosis, diffuse RCA disease,
and a patent Left Circumflex stent. A PTCA [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] was
successfully placed in LAD. The catherization was complicated
by the development of wide complex tachycardia and hypotension
(SBP 80s). As a result, the patient was defibrillated once,
given IV lopressor, IV Amiodarone,
Dopamine pressor, an Intraaortic Balloon Pump, and intubated to
protect airway. He was treated in the CCU, stabilized, and
discharged to [**Hospital **] Rehab. There he was doing well until he
developed a PNA, found to have RLL infiltrate on CXR. He was
started on Cefuroxime. He had increasing SOB over several days,
on [**2198-12-14**] had increased SOB and was given Lasix and Ativan. He
had no chest pain, N/V. He was found down at rehab and then
transferred to [**Hospital1 18**] for further care. In the ED he was found
to have severe CHF with complicating PNA, he was sent to the CCU
for further care.
Past Medical History:
Past Medical History:
CAD
-s/p PCI to L circ and LAD in [**2-12**]
-s/p MI [**04**] years ago
-[**9-12**]: pMIBI showed a small fixed inferior defect with slight
apical redistribution suggestive of ischemia.
-[**12-13**] Echo showed EF 20% with regional left ventricular
systolic dysfuntion, HK basal septum, AK distal septum, lat wall
and basal ant. wall
[**Month/Year (2) **]
[**Month/Year (2) **]
Atrial Fibrillation on coumadin
Sick sinus syndrome, s/p pacer
s/p bilateral total knee replacement
s/p umbilical hernia repair
Social History:
Denies tobacco, ETOH, Italian speaking
Family History:
No history of CAD
Physical Exam:
VS. T 99.6 BP 101/69 Pulse 100s a.fib RR 20-30s 92% NRB
GEN: Alert and oriented X3 in NAD
HEENT: PERRLA, MMM, OP clear
Neck: No elevated JVP apreciated
Lungs: Crackles [**4-12**] way up bilaterally
CV: Irregularly irregular, tachycardic, difficult to assess
rhythm
Abd: Soft, NT/ND, +BS
Ext: 2+ Edema, no clubbing or cyanosis
Neuro: A &O X 3in NAD, CN II-XII intact, strenght grossly
intact, no change in sensation
Pertinent Results:
[**2199-1-14**] 11:09PM TYPE-ART RATES-16/4 TIDAL VOL-650 PEEP-10
O2-100 PO2-127* PCO2-48* PH-7.49* TOTAL CO2-38* BASE XS-12
AADO2-566 REQ O2-90 INTUBATED-INTUBATED
[**2199-1-14**] 08:15PM TYPE-ART PO2-62* PCO2-56* PH-7.41 TOTAL
CO2-37* BASE XS-8
[**2199-1-14**] 06:40PM TYPE-ART PO2-55* PCO2-60* PH-7.42 TOTAL
CO2-40* BASE XS-11
[**2199-1-14**] 06:40PM LACTATE-2.2*
[**2199-1-14**] 06:08PM ALT(SGPT)-31 AST(SGOT)-37 CK(CPK)-146 ALK
PHOS-94 TOT BILI-1.1
[**2199-1-14**] 06:08PM CK-MB-6 cTropnT-0.16*
[**2199-1-14**] 05:25PM TYPE-ART O2-100 PO2-56* PCO2-75* PH-7.30*
TOTAL CO2-38* BASE XS-7 AADO2-610 REQ O2-96 INTUBATED-NOT INTUBA
VENT-SPONTANEOU
[**2199-1-14**] 01:30PM GLUCOSE-152* UREA N-22* CREAT-0.8 SODIUM-139
POTASSIUM-4.6 CHLORIDE-98 TOTAL CO2-32* ANION GAP-14
[**2199-1-14**] 01:30PM CK(CPK)-156
[**2199-1-14**] 01:30PM CK-MB-6 cTropnT-0.12*
[**2199-1-14**] 01:30PM CALCIUM-6.7* PHOSPHATE-3.1 MAGNESIUM-1.6
[**2199-1-14**] 06:51AM GLUCOSE-153* UREA N-22* CREAT-0.9 SODIUM-135
POTASSIUM-4.7 CHLORIDE-92* TOTAL CO2-31* ANION GAP-17
[**2199-1-14**] 06:51AM CK(CPK)-146
[**2199-1-14**] 06:51AM CK-MB-6 cTropnT-0.16*
[**2199-1-14**] 06:51AM CALCIUM-8.3* PHOSPHATE-3.9 MAGNESIUM-1.7
[**2199-1-14**] 06:51AM WBC-15.3* RBC-3.72* HGB-11.4* HCT-35.6*
MCV-96 MCH-30.6 MCHC-31.9 RDW-15.5
[**2199-1-14**] 06:51AM PLT COUNT-518*
[**2199-1-14**] 06:51AM PT-19.0* PTT-32.9 INR(PT)-2.3
[**2199-1-14**] 02:06AM COMMENTS-GREEN TOP
[**2199-1-14**] 02:06AM LACTATE-1.3
[**2199-1-14**] 01:30AM URINE HOURS-RANDOM
[**2199-1-14**] 01:30AM URINE GR HOLD-HOLD
[**2199-1-14**] 01:30AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.009
[**2199-1-14**] 01:30AM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2199-1-14**] 01:30AM URINE RBC-[**4-13**]* WBC-0-2 BACTERIA-RARE
YEAST-NONE EPI-<1
[**2199-1-14**] 01:20AM GLUCOSE-161* UREA N-22* CREAT-0.9 SODIUM-136
POTASSIUM-3.9 CHLORIDE-93* TOTAL CO2-32* ANION GAP-15
[**2199-1-14**] 01:20AM CK(CPK)-123
[**2199-1-14**] 01:20AM cTropnT-0.15*
[**2199-1-14**] 01:20AM CK-MB-5
[**2199-1-14**] 01:20AM MAGNESIUM-1.7
[**2199-1-14**] 01:20AM CALCIUM-8.2* PHOSPHATE-3.0 MAGNESIUM-1.6
[**2199-1-14**] 01:20AM DIGOXIN-0.7*
[**2199-1-14**] 01:20AM WBC-13.5*# RBC-3.68* HGB-11.3* HCT-34.9*
MCV-95 MCH-30.8 MCHC-32.5 RDW-15.5
[**2199-1-14**] 01:20AM HYPOCHROM-1+ POIKILOCY-1+ MACROCYT-1+
[**2199-1-14**] 01:20AM PLT COUNT-469*#
[**2199-1-14**] 01:20AM PT-18.6* PTT-30.7 INR(PT)-2.2
CT OF THE CHEST WITHOUT IV CONTRAST: Prominent right
paratracheal lymph node is present. This is non-pathologically
enlarged by CT criteria and is most likely reactive. There are
dense multifocal coronary artery calcifications as well as
cardiac enlargement. Previously evident small pericardial
effusion has slightly decreased in size since the prior study.
Assessment of lung fields again demonstrates findings of
congestive heart failure, with evidence of ground-glass
opacities and smooth thickening of septal lines. Small to
moderate bilateral pleural effusions slightly increased in size
in the interval. There has been development of areas of
organizing fibrosis peripherally with associated bronchiectasis
and bronchiolectasis. The airways are patent to the level of the
subsegmental bronchi bilaterally. Imaged portions of the upper
abdomen are notable for vascular calcifications and a left renal
cyst. IMPRESSION:
1) Cardiomegaly, coronary artery calcifications, and evidence of
congestive heart failure as above, with persistent ground-glass
opacities, smooth thickening of septal lines, and small to
moderate bilateral pleural effusions.
This process appears to be superimposed upon underlying ARDS as
described below
2) Progressive development of areas of organizing fibrosis along
the periphery of both lungs. The appearance is consistent with a
history of ARDS with an element of organizing fibrosis.
INTERPRETATION:
Findings:
This study was compared to the prior study of [**2198-12-21**].
LEFT ATRIUM: Moderate LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. A
catheter or pacing
wire is seen in the RA and/or RV.
LEFT VENTRICLE: Mild symmetric LVH. Top [**Doctor First Name **]/borderline dilated
LV cavity
size.
LV WALL MOTION: Regional LV wall motion abnormalities include:
mid anterior -
akinetic; mid anteroseptal - akinetic; basal inferior - hypo;
basal
inferolateral - hypo; anterior apex - akinetic; septal apex-
akinetic;
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Mildly dilated aortic root.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild to
moderate ([**2-10**]+)
MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild
to moderate
[[**2-10**]+] TR. Moderate PA systolic [**Month/Day (2) **].
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
PERICARDIUM: Small pericardial effusion. No echocardiographic
signs of
tamponade.
Conclusions:
The left atrium is moderately dilated. The right atrium is
moderately dilated.
There is mild symmetric left ventricular hypertrophy. The left
ventricular
cavity size is top normal/borderline dilated. Resting regional
wall motion
abnormalities include anteroseptal, anterior and apical
hypokinesis and basal
inferior and inferolateral hypokinesis. Right ventricular
chamber size and
free wall motion are normal. The aortic root is mildly dilated.
The aortic
valve leaflets (3) are mildly thickened. There is no aortic
valve stenosis.
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly
thickened. Mild to moderate ([**2-10**]+) mitral regurgitation is seen.
The tricuspid
valve leaflets are mildly thickened. There is moderate pulmonary
artery
systolic [**Month/Day (2) **]. There is a small pericardial effusion.
There are no
echocardiographic signs of tamponade.
Compared with the prior study (tape reviewed) of [**2198-12-21**],
left ventricular
systolic function appears slightly more vigorous.
Brief Hospital Course:
1. Pulmonary - This 85 year old male with history of CAD, s/p
recent STEMI with cardiac catheterization was admitted with SOB
and hypoxia. It was felt these symptoms were most likely
secondary to PNA and CHF exacerbation based upon history,
examination, and his admission CXR. He was admitted to the CCU
for continued care. His enzymes were cycled to rule out
ischemia as a cause of his CHF exacerbation. There was no
evidence of ischemia on EKG. He was treated with antibiotics
for presumed infection, he was initially started on
levofloxacin. He was also diuresed with Lasix. The day after
admission Vancomycin and Flagyl were added for additional
antibiotic coverage. On the evening after admission he
developed increased respiratory distress. Agressive diuresis,
morphine, nitro, and BIPAP were tried with no sucess. He was
intubated for respiratory distress, a SWAN was placed and a Head
CT was obtained. His SWAN numbers indicated that he was fluid
overloaded so he was diuresed.
He continued to spike temperatures despite being on Levo,
Vanco, and Flagyl. He was diuresed agressively with Lasix and
developed a metabolic alkalosis secondary to contraction. He
was treated with Bumex for a few days. Then his alkalosis was
treated with a tight KCl sliding scale. He continued to spike
fevers and sputum cultures revealed MRSA. His lines were
changed. Since he continued to spike and have positive cultures
despite Vanco he was changed to Linezolid and the Levofloxacin
and Flagyl were dcd. His WBC count continued to trend down from
admission. His respiratory status improved, his WBC count
improved, and his CXR improved. Based upon good response to a
pressure trial he was extubated on hospital day #9. He did well
post extubation. He had some diarrhea the evening following
extubation which was found to be c.diff positive. He was
restarted on Flagyl.
Based upon his improved respiratory status and lack of fevers
it was felt he was stable to be discharged from the CCU and sent
to the floor. We continued to diurese him but with much less
close monitoring than had been occuring in the unit. On
hospital day #14 he was found to be very crackly on exam with
marked respiratory distress. His antibiotics were broadened to
Zosyn, Flagyl, Linezolid. He was transferred up to the CCU with
concern that he had become fluid overloaded again. His lt IJ
was removed and a rt IJ placed with SWAN. The SWAN indicated
that he was fluid overloaded and he was aggressively diuresed
with Lasix. He was noted to have a swollen wrist and ankle on
arrival to the CCU. An attempt was made to remove fluid from
his ankle which was unsucessful. That evening he became
increasingly hypoxic with SOB, he also became hypotensive. He
was tried on BIPAP and given Neo then Dopamine for BP support.
He did not tolerate BIPAP and was intubated.
He continued to require Neo for BP support, which was weaned off
slowly. He was diuresed with Lasix based upon CXR which
indicated that he was fluid overloaded. A repeat Echo was
performed which indicated an improvement in his EF to 30-35%.
On hospital day 18 a bronchoscopy was performed and sample sent
for culture. He was was eventually exubated in the CCU after
aggresive diuresis. BAl results came back positive for
STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA which was sensitive
for bactrim. However at that point patient looked much improved
with no recent spike in temperature, respiratory decompensation,
or increase in WBC. It was agreed upon to hold off on treating
with Bactrim and if patient decomensated in future we would
treat. However patient never showed any evidence of furter
active infection. Linezolid and Zosyn course were completed
while patient was in hospital. Patient was transferred back to
the floor out of the unit. Patient still had crackles on lung
exam but based on exam and swan numbers (before swan taken out)
patient was dry. A CT Chest was ordered which showed resolving
ARDS and fibrosis. Patient should have repeat CT scan in [**7-17**]
weeks. While on floor patient was slowly transitioned from IV
lasix dose to PO lasix with close monitoring of fluid status.
2. CAD - He had a history of CAD, on this admission further
ischemia was ruled out by enzymes. He was continued on Aspirin,
Lipitor, and Plavix throughout his hospital stay. He was
started on Beta-blocker and ACE-I once BP could tolerate. His
EKGs remained unchanged.
3. Pump - His EF prior to admission was documented as 20%. On
admission a CXR showed evidence of CHF most likely due to PNA
c/b a.fib with RVR. He was agressively diuresed as mentioned
above. He was continued on his Digoxin. His ACE-I was given
when his pressure was able to tolerate it. A repeat Echo on
[**2199-1-30**] showed and EF of 30-35%. It also showed:
"anteroseptal, anterior and apical hypokinesis and basal
inferior and inferolateral hypokinesis, mild (1+) aortic
regurgitation, mild to moderate ([**2-10**]+) mitral regurgitation."
4. Rhythm - He had a history of A.fib with pacer placed for
SSS. On admission his rhythm was a.fib with lots of PVCs and
short runs of NSVT on telemetry. He was initially continued on
beta-blocker and Amiodarone. His beta-blocker was held when his
blood pressure could tolerate it, and then restarted once he
improved. His Amiodarone was discontinued on [**2199-1-28**] with
concern for Amiodarone induced lung toxicity. He was
anticoagulated throughout his hospital stay with Heparin IV or
Coumadin.
2. ID - He was treated for PNA with various antibiotics as
mentioned above. He had a c.diff positive stool for which he
was treated with Flagyl. Sputum cultures grew MRSA treated with
Vancomycin then Linezolid. BAL samples were sent for culture
and results mentioned above. Repeat c. diff toxin came back
negative. Patient was kept on flagyl until other antibiotic
courses were completed and he should continue on flagyl for two
more days since his zosyn was discontinued on the day of
discharge.
4. S/P Fall - He had a fall at the nursing home prior to coming
to the hospital. His neuro exam showed no deficits on arrival.
Head CT showed old lt temporal infarct, no new infarcts. He had
some increased confusion after sedation but had no focal
neurologic deficits.
5. Psych - All out-patient psych medications were held.
Medications on Admission:
Haloperidol 0.5 mg q 1700
Lorazepam 0.25 mg po q 8hrs prn
Aceotminophen 650 mg po q 4 hours prn
Furosemide 40 mg IV
Metop 50 mg po
Lansoprazole 30 mg ppo q d
Insulin
Digoxin 0.125 mg qd
Quetaiapine fumarate 25 mg po qhs
Haloperidol 1 mg p q4h PR IM
Haloperiodl 1 mg po q 4 hrs
Coumadin 1 dose?
Bisacodyl 10 mg qd
MgOH 30 mg
Laactulose 20 mg qd
Senna
Colace
Lisinopril 5 mg qd
Atorvastatin 80 mg qd
Amiodrarone 400 mg qd
Clopidogrel 75 mg qd
Aspirin 325 mg qd
Cefuroxime 500 mg po bid
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary
Pnemonia-MRSA
Congestive heart failure (EF 30 to 35%)
C difficile colitis
Questionable amiodarone pulmonary induced toxicity.
Secondary:
Coronary Artery Disease
[**Hospital1 **]
[**Hospital1 **]
Atrial Fibrillation on coumadin
Sick sinus syndrome, s/p pacer
s/p bilateral total knee replacement
s/p umbilical hernia repair
Discharge Condition:
Good, afebrile, tolerating po intake and sating comfortably on
3L NC.
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet.
Fluid Restriction: 1500 cc
Please return to the emergency room or your PCP if you
experience shortness of breath, chest pain or light headedness
or increasing weight gain not relieved by lasix. It is very
important to weigh yourself every day and call your physician if
you experience any weight gain.
Followup Instructions:
Please call your PCP doctor, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 54533**] at [**Telephone/Fax (1) 54534**]
to make a follow up appointment in one week.
Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Where: [**Hospital6 29**]
PULMONARY FUNCTION LAB Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2199-3-14**]
12:45
Provider: [**Name10 (NameIs) 1571**] EXAM ROOM IS (NO CHARGE) Where: IS (NO
CHARGE) Date/Time:[**2199-3-14**] 1:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Where: [**Hospital6 29**] MEDICAL
SPECIALTIES Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2199-3-14**] 1:00
Please have your son accompany you to assist in translation.
You have an appointment for a chest CT the morning of [**2199-3-14**].
You will be called about the time.
ICD9 Codes: 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3893
} | Medical Text: Admission Date: [**2121-1-19**] Discharge Date: [**2121-1-23**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Left sided weakness
Major Surgical or Invasive Procedure:
IV TPA
History of Present Illness:
HPI:Pt is a 89 yo with h/o AF, DMII, HTN, glaucoma, SBO in the
past, hypothyroidism who is here with bleeding hemorrhoids. She
was going to leave today, but couldn't get a ride. She was seen
normal at 8 pm by the nurse. She was then seen at 9 pm and was
found to be not moving her left side or speaking. The team
assessed her and then called me to assess her. Her BS was 124.
Her vitals were normal. On arrival, I found her saying only her
name and following only simple commands on the right. Her left
side was not moving. She had a left neglect and [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 11849**]
toe. NIHSS was limited by severe aphasia and poor cooperation.
She was brought to the CT scanner and found to have no bleed,
but
she did have a hyperdense MCA sign on the right(corresponding
with symptoms). A subsequent CTA demonstrated a cut-off of the
right MCA. She was emergently brought to the SICU after
speaking
with her attending and her sister to clarify both her wishes and
also the nature of her apparent hemorrhoidal bleeding given that
we were considering tpa. The attending felt that her risk was
very low for having a source of her bleeding other than
hemorrhoids. She was brought to the unit and tpa given at ~10:30
pm. She had no immediate changes.
Past Medical History:
- Atrial fibrillation with RVR - has been rate controlled on
metoprolol
- Insulin resistance/diabetes - diet controlled
- Hypertension - on metoprolol, lisinopril and HCTZ
- glaucoma
- cataracts s/p right eye surgery
- SBO s/p LOA in [**2117**]
- stable RUL opacity
Social History:
Lives alone, sister in area. Denies tobacco, ETOH, IVDU.
Retired from sales.
Family History:
Non contributory
Physical Exam:
Exam:Vitals:
Gen:NAD.
HEENT:MMM. Sclera clear. OP clear
Neck: No Carotid bruits
CV: Irreg, irreg., Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
Ext:No cyanosis/edema
Neurologic examination:
Mental status: Awake and alert
Pt is able to repeat single words only. She follows simple
commands with her right hand only. Will not follow midline
commands consistently.
Cranial Nerves:
I: not tested
II: Pupils 4 to 3 on right. 5 mm and min reactive on left.
Apparent left hemianopsia vs neglect.
III, IV, VI: Extraocular movements intact grossly, but no formal
eval.
V, VII: Left facial droop with unclear sensory changes
[**Name (NI) 7060**]: Hearing intact grossly.
IX, X: Palatal elevation symmetrical
XII: Tongue midline without fasciculations
Motor:
Unable to assess formally, but not moving left side at all, even
to nox stim. Moves right arm and leg freely and normally. Tone
is normal on right, increased in LUE and LLE bilaterally.
Sensation: Responds in some way to nox stim in all exts.
Reflexes: B T Br Pa Ankle
Right 3 3 2 3 0
Left 3 3 2 3 0
Toes were downgoing on right, up on left
Coordination: No cooperation
Gait: Unable
Pertinent Results:
[**2121-1-19**] 05:20PM ALBUMIN-4.2
[**2121-1-19**] 05:20PM LIPASE-44
[**2121-1-19**] 05:20PM GLUCOSE-92 UREA N-28* CREAT-0.9 SODIUM-137
POTASSIUM-3.8 CHLORIDE-99 TOTAL CO2-28 ANION GAP-14
[**2121-1-19**] 04:35PM PLT COUNT-271#
[**2121-1-19**] 05:20PM PT-11.0 PTT-23.5 INR(PT)-0.9
CT/CTA head [**2121-1-20**]:
IMPRESSION: Complete occlusion of the M1 segment of the right
MCA. CT perfusion conistent with right MCA stroke.
CT head [**2121-1-21**]: 1. Medullary hemorrhage, likely unchanged in
extent.
2. Progression of hypodensities corresponding to edema in areas
of restricted diffusion on MRI, consistent with evolving
ischemic infarct in these areas.3. Unchanged appearance of dense
right MCA, consistent with persistent clot despite thrombolysis
MRI head [**2121-1-21**]: Evolving right middle cerebral artery
infarction as well as hemorrhage within the medulla.
Ech [**2121-1-21**]: The left atrium is moderately dilated. The right
atrium is moderately dilated.
No atrial septal defect or patent foramen ovale is seen by 2D,
color Doppler
or saline contrast with maneuvers. Left ventricular wall
thicknesses are
normal. The left ventricular cavity size is normal. Overall left
ventricular
systolic function is moderately depressed with anteroseptal and
apical
akinesis with mild to moderate hypokinesis elsewhere. Right
ventricular
chamber size is normal. The aortic valve leaflets (3) are mildly
thickened.
There is no aortic valve stenosis. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Moderate
(2+) mitral regurgitation is seen. The tricuspid valve leaflets
are mildly thickened. Moderate [2+] tricuspid regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
There is no pericardial effusion.
Brief Hospital Course:
Neurology: Patient was admitted to ICU after patient received IV
TPA for acute stroke within 3 hours from onset of stroke
symptoms ([**2121-1-20**] 10 pm). She initially had no improvement in
exam. At 24 hours, patient became more somulent and required
intubation. Head CT 24 hours after IV TPA given showed a
medullary hemorrhage. Though she had some minimal responsiveness
to voice (awoke to voice)and was able to move right arm/leg
spontaneiously her family decided to make her CMO as she had
made prior wishes not to be in nursing care and would not have
liked to tracheostomy or PEG dependent. The patient was
extubated and she passed away hours later.
Medications on Admission:
Metoprolol
Lisinopril
HCTZ
synthroid
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
hemorroid
stroke
Discharge Condition:
deceased
Discharge Instructions:
none
Followup Instructions:
none
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
ICD9 Codes: 4019, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3894
} | Medical Text: Admission Date: [**2105-11-14**] Discharge Date: [**2105-11-22**]
Date of Birth: [**2089-5-16**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
16 F high speed MVC, unrestrained passenger, medflighted from
NH, prolonged extrication, GCS 13->7T intubated at scene.
Major Surgical or Invasive Procedure:
Open reduction and internal fixation or right tib/fib fx
History of Present Illness:
16 F high speed MVC, unrestrained passenger, medflighted from
NH, prolonged extrication, GCS 13->7T intubated at scene.
Physical Exam:
on arrival:
96.6 90 126/73 100%
paralyzed, intubated, ET midline
R eye lac, L eye echymosis, motic, swollen, lip lac, scalp lac
pupils 2+ b/l, equal and reactive
nares clear, TMs clear
symmetric b/l bs, no chest crepitus
RRR
ab nontender, nondistended, stable pelvis, FAST neg
rectal - guiac pos, normal tone
+pulses all 4 extremities
CTL spine - no step offs, no bruising
moving all etremities spontaneously
Pertinent Results:
[**2105-11-14**] 08:15PM BLOOD WBC-21.3* RBC-3.48* Hgb-10.6* Hct-28.0*
MCV-80* MCH-30.4 MCHC-37.9* RDW-12.9 Plt Ct-222
[**2105-11-15**] 04:20PM BLOOD WBC-5.5 RBC-2.63* Hgb-7.8* Hct-21.8*
MCV-83 MCH-29.5 MCHC-35.5* RDW-13.0 Plt Ct-124*
[**2105-11-21**] 06:55AM BLOOD WBC-8.7 RBC-2.90* Hgb-8.5* Hct-23.8*
MCV-82 MCH-29.4 MCHC-35.8* RDW-14.5 Plt Ct-259
[**2105-11-14**] 08:15PM BLOOD PT-14.0* PTT-31.7 INR(PT)-1.3
[**2105-11-14**] 08:15PM BLOOD Fibrino-103*
[**2105-11-15**] 12:47AM BLOOD Glucose-148* UreaN-8 Creat-0.5 Na-137
K-3.7 Cl-105 HCO3-23 AnGap-13
[**2105-11-19**] 04:10PM BLOOD Glucose-112* UreaN-8 Creat-0.5 Na-136
K-3.5 Cl-103 HCO3-24 AnGap-13
[**2105-11-14**] 08:15PM BLOOD Amylase-117*
[**2105-11-15**] 12:47AM BLOOD Calcium-7.5* Phos-4.2 Mg-1.2*
[**2105-11-19**] 04:10PM BLOOD Calcium-8.4* Phos-2.6* Mg-1.5
[**2105-11-15**] 02:46AM BLOOD Phenyto-16.3
[**2105-11-19**] 04:10PM BLOOD Phenyto-11.8
[**2105-11-14**] 08:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2105-11-14**] 08:23PM BLOOD Glucose-211* Lactate-3.0* Na-137 K-3.1*
Cl-109 calHCO3-20*
[**2105-11-14**] 08:15PM URINE Blood-MOD Nitrite-NEG Protein-NEG
Glucose-250 Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2105-11-14**] 08:15PM URINE RBC-[**10-18**]* WBC-0-2 Bacteri-RARE
Yeast-NONE Epi-0-2
[**2105-11-14**] 08:15PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.008
RADIOLOGY Final Report
CT PELVIS W/CONTRAST [**2105-11-14**] 10:43 PM
CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST
Reason: patient has hematuria after high speed MVC
Field of view: 36 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
16 year old woman with
REASON FOR THIS EXAMINATION:
patient has hematuria after high speed MVC
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Hematuria after high-speed MVC.
No prior studies are available for comparison.
TECHNIQUE: Contiguous axial images through the abdomen and
pelvis were obtained following the administration of 150 cc of
optiray contrast.
CT OF THE ABDOMEN WITH CONTRAST: The lung bases are clear. There
is an NG tube in place. The tip of the NG tube is within the
body of the stomach. The liver, gallbladder, spleen, pancreas,
and adrenal glands are normal. The kidneys enhance symmetrically
and excrete normally. There is a duplicated ureter on the right
side. The stomach has a fair amount of air within it. The
stomach, small and large bowel are otherwise unremarkable. No
free air or free fluid within the abdomen. The aorta is of
normal caliber, and the proximal celiac, SMA, and [**Female First Name (un) 899**] are
patent. No pathologically enlarged retroperitoneal or mesenteric
lymph nodes.
CT OF THE PELVIS WITH CONTRAST: There is a Foley catheter within
the bladder. The uterus, rectum, and sigmoid are normal. The
adnexa are normal. There is no free pelvic fluid. No
pathologically enlarged pelvic or inguinal lymph nodes.
BONE WINDOWS: There are no fractures identified. There are no
suspicious osteolytic or sclerotic lesions seen.
Multiplanar reformatted images were essential in delineating the
anatomy and pathology in this case (grade 1).
IMPRESSION:
1. No acute traumatic injury identified within the abdomen or
pelvis.
2. The stomach is moderately distended with air. NG tube in
place.
3. There is a duplicated ureter on the right side.
CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST [**2105-11-14**] 8:35 PM
CT SINUS/MANDIBLE/MAXILLOFACIA; CT RECONSTRUCTION
Reason: Trauma? fx
[**Hospital 93**] MEDICAL CONDITION:
20 year old woman s/p mvc w/ facial injury
REASON FOR THIS EXAMINATION:
Trauma? fx
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATIONS: 20-year-old woman with facial injury status post
motor vehicle accident.
TECHNIQUE: Axial non-contrast CT images were obtained through
the maxillary facial bones, orbits and sinuses. This study is
closely correlated with the CT scans of the head and cervical
spine of the same day. Coronal reconstructions were also
performed.
FINDINGS: There is pronounced soft tissue swelling over the
right orbit, and to a lesser extent over the left orbit. There
is bilateral orbital emphysema, including air in the postseptal
spaces bilaterally. The globes appear grossly intact, although
there is some proptosis of the right side relative to the left,
as well as mild inferior medial shift of the right globe. This
is likely related to a small hematoma in the superolateral
orbit, adjacent to the orbital roof fracture site.
The maxillary and sphenoid sinuses show air-fluid levels
consistent with hemorrhage. There is also soft tissue density,
presumably hemorrhage in the nasal and oropharynx. The mastoid
air cells are clear.
There are multiple fractures involving the facial bones. There
are bilateral nondisplaced frontal bone fractures. Also, the
orbital grooves and medial orbital walls have multiple minimally
displaced fractures bilaterally. The orbital roof fractures are
displaced upwards by 1-2 mm as best seen on the coronal images.
These fractures also involve the cribriform plates, without
significant displacement, and the lateral orbital walls as well.
In addition, there are multiple minimally displaced fractures in
the ethmoid cells and of the nasal bones. Bilaterally, the
maxillary bones show fractures along the anteromedial aspects of
the maxillary sinuses, with a few mm of posterior displacement
and impaction. There is no fracture evident involving either
carotid canal.
IMPRESSION:
1. Opacification of the paranasal sinuses with air-fluid levels,
consistent with hemorrhage. The presence of an air-fluid level
in the sphenoid sinus can be suggestive of an occult skull base
fracture as well although none is seen on this study.
2. Bilateral orbital emphysema and soft tissue swelling about
the orbits, although the globes appear intact. The postseptal
fat appears intact as well. Adjacent to the fracture of the
right orbital roof, there is a small hematoma , lying outside
the extraocular muscles, with mild downward displacement of the
globe on the right side.
3. Complex facial bone fractures, with posterior displacement to
a small extent of the nasal and anterior aspects of the
maxillary bones.
4. Fractures of the orbital rooves and medial orbital walls, as
well as the cribriform plates and frontal bones.
CT HEAD W/O CONTRAST [**2105-11-14**] 8:18 PM
CT HEAD W/O CONTRAST
Reason: fracture, bleed
[**Hospital 93**] MEDICAL CONDITION:
20 year old woman s/p mvc w/ multiple head injuries
REASON FOR THIS EXAMINATION:
fracture, bleed
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATIONS: 20-year-old woman status post motor vehicle
collision with multiple head injuries.
COMPARISONS: None.
FINDINGS: There is no mass effect, hydrocephalus, or shift of
the normally midline structures. The ventricles, cisterns, and
sulci are unremarkable without effacement. The [**Doctor Last Name 352**]-white matter
differentiation is intact. There is a punctate hemorrhagic focus
of 6 to 7 mm in diameter in the left frontal lobe with mild
surrounding edema. There is also a second equivocal hemorrhagic
contusion in the subinsular cortex on the left side, of about 3
mm in diameter. No other parenchymal abnormality is identified.
In spite of the presence of multiple non-displaced, or only
minimally displaced, fractures of the skull, there is no
definite extra-axial hemorrhage.
BONE WINDOWS: There are complex skull and facial fractures,
which are discussed in the accompanying report of the same day.
The paranasal sinuses show hemorrhagic contents that are also
better assessed on the other study. There is orbital emphysema
bilaterally, pronounced soft tissue swelling particularly over
the right orbit and multiple facial fractures. The mastoid air
cells are clear.
IMPRESSION:
1. Hemorrhagic contusions, but no evidence of significant mass
effect.
2. No definite extra-axial hemorrhage. However, given the
presence of fractures of the frontal bones and orbital rooves,
it would be appropriate to assess closely for extra-axial
hemorrhage on a close follow-up CT, at which time the contusions
can also be reassessed.
3. Complex orbital fractures, to be described in the
accompanying report.
TRAUMA #2 (AP CXR & PELVIS POR
Reason: TRAUMA
HISTORY: Trauma.
SUPINE AP VIEW OF THE CHEST: An endotracheal tube is noted with
tip at the carina. A gastric tube is seen with its side port in
the stomach. The heart is normal in size. The mediastinal and
hilar contours are normal. The lungs are clear. There are no
effusions, pneumothorax, or focal areas of consolidation
demonstrated. No gross rib fractures are noted.
SUPINE AP VIEW OF THE PELVIS: No fracture, dislocation, or focal
osseous abnormality is seen. The hips and sacroiliac joints
bilaterally are preserved. The sacrum is intact. Soft tissues
are unremarkable.
IMPRESSION:
1. Low lying endotracheal tube with tip at the carina. Dr.
[**Name (NI) 65522**] was informed of these findings at 8:45 p.m. on
[**2105-11-14**].
2. No acute cardiopulmonary abnormality.
3. No fracture or dislocation within the pelvis.
TIB/FIB (AP & LAT) RIGHT [**2105-11-15**] 4:53 PM
TIB/FIB (AP & LAT) RIGHT; LOWER EXTREMITY FLUORO WITHOUT
Reason: ORIF RT TIB FIB
EXAM DATE: [**2105-11-15**].
EXAM ORDER: Right tibia and fibula.
HISTORY: ORIF tibial shaft fracture.
RIGHT TIBIA AND FIBULA: Nine intraoperative fluoroscopic images
of the right tibia and fibula were obtained during open
reduction and internal fixation of essentially nondisplaced
mildly comminuted mid tibial shaft fracture with an
intramedullary rod and proximal and distal interlocking screws.
CT HEAD W/O CONTRAST [**2105-11-15**] 9:41 AM
CT HEAD W/O CONTRAST
Reason: eval for interval change
[**Hospital 93**] MEDICAL CONDITION:
16 year old woman with unrestrained MVC, intubated for decr GCS,
contusion on initial head CT
REASON FOR THIS EXAMINATION:
eval for interval change
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: MVC, contusion on initial head CT, evaluate for
interval change.
COMPARISON: CT dated [**2105-11-14**] at 8:22 p.m.
TECHNIQUE: Noncontrast images of the head were obtained.
FINDINGS: Small focus of intraparenchymal hemorrhage in the left
frontal lobe with a second tiny possible hyperdense focus in the
left temporal lobe are unchanged. There is a hyperdense region
overlying the right frontal convexity with maximal diameter of
approximately 5 mm, present in retrospect on the previous study
and not significantly changed. The ventricles are stable in
size. No significant midline shift. The basilar cisterns appear
patent. No definite new foci of hemorrhage seen.
Bone windows again demonstrate multiple fractures with
opacification of multiple sinuses. Orbital emphysema is also
again seen.
IMPRESSION:
1. Unchanged small focus of intraparenchymal hemorrhage in the
left frontal lobe and possible tiny second focus in the left
temporal lobe.
2. Right frontal convexity hyperdense extra-axial collection
that likely represents a subdural hematoma, present in
retrospect compared to the study of one day prior. This does not
appear significantly changed.
3. Multiple skull fractures.
Brief Hospital Course:
16 F high speed MVC unrestrained passenger, [**Location (un) **] from NH,
prolonged extrication, GCS-13->7 intubated at scene. Primary and
secondary survery were repeated at [**Hospital1 18**], CXR/PXR, CT
head/neck/face, R tib/fib xray, labs were obtained. neurosurg,
ortho, optho, and palstics were inmmediately consulted. Patient
was taken to the trauma SICU for monitoring/treatment.
Neurosurgery: R frontal SDH, L frontal puncate hemx2
no surgery; dilantin for seizure prophalaxis, initially q1 hours
neuro checks, HOB elevated and close SBP monitoring were
recommended. repeat head CT stable. Patient to follow up in
clinic.
Plastic surgery: L orbital wall fracture, frontal sinus
fractures, nasal fractures -
took to OR on HD7 for ORIF [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] fracture, closed nasal
reduction. Started on clindamycin immediately and continued for
7days post-op, peridex mouth rinses TID for 48hrs, then advanced
diet to soft mechanical. will f/u in clinic 1 week after
discharge.
Ortho: R tib/fib- nondisplaced fx (open)
HD2 had R ORIF and tibial IM nail placed. Started on lovenox,
non weight-bearing. Physical therapy
will f/u in clinic.
OPthalmology consult: ice packs for eccymosis, monitoing for
increased intra-ocular pressure, ointment to eyes. no obvious
eye injury. Patient will f/u in clinic.
HD3 self extubated
HD4 - doboff plecement unsuccessfully attempted
HD5 -transfer to floor p.m. had bedside swallow, passed
HD7 - to OR w/ plastics for ORIF facial fx
HD9 - d/c home on soft mechanical diet with instructions to f/u
in trauma clinic.
Medications on Admission:
none
Discharge Medications:
1. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day).
Disp:*qs container* Refills:*1*
2. Erythromycin 5 mg/g Ointment Sig: One (1) application
Ophthalmic QID (4 times a day).
Disp:*qs container* Refills:*2*
3. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours.
Disp:*45 Tablet(s)* Refills:*0*
4. Clindamycin HCl 300 mg Capsule Sig: One (1) Capsule PO four
times a day for 1 weeks.
Disp:*28 Capsule(s)* Refills:*0*
5. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
every six (6) hours as needed for shortness of breath or
wheezing.
Disp:*1 inhaler* Refills:*0*
6. other medications
You need to take a multivitamin with iron for the next month to
improve your anemia following surgery.
You should also take colace while using percocet to prevent
constipation.
Discharge Disposition:
Home With Service
Facility:
VNA of [**Location (un) 5450**] and Southern NH
Discharge Diagnosis:
s/p MVC
L frontal IPH
R subdural hemorrhage
frontal laceration
multiple frontal sinus, left orbital wall & nasal bone fractures
R tibial fracture repair
Discharge Condition:
good
Discharge Instructions:
Diet as tolerated. You should take a stool softener like colace
to prevent constipation while using narcotics.
Contact your MD if you develop fevers > 101, increasing pain or
headaches, redness about your wound, vomiting, or if you have
any questions or concerns.
Followup Instructions:
Contact the Plastic Surgery office to arrange a follow up
appointment with Dr. [**Last Name (STitle) **] in about 1 week.
Contact the Ophthalmology office to arrange follow up for your
vision testing.
Contact Dr.[**Name2 (NI) 4016**] office to arrange a follow up
appointment in several weeks regarding your leg repair.
Completed by:[**2106-3-23**]
ICD9 Codes: 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3895
} | Medical Text: Admission Date: [**2151-3-6**] Discharge Date: [**2151-3-17**]
Service: MEDICINE
Allergies:
Sulfonamides / Dicloxacillin
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
Transfer from assited living with worsening SOB
Major Surgical or Invasive Procedure:
central line placement
History of Present Illness:
This is a 86 y/o F with h/o atrial fibrillation off warfarin,
Diastolic CHF EF 70%, CAD, HTN, [**First Name3 (LF) **] sinus syndrom s/p PPm,
severe AS who presents with about 1 day of SOB.
.
Patient reports that she felt more SOB about 1 day ago. Denied
fevers, chills, chest pain. She reports being compliant with her
medications. No weight changes
.
In the Ed, VS 102 T Rectally, HR 104, BP 119/68, RR 37 Sats 97%
on NRB. chest x ray pulmonary edema. PRoBNP [**Numeric Identifier **]. She received
125 Iv solumedrol, 40 lasix, cefepime, Levofloxacine. She was
place CPAP initially tolerated it, then BP droped into the 60's
SBP, dopamine was started and a central line was placed.
.
ROS: Denied fever, chills, SOB, cough, chest pain, abdominal
pain, blood in stools, weight gain or weight loss
Past Medical History:
- Atrial fibrillation: off coumadin secondary to epistaxis
- [**Numeric Identifier **] sinus syndrome: temporary pacer placed during [**11-20**]
admission, was to return for permanent [**Month/Year (2) 4448**] placement,
which was again deferred during [**1-21**] admission secondary to
medical illness
- hx of VT with torsades morphology in [**3-22**], was on amiodarone,
recently stopped for hypothyroidism
- Aortic stenosis-> echo [**8-22**] showing peak gradient 76 mm Hg.
- CAD s/p NSTEMI in [**1-21**] and [**2-19**] s/p ballooning of LAD
- diasolic CHF (EF 70%)
- HTN
- Hyperlipidemia
- Chronic venous stasis
- Squamous cell carcinoma: right medial calf, s/p excision
[**11-20**], positive margins on 1st and 2nd excision attempts, needs
XRT to area 6 weeks after the wound heals.
- UTI
- rectal ulcers: possibly from constipation and straining
- History of C diff colitis
- Anemia: from blood loss after GI bleed
- Urge incontinence
- Depression
- Colon adenoma in [**2141**]: last colonoscopy in [**2143**], no polyps
- s/p hysterectomy
- Hypothyroidism
Social History:
Currently living in Chestnut park [**Doctor Last Name **]. No tobacco use. no
history of alcohol abuse. Her husband is deceased. She has a
social worker [**Name (NI) **] [**Name (NI) 33578**] at [**Telephone/Fax (1) 101940**] who follows her
closely.
Family History:
non contributory
Physical Exam:
Vitals: T: 96.6 P:95 R:25 BP: 131/66 SaO2: 95% NRB
General:
HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus
noted, MMM, no lesions noted in OP
Neck: JVD 15
Pulmonary: Lungs crackles bilaterally
Cardiac: RRR, nl s1-s2. RUSB eyection murmur
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: 1+ edema. + R tibial ulcer.
Neurologic: alert, oriented, x3, non focal.
Pertinent Results:
Admit Labs:
-----------
[**2151-3-6**] 03:10PM WBC-6.1 RBC-4.10* HGB-12.6 HCT-38.7 MCV-94
MCH-30.7 MCHC-32.6 RDW-15.2
[**2151-3-6**] 03:10PM NEUTS-78.7* LYMPHS-12.5* MONOS-8.0 EOS-0.6
BASOS-0.3
[**2151-3-6**] 03:10PM GLUCOSE-145* UREA N-23* CREAT-1.2* SODIUM-136
POTASSIUM-5.4* CHLORIDE-103 TOTAL CO2-22 ANION GAP-16
[**2151-3-6**] 03:10PM CK(CPK)-86
[**2151-3-6**] 03:10PM cTropnT-<0.01
[**2151-3-6**] 03:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2151-3-6**] 03:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2151-3-6**] 09:22PM TYPE-ART TEMP-37.0 RATES-/18 O2-100 O2
FLOW-10 PO2-73* PCO2-40 PH-7.41 TOTAL CO2-26 BASE XS-0 AADO2-613
REQ O2-98 INTUBATED-NOT INTUBA
[**2151-3-6**] 11:18PM TSH-4.5*
[**2151-3-6**] 11:18PM CK-MB-5 cTropnT-0.08*
[**2151-3-6**] 11:18PM CK(CPK)-62
.
Other Labs/Studies:
-------------------
[**2151-3-9**] 03:59AM BLOOD WBC-3.3* RBC-3.52* Hgb-11.2* Hct-33.7*
MCV-96 MCH-31.9 MCHC-33.3 RDW-14.5 Plt Ct-105*
[**2151-3-12**] 07:00AM BLOOD WBC-3.5* RBC-3.53* Hgb-11.2* Hct-33.2*
MCV-94 MCH-31.7 MCHC-33.6 RDW-14.2 Plt Ct-110*
[**2151-3-6**] 03:10PM BLOOD CK-MB-NotDone proBNP-[**Numeric Identifier **]*
[**2151-3-11**] 08:00AM BLOOD T4-6.6 calcTBG-1.00 TUptake-1.00
T4Index-6.6 Free T4-1.0
[**2151-3-11**] 08:00AM BLOOD TSH-14*
[**2151-3-7**] 5:59 am URINE Source: Catheter.
**FINAL REPORT [**2151-3-8**]**
Legionella Urinary Antigen (Final [**2151-3-8**]):
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
[**2151-3-7**] 5:30 am Influenza A/B by DFA
Source: Nasopharyngeal aspirate.
**FINAL REPORT [**2151-3-7**]**
DIRECT INFLUENZA A ANTIGEN TEST (Final [**2151-3-7**]):
Negative for Influenza A viral antigen.
DIRECT INFLUENZA B ANTIGEN TEST (Final [**2151-3-7**]):
POSITIVE FOR INFLUENZA B VIRAL ANTIGEN.
.
TTE ([**3-12**]):
The left atrium is markedly dilated. There is moderate symmetric
left ventricular hypertrophy. There is severe regional left
ventricular systolic dysfunction with global hypokinesis,
akinesis of the mid and distal anterior wall and apex. Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). Right ventricular chamber size is
normal. with mild global free wall hypokinesis. The ascending
aorta is moderately dilated. The aortic valve leaflets are
severely thickened/deformed. Significant aortic stenosis is
present (not quantified). No aortic regurgitation is seen. The
mitral valve leaflets are moderately thickened. There is
moderate thickening of the mitral valve chordae. Mild to
moderate ([**12-16**]+) mitral regurgitation is seen. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of [**2151-3-8**]
.
CHEST (PA & LAT) [**2151-3-12**] 9:30 AM
There has been marked improvement in pulmonary edema, still
there is mild interstitial pulmonary edema. Left lower lobe
retrocardiac atelectasis has decreased. There is a small left
pleural effusion. There is no pneumothorax. Moderate
cardiomegaly is stable as are enlarged central pulmonary
arteries very suggestive of pulmonary hypertension. Left
transvenous [**Month/Day/Year 4448**] leads terminate in standard position in
the right atrium and right ventricle. There is also a small
right pleural effusion, lesser in amount than in the left side.
IMPRESSION: Improved pulmonary edema.
.
TTE ([**3-8**]):
The left atrium is markedly dilated. The right atrium is
markedly dilated. The estimated right atrial pressure is
10-15mmHg. There is moderate symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. There
is severe global left ventricular hypokinesis (LVEF = 20-25 %)
(basal lateral wall has preserved systolic function). No masses
or thrombi are seen in the left ventricle. Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). There is no ventricular septal defect. with
depressed free wall contractility. The ascending aorta is
moderately dilated. The aortic valve leaflets are severely
thickened/deformed. There is severe aortic valve stenosis (area
<0.8cm2). Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Moderate (2+) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
The left ventricular inflow pattern suggests a restrictive
filling abnormality, with elevated left atrial pressure. The
tricuspid valve leaflets are mildly thickened. There is moderate
to severe pulmonary artery systolic hypertension. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of [**2150-8-28**],
the LVEF is now severely depressed
.
BILAT LOWER EXT VEINS [**2151-3-8**] 11:18 AM
BILATERAL LOWER EXTREMITY ULTRASOUND: Grayscale and Doppler
son[**Name (NI) 1417**] of bilateral common femoral, superficial femoral, and
popliteal veins were performed which demonstrate normal
compressibility, flow, and augmentation.
IMPRESSION: No evidence of DVT.
.
US ABD LIMIT, SINGLE ORGAN PORT [**2151-3-7**] 1:14 PM
A limited portable ultrasound examination was performed by the
radiology resident. Survey demonstrates dirty shadowing from
numerous loops of small bowel within the lower abdomen and
pelvis. No mass lesions were identified. The bladder cannot be
evaluated given intraluminal Foley catheter.
IMPRESSION: Limited ultrasound demonstrates no superficial mass
lesions identified within the abdomen or pelvis. Findings may be
confirmed with non- emergent CT of the abdomen and pelvis if
clinically warranted.
Brief Hospital Course:
87 yo woman with multiple medical problems including [**Name2 (NI) **] sinus
s/p PPM, afib (off anticoagulation [**1-16**] epistaxis), pumonary HTN,
diastolic CHF, CAD, severe AS, COPD who presents with shortness
of [**Month/Day (2) 1440**], DFA positive for Flu B.
.
The patient was initially admitted to the [**Hospital Unit Name 153**] due to
hypotension and need for vasopressors.
.
# Respiratory Distress/Hypoxemia
Likely multifactorial, including Influenza and acute heart
failure (systolic). Initially was on antibiotics for possible
pneumonia, however there was no evidence of a bacterial
pneumonia, so these were stopped.
.
# Influenza
DFA for Influenza B was positive. Patient was given a 5-day
course of Tamiflu. Her oxygen saturation and overall
respiratory status improved. She was maintained in respiratory
isolation.
.
# Acute Systolic CHF with h/o Chronic Diastolic CHF
This was likely in setting of acute viral illness (?-viral
myocarditis). EF dropped from normal to 20-25%. The patient
had significant pulmonary edema. She was diuresed with IV lasix
with improvement in respiratory status. Her B-blocker was
subsequently restarted. ACE inhibitor was held due to
borderline blood pressure. A TTE was repeated 4 days later and
did not show any signifcant change. This should be re-assessed
in about 3 months to determine need for ICD. Cardiac enzymes
were mildly elevated (likely in setting of demand), however did
not meet criteria for an NSTEMI.
.
# Severe Aortic Stenosis
Confirmed on both echocardiograms. Given this condition,
patient was not diuresed more aggressively. Patient will follow
up with outpatient cardiologist to discuss treatment options;
and lasix daily dose was halved to 20 mg daily.
.
# Hypotension: normal WBC, no left shift in differential. Normal
lactate. In the setting of fevers concerning for sepsis. U/A
negative. Was initially on dopamine, however this was titrated
off. Blood pressure medications were slowly introduced.
.
# Rhythm - Atrial Fibrillation/SSS s/p PPM
Rate was well controlled. She had an episode in which she had an
80-beat run of what appeared to be a wide complex tachycardia.
There was some thought that was V-tach and she was started on an
amiodarone drip and then coverted to oral amiodarone. After
discussion with her primary cardiologist, this appeared to be
most consistent with an SVT. After transfer to the medicine
floor, the amiodarone was stopped as she has no tolerated this
in the past and since a B-blocker had been restarted.
.
# CKD: basline 1-1.1. This was stable.
.
# hypothyroidism
Was continued on her home meds. Rechecking TSH showed a level
of 14. Free T4 and Free T4 index were normal. Since dose was
only adjusted two weeks prior, dose was left as is. TSH should
be rechecked 6 weeks after dose adjustment to ensure adequate
level.
.
# depression: continued on outpatient regimen
Medications on Admission:
tylenol
Advair1 1 puff [**Hospital1 **]
Albuterol sulfate 90 mcg 2 puff q4-6h as needed
Aspirin 81
Atorvastatin 80 mg once a day
Atrovent HFA
Calcium 500
Celexa 60 mg qd
Colace [**Hospital1 **] 100 mg\
Iron 325
Lasix 40 qd
Levoxyl 100 qd
Metoprolol xl 37 qd
Lisinopril 10 mg qd
prilosec 20 qd
senna
Vitamin C
Vitamin D
Discharge Medications:
1. Becaplermin 0.01 % Gel Sig: One (1) Appl Topical DAILY
(Daily): To R calf ulceration. .
2. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
5. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Calcium 500 500 mg (1,250 mg) Tablet Sig: One (1) Tablet PO
three times a day.
8. Ergocalciferol (Vitamin D2) 400 unit Tablet Sig: 2.5 Tablets
PO once a day.
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as
needed for constipation.
10. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: 1.5
Tablet Sustained Release 24 hrs PO once a day: 37.5mg daily.
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
13. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One
(1) Tablet PO twice a day.
14. Multiple Vitamin Tablet Sig: One (1) Tablet PO once a
day.
15. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation every six (6) hours as needed for shortness of [**Hospital1 1440**]
or wheezing.
16. Atrovent HFA 17 mcg/Actuation Aerosol Sig: One (1) puff
Inhalation three times a day.
17. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
Primary: 428.33 HEART FAILURE, (B2) ACUTE ON CHRONIC DIASTOLIC
Secondary: 401.1 HYPERTENSION, BENIGN
Secondary: 414.01 CAD, NATIVE VESSEL
Secondary: 311 DEPRESSION, NOS
Secondary: 496 CHRONIC OBSTRUCTIVE PULMONARY DISEASE
Secondary: 427.31 ATRIAL FIBRILLATION
Secondary: 424.1 AORTIC STENOSIS-INSUFFICIENCY
Secondary: 428.21 HEART FAILURE, (A1) ACUTE SYSTOLIC
Secondary: 244.9 HYPOTHYROIDISM
Secondary: 284.1 PANCYTOPENIA
Secondary: 427.0 TACHYCARDIA, SUPRAVENTRICULAR
Secondary: 487.1 INFLUENZA WITH OTHER RESPIRATORY MANIFESTATIONS
Unsigned
Discharge Condition:
Stable
Discharge Instructions:
Return to the [**Hospital1 18**] Emergency Department for: Shortness of
[**Hospital1 1440**], fevers.
Followup Instructions:
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2151-3-24**]
9:30
Provider: [**Name10 (NameIs) 900**] [**Name8 (MD) 901**], M.D. Phone:[**Telephone/Fax (1) 902**]
Date/Time:[**2151-3-24**] 10:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1879**], M.D. Date/Time:[**2151-3-30**] 2:30
ICD9 Codes: 4280, 4241, 5859, 496, 2449, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3896
} | Medical Text: Admission Date: [**2121-11-3**] Discharge Date: [**2121-11-17**]
Date of Birth: [**2048-1-11**] Sex: F
Service: [**Last Name (un) **]
ADMISSION DIAGNOSIS: Incarcerated parastomal hernia.
DISCHARGE DIAGNOSES: Incarcerated parastomal hernia.
Status post reduction of hernia, re-siting of colostomy.
Aspiration pneumonia.
ETOH withdrawal.
Respiratory failure.
Status post tracheostomy.
HISTORY OF PRESENT ILLNESS: The patient is a 73-year-old
woman who has a history of parastomal hernias and has had
these hernias repaired times four or five. She now presents
with acute onset of abdominal distention, nausea and
vomiting, as well as a mass in the parastomal region.
PAST MEDICAL HISTORY: ETOH (one bottle of wine per day).
Hypertension.
Gastroesophageal reflux disease.
Hepatitis C.
Anxiety.
Depression.
Etiopathic splenomegaly.
Etiopathic thrombocytopenia.
Heparin induced thrombocytopenia negative.
PAST SURGICAL HISTORY: Status post [**Month (only) **].
Parastomal hernia repair times four or five.
Total abdominal hysterectomy.
Breast biopsy.
Cataract surgery.
MEDICATIONS AT HOME:
1. Aspirin 325 mg once daily.
2. Hydrochlorothiazide 25 mg once daily.
3. Zoloft 50 mg once daily.
4. Lisinopril 10 mg once daily.
5. Ibuprofen 600 mg once daily p.r.n.
6. Serax 15 mg t.i.d.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: On admission, the patient is afebrile.
Vital signs are stable. Generally, she is in some distress.
Chest is clear to auscultation bilaterally. Cardiovascular is
regular rate and rhythm without murmur, rub or gallop.
Abdomen is soft, mildly distended and tender to palpation.
Tenderness is localized to the lower abdomen and more so in
the parastomal region. There is a large bulge around the
ostomy. Stoma itself is fairly pink and healthy. Extremities
are warm and well perfused with minimal edema.
HOSPITAL COURSE: The patient was admitted for repair of her
incarcerated parastomal hernia. She was taken to the
Operating Room on [**2121-11-3**] for reduction, as well as
colostomy re-siting into the left upper quadrant. For details
of this, please see the previously dictated operative note.
Postoperatively, the patient's course was complicated by what
was thought to be an aspiration event on the evening of
postoperative day number two. She had acute respiratory
distress, as well as change in mental status, which is
different from her baseline. She was maintained with Lasix
diuresis and face mask for approximately 8-12 hours but then
was subsequently intubated and transferred to the Intensive
Care Unit for worsening respiratory status. She was initially
only intubated for about 24 hours and met all criteria for
extubation. Chest x-ray did confirm that she had bilateral
upper zone infiltrates and the patient was empirically
treated with a seven day course of vancomycin and Levaquin.
After the patient met her respiratory extubation criteria,
she was extubated. She continued to do fairly well but had
change in mental status, which could not be attributed to
anything other than alcohol withdrawal. TSH, B-12 and folate
levels were checked, which were normal. CT scan of the head
was obtained on [**2121-11-10**], which did not show any evidence
of acute injury. There was some evidence of old lacunar
infarcts. MR of the head was completed on [**2121-11-12**], which
confirmed the above. In addition, the Neurology service was
consulted for her change in mental status and they felt it
was best attributed also to her alcohol withdrawal, as well
as withdrawal from her Serax. These were restarted per their
recommendations and the patient gradually improved some of
her mental status.
On [**2121-11-10**], the patient was re-intubated (postoperative
day number seven) for worsening respiratory status. She was
maintained and ventilated during this time and had a
bronchoscopy performed on [**2121-11-13**], which proved to be
negative for any significant pluggings or other bronchial
disease. The patient was extubated later that day on
[**2121-11-13**], but then quickly failed her extubation trial
within approximately six hours. She was emergently re-
intubated and there was seen to be a fair amount of tracheal
and laryngeal edema at that time. The decision was then made
to give the patient a surgical airway and percutaneous
tracheostomy was performed on [**2121-11-14**]. This was done in
accordance and consent with her son, who was the healthcare
proxy during her change in mental status.
Ultimately, the patient was discharged on postoperative day
number fourteen to a [**Hospital 4820**] rehabilitation facility for
ventilatory weaning, as well as allowing clearance of her
mental status. The Neurology service had seen the patient on
the day of discharge and agreed with the above and to
continue present management. The patient had a post-pyloric
feeding tube placed in Interventional Radiology on the day of
discharge in order to decrease the risk of aspiration
pneumonia. The patient was tolerating tube feeds adequate and
had good function with occasional tracheostomy mask trials
from the vent.
DISPOSITION: To [**Hospital 4820**] rehabilitation facility.
DIET: Tube feedings: Impact with fiber (or other
immunogenic tube feed formulation) at 75 cc/hr.
DISCHARGE MEDICATIONS:
1. Albuterol nebulizers q 6 hours p.r.n.
2. Lopressor 5 mg intravenously q 6 hours, hold for heart
rate less than 60 or systolic blood pressure of less than
100.
3. Zyprexa 5 mg p.o. or per nasogastric tube daily.
4. Roxicet elixir 5-10 cc p.o. or nasogastric tube q 4 hours
p.r.n. for pain.
5. Serax 15 mg p.o. or per nasogastric tube t.i.d.
6. Heparin 5,000 units subcutaneously t.i.d.
7. Dilaudid 0.5-2.0 mg intravenously or subcutaneously q 4
hours p.r.n. for pain.
8. Insulin sliding scale to cover blood sugars. This should
begin at 120 and advance every 40 points of a blood sugar.
The beginning scale should start at two and increase two
units of insulin per 40 points of blood sugar.
9. Atrovent nebulizers inhaled q 6 hours p.r.n.
10. Ativan 0.5-1.0 mg intravenously q 6 hours p.r.n.
11. Prevacid 30 mg per nasogastric tube q 24 hours.
12. Zoloft 100 mg p.o. or per nasogastric tube daily.
DISCHARGE INSTRUCTIONS: The patient is to follow-up with Dr.
[**Last Name (STitle) **] in four weeks' time. The patient should continue
receiving tube feeds of an immunogenic formula at
approximately 75 cc/hour. The patient should continue all of
her medications as described above. In particular, it is
important to continue the Serax and give Ativan p.r.n. for
withdrawal symptoms. The patient should have ventilatory
weaning with tracheostomy mask trials everyday until the
patient can be weaned off of mechanical ventilation. The
patient should have ostomy care per standard protocol.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1286**], MD [**MD Number(1) 11126**]
Dictated By:[**Last Name (NamePattern1) 23688**]
MEDQUIST36
D: [**2121-11-17**] 14:48:09
T: [**2121-11-17**] 15:25:35
Job#: [**Job Number 111143**]
ICD9 Codes: 5070, 5185, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3897
} | Medical Text: Admission Date: [**2162-5-20**] Discharge Date: [**2162-6-15**]
Date of Birth: [**2162-5-20**] Sex: F
Service: NB
LAST NAME AT DISCHARGE IS [**Known lastname **].
HISTORY: [**Doctor Last Name **] is the 1190 g product of a twin gestation
born to a 33 year old G1 P0 now 2 mother born at 31-0/7
weeks. Prenatal screens were O positive, antibody negative,
RPR nonreactive, hepatitis surface antigen negative, Rubella
immune, GBS unknown. This pregnancy was conceived with IVF
with dichorionic, diamniotic twins, history of preterm labor.
Mother was betamethasone complete and presented at [**Hospital3 38285**] on day of delivery with progressive labor and
cervical dilatation. She was transferred to the [**Hospital3 **].
Infant was delivered by C-section for breech presentation of
twin 2. Infant emerged with spontaneous crying and good tone.
Apgars were 8 and 9.
PHYSICAL EXAM ON ADMISSION: 1190 g, 10-25th percentile,
length 38.5 cm, greater than 25th percentile, head
circumference 27.5 cm, approximately 25th percentile, small-
appearing newborn, but appropriate for gestational age,
nondysmorphic, anterior fontanelle soft and flat. Eyes -
deferred. Palate was intact. Neck was supple with clavicles
intact. Cardiovascular - regular rate and rhythm, no murmur,
2+ femoral pulses with good peripheral perfusion. Flaring and
retractions noted with fair aeration, equal bilaterally.
Abdomen was soft with positive bowel sounds, 3-vessel cord.
GU - normal for preterm female, patent anus, no sacral
anomalies. Hips were stable. Infant moves all extremities
well.
HISTORY OF HOSPITAL COURSE BY SYSTEMS:
Respiratory - [**Last Name (un) **] was started on CPAP and remained on CPAP for a
total of 72 hours at which time she transitioned to room air and
has been stable in room air since that time. Caffeine citrate was
started empirically due to gestational age. Caffeine was
discontinued on [**2162-6-4**]. Her last episode of apnea and
bradycardia was on [**2162-6-4**].
Cardiovascular - has been stable throughout hospital course
without any issues.
Fluids and Electrolytes - birth weight was 1190 g. She was
initially started on 60 cc/kg/day of D10W. Enteral feedings
were initiated on day of life #2. The infant advanced to full
enteral feedings by day of life #6. Maximum enteral intake
was 130 cc/kg/day of Premature Enfamil 30 calories with
ProMod. She is currently ad lib feeding with a minimum of 130
cc/kg/day of Enfamil 26 calorie by concentration and corn
oil. Her discharge weight is 1790 grams.
GI - Peak bilirubin was on day of life #2 of 7.1/0.3. She
received phototherapy for a total of 4 days. Phototherapy was
discontinued and the infant has been otherwise stable.
Hematology - hematocrit on admission was 45.5. She has not
required any blood transfusions during this hospital course.
Infectious Disease - a CBC and blood culture were obtained on
admission. CBC was benign. Blood cultures remained negative
at 48 hours at which time ampicillin and gentamicin were
discontinued. She has had no further sepsis issues.
Neuro - head ultrasound was performed on day of life #8 and
was within normal limits and the exam has been appropriate
for gestational age.
Ophthalmology - infant was most recently examined on [**6-7**],
demonstrating immature retina with vessel growth to zone 3.
Recommended follow-up the week of [**6-29**] with Dr.[**First Name9 (NamePattern2) **]
[**Name (STitle) **].
CONDITION AT DISCHARGE: Stable.
DISCHARGE DISPOSITION: To home.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) **]
CARE RECOMMENDATIONS: Continue ad lib feeding with a minimum
of 130 cc/kg/day of Enfamil 26 calorie by concentration and
corn oil. Car seat position screening has been performed and
the infant passed. State newborn screens have been sent per
protocol and have been within normal limits.
IMMUNIZATIONS RECEIVED: The infant has not received any
immunizations at this time.
DISCHARGE DIAGNOSES: Premature twin #1 - mild respiratory
distress, rule out sepsis with antibiotics,
hyperbilirubinemia, apnea and bradycardia at prematurity.
Reviewed By: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 53043**], [**MD Number(1) 53044**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2162-6-14**] 20:56:56
T: [**2162-6-14**] 22:07:35
Job#: [**Job Number 61485**]
ICD9 Codes: 769, 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3898
} | Medical Text: Admission Date: [**2161-10-27**] Discharge Date: [**2161-10-30**]
Date of Birth: [**2089-10-2**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Codeine / Sulfamethoxazole/Trimethoprim
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2161-10-27**] Redo-sternotomy x 3, replacement of ascending aorta and
aortic arch reimplantation of the arch vessels, repair of the
main pulmonary and right and left pulmonary arteries with bovine
pericardial patch and replacement of the mitral valve with a
size 25 [**Company 1543**] Mosaic tissue valve
History of Present Illness:
72 y/o female with extensive past medical history (see below)
who has been c/o progressively worsening dyspnea on exertion
over the past six months. Most recent cardiac cath and echo
revealed severe MR along with moderate AI.
Past Medical History:
Mitral Regurgitation and Aortic Insufficiency
Aortic Dissection s/p Aortic Root Replacement [**2153**]
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 2
[**2155**], s/p Stents to left main and POBA of OM1 [**2155**]
Complete Heart Block s/p PPM [**2160**]
Hypertension
Hyperlipidemia
s/p Appendectomy
s/p Tonsillectomy
Social History:
Retired. Quit smoking [**2152**]. Denies ETOH.
Family History:
Mother with hypertension. Father died from brain tumor/cancer.
Physical Exam:
VS: 62 130/69 5'3" 136#
Gen: WDWN elderly female in NAD
HEENT: EOMI, PERRL, NCAT, OP benign
Neck: Supple, FROM, -JVD, -bruit
Chest: CTAB -w/r/r, well-healed MSI
Heart: RRR 3/6 SEM
Abd: Soft, NT/ND, +BS
Ext: Warm, well-perfused -Edema, well-healed right EVH incision
Neuro: A&O x 3, MAE, non-focal
Pertinent Results:
[**10-27**] Echo: PRE-BYPASS: 1. The left atrium is moderately
dilated. No atrial septal defect is seen by 2D or color Doppler.
2. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is low normal (LVEF 50-55%). 3. Right
ventricular chamber size and free wall motion are normal. 4. An
ascending aortic graft is noted consistent with previous
replacement surgery. The descending thoracic aorta is mildly
dilated. There are simple atheroma in the descending thoracic
aorta. 5. There are three aortic valve leaflets. There is no
aortic valve stenosis. Moderate(2+) aortic regurgitation is
seen. 6. The mitral valve leaflets are moderately thickened.
There is mild valvular mitral stenosis (area 1.5-2.0cm2).
Moderate (2+) mitral regurgitation is seen. POST-BYPASS: For the
post-bypass study, the patient was receiving vasoactive
infusions including epinephrine and phenylephrine. 1. A
well-seated bioprosthetic valve is seen in the mitral position
with normal leaflet motion and gradients. No mitral
regurgitation is seen. 2. An ascending aortic and arch graft is
also seen. 3. Biventricular function is unchanged, AI is
unchanged. 4. Other findings are unchanged
[**10-29**] Head CT: There is diffuse cerebral edema identified with
compression of the ventricles. There is obliteration of the
basal cisterns identified with deformity of the brain stem
indicating central herniation. At the foramen magnum, downward
displacement of the cerebellar tonsils indicates tonsillar
herniation. There are multiple infarcts identified bilaterally
involving the posterior cerebral and anterior cerebral arteries
as well as the right superior cerebellar artery as well as the
watershed distribution. There is no hemorrhage identified.
[**2161-10-27**] 03:24PM BLOOD WBC-13.2*# RBC-3.02*# Hgb-9.6*#
Hct-27.5*# MCV-91 MCH-31.7 MCHC-34.7 RDW-14.3 Plt Ct-101*
[**2161-10-30**] 02:53AM BLOOD WBC-12.1* RBC-3.34* Hgb-10.5* Hct-31.3*
MCV-94 MCH-31.4 MCHC-33.5 RDW-14.9 Plt Ct-76*
[**2161-10-27**] 03:24PM BLOOD PT-18.2* PTT-69.9* INR(PT)-1.7*
[**2161-10-29**] 02:37AM BLOOD PT-13.3* PTT-35.1* INR(PT)-1.2*
[**2161-10-27**] 04:58PM BLOOD UreaN-11 Creat-0.6 Cl-114* HCO3-24
[**2161-10-30**] 02:53AM BLOOD Glucose-145* UreaN-12 Creat-0.5 Na-141
K-3.8 Cl-106 HCO3-26 AnGap-13
[**2161-10-30**] 02:53AM BLOOD Calcium-8.6 Phos-3.4 Mg-1.8
Brief Hospital Course:
Mrs. [**Known lastname 5719**] was admitted and taken directly to the operating
room with plans for a redo-sternotomy, along with aortic and
mitral valve replacements. Unfortunately due to a very fragile
and heavily calcified aorta along with adherent scar tissue,
aortic valve replacement could not be performed. Mitral valve
replacement was performed along with an unplanned replacement of
her ascending aorta and total arch with reimplantation of the
head vessels which required circulatory arrest for 24 minutes.
For additional surgical details, please see seperate dictated
operative note. Following the operation, she was brought to the
CVICU in critical condition. Due to the heavily calcified aorta
and unplanned circulatory arrest, there was much concern for
neurologic injury. Over 48 hours, she remained unreponsive. A
head CT scan on postoperative day two showed diffuse cerebral
edema with deformity of the brain stem indicating central
herniation. There was also downward displacement of the
cerebellar tonsils indicating tonsillar herniation. The CT scan
also showed multiple infarcts involving the posterior cerebral
and anterior cerebral arteries as well as the right superior
cerebellar artery as well as the watershed distribution. No
hemorrhage was identified. The neurology service was consulted
and brain death examination was performed on [**10-30**]. After
declaration of brain death, a family meeting was held, and the
patient was withdrawn from ventilatory support. She expired
soon after. The medical examiner was notified, and post mortem
was refused.
Medications on Admission:
Lisinopril 20mg qd, Lopressor 50mg [**Hospital1 **], Lasix 20mg qd, Crestor
10mg qd, Norvasc 5mg qd, Aspirin 81mg qd
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Mitral Regurgitation and Aortic Insufficiency
Aortic Dissection s/p Aortic Root Replacement [**2153**]
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 2
[**2155**], s/p Stents to left main and POBA of OM1 [**2155**]
Complete Heart Block s/p PPM [**2160**]
Hypertension
Hyperlipidemia
s/p Appendectomy
s/p Tonsillectomy
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
ICD9 Codes: 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3899
} | Medical Text: Admission Date: [**2168-5-9**] Discharge Date: [**2168-5-20**]
Date of Birth: [**2119-2-6**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Compazine / Erythromycin Base
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
resp failure
Major Surgical or Invasive Procedure:
Arterial line
PICC line
Tracheostomy
History of Present Illness:
HPI: 49 y/o female with HTN, COPD/Emphysema, and CHF who has had
two admissions (first to B&W hospital and most recently to
[**Hospital 16843**] Hospital, where she was discharged from last week) in
the last month for COPD/PNA requiring intubation. She was doing
well after her discharge last week, but her daughter had a cold,
and the patient began to develop cough with sputum leading to
fevers, chills, and eventually lethargy on the morning of
admission, prompting her daughter to call EMS. Per her daughter,
she was not having chest pain, but was having increased leg
swelling, and orthopnea/dyspnea causing her to be unable to move
about the house and requiring her to sleep sitting up at the
kitchen table.
.
Arrived at [**Hospital 16843**] Hospital at 4AM [**2168-5-9**], Temp 99.5, Tachy
to
154 (MAT vs. ST with ectopy), RR 28 with sat 98% on nebulizer.
Intubated at 5AM with 8.0 tube after being given 6mg versed, 4mg
ativan, 140mg succinyl choline, 20 mg norcuron. Treated with 250
mg solumedrol (6AM), 2g Ceftriaxone (7AM), and 500mg Levaquin.
Blood pressure stable throughout with a low SBP of 115. Labs
showed WBC 19.8, HCT 36.7, Plt 356, CHem 10 with K 3.3,Hco3 of
36.6, BUN 10, Cr 0.6, CK13 with trop I 0.10 (0.00-0.40 normal
range). BNP 49. U/A showed tr blood, 300 prot, and 100 glucose.
No evidence of urinary tract infection. Digoxin level 0.15.
Past Medical History:
Obesity
HTN
COPD/Emphysema- on home O2 at 2 liters constantly and on
prednisone after hospitalizations. Two previous intubations in
the last month, but for the two years prior had not required
intubation. Would like trach if needed.
Pulmonary Hypertension
Question of CHF/Right Sided Failure
Presumed Sleep Apnea- on home BIPAP
Depression
h/o Afib
Social History:
Lives with her two daughters. Smoking history
unclear. Recently in and out of hospitals over the last several
months for PNA and COPD with intubations.
Family History:
NC
Physical Exam:
On admission:
Obese female, lying in bed, intubated with Foley in place.
Responds to basic commands. Moving all four extremities.
T 96.4 BP 131/113 HR 130 RR 29 SAT 95%
on AC 470x16 FIO2 .50 PEEP 5
HEENT: Pupils 2mm and reactive to light bilaterally. Sclera
anicteric. Moist mucous membranes.
NECK: No LAD. No thyromegaly or nodules.
CHEST: Lung sounds faint but audible bilaterally. No rales or
wheezes.
HEART: Tachycardic. No audible murmurs.
ABD: Obese, soft, NT, ND. No masses or palpable organomegaly.
EXT: Left leg mildly larger than right leg, with pitting edema
to
shin. Bilateral chronic venous stasis changes bilaterally with
poor foot care.
NEURO: Responds with head nods. Moves hands and feet bilaterally
to command.
Pertinent Results:
Labs on admission:
[**2168-5-9**] 11:28AM TYPE-ART PO2-84* PCO2-86* PH-7.22* TOTAL
CO2-37* [**2168-5-9**] 11:28AM LACTATE-1.0
[**2168-5-9**] 11:11AM GLUCOSE-347* UREA N-14 CREAT-0.5 SODIUM-143
POTASSIUM-4.8 CHLORIDE-100 TOTAL CO2-33* ANION GAP-15
[**2168-5-9**] 11:11AM ALT(SGPT)-53* AST(SGOT)-30 LD(LDH)-307*
CK(CPK)-34 ALK PHOS-94 AMYLASE-20 TOT BILI-0.3
[**2168-5-9**] 11:11AM CK-MB-3 cTropnT-<0.01
[**2168-5-9**] 11:11AM ALBUMIN-3.6 CALCIUM-8.7 PHOSPHATE-6.1*
MAGNESIUM-1.7
[**2168-5-9**] 11:11AM WBC-27.7* RBC-4.58 HGB-11.6* HCT-38.1 MCV-83
MCH-25.3* MCHC-30.4* RDW-14.6
[**2168-5-9**] 11:11AM PLT COUNT-414
[**2168-5-9**] 11:11AM PT-11.2 PTT-23.1 INR(PT)-0.9
[**2168-5-9**] 12:18PM URINE BLOOD-TR NITRITE-NEG PROTEIN-100
GLUCOSE-1000 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
Labs on discharge:
[**2168-5-18**] 04:21AM BLOOD WBC-14.9* RBC-4.34 Hgb-10.8* Hct-33.7*
MCV-78* MCH-24.8* MCHC-31.9 RDW-15.5 Plt Ct-227
[**2168-5-18**] 04:21AM BLOOD Glucose-125* UreaN-36* Creat-0.9 Na-139
K-3.9 Cl-93* HCO3-38* AnGap-12
[**2168-5-18**] 04:21AM BLOOD Calcium-9.4 Phos-4.8* Mg-2.1
[**2168-5-18**] 08:29AM BLOOD Type-ART Temp-36.2 PEEP-8 FiO2-40 pO2-82*
pCO2-58* pH-7.45 calTCO2-42* INTUBATED Comment-PSV 12/8
[**2168-5-17**] 03:33AM BLOOD ALPHA-1-ANTITRYPSIN-PND
Echo ([**2168-5-10**]): The left atrium is normal in size. The estimated
right atrial pressure is 16-20 mmHg. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Overall left
ventricular systolic function is normal (LVEF 70%). There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The number of aortic valve
leaflets cannot be determined. There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
There is an anterior space which most likely represents a fat
pad.
BILATERAL LOWER EXTREMITY ULTRASOUNDS ([**2168-5-10**]): No evidence of
bilateral lower extremity DVT.
CXR on admission ([**2168-5-9**]): Mild upper lobe vascular
re-distribution and possible small bilateral pleural effusions
likely representing mild CHF.
CXR prior to discharge ([**2168-5-19**]): The tip of the nasogastric
tube does appear to lie below the diaphragm. The lung fields
appear clear.
Micro: (note - no positive growth at time of discharge)
[**2168-5-19**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC
BOTTLE-PENDING INPATIENT
[**2168-5-19**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC
BOTTLE-PENDING INPATIENT
[**2168-5-19**] URINE URINE CULTURE-PENDING INPATIENT
[**2168-5-19**] URINE URINE CULTURE-PENDING INPATIENT
[**2168-5-9**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL INPATIENT
[**2168-5-9**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL INPATIENT
[**2168-5-9**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
INPATIENT
[**2168-5-9**] URINE URINE CULTURE-FINAL
Brief Hospital Course:
The patient was admitted to the [**Hospital Unit Name 153**] on [**5-9**]. By problem:
# Hypercarbic Respiratory Failure: Etiology of CO2 retention
likely multifactorial--COPD flare in setting of bronchitis,
obstructive sleep apnea, with possible contribution of pulmonary
edema. She was treated with combivent nebulizers,
corticosteroids, and 10d course of levofloxacin for presumed
bronchitis. Despite positive d-dimer, PE was deemed unlikely
given clinical picture and negative LENIs, but her body habitus
precluded CT angiogram. Given 3 intubations within past six
weeks and OSA component, thoracic surgery was consulted and a
7mm [**Last Name (un) 295**] trach was placed on [**2168-5-11**] in the OR. Weaning pt from
the vent proved difficult; pt initially did not tolerate trials
of pressure support ventilation (she would become agitated and
anxious, and blood pressure would increase). With diuresis and
decrease of airway resistance with abx/steroids, she was finally
able to tolerate pressure support ventilation on [**2168-5-18**]. On
[**5-19**] she was able to transition off the vent for up to 2 hours
at a time. A Passey-Muir valve was attempted but tracheal
pressures were too high (20) and so it was not continued.
Eventually the trach can be replaced with a smaller trach for
re-attempt of PMV. She should remain on 20 mg predisone until
follow up with pulmonary after dischartge from rehab.
.
# CHF: An echocardiogram was performed which showed LVEF 70%,
mild symmetric LVH, moderate pulmonary hypertension, and R
atrial pressures of 16-20mm Hg. Admission cxr showed bl pleural
effusions and prominent pulmonary vasculature; pt was diuresed
with Lasix with good effect on pulmonary function and LE edema.
She was maintained on Digoxin 0.125mcg daily and lasix was
restarted at 80 po daily on discharge, which can be increased to
120 po daily (her home dose) if maintaining a positive fluid
balance and her electrolytes are stable.
.
# HTN: Pt was initially very hypertensive (SBPs as high as 210)
while intubated despite being given home meds (Diovan and
Cartia, her doses were initially unknown, therefore they were
titrated up). Hypertension was observed to worsen when pt was
anxious or agitated. She was started on atenolol for further
control. At one point, during an episode of extreme anxiety and
agitation, she briefly was placed on labetalol drip, which was
stopped after BPs came under control. Toward the end of her
course, her blood pressure was actually over-controlled and so
BP meds were down-titrated and lasix was held. This brief
episode of hypotension was due to mild volume depletion but
mostly due to the inaccurate BP cuff readings on her arm
(NOTE:calf measurements much more reliable). He blood pressure
was stable for 24 hours prior to discharge.
.
# Elevated WBC count: Initial WBC count of 27.7 rapidly came
down to mid teen's after starting antibiotics. WBC count
remained at 14-16 throughout course, most likely secondary to
corticosteroids. Pt was afebrile throughout course, with
negative cultures (blood, urine, negative. Pt was treated with
10 days of levofloxacin for presumed bronchitis.
.
# Hyperglycemia: Pt carried a diagnosis of steroid-induced DM
prior to admission. Blood sugars were initially very high,
brought under control with insulin drip which was then
transitioned to long-acting insulin regimen (lantus 20U) with
sliding scale coverage qAC and qhs. Finger sticks were stable
on this regimen.
.
# Depression: Pt was intermittently anxious and tearful during
her course, as was having trouble dealing with tracheostomy
(unable to talk, uncomfortable sensation). She was continued on
her home regimen of Zoloft, Lorazepam, and Seroquel. Trazodone
was held while in house as we did not want her too sedated.
Social work was consulted to help pt deal with feelings of
helplessness/anxiety s/p trach placement. NOTE: She became VERY
tearful s/p failure of passey-muir valve as she considers it
essential to regain speech. This will be a priority in
optimizing her care.
.
# Prophylaxis: Pt was maintained on subQ heparin, pneumoboots,
and a proton pump inhibitor.
# Diet: Pt received Promote w/ fiber tube feeds through an NG
tube.
# Access: Right radial arterial line and Picc line (placed as
she has very poor IV access).
# Code: FULL
# Contact: daughter [**Name (NI) 72523**] [**Telephone/Fax (1) 72524**]
Medications on Admission:
(meds obtained thru d/c summary from [**Hospital **] hospital)
Prednisone 20mg daily
Home Oxygen 2L Day and Night
BIPAP
Albuterol nebulizer
Cartia XT 120mg daily
Lipitor 20mg qhs
Trazodone 50mg qhs
Digoxin 0.125 mcg daily alternating with 0.250mcg daily
Lasix 80mg po daily
Lorazepam 1mg po tid
Advair 500/50 1 puff twice a day
Zoloft 150mg daily
Singulair 10mg daily
Diovan 80mg daily
Seroquel 50mg daily
Protonix 40mg daily
Spiriva, unknown dose
Glyburide 5mg daily (started on [**2168-4-30**], unclear if was taking
prior to admission [**2168-5-9**])
Discharge Medications:
1. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
3. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4H (every 4 hours).
4. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q4H (every 4 hours).
5. Sertraline 50 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
6. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1)
Appl Ophthalmic PRN (as needed).
9. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
11. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed for back pain.
12. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
13. Insulin Glargine Subcutaneous
14. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
15. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for bloating/gas pain.
16. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) dose PO BID
(2 times a day).
17. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
19. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
20. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
21. Valsartan 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
22. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
23. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
24. Lasix 80 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 32674**]
Discharge Diagnosis:
Hypercarbic Respiratory Failure, likley chronic obstructive
pulmonary exacerbation
Congestive heart failure
.
Obesity
HTN
Pulmonary Hypertension
Sleep Apnea- on home BIPAP- however no confirmative sleep study
Depression
h/o Afib
Discharge Condition:
BP 150/70 by arm/leg cuff, breathing comfortably on PS 12/5 with
trach in place.
Discharge Instructions:
You were admitted for difficulty breathing and underwent
placement of a tracheostomy.
Please follow the instructions below and ensure follow up for
the patient.
Followup Instructions:
Please see Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for follow up in pulmonary clinic
afer discharge from rehab - call [**Telephone/Fax (1) 612**] for an
appointment.
.
Please follow up with your PCP [**Name Initial (PRE) 176**] 1 week following discharge
from rehab.
ICD9 Codes: 2762, 4280, 4019, 4168, 311 |
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